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European Urology Today Official newsletter of the European Association of Urology

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Vol. 28 No.4 - August/September 2016

Setting up a stone clinic

ESUT16 in Athens

Japanese Tour 2016

Expert assessment is crucial in following-up stone patients

New technology takes centre-stage in ESUT meeting

Whirlwind tour in Japan yields insights

Dr. A. Trinchieri

8

Prof. R. Vela Navarrete

26

Dr. G. Pignot

Through the years: Role of the EAU Section Office Efficient, productive collaboration is crucial to success of Section Office Prof. Jens Rassweiler Chairman EAU Section Office Heilbronn (DE)

(ESTU), European Society of Female Urology (ESFU), and the European Society of Infections in Urology (ESIU). Unfortunately, the EUSP did not join the EAU Section Office. In 2004 the EULIS became full member followed by the ESUR in 2009. The ESFU and ESNU later fused and joined as ESFFU. In 2011, the European Robotic Urologic Society was integrated into the EAU Section Office as ERUS (Table 1). A new Section of Adolescent Urology is currently being formed.

elected as an expert (i.e. associate). The Board of the Section is formed by election of the associates based on proposals of the respective Chairman. There are also several ex-officio Board Members who support certain collaborations (i.e. representatives of Young Academic Urologists (YAO).

Future role The current activities (Section Sessions at EAU Congress, Section Meetings) are currently Since 2009, then chairman Luis Martínez-Piñeiro complemented by educational events organised in initiated major structural changes of the Section Office close collaboration with the European School of There are currently 12 very active EAU Sections in collaboration with the EAU Executive (i.e. Walter Urology (ESU, Chairman Joan Palou), including focussing on subspecialties in urology (Table 1). Artibani) and with the administrative support of the masterclasses (ESFFU, ESUT, ESAU), hands-on training To understand the current status and, particularly, courses (ESUT, ERUS, EULIS, ESUI), and expert Section Office Secretary Angela Terberg by including the future role of all Sections, this article presents the creation of bylaws that summarised the structure, meetings (ESUT, ESOU, EULIS, ESUI). With the prospect an overview of the history of the Section Office. that Regional Meetings such as the Central Early years: Section Office and the ESUT European Meeting would Nearly 20 years ago, a group of active European be discontinued, the role of Chair endourologists founded ESUT or the European Society the Sections will increase of Uro-Technology. In discussions with then EAU to address and respond to Expert Expert Expert Expert EUT / Secretary General Frans Debruyne it was soon agreed the needs of young Training Group 1 Group 2 Group 3 Group 4 Secretary to integrate the ESUT’s activities with the EAU. Thus, urologists throughout Section Offices organise specialised meetings during the the ESUT became the first Section Office with several Europe, particularly to Annual EAU Congress Ex-officio: -  representative of collaborating section privileges (budget for activities, position of a Section boost the recruitment to -  representative in ESU Editor in European Urology) with Adrian Joyce elected these subspecialties. -  representative in Guidelines Office as chairman in 1999. The early activities of the ESUT ESUT16, organised by the Finally, most of the Sections are closely involved in -  representative in EUSP EAU initiatives such as the Guidelines, Patient focused at that time on organising Live Surgery at the recently elected ESUT EAU Congress in Stockholm. The next big event was Chairman Evangelos Information, and staff education (EAUN), which will the planning and organisation of the First ESUT Winter Figure 1 Liatsikos, provides a good definitively continue to be major commitments. Meeting with David Tolley taking the lead as organiser. example of this new One challenge is to further develop the already The meeting took place from 10 to 11 December 1999 in direction. Apart from the efficient collaborations among the Sections. Expert meetings, Live Surgeries, Masterclasses and even Nice with about 250 delegates and Live Surgery duties and privileges of the EAU Sections. At that time, main programme that included Live and Semi-Live transmitted from Paris-Créteil (with Claude Abbou). the name EAU Section replaced the respective Surgeries, there have been a variety of hands-on Joint Meetings are examples which we will see more “society,” which was logical. Depending on the size of training courses (i.e. E-BLUS exam) and the four poster in the coming years. sessions gave young researchers the the individual section, the structure may differ: Expanding the Section Office Parallel to the aforementioned developments, other Smaller sections like the EAU Section of Uropathology possibility to present their data in a Table 1: Overview of all EAU Sections subspecialty societies were integrated in the newly (ESUP) consist only of a board while larger sections relaxed atmosphere than during the EAU Section of Since Chairman formed Section Office such the European Society for EAU Congress. The same approach (ESUT, EULIS, ERUS, ESOU) consist of a board, expert Male Genital Surgery (ESMGS), the EORTC-GU Group, will be taken during the upcoming groups, and affiliates (Fig. 1). In summary, Luis Uro-Technology (ESUT) 1999 Evangelos Liatsikos (GR) European Society of Urological Oncology and Martínez-Piñeiro and Walter Artibani delivered EULIS17 Meeting in Vienna. Female and Functional Urology 2000 Francesco Cruz (PT) Endocrinology (ESUOE), European Society for Impotence excellent work to convert almost all relevant affiliated (ESFFU) Research (ESIR), European Society of Stone Research Almost all Sections play an important “European Subspecialty Societies” into full members (ESSR), European Society of Neuro-Urology (ESNU), of the EAU Section Office based on the existing bylaws. role to represent, reinforce and develop Genito-Urinary Reconstructive 2001 Rados Djinovic (RS) Surgeons (ESGURS) European Society for Reconstructive Urology (ESRU), the position of urology vis-a-vis other and the European Society of Paediatric Urology (ESPU). Current role of the Sections medical faculties. One way to promote Oncological Urology (ESOU) 2001 Maurizio Brausi (IT) All Sections consist of key opinion leaders in the urology was demonstrated by the ESAU Andrological Urology (ESAU) 2001 Nikolaos Sofikitis (GR) subspecialty; their mission is to promote their field in when it initiated an excellent research Infections in Urology (ESIU) 2001 Florian Wagenlehner (DE) the EAU by way of teaching and research activities, fellowship in collaboration with the and they are considered or seen as the “scientific Nordic Andrology Group (ReproUnion) Transplantation Urology (ESTU) 2001 Enrique Lledó García (ES) back bone” of our association. They organise scientific and the European Urological Uropathology (ESUP) 2008 Rodolfo Montironi (IT) sessions on the second day (Saturday) of the Annual Scholarship Programme (EUSP, EAU Congress, including the Live Surgery coordinated chairman Vincenzo Mirone). Other Urolithiasis (EULIS) 2009 Kemal Sarica (TR) by ESUT. In addition, eight sections (ESOU, ERUS, examples are the Junior ERUS Robotic Urological Imaging (ESUI) 2009 Jochen Walz (FR) ESUT, ESGURS, EULIS, ESUR, ESAU, ESUI) organise Fellowship programme and the Urological Research (ESUR) 2009 Kerstin Junker (DE) Section Meetings on a regular basis, and which are Dominique Chopin Award given yearly often integrated with other events. During these by the EAU Section of Urological Robotic Urology (ERUS) 2011 Alex Mottrie (BE) events, all delegates interested in the particular field Research (ESUR). have the opportunity to contact directly and informally all associate members. Moreover, the Sections are the Skills exchange such as Live Surgeries are among the ambassadors of the EAU in collaboration with the well-attended Section Office activities national and international subspecialty societies. An example, the ESUT and EULIS organise a joint session during the World Congress of Endourology. www.eau17.org In 2000 Udo Jonas was appointed as the first This newsletter also offers all Sections the space chairman of the Section Office. At that time, there which serves as an optimal platform to inform all EAU were full (ESUT, ESMGS, ESNU, ESRU) and affiliated sections (EORTC GU-Group, ESUOE, ESSR, ESIR, ESPU, members about their achievements, goals and ESUR). Already in 2001, four new sections became full planned activities. members: ESAU (which replaced the ESMGS and ESIR), European Society of Transplantation in Urology Becoming a member of the Sections There are many ways to be involved in the activities of the Sections (Fig. 4). The first step is to join the Cutting-edge Science at Europe’s largest Urology Congress meetings as a delegate or presenter of a poster. This could be the basis to become an affiliate, which means participating in subsequent events (i.e. as a tutor for Abstract submission now open! Deadline: 1 November 2016 hands-on training courses, as an invited speaker or a moderator) or in scientific projects. This will help establish close relationships with the associates and the respective Board Members and could lead to being jens.rassweiler@ slk-kliniken.de

August/September 2016

European Urology Today

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

paul.meria@ sls.aphp.fr

Handbook of Urinary Stents

Atlas of Urologic Surgery: Surgical Anatomy F. Dal Moro recently authored a book addressing technical aspects of bladder replacement. The second volume of this collection is now available. It was built on the same basic concept and consists of several personal drawings but excluding any form of text and comments.

Interventional Urology

The most important part of the textbook addressed prostate imaging and image-guided treatments. The authors focused on various techniques available for cancer diagnosis, including recent developments in contrast-enhanced ultrasound and elastographic imaging. Various focal treatments of prostate cancer were described such as cryotherapy or irreversible electroporation with two chapters dedicated to BPH management.

European Urology Today Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Dr. M.A. Behrendt, Amsterdam (NL) Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Dr. F. Sanguedolce, London (GB)

The succeeding section provided descriptions of various techniques in kidney imaging and addressed currently available percutaneous treatments of renal tumors such as cryoablation and radiofrequency. Renal vascular interventional treatments were also described. The remaining chapters were dedicated to various management techniques for certain diseases affecting the bladder, penis, adrenals and retroperitoneum. This text book is well-illustrated and represents an excellent tool for all urologists who are looking for in-depth information on this essential topic. We hope the next edition will be supplemented with some videos.

Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL)

Consequently, many devices are currently available for ureter, prostate and urethra. Editors N. Buchholz, O. Hakenberg, J. Masood and C. Bach assembled in the first edition of this original textbook comprehensive information about such stents. With contributions from nearly 70 worldwide experts they focused on the physical and technological aspects of urinary stents and addressed various clinical situations requiring stent placement. The first section covered general aspects of ureteral stents, including coating. The following section considered various aspects of polymer ureteric stents, including technical advice, tips and tricks tips for insertion, and postoperative management. Metallic stents, widely used at present, either in the ureter or in the urethra, were exhaustively described in the succeeding section and the authors gave detailed descriptions of currently available devices. Related complications and their management were also provided. Drug-eluting and absorbable stents were also described.

The current evolution of urology undoubtedly includes the important development of interventional procedures. The role of imaging techniques is crucial since they provide real-time interior views of the human body and allow many percutaneous techniques. Indeed, image-guided procedures do compete with surgical or laparoscopic techniques but they also enable complementary and innovative approaches in urology through collaborative work among various disciplines. Editors A.R. Rastinehad, D.N. Siegel, P.A. Pinto and B.J. Wood edited this outstanding textbook with contributions from more than 70 worldwide experts and collated updated information to describe current and forthcoming interventional techniques. After an overview of various historical aspects of interventional urology, including recent developments in imaging techniques, the authors separately considered each organ.

Stents are widely used in urology and each of us utilizes various models for urethral or ureteral stenting. Recent advances in research and development provided the urologists with new devices, specially intended for a urinary environment.

The last sections addressed prostatic and urethral stents and the authors presented an overview of currently available models. Clinical conditions requiring stent insertion were reviewed as well as planning for the future development of urological stents.

The author, originally from Padova, mentioned the historical interest of the University of Padua for anatomy and also stated his aim to collate various black and white labelled drawings depicting the urogenital organs. He first described the kidney’s anatomy and neighbouring organs before addressing renal and ureteral vascularisation. Retroperitoneal anatomy, including lymph nodes, was described separately. The author also gave his own illustrations of the veins and arteries and their terminal branches.

Congratulations to the authors for this comprehensive overview which undoubtedly provides a practical guide to urologists.

Genitalia, bladder, and prostate were also drawn in the same detailed way with the author focusing on the special aspects of prostatic innervation. The last part of the book was dedicated to the female pelvis and included various figures illustrating pelvic organs and musculature. This original work remains as surprising as the first one and provides the reader with simple but accurate descriptions of the urogenital anatomy. Author ISBN Publisher e-Book Publication Edition Binding Price Pages Illustrations Website

: F. Dal Moro : 979-12-200-1058-0 : CreateSpace Independent Publishing Platform : available (Amazon.it) : June 2016 : 1st : Paperback cover : 45.84 euro : 96 : 46 : www.amazon.it

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

Editors ISBN Publisher e-Book Publication Edition Binding Price Pages Illustrations Website

: N. Buchholz, O. Hakenberg, J. Masood, C. Bach : 978-1-907816-65-9 : JB Medical LTD : available : 2016 : 1st : Hard cover : ± 100 euro : 345 : 150 (50 ill., 100 images) : www.jpmedpub.com

Grab hold of the possibilities.

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.

Editors ISBN Published Publisher Edition Binding Price Pages Illustrations Website

: A.R. Rastinehad, D.N. Siegel, P.A. Pinto, B.J. Wood : 978-3-319-23463-2 : 2016 : Springer : 1st : Hardcover : 128.39 euro : 408 : 254 (133 colour) : www.springer.com/shop

Book reviews

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European Urology Today

Perc NCircle® Nitinol Tipless Stone Extractor

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Perc NCompass® Nitinol Stone Extractor

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August/September 2016


Update from the Guidelines Office Summer Edition 2016 Recent publications from Guidelines Panels We are very pleased to announce that a large number of scientific papers from Guidelines Panels have recently been accepted and published by European Urology:

New Staff Member We are pleased to welcome a new member of staff – Rob Shepherd – who will be working at the Guidelines Office from 1 August. We wish him every success in his new position.

• EAU Guidelines on Non-muscle Invasive Urothelial Carcinoma of the Bladder: Update 2016. Marko Babjuk, et al. in press. http://dx.doi. org/10.1016/j.eururo.2016.05.041 (Photo 1)

#eauguidelines - Dissemination of the Guidelines on Twitter Over the last 18 months, the Guidelines Panels have been very successfully using Twitter to disseminate information about their Guidelines in <140 character format using the #eauguidelines. Just from Guideline Panel tweets alone, the following statistics have been achieved in the first half of this year: • • • •

Photo 1: EAU Guidelines on Non-muscle Invasive Urothelial Carcinoma of the Bladder: Update 2016

• Updated 2016 EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. J Alfred Witjes, et al. in press. http://dx.doi.org/10.1016/j.eururo.2016.06.020 • EAU Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis and local treatment with curative intent. Nicolas Mottet, et al. in press. • EAU Guidelines on Prostate Cancer. Part II: Treatment of Relapsing, Metastatic, and Castration-Resistant Prostate Cancer. Philip Cornford, et al. in press. • Oncologic Outcomes of Kidney-sparing Surgery Versus Radical Nephrourecterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the EAU Non-muscle Invasive Bladder Cancer Guidelines Panel. Thomas Seisen, et al. in press. http://dx.doi.org/10.1016/j.eururo.2016.07.014 • The Role of Cytoreductive Nephrectomy: The Current EAU Position. Axel Bex, et al. in press. http://dx.doi.org/10.1016/j.eururo.2016.07.005 • European Association of Urology Guidelines for Clear Cell Renal Cancers That Are Resistant to Vascular Endothelial Growth Factor ReceptorTargeted Therapy. Thomas Powles, et al. in press. http://dx.doi.org/10.1016/j.eururo.2016.06.009 (Photo 2)

Total number of impressions = 4.9 million Sum of retweets = 4,092 Number of people reweeting = 722 New followers @uroweb = 423 per month

Further good news is that we have more than 10,000 followers with Uroweb on Twitter. This makes the EAU the second association or journal account to achieve this success, most of which can be attributed to the EAU Guidelines tweets. In addition, the EAU account on Twitter has a blue verified badge which lets users know that an account of public interest is authentic. It is interesting to note that, in February 2016, the following Tweet from the Male Infertility Guidelines Panel was the most popular tweet overall on @uroweb:

Photo 3: Male Sexual Dysfunction Panel meeting

approaching 14 October deadline for the 2017 version of the Guidelines. In May, the Male Sexual Dysfunction Guidelines Panel met in Amsterdam. The key aims of the meeting were to discuss the progress on literature searches and text updates for the 2017 version, planned publications from the panel, and to receive an update on progress made on the 2 systematic reviews (see photo 3). Other meetings held were the Urological Trauma Guidelines Panel in Athens in June (see photo 4) and the Prostate Cancer Panel (photo 5) met in Amsterdam, last July. The Prostate Cancer Guidelines Panel have set up a four-year project, led by Dr. Liam Bourke, addressing patient quality-of-life outcomes. Aside from a patient advocate, a multi-disciplinary group of members from the Prostate Cancer Panel are assisting. Progressing ongoing systematic reviews and the annual text updates are standard topics included in all Guidelines Panel meeting agendas.

Through the years: Role of the EAU Section Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Diagram: The most popular tweet overall on @uroweb in February

Book reviews . . . . . . . . . . . . . . . . . . . . . . . 2

The Dissemination Committee, led by Prof. Maria Ribal, are currently working on a programme of additional activities to develop the dissemination of the EAU guidelines further.

EULIS: How to set up a stone clinic?. . . . . . . . 4

Panel meetings It is a busy time for Guideline Panel meetings with the Panels formalising their text to meet the fast

ESUT16: 3-day demonstration of the latest in urotechnology. . . . . . . . . . . . . . . . . . . . . 8-9

Update from the Guidelines Office. . . . . . . . . 3

ESFFU: My current approach to female OAB. . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . 7

Photo 4: Urological Trauma Panel in Athens

Key articles from international medical journals . . . . . . . . . . . . . . . . . . . . . . . 10-13 ESU section: Surgery in Motion School . . . . . . . . . . . . . . Salzburg Masterclass 2016: Bridging various viewpoints . . . . . . . . . . . . . . . . . . . . . . . . ESU Course in Romania. . . . . . . . . . . . . . . . 23rd Slovak Urological Society Annual Conference . . . . . . . . . . . . . . . . . . . . . . . . Katowice hosts 46th PUA Congress . . . . . . .

Photo 5: Prostate Cancer Panel in Amsterdam

And the following have been or are about to be published in European Urology Focus: • Grey Areas: Challenges of Developing Guidelines in Adult Urological Trauma. Davendra M. Sharma, et al. Eur Urol Focus 2016;2(1):109-10. • Grey Areas: Imaging Terminology and Reporting. Tillmann Loch. Eur Urol Focus 2016;2(2):225-7. • Grey Zone: Urinary Incontinence. Andrea Tubaro, et al. Eur Urol Focus 2016;2(2):337-8. • A Quality Assessment of Patient-Reported Outcome Measures for Sexual Function in Neurologic Patients Using the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist: A Systematic Review. Lisette A. ‘t Hoen, et al. in press. http://dx.doi.org/10.1016/j.euf.2016.06.009.

Guidelines Office

August/September 2016

17 18 19 19

EAU RF section: MAGNOLIA Study: Call for proposals using biological samples. . . . . . . . . . . . . . . . . . . 21 EAU RF NIMBUS trial recruits 100th patient . . 21 EAU RF PRECISION study recruits ahead of schedule. . . . . . . . . . . . . . . . . . . . . . . . . . 23

Photo 2: EAU Guidelines for Clear Cell Renal Cancers That Are Resistant to Vascular Endothelial Growth Factor Receptor -Targeted Therapy

• Medical Expulsive Therapy in View of Current Discussion: The EAU Position in 2016. Christian Türk, et al. in press. http://dx.doi.org/10.1016/j.eururo.2016.07.024

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European Urological Scholarship Programme (EUSP) Do not forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme, before the next deadline of 1 January 2017! For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website http://www.uroweb.org/education/scholarship/

YUO/YAU section: First E-BLUS exam at the Spanish National Congress. . . . . . . . . . . . . . . . . . . . . . . . . . 24 5th School on Paediatric Urology, Andrology held in Moscow. . . . . . . . . . . . . . . . . . . . . 24 Novel urological evaluation system of surgical competences. . . . . . . . . . . . . . . . . . . . . . . 24 81st AEU Congress and 1st Spanish Residents Day. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 ESUT16 kick-starts ESRU-ESU collaboration. . 25 International relations section: EAU Statement on “Brexit” referendum . . . . 26 Azerbaijan Urology Association holds 2nd congress . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Japanese Tour 2016 . . . . . . . . . . . . . . . . . . 27 EAUN section: Improving follow-up care after nephrectomy. . . . . . . . . . . . . . . . . . . . . . . 34 EAUN provides insightful training to Danish nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Monitoring patients on abiraterone. . . . . . . 36

European Urology Today

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How to set up a stone clinic? Renal stone patients should be evaluated by a team of experts Dr. Alberto Trinchieri Manzoni Hospital Urology Unit Lecco (IT)

a.trinchieri@ ospedale.lecco.it

Dr. Noor Buchholz Sobeh’s Vascular and Medical Center Dubai Health Care City (UAE)

noor.buchholz@ gmail.com Co-authors: Dr Juan Pablo Caballero, Urology Department, University General Hospital, Alicante (Spain); Dr José Luis Palmero, SWL & Endourology Section, La Ribera Hospital, Alzira, Valencia (Spain) Flow-chart for evaluation of the renal stone patient An ideal "stone clinic" must involve a urologist, a nephrologist, a dietician and a geneticist. It must be connected to a laboratory for appropriate analysis of the stone and measurement of urinary risk factors. Otherwise, analyses should be outsourced to specialised laboratories. The patient’s journey through the stone clinic begins with collecting data on medical history and a physical examination. Existing imaging is reviewed to identify actual stone burden and underlying anatomical abnormalities. Whenever possible, stone analysis and a metabolic evaluation are done. Dietary evaluation is recommended. If chronic kidney disease (CKD) or metabolic bone disease (MBD) is suspected nephrological advice is sought. Certain underlying diseases require genetic counseling. A complete medical and family history should be obtained, including information on habits, lifestyle, diet, fluid intake, history of kidney stones and other urological conditions, metabolic diseases, and medication. Questionnaires or computer-assisted history taking systems (CAHTS) can be helpful. Weight, height and BMI will complete the basic data set. Ultrasound (US) is the primary diagnostic tool in a stone clinic. Doppler ultrasound can be helpful to see ureteral jet or measure the resistance index of the renal arteries. Kidney-Ureter-Bladder (KUB) radiography will differentiate between radiolucent and -opaque stones. Non-contrast enhanced CT scan is nowadays the gold standard for the diagnosis of urolithiasis. In case of suspected anatomic alterations, contrast-enhanced imaging (enhanced CT) is recommended. Stone analysis can bring important information as to the cause of stone disease. Wet chemical analysis and optical polarising microscopy are today obsolete. Reliable are infrared spectroscopy (IR) and X-ray powder diffraction (XRD). IR identifies crystalline and non-crystalline materials, amorphous substances and fats. XRD identifies pure and mixed crystals. Alternatively, low-dose dual-energy computed tomography (DECT) can reliably analyse most calculi before fragmentation. Metabolic evaluation Any renal colic or stone patient should have serum creatinine, uric acid, calcium, sodium, potassium, leucocytes, C-reactive protein tests, and a coagulation panel in case of a planned surgery. High risk stone formers should also have serum phosphate, magnesium, chloride and blood gas analysis (pH, pO2, pCO2, HCO3, BE). Metabolic evaluation for urolithiasis is based on biochemical measurements in 24-hour urine samples. The pre-analytical phase is of great importance because the collection, storage and preservation of the samples may have a significant effect on the results. Patients should be instructed in detail on how to collect urine, possibly with the help of an instruction sheet. EAU Section of Urolithiasis (EULIS)

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European Urology Today

Briefly, the first morning urines should be discarded because they belong to the previous 24 hours while the last collection should be in the morning of the following day. Urine collection may be considered inadequate based on reference ranges for 24-hour creatinine / kilogram (15.0-20.0 mg / kg for females and 18.0-24.0 mg / kg for males) or discrepancy in total 24-hour urine creatinine between 24-hour urine collections1. Storage and preservation errors are related to the initial concentration of the analyte, the period of storage, and the original pH of the urine sample. Different types of additives (thymol, toluene, HCL) are used to prevent bacterial growth and, consequently, avoid degradation of some of the substances contained in the urine. On the other hand, precipitation of crystals of calcium oxalate during storage can cause a reduction of the urinary concentration of calcium and oxalate. Therefore, the pH should be maintained very low by adding hydrochloric acid in order to minimise the rate of crystallisation of calcium oxalate. Unfortunately, urinary uric acid and citrate cannot be determined after addition of acid preservative. Consequently, it is common use to collect two consecutive samples of 24-hour urine, one with addition of a preservative to measure pH, citrate, uric acid, the other one with addition of HCl for the assay of calcium, magnesium and oxalate. As an alternative, acid can be added as soon as the urine sample is received in the laboratory after the removal of a small aliquot for citrate and uric acid measurement. Spot urine samples are an alternative when 24-hour collection is difficult (non-toilet trained children). When spot urines are considered, the values of excretion must be related to urinary creatinine. Identification of urinary risk factors in 24-hour urine is an opportunity to prevent stone recurrence by modifying eating and lifestyle habits and / or drug treatment. Hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia, hypomagnesiuria and modification of urinary pH (< 5.5 or > 6.5) should be ruled out. For this reason, urinary calcium, magnesium, uric acid, oxalate and citrate should be measured in the 24-hour urinary samples. Reference ranges are listed in table 1. The urinary pH influences the risk of stone formation: an alkaline pH (> 7) favours crystallisation of calcium-containing phosphate stones whereas an acidic pH (< 5.4) promotes uric acid stone formation. The urinary pH can be easily performed by the patient and follows a circadian rhythm being acidic in the early morning and increasing over time during the day to a more alkaline level after meals ("morning alkaline tide").

FLOW CHART FOR EVALUATION OF THE RENAL STONE PATIENT UROLOGIST MEDICAL HISTORY & PHYSICAL EXAMINATION (QUESTIONNAIRES, COMPUTER ASSISTED TAKING HISTORY SYSTEMS) REVIEW OF EXISTING MEDICAL IMAGING RENAL ULTRASOUND

NEPHROLOGIST DIETICIAN

CHRONIC KIDNEY DISEASE

DIETARY EVALUATION

METABOLIC BONE DISEASE

GENETICIST GENETIC DEFECTS SUSPECTED

A genetic should be in suspected case formation of stone formation in pre-pubertal children the A genetic defect shoulddefect be suspected the caseinofthestone in pre-pubertal children or inor thein presence of presence nephrocalcinosis, also in recurrent or multiple stone onset diseaseorwith earlyofonset or in case of creatinine nephrocalcinosis, but of also in recurrent orbut multiple stone disease with early in case elevated serum elevated serum creatinine and/or reduced glomerular filtration rare (GFR). An accurate stone analysis can and/or reduced glomerular filtration rare (GFR). An accurate stone analysis can help to diagnose some rare disease such as help to diagnose some rare disease such as cystinuria, adenine phosphoribosyltransferase (APRT) deficiency cystinuria, adenine phosphoribosyltransferase (APRT) deficiency with dihydrossiadenine (DHA) stones and xantinuria. Other with dihydrossiadenine (DHA) stones and xantinuria. Other genetic diseases are associated with the genetic diseases are associated theDent formation calcium stones. Dent disease, hypomagnesaemia with formation of calciumwith stones. disease,ofhereditary hypomagnesaemia withhereditary hypercalciuria and (FHHNC),(FHHNC), and primary (PH) are rare (PH) but important causes of calcium stone of calcium hypercalciurianephrocalcinosis and nephrocalcinosis andhyperoxaluria primary hyperoxaluria are rare but important causes that be suspected in mild to moderate proteinuria,combined combinedwith with hypomagnesaemia, hypomagnesaemia, hypercalciuria, and stone diseasedisease that can becan suspected in mild to moderate proteinuria, and hyperoxaluria (3). 3 hyperoxaluriahypercalciuria, .

compliance and results of treatment. The follow-up schedule should be tailored on the individual patient on the basis of family history, recurrence rate, patient age, stone composition, comorbidities and presence of residual stones. Acknowledgement This article is an abbreviated version of an article with the same title submitted to a special edition of the Egyptian Journal of Urology on conservative stone treatment on behalf of EAU-EULIS.

References 1) Sawyer MD, MS Dietrich, Pickens RB, Herrell SD, Miller NL. Adequate or not? A comparison of 24-hour urine studies for renal stone prevention by creatinine to weight ratio. J Endourol. 2013; 27: 366-9 2) Bordier P, Ryckewart A, Gueris J, Rasmussen H. On the pathogenesis of so-called idiopathic hypercalciuria. Am J Med. 1977;63:398-409 3) Edvardsson VO, Goldfarb DS, Lieske JC, Beara-Lasic L, Anglani F, Milliner DS, Palsson R Hereditary causes of kidney stones and chronic kidney disease Pediatr Nephrol. 2013 ; 28: 1923–1942

Table 1: Reference ranges for laboratory values in serum and 24-hour urine Parameter

Serum reference ranges

24 hour urine - reference ranges and limits for medical attention

Creatinine

20-100 μmol/L

7-13 mmol/day (females), 13-18 mmol/day (males)

Bicarbonate

22-26 mmol/L

Sodium

135-145 mmol/L

Incomplete distal renal tubular acidosis (dRTA) is diagnosed by means of an oral acid-loading test. This test involves administration of an oral NH4C load at a dose of 100 mg/kg body weight (given as 500 mg gelatin capsules). Normal subjects acidify their urine to pH < 5.3 within 8 hours.

Potassium

3.5-5.5 mmol/L

Calcium

2.0-2.5 mmol/L (total calcium) 1.12-1.32 mmol/L (ionised calcium)

> 5.0 mmol/day

Magnesium

1.5-2.4 mmol/L

< 3.0 mmol/day

Uric acid

119-380 μmol/L

> 4.0 mmol/day (females),5.0 mmol/day (males)

The calcium loading test can be used to diagnose various forms of hypercalciuria. A two-hour urine sample after an overnight fast and a four-hour urine sample after 1 g of calcium orally are analysed for calcium and creatinine. Normocalcemic and hypercalciuric patients with normal fasting urinary calcium (less than 0.11 mg per milligram of urinary creatinine) and high urinary calcium after a calcium load (greater than or equal to 0.2 mg per milligram of creatinine) are classified as having an absorptive hypercalciuria. Patients with hypercalciuria and normocalcemia with high fasting urinary calcium and high urinary calcium after calcium load are classified as renal leak hypercalciuric and can be differentiated from patients with primary hyperparathyroidism by measurement of less elevated urinary cyclic AMP (or serum parathormone). Absorptive hypercalciuria can be differentiated in type I (persisting hypercalciuria on a 400 mg low calcium diet) and II (normal urinary calcium levels while on the lowcalcium diet). An adjunctive form of absorptive hypercalciuria was identified by Bordier in patients with primary renal tubular phosphate leak and increased 1,25(OH)2D3 vitamin2.

Chloride

98-112 mmol/L

Phosphate

0.81-1.29 mmol/L

The graphic presentation of the results of the metabolic study is very important to facilitate the understanding of the results by the patient and by his general practitioner. These should be complemented by brochures on fluid intake and diet for the prevention of different types of kidney stones Follow-up aims at the diagnosis of recurrence or stone growth and the evaluation of patient

> 35 mmol/day

Oxalate

> 0.5 mmol/day

Citrate

< 2.5 mmol/day

Ammonium

> 50 mmol/day

Cystine

> 0.8 mmol/day

pH

Constantly < 5.4 (risk for uric acid stones) Constantly > 5.8 (suspicious of RTA) Constantly > 7.0 (suspicious of infection)

Specific weight

> 1.010

Help urologists collect CME credits and register your activity today! (Inter)National Urological Associations and the CME providers (organisers of CME activities) are invited and encouraged to send in requests to register nationally accredited CME activities or requests for European accreditation.

www.eu-acme.org

Have you moved? Changed name? New employer? Alter your personal data on-line: fast and easy -

www.eu.acme.org August/September 2016


#EAU17 Cutting-edge Science at Europe’s largest Urology Congress

What to expect at EAU17:

Important dates

A Sneak Peek at the Scientific Programme The members of the EAU Scientific Congress Office (SCO) represent various urological sub-specialties. They are distinguished experts in Europe who deliberate on the key and controversial issues in urology. The SCO also examines prospects that will shape current management strategies. Their evaluations and discussions culminate into the comprehensive Scientific Programme of the always anticipated EAU Annual Congress.

Opening Ceremony, wherein the most prestigious EAU awards will be handed out. On Saturday, the second congress day, the always popular EAU Section Meetings will be in the programme. Moreover, there will be a special training-based session YUORDay17 organised by the EAU Young Urologists Office & European Society of Residents in Urology. Aside from the official EAU Scientific Programme, there will be

numerous industry sessions at the end of each congress day. More details on the Scientific Programme will be available shortly. Specific sessions and speakers are currently finalised. Please visit the EAU17 webpage www.eau17.org/scientific-programme regularly for updates and do not miss the abstract submission deadline of 1 November 2016!

Exhibition dates 25-27 March 2017 Registration open 1 October 2016 Abstract submission deadline 1 November 2016

The 32nd Annual EAU Congress in London (EAU17) will have seven Plenary Sessions in contrast to previous years. The topics will include andrology, management of prostate cancer, stones, functional urology, and BPH to name a few. Each morning will be dedicated to two simultaneous Plenary Sessions. In addition, there will be 18 Thematic Sessions categorised according to core issues and challenges in urology. The SCO will also introduce innovative sessions which will combine video and poster abstract presentations for selected topics such as erectile dysfunction, bladder cancer, and many others.

Award submission deadline 1 November 2016 Early fee registration deadline 16 January 2017 Late fee registration deadline 13 February 2017

EAU17 attendees can again look forward to many intensive ESU and Hands-On Training courses; and special programmes such as the Urology Beyond Europe sessions on Friday which will bring urologists from all over the world together. Friday, the first congress day, will begin with abstract sessions and will conclude with the

Congress dates 24-28 March 2017

Check out the programme ove

www.eau17.org

rview at

The EAU17 Scientific Congress Office Members

EAU Awards: Honouring innovative, pioneering work The EAU highlights the pioneering achievements of urologists across Europe. Each year, the EAU grants prestigious awards for the dedication and innovation in urological research and practice. This year, these awards will be given during the 32nd Annual EAU Congress in London. Awardees will be recognised in the EAU Award Gallery and the Programme Book. EAU Best Papers Published in Urological Literature Awards This award is to inspire young and promising urological scientists to continue their work and to communicate their achievements to the European urological community. There are two categories for this award: the Best Paper Published on Fundamental Research in the Urological Literature and the Best Paper Published on Clinical Research in the Urological Literature. Fundamental Research awardee of 2016, Dr. Pieter Uvin of the University Hospitals Leuven, has submitted “Essential Role of Transient Receptor Potential M8 (TRPM8) in a Model of Acute Coldinduced Urinary Urgency”. The core aim of his paper was to develop an animal model for “acute coldinduced urgency” and to test the involvement of the cold-activated ion channels TRPM8 and TRPA1. Clinical Research awardee of 2016, Dr. Peter Black of the University of British Columbia, has submitted “Discovery and Validation of Novel Expression Signature for Postcystectomy Recurrence in High-Risk Bladder Cancer”. The main purpose for this research was to develop a gene expression signature from

Apply now and win!

radical cystectomy specimens to predict survival after surgery, with the intent of prioritising patients with likely adverse outcomes for treatment intensification. EAU Hans Marberger Award Annually given since 2004, this award is for the best European paper published on Minimally Invasive Surgery in Urology. The award is named after Prof. Hans Marberger to honour his pioneering contributions to endourology and to the development of urologic minimally invasive surgical procedures. Last year’s awardee Dr. Mohan Gundeti of The University of Chicago Medicine: Comer Children’s Hospital has submitted “Robot-assisted Laparoscopic Augmentation Ileocystoplasty and Mitrofanoff Appendicovesicostomy in Children: Updated Interim Results” where the perioperative outcomes, complications and safety of open versus robotic augmentation cystoplasty with or without catherizable channels were compared. Dr. Gundeti’s message to future applicants: “We have to question the current surgical practice and see what changes we can adopt to reduce the morbidity for patient without compromising the outcomes and safety. This will lead into newer concepts and advance the science for the betterment of humanity.” EAU Prostate Cancer Research Award With the goal to encourage innovative, high-quality research in prostate cancer, the EAU has launched the EAU Prostate Cancer Research Award. An expert jury will select the best paper dealing with clinical or experimental studies in prostate cancer. The paper should also be published or accepted by a renowned international scientific journal.

Last year’s awardee Dr. Jan Pencik of the Medical University of Vienna has submitted “STAT3 regulated ARF expression suppresses prostate cancer metastasis.” The observation is that IL-6 therapy in PCa lacks efficacy. The preliminary data prompted Dr. Pencik and his team to propose that the IL-6/ STAT3 axis can act as a tumour suppressor in PCa. Therefore, the hypothesis is that in a subset of PCa IL-6/Stat3 signalling is inactivated, resulting in a more rapid tumour progression compared to PCa were IL-6/Stat3 is active. Dr. Pencik’s message to future applicants, “It is always important to follow your own ideas even if they seem to be very controversial or non-orthodox because surprisingly, they might be true.”

EAU Crystal Matula Award The EAU Crystal Matula Award 2017 is the most prestigious prize given to a young promising European urologist under the age of 40 who has the potential to become one of the future leaders in academic European urology. National societies can nominate a candidate, but eligible candidates can also apply for this award by contacting their national urological societies directly. How to apply Interested in applying or nominating someone you know? Please send an email to Ms Marian Smink. Entry requirements for all awards mentioned above can be found at www.eau17.org/the-congress/awards

Do’s and Don’ts of submitting an Abstract The Annual EAU Congress attracts abstract submissions from urologists and other medical professionals from around the world. In the previous congress in Munich, more than 4,400 abstracts were submitted but only 29% (1,230 abstracts and 78 video abstracts) were accepted. Competition is indeed tough. So here are some do’s and don’ts to help your abstract stand out: Your text • Do check your facts thoroughly. Then re-check them. • Do write clearly and concisely. Get straight to the point. Unnecessary words add confusion. • Do check your spelling and grammar. Ask someone to proofread your work to make sure you didn’t overlook anything. • Do adopt a neutral tone. Don’t write in an argumentative manner because it doesn’t convey objectivity. • Do prepare and submit on time. Don’t wait until the last minute.

Your images and videos • Do use high-resolution images and/or illustrations. These should complement your text and not distract the reviewers from it. • Do make sure that your video is in the final format. It should include the exact title, authors’ names, production date and running time. • Do check if your video has audio (music and/ or voice-over). Most importantly, do deliver original and innovative work. Quality research is the cornerstone of improving patient care. These are only a few suggestions. Please refer to the “Abstract Rules and Regulations” on the EAU London Congress website for more information. Good luck!

You still have some weeks to go! Abstract submission deadline is 1 November 2016

EAU congresses and courses are accredited by the EBU in compliance with the UEMS/EACCME regulations

August/September 2016

European Urology Today

5


My current approach to female OAB Detailed medical and lifestyle history is crucial in managing OAB cases Dr. Stavros Charalampous European Certified Urological Surgeon Institute of Functional & Reconstructive Urology Limassol (CY) st.charalampous@ urologycare.eu Co-author: Dr. Stavros Deirmentzoglou The overactive bladder syndrome (OAB) is defined by the presence of urgency (acute desire to void) with or without urinary incontinence. These symptoms are often accompanied by frequency and nocturia. Urgency, being the main symptom of OAB, is quite prevalent in the general population. According to the EpiLUTS study 35.7% of women described urgency being present at least sometimes, while 11.8% experienced it at least often. EpiLUTS study was performed on the general population in three countries (USA, UK and Sweden). The current 2002 International Continence Society (ICS) definitions were used. Nocturia and urgency incontinence were present at least sometimes in 33.7% and 24.4%, respectively1. The diagnosis of OAB is based on patient’s complaint. Taking a detailed history (including lifestyle, medication and toilet habits) is the cornerstone of the assessment procedure. A bladder diary or a frequency-voiding chart (FVC) of at least a three-day period can also help the diagnosis. Urine analysis is mandatory since a lot of information can be extracted about the presence of bladder infection, lithiasis, tumour, etc. A neurological assessment related to the lower urinary tract may also be of benefit. Urodynamics can offer information on the presence of detrusor overactivity, maximum detrusor pressure during an overactivity event, the volume in which such overactivity occurs, maximum cystometric capacity and possible coexisting stress incontinence. Being diagnosed the OAB syndrome must be managed in a proper way. The current treatment methods can be divided in non-invasive, minimal invasive and invasive. Lifestyle advice Lifestyle advice must be at first-line. Reduction of fluid intake at specific times aimed at reducing urinary frequency when it is most inconvenient (e.g. at night or when going out in public) can help. Patients should be encouraged to avoid or at least exert moderate caffeine and alcohol consumption, substances that increase the urine output and enhance frequency, urgency and nocturia. They should also be advised to relax before voiding in order to prevent bladder straining and pseudodyssynergia. When sensory urgency is prominent, trying to retrain the bladder by holding on in order to increase bladder capacity and the time between voids should be proposed. Medication should be reviewed. So should the time of their administration without even ruling out the possibility of substitution for others that have fewer urinary effects. If these measures are not efficient to control the symptoms, commencing treatment with the appropriate drug is the next step. For many years, anticholinergic and antimuscarinic drugs have been the gold standard choice for managing OAB. Main agents are solifenacin, fesoterodin and older drugs such as tolterodin, oxybutinin and propiverin. Their efficacy has been proven throughout the years but side effects are not uncommon. Constipation and dry mouth are among the most often presented sideeffects while hypertension and dizziness may occur. Gastroesofageal reflux and closed-ankle glaucoma are contraindications for these drugs. However, despite their general acceptance antimuscarinics have been shown to have a large dropout rate. After the first year nearly more than 70% of patients stop taking the drugs while solifenacin is the most preferable drug for staying on therapy (40%). Although side-effects would seem to be the main problem and reason for dropout, research showed that patients stopped taking the drug because they did not work as expected. The need for a new drug was indicated such as EAU Section of Female and Functional Urology

6

European Urology Today

mirabegron. It is a β3-agonist with proven efficacy on the number of micturitions, incontinence episodes, mean voided volume (MVV) and quality of life (QoL).

something the patients must be informed of. 20% had 5. Montecucco C, Molgó J. Botulinal neurotoxins: revival of dry mouth and 13-44% developed UTI according to an old killer.Curr Opin Pharmacol. 2005 Jun;5(3):274-9. Kuo et al10. 6. Mangera A, Apostolidis A, Andersson KE, Dasgupta P,

On the other hand, there are side effects with hypertension being the most prevalent. Therefore, there is contraindication for using this drug for patients with unregulated blood pressure. Less common side effects are headache (4.1%), arrhythmia (3.9%), dry mouth (2.8%) and constipation (2.8%)2,3.

updated systematic review and statistical comparison of Alternatively, there is also another minimally invasive standardised mean outcomes for the use of botulinum technique for trying to control the involuntary toxin in the management of lower urinary tract detrusor contractions. Percutaneus tibial nerve disorders. Eur Urol. 2014 May;65(5):981-90. stimulation (PTNS) is based on the Stoller afferent nerve stimulation. The posterior tibial nerve contains 7. Mangera A, Andersson KE, Apostolidis A, Chapple C, Dasgupta P, Giannantoni A, Gravas S, Madersbacher fibers from roots L4-S3 that supply pelvic floor and SContemporary management of lower urinary tract innervate directly the bladder and the urethral disease with botulinum toxin A: a systematic review of sphincter. A removable device with a 34G fine needle botox (onabotulinumtoxinA) and dysport that penetrates the skin at the level of the nerve two (abobotulinumtoxinA).Eur Urol. 2011 Oct;60(4):784-95. fingers above the malleolus medialis of the ankle, is used (urgent® PC). The treatment model consists of 12 8. Schurch B, de Sèze M, Denys P, Chartier-Kastler E, Haab F, Everaert K, Plante P, Perrouin-Verbe B, Kumar C, weekly visits at the office of 30- minute duration. Its Fraczek S, Brin MF; Botox Detrusor Hyperreflexia Study efficacy was proven by showing reduction of UI Team. Botulinum toxin type a is a safe and effective episodes from three to 0.3 per day and by reducing treatment for neurogenic urinary incontinence: results of the number of micturitions from 12.3 to 9.8 per day11.

Giannantoni A, Roehrborn C, Novara G, Chapple C.An

Recently, combination treatment with antimuscarinics (solifenacin) and mirabegron was proposed, at first for patients with idiopathic OAB. A randomized double-blind clinical study compared combination therapy with solifenacin 5 mg or 10 mg and mirabegron 25 mg or 50 mg to solifenacin 5 mg monotherapy and placebo. Combination therapy was superior to monotherapy or placebo in almost all the investigated parameters (MVV, incontinence episodes, number of micturitions and urgency episodes). On the other hand, the incidence of side effects was more or less the same concerning the type and the occurrence compared to the widespread antimuscarinics. Therefore, the use of mirabegron and solifenacin at the same time may be a rational solution to monotherapy refractory OAB4.

Other options Other studies show increase of MVV12 and MCC13 by approximately 20%. These researchers proposed PTNS as a good option. However, symptoms and findings returned to the pre-treatment levels after the end of therapy14. Adverse events were observed in 1-2%. Site bruising, minor bleeding, tingling of the leg and temporary numb or pain feeling at the insertion site or the sole of the foot were the more common ones15.

Invasive solutions In case of drug refractory OAB the urologist has to choose between more invasive solutions. One of the first and more efficient solutions that become more common day by day is the use of botulinum toxin A. Its mechanism is related with the presynaptic hyperselective neuromuscular blockade of acetylcholine secretion at somatic and autonomous neurons5. The available types of botulinum toxin A in the market are onabotulinum toxin A, abobotulinum toxin A and incobotulinum toxin A with their bioequivalence being 1:3:1. The most widely used type is onabutulinum toxin A (BOTOX®).

Finally, and before ending up with bladder enlargement with the use of bowel, a procedure very invasive and scarcely needed nowadays, sacral nerve stimulation (SNS) or more appropriately sacral nerve modulation (SNM) can be a solution. The precise mechanism of action is still not entirely clear16. The two-stage procedure is much better than the one stage17. During the first stage, which takes about 30 to 45 minutes, the test-stimulation guide lead is implanted at the S3 foramina.

In patients with neurogenic OAB, 200 IU in total are injected in 20 different sites (equally divided doses) intramuscularly in the bladder, preferably avoiding the trigone and approximately 1 cm between them. The injection can be done under either rigid or flexible cystoscopy depending on the urologist’s skills. Concerning its efficacy; daily incontinence and number of intermittent self-catheterisations (ISC) were proven to be reduced by 63% and 18%, respectively.

For the next one to two weeks an external pulse generator is used. After this period, an objective (questionnaire) and subjective (with the use of frequency voiding chart) improvement of more than 50% is the reason to proceed to stage two. During that, permanent wire leads and stimulator (Interstim II) are implanted subcutaneously (15 min procedure). 64-88 % have good clinical response. The number of voids was reduced by 23-46% and the MVV increased by 44-77%18,19,20. QoL was also improved21. For three to six weeks after the implantation the patient must limit her activities. A few revisions were needed in the first six months (fine-tuning). Battery replacement is necessary every five years and a special attention must be paid because the patients cannot undergo MRI or diathermy use. Lead migration (1–21%), bowel dysfunction (4–7%) and infection (4–10%) are the most common adverse events, while bleeding, pain and unwanted stimulation of the extremities may also occur22.

Crystal structure of botulinum neurotoxin type A (Courtesy Lacy et al. 1998).

Managing women with OAB is quite a challenging procedure. Detailed medical and lifestyle history are the corner stones of accessing the problem. Additional testing is available and can be performed. Fortunately, new treatment options develop every day and it is just a matter of evaluation which treatment suits which patient.

Maximum cystometric capacity (MCC) and reflex References volume were increased by 68% and 61%, respectively, 1. Coyne KS, Sexton CC, Thompson CL, Milsom I, Irwin D, while maximum detrusor pressure (MDP) was Kopp ZS, Chapple CR, Kaplan S, Tubaro A, Aiyer LP, decreased by 42%. The most severe but also the most Wein AJ.The prevalence of lower urinary tract rare (< 0.01%) adverse event was muscle weakness symptoms (LUTS) in the USA, the UK and Sweden: (hypoasthenia) that was self-limiting and transient6,7. results from the Epidemiology of LUTS (EpiLUTS) study. BJU Int. 2009 Aug;104(3):352-60 Urinary tract infection (UTI) including asymptomatic 2. Khullar V., Cambronero J., Stroberg P., Angulo J., bacteriuria, and pain at the injection site were Boerrigter P., Blauwet M., et al. (2011) The efficacy and present in 21-39% and 10%, respectively8. Its efficacy tolerability of mirabegron in patients with overactive may last for six months. In patients with idiopathic OAB both onabotulinum toxin A (BOTOX ®) and abobotulinum toxin A (Dysport ®) are used. The recommended total dose is 100 IU (BOTOX ®). Daily frequency, urgency and incontinence were reduced by 29%, 38% and 59%, respectively, while MCC was increased by 58%. MDP was, also, reduced by 29%. There was a similar reduction of the UI episodes compared to the anticholinergics but 13% of women became completely dry versus 27% at the anticholinergic arm. Its endurance was up to 12 months for dose of 200 IU9. Concerning the adverse events, seven to 10% of patients will have the need to use ISC and that is

bladder-results from a European–Australian phase III trial. Eur Urol Suppl 10: 278–279 3. Chapple C., Kaplan S., Mitcheson H., Klecka J., Cummings J., Drogendijk T., et al. (2012) Randomised, double-blind, active-controlled phase III study to assess the long-term safety and efficacy of mirabegron in overactive bladder (OAB). Eur Urol Suppl 11: e683– e683a 4. Abrams P, Kelleher C, Staskin D, Rechberger T, Kay R, Martina R, Newgreen D, Paireddy A, van Maanen R, Ridder A.Combination treatment with mirabegron and solifenacin in patients with overactive bladder: efficacy and safety results from a randomised, double-blind, dose-ranging, phase 2 study (Symphony). Eur Urol. 2015 Mar;67(3):577-88.

a single treatment, randomized, placebo controlled 6-month study. J Urol. 2005 Jul;174(1):196-200. 9. Brubaker L, Richter HE, Visco A, Mahajan S, Nygaard I, Braun TM, Barber MD, Menefee S, Schaffer J, Weber AM, Wei J; Pelvic Floor Disorders Network Refractory idiopathic urge urinary incontinence and botulinum A injection.J Urol. 2008 Jul;180(1):217-22. 10. Kuo HC. Comparison of effectiveness of detrusor, suburothelial and bladder base injections of botulinum toxin a for idiopathic detrusor overactivity.. J Urol. 2007 Oct;178(4 Pt 1):1359-63. 11. Peters KM, Carrico DJ, Perez-Marrero RA, Khan AU, Wooldridge LS, Davis GL, Macdiarmid SA. Randomized trial of percutaneous tibial nerve stimulation versus Sham efficacy in the treatment of overactive bladder syndrome: results from the SUmiT trial J Urol. 2010 Apr;183(4) 12. Finazzi-Agrò E, Petta F, Sciobica F, Pasqualetti P, Musco S, Bove P Percutaneous tibial nerve stimulation effects on detrusor overactivity incontinence are not due to a placebo effect: a randomized, double-blind, placebo controlled trial.J Urol. 2010 Nov;184(5) 13. Klingler HC1, Pycha A, Schmidbauer J, Marberger M Use of peripheral neuromodulation of the S3 region for treatment of detrusor overactivity: a urodynamicbased study.Urology. 2000 Nov 1;56(5):766-71. 14. Nuhoğlu B, Fidan V, Ayyildiz A, Ersoy E, Germiyanoğlu C. Stoller afferent nerve stimulation in woman with therapy resistant over active bladder; a 1-year follow up.Int Urogynecol J Pelvic Floor Dysfunct. 2006 May;17(3):204-7. 15. Moossdorff-Steinhauser HF, Berghmans B. Effects of percutaneous tibial nerve stimulation on adult patients with overactive bladder syndrome: a systematic review Neurourol Urodyn. 2013 Mar;32(3):206-14. 16. Banakhar MA, Al-Shaiji T, Hassouna M. Sacral neuromodulation and refractory overactive bladder: an emerging tool for an old problem.Ther Adv Urol. 2012 Aug;4(4):179-85. 17. Everaert K, Kerckhaert W, Caluwaerts H, Audenaert M, Vereecke H, De Cuypere G, Boelaert A, Van den Hombergh U, Oosterlinck W. A prospective randomized trial comparing the 1-stage with the 2-stage implantation of a pulse generator in patients with pelvic floor dysfunction selected for sacral nerve stimulation. Eur Urol. 2004 May;45(5):649-54. 18. Reynolds WS, Bales GT. Re: Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. P. E. van Kerrebroeck, A. C. van Voskuilen, J. P. Heesakkers, A. A. Lycklama a Nijholt, S. Siegel, U. Jonas, C. J. Fowler, M. Fall, J. B. Gajewski, M. M. Hassouna, F. Cappellano, M. M. Elhilali, D. F. Milam, A. K. Das, H. E. Dijkema and U. van den Hombergh. J Urol 2007; 178: 2029-2034. J Urol. 2008 Jun;179(6):2483-4 19. van Voskuilen AC, Oerlemans DJ, Weil EH, de Bie RA, van Kerrebroeck PE. Long term results of neuromodulation by sacral nerve stimulation for lower urinary tract symptoms: a retrospective single center study Eur Urol. 2006 Feb;49(2):366-72. 20. Van Voskuilen AC, Oerlemans DJ, Weil EH, van den Hombergh U, van Kerrebroeck PE. Medium-term experience of sacral neuromodulation by tined lead implantation.BJU Int. 2007 Jan;99(1):107-10. 21. Cappellano F, Bertapelle P, Spinelli M, Catanzaro F, Carone R, Zanollo A, De Seta F, Giardiello G; Italian Group of Sacral Neuromodulation (GINS). Quality of life assessment in patients who undergo sacral neuromodulation implantation for urge incontinence: an additional tool for evaluating outcome. J Urol. 2001 Dec;166(6):2277-80. 22. Weil EH, Ruiz-Cerdá JL, Eerdmans PH, Janknegt RA, Bemelmans BL, van Kerrebroeck PE. Eur Urol. Sacral root neuromodulation in the treatment of refractory urinary urge incontinence: a prospective randomized clinical trial. 2000 Feb;37(2):161-71.

August/September 2016


Clinical challenge Prof. Oliver Hakenberg Section editor 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

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 48

Case study No. 47 This 47-year old woman was referred by an office urologist for treatment with the suspected diagnosis of renal cancer. She had been completely asymptomatic and an ultrasound done for a general health check-up had shown a left renal lesion. The ultrasound result was followed-up by computed tomography (CT) scanning (Fig.1 A-C). There was no relevant history of medical disease and the patient had no medications and is a non-smoker. A CT scan of the thorax showed no abnormalities and the full abdominal and pelvic CT did not show other lesions. Physical examination and clinical chemistry results were completely normal.

Figure 1 A-C: Abdominal CT scan

Discussion points: 1. What differential diagnosis should be considered? 2. Are further investigations needed? 3. Which treatment is appropriate?

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

Biopsy before any decisions Comments by Kurt Miller Berlin (DE)

The renal mass cannot be completely assessed since no native CT scans were provided and contrast enhancement was therefore unclear (renal tumour? haemorrhagic cyst?). Moreover, the CT report said „ ...and the full abdominal and pelvic CT did not show other lesions.“ I see another mass, ventrally, of the left kidney, immediately adjacent to the renal vein but which I cannot assess (bowel? stomach? tumour?).

The full set of CT scans is needed to get an idea what this could be. If it turns out that this is a solid renal mass with contrast enhancement, I would offer a biopsy. The same is true for the lesion ventrally to the left kidney, if confirmed.

Surgery seems good, but on second thought biopsy first Comments by Maximilian Burger Regensburg (DE)

How do you approach renal masses? Let’s be frank and face this fact: urologists are surgeons. When looking at any renal mass we almost instinctively opt for surgery right away. This scenario is true, for me at least. And how does one go through a CT-scan? Let’s be honest again and face another fact: urologists do a lot of radiological assessment of high quality. We all have our schemes but usually start with the organs of interest. Looking at this left-sided renal tumour my first thought was that it is renal cell cancer and I considered partial nephrectomy, either open or robotic. I noted the para-aortic bulk and changed

my mind for a Chevron incision to resect it as I am convinced that the patient would benefit from such lymph-node dissection. But such a rather small renal cell cancer would not likely trigger prominent lymph node metastasis. Noting the para-caval bulks on the other side of similar texture as the para-aortic one, I changed my surgery-prone approach as I thought that this looks a lot like a lymphoma. Besides, the left-hand bulk seems to be located just right for a CT-guided biopsy. With these considerations, I would go for a CT-guided biopsy of the renal as well as the para-aortic mass and, of course, full staging. Should both biopsies reveal lymphoma the path for chemotherapy is set. If both reveal renal cell cancer, I would go for surgery and resect all masses to avoid local recurrence, if possible. If the para-aortic mass represents lymphoma and the kidney mass renal cell cancer, then each must receive its appropriate treatment which would be surgery for the renal mass.

Case Study No. 47 continued Open surgical exploration was performed which showed a solid renal tumour as well as an unconnected solid pararenal tumour. Partial nephrectomy was done and final histology of this renal tumour was a chromophobe renal cell carcinoma pT1b R0. Of the pararenal tumour, frozen section biopsies were obtained intraoperatively which were reported as a neoplastic growth; however this could not be differentiated further on frozen section. This pararenal tumour was, therefore, also resected and final histology reported it as a completely resected, partially regressive schwannoma; thus, a benign neoplasia. Postopoerative recovery was uneventful.

A 55 year-old high school teacher with a history of ischemic heart disease since 2004, presented with a complaint of spontaneous erections whenever he walks or stands for five to 10 minutes. These erections are not accompanied by sexual desire but induced by standing or walking. There is no pain or discomfort except for a sensation of urinary urgency. The erection subside within one to two minutes after sitting or lying down but reappears with standing or walking. The patient has no other lower urinary tract symptoms and has an otherwise normal sexual function. There is a history of backache radiating to the posterior thigh since 2005. During the last three years he developed paresthesia in the legs which also increases in magnitude when he stands or walks. Physical examination is largely normal including the external genitalia and DRE. Examination of the penis, after asking the patient to walk for a few minutes, revealed a rigid erection of both corpora cavernosa, the corpus spongiosus and the glans. Complete detumescence occurs one minute after lying down. Neurological examination revealed sensory loss in the L5 dermatomes in both lower limbs without any loss in motor function. All laboratory investigations were normal including urinalysis, blood sugar, renal function tests, complete blood count, ESR and sickle cell tests as well as serum testosterone, LH, FSH, and prolactin. An MRI of the spinal cord revealed a central herniation of several lumbar intervertebral discs at multiple levels causing spinal stenosis in addition to bilateral root compression at L 5. The patient was advised to undergo surgery for his spinal cord problem, but he refused since his cardiologist had informed him that it would be too risky due to his ischemic cardiac disease. Medical treatment was started using oral baclofen titrated up to 15 mg daily and later flutamide 250 mg every eight hours. Baclofen had no effect at all, flutamide resulted in an initial response for two weeks but none thereafter. Discussion points: • Is this a case of stuttering priapism or not? • Is there any medical treatment that may prevent these erections? • Is spinal surgery likely to solve the problem? Case provided by Dr. Nihad P. Sh. Al-Ibraheem, Urology Specialist, Department of Urology, Rizgary Teaching Hospital, Erbil , Iraq; nihadpauls@yahoo.com

European Urology Today - Manuscript Submission European Urology Today, the EAU newsletter is published five times each year. Its main role is to function as the European Association of Urology’s bulletin, as a platform for the EAU to present their meetings, the various sections and offices, as well as discuss general issues of interest to their members. Another important objective is to have a platform that allows for the inclusion of a range of scientific papers which are considered of interest to a large readership.

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August/September 2016

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European Urology Today

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ESUT16: 3-day demonstration of the latest in urotechnology Uro-Technology meeting in Athens breaks new ground for EAU Section By Loek Keizer The EAU Section of Uro-Technology (ESUT) can look back on a highly successful section meeting, which took place in Athens on 8-10 July. It marked the first stand-alone meeting for the Section in many years, and the first meeting to be organised by its new chairman, Prof. Evangelos Liatsikos (Patras, GR).

Patient care Live surgery involves the informed consent of participating patients, and the EAU has stringent requirements for events that organise live surgery sessions in its name. The patients at ESUT16 were Prof. Liatsikos’s own.

The meeting offered three days of live and prerecorded surgery, 37 hands-on training courses, a comprehensive technical exhibition with all the latest in uro-technology, and distinguished speakers from all across the world. Almost 600 participants received a comprehensive update on the technology that drives urology.

“All patients were originally my own from Patras. On Thursday morning [July 7th] they came to Athens by bus, together with their relatives. They were well-informed on the procedure, on who would be performing the surgery, and they were enthusiastic about it. Every procedure went as it should. Everyone went home with the same bus after the meeting ended, and everyone is at home. That should say everything!”

“Looking back, I’m very pleased with the number of registrations,” Prof. Liatsikos reflected. “Both the attending surgeons and the tech companies were happy with the meeting, which in turn makes me happy!”

In accordance with the EAU Policy on Live Surgery, three patient advocates were on hand to make sure that the live broadcasting did not interfere with patient care. The cases of the patients will be revisited at a future meeting, as required by the Policy.

Live surgery at ESUT16 The largest part of the scientific programme was built on live surgery, as broadcasted from the Lefkos Stavros Medical Center in Athens, or pre-recorded and narrated by the experts. The first day was mainly focussed on endourology, BPO and stone surgery. The second day was devoted to laparoscopy. The format allowed for 50-60 minutes of each surgery.

ESUT and other Sections The EAU’s Uro-Technology Section has traditionally facilitated and supported live surgery sessions and training at other meetings, such as the Annual EAU Congress or other section meetings. It is closely affiliated with the EAU’s Robotic Urology and Urolithiasis Sections (ERUS and EULIS respectively), and prominent speakers from both sections were in Athens, as were the Section Chairs, Profs. Mottrie and Sarica.

Liatsikos: “We let the surgeon explain exactly how the procedure goes, not just highlights of 10-15 minutes as you sometimes see. The procedures and the broadcasting went well. The live surgery served mainly as a technical demonstration to inform the people of newest tech. The procedures themselves were not particularly rare, but showcased the new techniques and technology.”

Prof. Liatsikos, speaking as the new Chairman of ESUT: “These sections are all part of the same family, and we support one another. EULIS and ERUS are brother sections, dealing as we all do with advanced technology and surgical techniques. It’s not a problem for us to work together at meetings, it’s a matter of

ESUT 16

Current and former ESUT Chairs, Profs. Liatsikos and Rassweiler close ESUT16

“Is it our goal to have more regular meetings? ESUT is going to be a bi-annual meeting. We will support EULIS next year, and the year after that, we’ll see how it plays out. As I said, it’s my dream to have endourology as a big family and we still have a lot to discuss in that regard!” EULIS17, the 4th Meeting of the EAU Section of Urolithiasis will be held in Vienna, Austria from 5-7 October 2017. Just as EULIS supported ESUT in Athens, ESUT will lend its technical expertise and send key speakers to Vienna next year.

“It’s all connected to each other. Technique is influenced by the development of new instruments, and vice-versa. If the surgeon has an idea for an approach or technique, and wants to promote this, he or she needs to make new instruments. The surgeon approaches the instrument companies, discusses with them, and together they develop new technology.” “No company produces instruments just because they want to, we as surgeons are pushing them to do that. This is how it’s always been: the urologist has to take the lead in pushing for new developments.”

Live surgery sessions consisted of pre-recorded, live-presented cases, or real-time live broadcasts

Close to 600 delegates visited ESUT16 over the course of the three-day meeting in Athens

The mix of live and pre-recorded surgery was a first for an ESUT meeting. Pre-recorded presentations have their own advantages according to Prof. Liatsikos: “The nice thing about the pre-recorded videos was that they came from the institutions of the surgeons themselves. They were presented without audio, but with a live lecture from the attending surgeon. They could narrate and describe their case as it was played back. There was real interaction between panel and surgeon, which was I think was really beneficial.”

The current state of Uro-technology As much as ESUT16 was about showcasing technical innovations such as robots, imaging techniques, new tools and new training methods, many of the speakers touched on “technique” as much as technology. Prof. Liatsikos reflected on their symbiotic relationship:

Asst. Prof. Stavros Gravas (Larissa, GR) chaired one of the sessions and also pointed out some differences between live and pre-recorded cases: “It’s good to see surgeons in action without any pre-edited videos. When the procedure is performed live, the audience can really see difficulties a surgeon can face, but sometimes it takes a long time to see the whole procedure.” “The advantage of pre-recorded videos is that it allows the presenter to focus on key points of the procedure, and it is less stressful for the surgeons. There is always enough time to discuss with them. So at a meeting like ESUT16, it’s important to have a balance between the two.”

EAU Section of Uro-Technology (ESUT)

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European Urology Today

being willing to do it. And ESUT is really keen to work with them!” The “changing of the guard” for ESUT took place at EAU16 in Munich. Prof. Jens Rassweiler (Heilbronn, DE) stepped down as ESUT Chair and became Chairman of the EAU’s Section Office. Profs Liatsikos and Rassweiler both prominently featured in the scientific programme to emphasise the transition, with the latter calling it “a new era for ESUT”. Liatsikos: “Jens did a great job as ESUT Chairman and we will continue his work and expand the section. I hope to do at least as well as Jens, and leave my stamp on it too.”

8-10 July 2016 Athens, Greece

At ESUT16, several hot topics were addressed, also hinting at near-future breakthroughs that will be achieved together with instrument developers. Liatsikos: “As surgeons, we are dealing a lot with BPO right now. The treatment of prostate enlargement is booming with enucleation procedures, both laser and

“My vision for the section is to attract young people, and to have them participate in our meetings and training sessions. ESUT welcomes anyone if they are interested in endourology or new technology. Additionally, I would like to bring endourology to the EAU. There have been some independent initiatives in the field and I would like to see everything grouped within the EAU.” Prof. Liatsikos also mentioned some topics that are on the table at ESUT board meetings, the first of which under his chairmanship also took place in Athens. “Attracting new members, and entering new activities like more intensive research. We also discussed how our Section should be organised, in terms of working groups.”

Profs. Pansadoro and Chlosta listen to a comment by Prof. Janetschek following their debate

August/September 2016


bipolar, and focal therapy is important for the treatment of cancer patients.” “We are seeing big strides in 3D vision for laparoscopic procedures: the image quality is constantly improving. In recent years, endoscopy is improving rapidly, the companies are really producing excellent stuff.” Debates One debate at ESUT16 that toed the fine line between technology and technique was between Profs. Chlosta (Krakow, PL) and Pansadoro (Rome, IT). They defended the merits of laparoscopic and robotic prostatectomy, respectively. Chlosta made his case carefully, pointing to the lack of solid evidence for the advantages of robotic surgery, despite it already being an essential part of the urologist’s armamentarium. “Benefits for patients like recovery, or sexual function are still unclear or statistically insignificant.” Chlosta emphasised that the experience of the surgeon is key, irrespective of the tools used. “In experienced hands, both laparoscopic and robotic radical prostatectomy yield comparable rates of cancer control, shorter lengths of hospital stay and fewer blood transfusions than open RP. All are technically challenging procedures, with outcomes primarily related to surgeon skill and experience. Robotic surgery is clearly the future, but when you also factor in cost, it’s clear that laparoscopic prostatectomy very much still has its use.” Prof. Pansadoro came straight to the point, citing figures of the huge adoption of surgical robots since their commercial introduction. For radical prostatectomy, 86% of all procedures were performed robotically in 2015. “This success story speaks for itself. The skills of the surgeon count, but we can safely say that we’ve reached the ‘end of controversy’ with regards to the adoption of robotic urology. We are not likely to see a randomized controlled trial of the two techniques, and studies of administrative databases are probably as good as it’s going to get.” Pansadoro also mentioned the ergonomic benefits for surgeons as the two speakers rebutted each other, also taking questions from the audience. “Being seated, with arm- and headrests and with hand tremors being less of an issue: all of these are advantageous to the surgeon.” Speaking after the debate, Prof. Chlosta was asked if the debate was illustrative and academic, or if urologists were still evaluating robotic surgery. “We were not really debating the future of urotechnology, but more establishing the ‘final role’ for older techniques like open surgery or manual laparoscopy for the treatment of prostate cancer,” he concluded.

Digitising Informed Consent with MHealth Poster shows encouraging results on use of tablets for patient information In addition to the multitude of live surgery sessions and the possibilities for hands-ontraining as coordinated with the European School of Urology, ESUT16 also had four poster sessions for the showcasing of new research from young urologists. Each session produced a “Best Oral Presentation”, which awarded the presenter with a cash prize. We spoke to Dr. Sebastian Armijos Leon (Puerto Real, ES), who presented on behalf of the team that produced poster O40: MHealth: The use of portable video media versus standard verbal communication in the informed consent. “Our poster was on the topic of mobile health and improving the provision of information for patients, pre-surgery. We use a tablet computer to show video and pictures to explain what they can expect during and after surgery.” “Ideally, we would like to use a system like this to replace traditional informed consent. Our health records are digitalised but informed consent is not. The second phase of our research will entail the developing of a concept that would allow informed consent through an application.” “So far, we have tested around 200 patients in our hospital in Cádiz and the results are very encouraging. Patients are happy to use the tablet, and it really helps them understand the procedure. In the past, patients would simply sign the consent form without really knowing what to expect, and now they can.”

“I must emphasise: we are keyhole surgeons, enthusiastic about technology. Our goal is the patient and achieving the best medical result. We cannot be uro-technicians.”

“Patients feel less anxiety, the interviewers concluded. All the patients who were surveyed after using the tablet and application felt more comfortable going into surgery.”

O46: Upper urinary tract urothelial tumours targeted with biodegradable drugeluting stents Barros A., Browne S., Oliveira C., Duarte A.R., Reis R., Healy K., Lima E. (Barco, Braga, Portugal; Berkeley, United States of America)

Rather than replacing a personal approach between physician and patient, the tablet and video application merely augments it. The patient is also introduced to “their” surgeon, and is encouraged to ask any further questions. Dr. Leon hypothesised that his presentation was well-received for three specific reasons: “I was told that the idea is good, that it’s unique in this meeting in that it is not related specifically to urology, and third, they liked my presentation!”

Best Oral Presentations at ESUT16: O13: Is self-anchoring suture technology safe? In-Vivo comparison with conventional sutures in regard to inflammation-fibrosis, migration, adhesion and stone formation Yalcin S., Kibar Y., Gezginci E., Gunal A., Ozgok I.Y., Gozen A.S. (Agri, Ankara,Turkey; Heilbronn, Germany) O23: Large percentage of potential TURP candidates: Mid-term results Schonthaler M., Berges R., Amend B., Wetterauer U., Sievert K-D. (Freiburg, Cologne, Tübingen, Germany; Salzburg, Austria) O40: MHealth: The use of portable video media versus standard verbal communication in the informed consent Armijos Leon S.A., Rodriguez-Rubio Costadellas F., Rioja Zuazu J., González Caballero J.L., Sanchez Barrios V., Rebelo Cadena I. (Puerto Real, Zaragoza, Cádiz, Spain; Guildford, United Kingdom)

Dr. Sebastian Armijos Leon, presenting author of abstract O40 receives his award on the final day of ESUT16, from Dr. Domenico Veneziano, one of the chairs of the poster session.

Hands-on training courses ESUT16 also offered 37 industry-supported hands-on training courses where trainees had the chance to refine their skills or learn new techniques. Moreover, the URS sessions included a new standardised endourological training curriculum. Fully booked and led by enthusiastic tutors, the course provided participants the benefit of one-on-one mentorship. “Numerous young urologists benefited from the expertise of mentors and the dedicated coaching” said trainer Dr. Jan Klein, as he added that the ESUT has earned a reliable name as a frontline meeting for practical training workshops.

Science at your fingertips

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August/September 2016

European Urology Today

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

Oliver.Hakenberg@ med.uni-rostock.de

Male veterans with complicated UTIs: A stewardship programme The influence of antimicrobial stewardship programmes (ASPs) on outcomes in male veterans treated for complicated urinary tract infection has not been determined. Authors performed a retrospective cohort study encompassing the study period January 1, 2005-October 31, 2014, which was conducted at a 150-bed Veterans Affairs Healthcare System facility in Buffalo, NY. Male veterans admitted for treatment of complicated urinary tract infection were identified using ICD-9-CM codes. Outcomes before and after implementation of a patient-centered ASP, including duration of antibiotic therapy, length of hospitalisation, readmission within 30 days, and Clostridium difficile infection were compared. Interventions resulting from the ASP were categorised. Of the 1,268 patients screened, 241 met the criteria for inclusion in the study (n = 118 and n = 123 in the pre-ASP and ASP group, respectively).

…ASPs may be useful to improve clinical outcomes in men with complicated urinary tract infection…

The authors searched MEDLINE, EMBASE, BIOSIS, and the Cochrane Register of Diagnostic Test Accuracy Studies from 1985 to 31 March 2016. The reference lists of relevant review articles were searched to identify additional studies not found through the electronic search. The following publications were considered: cross-sectional or cohort studies that compared the results of the index tests (DMSA scan or RBUS) with the results of radiographic VCUG in children less than 19 years of age with a culture-confirmed urinary tract infection. Two authors independently applied the selection criteria to all citations and independently abstracted data. The bivariate model was used to calculate summary sensitivity and specificity values.

increased odds of UTI. Vitamin D supplementation (OR 0.298, 95% CI 0.150-0.591; p = 0.001) was associated with a decreased likelihood of UTI. Investigators concluded that vitamin D deficiency in infants was associated with increased odds of UTI. Interventional studies evaluating the role of vitamin D supplementation to reduce the burden of UTI are warranted.

Source: Low serum 25-hydroxyvitamin D level and risk of urinary tract infection in infants. Yang J, Chen G, Wang D, Chen M, Xing C, Wang B. Medicine (Baltimore). 2016 Jul; 95(27):e4137.

Predicting progression in Investigators concluded that neither G3pT1 TCC the renal ultrasound nor the DMSA At diagnosis 75% of urothelial bladder cancers are scan is accurate enough to detect non-muscle invasive (NMIBC). They have a risk of up to 85% of recurrence and up to 17% will eventually VUR (of all grades) A total of 42 studies met the inclusion criteria. Twenty studies reported data on the test performance of RBUS in detecting VUR; the summary sensitivity and specificity estimates were 0.44 (95% CI 0.34 to 0.54) and 0.78 (95% CI 0.68 to 0.86), respectively. A total of 11 studies reported data on the test performance of RBUS in detecting high-grade VUR; the summary sensitivity and specificity estimates were 0.59 (95% CI 0.45 to 0.72) and 0.79 (95% CI 0.65 to 0.87), respectively. A total of 19 studies reported data on the test performance of DMSA in detecting VUR; the summary sensitivity and specificity estimates were 0.75 (95% CI 0.67 to 0.81) and 0.48 (95% CI 0.38 to 0.57), respectively. A total of 10 studies reported data on the accuracy of DMSA in detecting high-grade VUR. The summary sensitivity and specificity estimates were 0.93 (95% CI 0.77 to 0.98) and 0.44 (95% CI 0.33 to 0.56), respectively.

progress to muscle-invasive bladder cancer. Progression depends upon stage, grade and presence of concomitant carcinoma in situ (CIS). Progression is associated with a significantly worse outcome and thus there is a need for predictive biomarkers, which can distinguish progressive from non-progressive NMIBC. This paper presents data from Barcelona, which was subsequently validated in a separate sample from both Barcelona and Nijmegen. 96 patients with G3pT1 TCC but no CIS were included. Most had at least an induction course of BCG. Separated into 56 patients with recurrent nonprogressive patients (with two to 10.9 years of follow-up) and 40 progressive patients. All patients had at least 1 cystoscopy at three months showing no tumour to exclude residual disease. The known clinical classifiers for progression, multiplicity and tumour size were similar between the groups.

Investigators concluded that neither the renal ultrasound nor the DMSA scan is accurate enough to detect VUR (of all grades).

Formalin-fixed paraffin-embedded tissue samples were collected. Global gene expression patterns were Duration of antibiotic therapy was significantly shorter analysed in 21 selected samples (12 progressive and in the ASP group (10.32 days vs 11.96 days; P < .0001), as nine non-progressive) from patients in Barcelona Although a child with a negative DMSA test has an < was length of hospitalisation (5.76 days vs 6.76 days; using Illumina microarrays. Expression levels of 75 1% probability of having high-grade VUR, performing genes selected based on microarray data and 19 p = .015). There was no difference in 30-day a screening DMSA will result in a large number of readmission. A total of 170 interventions were based on literature were studied by quantitative identified that resulted from the ASP (1.39 interventions children falsely labelled as being at risk for highpolymerase chain reaction (qPCR) in an independent grade VUR. per patient). series of 75 G3pT1 TCC patients (28 progressive and 47 non-progressive). Univariate logistic regression was It was concluded that ASPs may be useful to improve Accordingly, the usefulness of the DMSA as a screening used to identify individual predictors. A variable clinical outcomes in men with complicated urinary test for high-grade VUR should be questioned. selection method was used to develop a multiplex biomarker model. tract infection. Implementation of an ASP was associated with significant decreases in duration of antibiotic therapy and length of hospitalisation, without adversely affecting 30-day readmission rates.

Source: Male veterans with complicated urinary tract infections: Influence of a patient-centered antimicrobial stewardship program. Carbo JF, Ruh CA, Kurtzhalts KE, Ott MC, Sellick JA, Mergenhagen KA. Am J Infect Control. 2016 Jul 4.

Detecting vesicoureteral reflux among children with UTIs There is considerable interest in detecting vesicoureteral reflux (VUR) because its presence, especially when severe, has been linked to an increased risk of urinary tract infections and renal scarring. Voiding cystourethrography (VCUG), also known as micturition cystourethrography, is the gold standard for the diagnosis of VUR, and the grading of its severity. Since VCUG requires bladder catheterisation and exposes children to radiation, there has been a growing interest in other screening strategies that could identify at-risk children without the risks and discomfort associated with VCUG. The objective of this review was to evaluate the accuracy of two alternative imaging tests - the dimercaptosuccinic acid renal scan (DMSA) and renal-bladder ultrasound (RBUS) - in diagnosing VUR and high-grade VUR (Grade III-V VUR). Key articles

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Source: Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections. Shaikh N, Spingarn RB, Hum SW. Cochrane Database Syst.

This is not a large study and will require further validation in an independent series prior to clinical implementation

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

Increasing evidence of the role of PD-L1 in advanced urothelial cancer Systemic platinum-based chemotherapy introduced nearly 30 years ago remains the standard of care for patients with inoperable or metastatic transitional cell carcinoma (TCC) and the prognosis for patients who fail is dismal. Novel immunotherapies that can interrupt signals generated by immune checkpoint proteins can effectively enhance antitumour T-cell immunity. Tumour cells often hijack the PD-1/PD-L1 pathway to protect themselves from tumour-specific T cells. Moreover, immune cells in the tumour microenvironment may also express PD-L1 and similarly inhibit T-cell responses at the tumour site. To date, PD-1 monoclonal antibodies nivolumab and pembrolizumab have been approved for the treatment of advanced melanoma, non–small-cell lung cancer, and renal cell carcinoma (nivolumab only). Blockade of immune checkpoints activated by the PD-1/PD-L1 pathway has also shown promising early clinical activity in TCC. Durvalumab is a selective high-affinity monoclonal antibody that blocks PD-L1 binding and allows T cells to recognise and kill tumour cells. This paper reports results from the TCC expansion cohort of a phase 1/2 open-label dose escalation and dose-expansion study. Durvalumab (MEDI4736, 10 mg/kg every two weeks) was administered intravenously for up to 12 months to patients with inoperable or metastatic TCC and performance status 0-1 who had progressed on or been ineligible for any number of prior therapies. The primary end point was safety, and objective response rate (ORR, confirmed) was a key secondary end point.

This study shows clinically significant responses to PD-L1 inhibition in a group of heavily pretreated bladder cancer patients

Patients underwent cross-sectional imaging at weeks 6, 12 and 16 and then every eight weeks during treatment. An exploratory analysis of pretreatment tumour biopsies led to defining PD-L1–positive as 25% of tumour cells or tumour-infiltrating immune Low serum 25-hydroxyvitamin A total of 1294 genes were found differentially expressed ≥cells expressing membrane PD-L1. On the basis of D level and risk of UTI in between progressive and non-progressive patients in fresh tumour biopsies obtained during screening the first group. Of these 75 genes were examined in the (n=183) the prevalence of PD-L1-positive staining was infants second cohort along with 19 selected on the basis of the estimated to be 59%. This cut-off is also used for literature and differential expression of 15 genes was selection of patients with non-small-cell lung cancer The aim of this study was to determine whether serum validated by qPCR. A five-gene expression signature and squamous cell carcinoma of the head and neck. 25-hydroxyvitamin D (25(OH)D) deficiency in infants (ANXA10, DAB2, HYAL2, SPOCD1, and MAP4K1) 61 patients (40 PD-L1-positive, 21 PD-L1-negative) increased the odds of urinary tract infection (UTI). discriminated progressive from non-progressive G3pT1 TCC patients with a sensitivity of 79% and a specificity of were enrolled between 28/8/14 and 10/11/15. Median A total of 238 infants including 132 patients 86% (AUC Z 0.83). Direct interactions between the five follow-up was 4.3 months and median duration of experiencing a first episode of UTI and 106 controls, genes of the model were not found. exposure was eight weeks. (9.2 weeks for the positive subgroup and 6.0 weeks for the negative group). 39 aged from 1 to 12 months, were enrolled. Serum 25(OH)D levels were tested through blood sampling. reported a treatment-related AE of any grade most The regulation of cancer progression by more than frequently fatigue (13.1%), diarrhoea (9.8%) and one pathway is supported by the realisation that the decreased appetite (8.2%). Three patients developed genes of the model have no direct interaction and …vitamin D deficiency in infants was derive from different pathways. This is not a large acute kidney injury due to nephritis and stopped drug as a consequence. study and will require further validation in an associated with increased odds of independent series prior to clinical implementation. UTI Treatment with steroids led to resolution. Among the However, it raises the possibility of more accurate counselling for patient presenting with G3pT1 TCC and 42 response-evaluable patients the ORR was 46.4% The serum 25(OH)D levels were significantly lower in in the PDL-1-positive subgroup and 0% in the the uses of early cystectomy for those at highest risk negative subgroup. Responses were ongoing at data cases with UTI than controls. The mean serum 25(OH) of progression. cut-off in 12 of 13 patients with median duration of D levels were 29.09 ± 9.56 ng/mL in UTIs and 38.59 ± 12.41 ng/mL in controls (P < 0.001). Infants with Source: A five-gene expression signature to response not yet reached. acute pyelonephritis (APN) had lower serum 25(OH)D predict progression in T1G3 bladder cancer. than those with lower UTI. This study shows clinically significant responses to Van der Heijden AG, Mengual L, Lozano JJ, PD-L1 inhibition in a group of heavily pre-treated Ingelmo-Torres M, Ribal MJ, Fernandez PL, The multivariate logistic regression analyses showed bladder cancer patients. Those of you who read this Oosterwijk E, Schalken JA, Alcaraz A, Wites JA. that serum 25(OH)D < 20 ng/mL (OR 5.619, 95% CI section regularly may remember similar results with Eur. J. Cancer. 2016; 64:127-136. 1.469-21.484, p = 0.012) was positively related to an Atezolizumab. Together they suggest this may be a Rev. 2016 Jul 5; 7:CD010657.

EAU EU-ACME Office

European Urology Today

August/September 2016


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

tebj@medisin.uio.no useful therapeutic pathway for patients with metastatic TCC.

varies in function of active surveillance protocols and among countries, and the current definition used in this study did not fit with any definition validated in large prospective active surveillance trials. Further improvements in biomarkers, genomic tests, and imaging developments have to be made to identify the low proportion (< 10%) of these presumed very-low-risk patients who have unsuspected aggressive prostate cancer which needs to be treated radically and immediately.

Source: Oncological and functionla outcomes 1 year after radical prostatectomy for very-lowrisk prostate cancer: Results from the prospective LAPPRO trial. Carlsson S, Jäderling F, Wallerstedt A et al.

Source: Safety and efficacy of Durvalumab BJU Int 2016 doi :10.1 111/bju.13444. (MEDI4736), an anti-programmed cell death ligand-1 immune checkpoint inhibitor, in patients with advanced urothelial bladder cancer. Massard C, Gordon MS, Shama S, Rafii Suprapubic drainage versus S, Wainberg ZA, Luke J, Curiel TJ, Colon-Otero G, Hamid O, Sanborn RE, O’Donnell PH, Drakaki A, transurethral catheterisation Tan W, Kurland JF, Rebelatto MC, Jin X, Blakeafter radical prostatectomy: Haskins JA, Gupta A, Segal NH. JCO. 2016; 10.1200/JCO.2016.67.9761

Does it really matter?

Few surgeons use a suprapubic catheterisation for urinary drainage after radical prostatectomy given Outcomes after surgery for that the transurethral catheter remains the method of prostate cancer patients choice offering the advantage to potentially prevent anastomotic strictures by splinting the anastomosis. eligible for surveillance Moreover, the duration of bladder catheterisation is The very-low-risk prostate cancer (PCa) patient group supposed to be short (< 1 week) and well tolerated by is the ideal target for a non-aggressive management. the patients. Thus, few studies have assessed an alternative method of catheterisation in the literature. In many countries, active surveillance is the However, it can cause a certain degree of discomfort recommended first-line treatment for this sub-group of patients, and radical prostatectomy only comes as a and be a source of bacteriuria. therapy option in selected patients. Nevertheless, in In the present study, the authors have assessed the spite of the progress in initial PCa risk assessment, impact of a suprapubic catheterisation on postusing biomarkers, risk calculators, and magnetic operative pain, development of bacteriuria and resonance imaging, several series continue to report long-term functional outcomes. Overall, 160 patients not negligible rates of upstaging/upgrading even in undergoing a transperitoneal robot-assisted radical carefully selected low risk PCa cases. prostatectomy were included in a prospective trial and randomised in two comparable arms: suprapubic In the present study, the authors evaluated the versus transurethral catheterisation. One experienced oncological and functional outcomes after radical prostatectomy for very-low-risk patients as described surgeon performed all the procedures. In the by the Swedish national guidelines: PSA < 10, T1c, PSA suprapubic catheter group, an additional transurethral catheter was left during the first density < 0.15, Gleason score 6, up to 4 positives post-operative night for security reasons in case of cores, < 8 mm in total tumour length. The main gross haematuria, and then was removed at Day 1 strengthen of this studies was that the authors used after surgery. data from the prospective LAPPRO trial which included patients from 14 participating centres in Functional outcomes were assessed at month 24 Sweden aiming at determining outcomes 12 months after radical prostatectomy by using IPSS, ICIQ-SF after surgery. This study involved a mixture of and EORTC QLQ-C30 questionnaires. Pain was high- and low-volume centres in order to reflect the evaluated by a numeric rating scale on a daily basis. current clinical practice among the country. Urine analysis was performed on the second void Functional outcomes were measured with selfurine sample after catheter removal (at day 5). Both reported questionnaires. The trifecta rate was also groups were comparable in terms of preoperative assessed by adding to these functional outcomes a features. cut-off of post-operative PSA > 0.25 ng/ml to define biochemical failure.

Pooling these results with the potential uselessness of radical treatment in this sub-group of verylow-risk patients, the conclusions of this study highlighted the need for promoting active surveillance in this setting Among the 4003 men included in the overall analysis, 8.4% (338) fulfilled the very-low-risk definition. Regarding the oncological outcomes, 4.5% of men experienced PSA failure during the first 12 months, and surgical margins were positive in 16% of cases. Adverse pathology defined by a Gleason score >6 or a pT3 stage was reported in more than one-third of cases (pT3: 8.1%; Gleason score > 6: 31%). A dominant grade 4 was reported in only 5% of cases. Urinary continence was reached in 84%. Interestingly, this rate varied from 47% when using a strict definition (no pad, no leakage) to 92.6% when one daily pad was tolerated. Erectile function was good in 44% of men. This ranged from 16% when considering an IIEF score > 21 as definition to 50% when using the preservation of penetration ability as main criterion. The trifecta rate was obtained in only 38% of patients. Pooling these results with the potential uselessness of radical treatment in this sub-group of very-low-risk patients, the conclusions of this study highlighted the need for promoting active surveillance in this setting. However, there’s no consensus regarding the ideal definition of this very-low risk group. It thoroughly Key articles

August/September 2016

In this randomised not blinded trial, suprapubic drainage has shown to reduce significantly post-operative pain as compared to standard transurethral catheter Postoperative pain (primary endpoint) was found to be significantly different between groups with more favourable results for the suprapubic diversion group. Median overall pain including 12 time points before catheter removal was higher in the transurethral catheter group (p = 0.012). These differences remained significant even at Day 5 after the catheter removal. No further differences were observed after Day 6. Regarding secondary endpoints, bacteriuria was found in 10% of men in the transurethral group versus only 5% in the suprapubic group (p = 0.35). The need for prolonged catheterisation due to urinary leakage or retention did not differ between groups (5%). No differences in terms of complications rate, levels of quality of life, micturition status, or continence rates were reported after the two-year follow-up. The major limitations of this series were the relative small sample size as well as the exclusion of > 50% of men at inclusion because of bladder neck reconstruction or hernia repair. Nevertheless, the authors highlighted that this exclusion criteria did not contraindicate suprapubic drainage in their subsequent experience. In this randomised not blinded trial, suprapubic drainage has shown to reduce significantly postoperative pain as compared to standard transurethral

catheter. The two-fold decrease in bacteriuria rate was not significant. Given that suprapubic drainage did not negatively impact on overall complication rate, anastomotic leakage or stricture rate, and mid-term functional outcomes, this method of catheterisation might be a routine option to reduce patient discomfort after robot-assisted radical prostatectomy.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

Source: Postoperative patient comfort in suprapubic drainage versus transurethral catheterization following robot-assisted radical prostatectomy: a prospective randomized clinical trial. Harke N, Godes M, Habibzada J et al.

g.ploussard@ gmail.com

World J Urol 2016 doi :10.1007/s00345-016-1883-6.

Vesicourethral reconstruction using a levator ani muscle reconstruction might improve continence rate after radical prostatectomy Posterior and/or anterior reconstruction around the vesicourethral anastomosis has been suggested to improve the return to continence after robot-assisted radical prostatectomy. However, no strong level of evidence exists. The most common reconstruction is the posterior one as described by Rocco et al, consisting in a Denonvilliers fascia and a rectourethral muscle-bladder neck suturing to strengthen the posterior part of the anastomosis. In the present study, the authors have compared this posterior “reference” reconstruction to a more advanced reconstruction involving the levator ani bundles (named ARVUS). Functional outcomes in terms of continence and erectile functions have been assessed in this prospective randomised (not blinded) trial. Only one experienced surgeon (> 800 cases) performed all the operation. The learning curve of the ARVUS was achieved in 15 consecutive patients who were not included for eligibility. The ARVUS was described as follows. An absorbable monofilament barbed V-loc suture was passed through the right levator ani muscle, then through the Denonvilliers fascia (without injuring the neurovascular bundles), then through the left levator ani muscle, and back to the Denonvilliers fascia. Then, the suture was passed under the urethra and then through the bladder neck. This could be summarised by a Rocco suture to which was added a bilateral levator ani muscle suture. The tension-free anastomosis was then created in the same manner in both groups. Postoperative care did not differ between groups, and the catheter was removed at Day 5.

This method of posterior reconstruction of the vesicourethral anastomosis appeared easily feasible and efficient for early continence recovery. This led to restore the functional and anatomical relations between the urethra and the muscle fibers… Sixty-six patients were included and randomised in two comparable groups in terms of pre-operative characteristics. Median operative time was comparable in both groups. Bilateral nerve-sparing surgery was performed in two-thirds of patients. No urinary retention was noted, and complication rates were globally low without any significant difference whatever the suture technique. At Day 1 after catheter removal, 22% of patients in the ARVUS group compared with 6% in the control group were continent. At the later time points, the difference was significantly maintained: 44% vs 12% at week 2, 62% vs 15% at week 4, 75% vs 44% at month 6, and 87% vs 63% at month 12. The definition of continence was strict and described as 0 pads per day. Measurements of continence rates using the ICIQ-SF also confirmed these findings at each time point. The use of ARVUS was the only predictive factor for continence in univariate analyses with an OR of 8.5 (95% CI 2.7-26). No significant difference in terms of potency recovery and postoperative IIEF-5 scores was noted between the two groups.

This method of posterior reconstruction of the vesicourethral anastomosis appeared easily feasible and efficient for early continence recovery. This led to restore the functional and anatomical relations between the urethra and the muscle fibers, and thus, to create a dorsal dynamic suspensory support for the vesicourethral anastomosis. The methodology used in this trial was interesting: randomisation by software with members of the team (except the surgeon) blinded for group allocation, single experienced surgeon, no impact of learning curve, questionnaires collected by a study nurse blinded to the type of operation. However, limitations such as the small sample size and the single-institution questioned the reproducibility of the study findings. The potential damages created on the levator ani muscle fibers by suturing could also be considered. Thus, external validations of this technique are mandatory before a potential widespread use in the robotic field.

Source: Advanced reconstruction of vesicourethral support (ARVUS) during robotassisted radical prostatectomy: One-year functional outcomes in a two-group randomised controlled trial. Student V, Vidlar A, Grepl M, et al. Eur Urol 2016 doi/10.1016/j.eururo.2016.05.032.

Should prostate cancer screening be supported after all? The ERSPC showed that regular PSA screening leads to a 21% relative reduction in prostate cancer-specific mortality but harms in terms of over diagnosis and loss in quality-adjusted life-years has led to a clear recommendation against PSA screening. Empirical data suggest that the ratio of benefit-to-harm could be improved by restricting screening to appropriate age ranges, restricting biopsy and treatment to men at highest risk. This paper quantify the effects of implementing these recommendations on the outcomes of PC screening using MISCAN comparing a “recommended good practice” model versus a model reflecting common screening and treatment practices

It is clear that commonly used PSA screening and treatment practices are associated with little net benefit The MISCAN model simulates individual life histories with and without PSA screening and with and without the development of PC. Survival was modelled using the Gleason score-dependent data published by Albertson as well as SEER data. If four recommendations were followed: limited screening in older men, selective biopsy in men with elevated PSA, active surveillance for low-risk tumours, and treatment preferentially delivered at high-volume centres. Outcomes were compared with a base model in which annual screening started at ages 55 to 69 years and were simulated using data from the ERSPC In terms of QALYs gained compared with no screening, for 1000 screened men who were followed over their lifetime, recommended good practice led to 73 life-years (LYs) and 74 QALYs gained compared with 73 LYs and 56 QALYs for the base model. In contrast, common practice led to 78 LYs gained but only 19 QALYs gained, for a greater than 75% relative reduction in QALYs gained from unadjusted LYs gained. The poor outcomes for common practice were influenced predominantly by the use of aggressive treatment for men with low-risk disease, and PSA testing in older men also strongly reduced potential QALY gains Naturally any modelling study is only as good as the model used and can do no more than suggests a hypothesis. It is clear that commonly used PSA screening

EAU EU-ACME Office

European Urology Today

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Dr. Francesco Sanguedolce Section editor London (UK)

fsangue@ hotmail.com

and treatment practices are associated with little net benefit. However, the increasing use of active surveillance for men with low-risk disease and limitation of PSA testing in men over the age of 70 years might significantly alter the balance of risk to benefits

Source: Estimating the harms and benefits of prostate cancer screening as used in common practice versus recommended good practice: A microsimulation screening analysis. Carlsson SV, de Carvalho TM, Roobal MJ, Hugosson J, Auvinen A, Kwiatkowski M, Villers A, Zappa M, Nelen V, Paez A, Eastham JA, Lija H, de Koning HJ, Vickers A, Heijnsdijk EAM.

Chi-square and Student's t tests, Kaplan-Meier sub-analysis showed a potential benefit of alphaanalysis, binary logistic regression and Cox regression blockers in the stone passage rate within patients analysis were used to determine statistical significance. with 5 to 10 mm stones (Furyk et al.) or in the case of distal stones (Sur et al). Nearly all men with AUS cuff erosions had low serum testosterone (18/20, 90.0%) compared to those The authors also reviewed the current without erosions (12/33, 36.4%, p < 0.001). Mean time recommendation from the EAU and AUA guidelines, to erosion was 1.70 years (0.83-6.86), mean follow-up with the former still supporting the use of alpha2.76 years (0.34-7.92). Low testosterone had a hazard blockers for ureteric stones but under-grading the ratio of 7.15 for erosion in a Cox regression analysis recommendation from A to C, and the latter (95% CI 1.64-31.17, p = 0.009) and Kaplan-Meier supporting alpha-blockers only in case of distal analysis demonstrated decreased erosion-free ureteric stone < 10 mm in size. follow-up (log-rank p = 0.002).

…men with low testosterone levels are at a significantly higher risk to experience AUS cuff erosion. … Low testosterone was the sole independent risk factor for erosion in a multivariable model including coronary artery disease and radiation (OR 15.78 (95% CI 2.77-89.92, p = 0.002). Notably, history of prior AUS, radiation, androgen ablation therapy or concomitant penile implant did not confound risk of cuff erosion in men with low testosterone levels.

Cancer. 2016; 10.1002/cncr.30192.

Heritability of LUTS symptoms in men Symptoms of urinary irritation, urgency, frequency, and obstruction, known as lower urinary tract symptoms (LUTS), are common in urological practice. However, little is known about the aetiology or pathogenesis of LUTS, especially the relative contributions of genetic and environmental factors to development of these symptoms. The authors used a classical twin study design to examine the relative contribution of genetic and environmental factors to the occurrence of LUTS in middle-aged men.

The authors concluded that men with low testosterone levels are at a significantly higher risk to experience AUS cuff erosion. Appropriate counselling before AUS implantation is warranted and it remains yet unclear whether testosterone re-supplementation will mitigate this risk.

Source: Low Serum Testosterone Level Predisposes to Artificial Urinary Sphincter Cuff Erosion. Hofer MD, Morey AF, Sheth K, Tausch TJ, Siegel J, Cordon BH, Bury MI, Cheng EY, Sharma AK, Gonzalez CM, Kaplan WE, Kavoussi NL, Klein A, Roehrborn CG. Urology 2016 Jul 20. pii: S0090-4295(16)30422-8. doi: 10.1016/j.urology.2016.04.065. [Epub ahead of print]

Twins were members of the Vietnam Era Twin (VET) Is it game over for medical Registry. The investigators used a mail survey to collect lower urinary tract symptoms (LUTS) using the expulsive therapy? Yes…No… International Prostate Symptom Score (I-PSS) Not yet! instrument. Twin correlations and biometric modelling were used to determine the relative genetic and environmental contributions to variance in I-PSS Medical Expulsive Therapy (MET) has been widely total score and individual items. investigated in the last 20 years. Several small Randomised Controlled Trials (RCT) and pooled …genetic factors provide a moderate results from different meta-analysis provided Level 1a evidence that alpha-blockers and calcium channel contribution (20-40%) to LUTS in blockers are effective treatments to facilitate spontaneous passage and for symptom relief in the middle-aged men… case of ureteric stones < 1 cm. Participants were 1,002 monozygotic and 580 dizygotic middle-aged male twin pairs (mean age = 50.2 years; S.D. = 3.0 years). Nearly 25% of the sample had an I-PSS score > 8, indicating at least moderate LUTS. The heritability of the total I-PSS was 37% (95% CI = 32-42%). Heritability estimates ranged from 21% for nocturia to 40% for straining, with moderate heritability (34-36%) for urinary frequency and urgency. The authors concluded that genetic factors provide a moderate contribution (20-40%) to LUTS in middleaged men, suggesting that environmental factors may also contribute substantially to LUTS. In summary, future research is needed to define specific genetic and environmental mechanisms that underlie the development of these symptoms and conditions associated with LUTS.

Source: Heritability of Lower Urinary Tract Symptoms in Men: A Twin Study. Afari N, Gasperi M, Forsberg CW, Goldberg J, Buchwald D, Krieger JN. J Urol. 2016 Jun 13. pii: S0022-5347(16)30597-3. doi: 10.1016/j.juro.2016.06.018. [Epub ahead of print]

Low serum testosterone level predisposes to Artificial Urinary Sphincter cuff erosion The investigators examined the association between decreased serum testosterone levels and Artificial Urinary Sphincter (AUS) cuff erosion. They evaluated serum testosterone levels in 53 consecutive patients. Low testosterone was defined as < 280 ng/dl and found in 30/53 patients (56.6%). Key articles

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At the AUA the panel reiterated the statement already included in the relevant Guidelines recently updated where alpha-blockers are recommended for distal ureteric stone of 5-10 mm in size

More interestingly, authors mentioned the outcomes of panel discussions held in both the Annual EAU and AUA meetings: in the former, some criticisms were raised with respect methodology followed in the largest of the three studies, especially when considering that speed of stone passage was not assessed and that a powered sub-analysis for patients with > 5 mm stones was not performed. On the other hand, it was recognised that the small size of the single-centre studies included in previous meta-analysis could likely show a more extensive treatment effects than large multicentric RCTs can do. As a result, MET was still recommended but with the view to reconsider the statement at the time results from a further ongoing large RCT will be available. At the AUA the panel reiterated the statement already included in the relevant Guidelines recently updated where alpha-blockers are recommended for distal ureteric stone of 5-10 mm in size. It is interesting to note that this latter position has been finally the one officially endorsed in the conclusion of the EAU paper. Most noteworthy, the need to further counsel patients about the not-yet-proven beneficial effect of an already off-label medication (alpha-blocker) was also highlighted. On the other hand, while this may sound as a protective but necessary approach, it may raise further concerns on practitioners: just to give an easy case, it may be quite hard to prescribe to a young female patient a medication which usually is prescribed for elder and male patients with enlarged prostate, and with no clear benefits for her stone…

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk

Advances in technique have included the selective arterial clamping (SAC) or even the clampless in an attempt to minimise the ischaemic insult when performing PN: it is well known that the longer the ischaemic period of health tissue, the higher the risk of irreversible loss of normal nephrons. These technical variants make more challenging the PN with standard main arterial clamping (MAC), especially for the identification and dissection of the selective artery (SAC) or for the bleeding during clampless PN which can also make resection difficult or not effective (clampless). However, two recent publications have questioned whether these techniques are worth the effort. In a propensity score matching multicentric study, Paulucci et al.1 have compared a group of patients undergoing SAC-PN with another one who received MAC-PN; this latter group was the result of the matching process from a pool of 589 MAC-PN cases adjusted for patients characteristics (age, sex, BMI, ASA, Charlson Comorbidity Index), tumour features (R.E.N.A.L. nephrometry score, tumour size), warm ischaemia time (WIT) and baseline eGFR. The final cohort consisted of 132 MAC-PN compared to 66 SAC-PN, and all procedures were roboticallyassisted: tumour size was < 3 cm (2.7 vs. 2.5 cm, respectively), mean warm ischaemia time was < 15 mins (14.1 vs. 14.9 mins, respectively) and percentage of warm ischaemia time < 25 mins was > 90% (93.2 vs. 92.4%, respectively).

Overall, results from these two studies may indicate that SAC-PN or clampless PN may not necessary translate to fewer traumas to health nephrons and better functional results...

After a mean follow-up time of 8.9 and six months respectively, authors did not find any difference in However, results from some recent large doublemain endpoints including surgical (complications and …but this is where we are, at least by now! blinded RCTs challenged previous findings showing hospital stay), oncological (positive surgical margins) no benefit from the drugs in question with respect to Sources: and functional outcomes. More specifically on this placebo for the overall passage rate of ureteral stones. 1. Medical Expulsive Therapy in View of Current latter regard, no differences were detected in the Discussion: The EAU Position in 2016. Turk C, post-operative period (i.e. within 30 days from This is one of the most striking discrepancies in Knoll T, Seitz C, Skolarikos A, Chapple C, surgery) in terms of percentage of eGFR changes and literature in the very last few years between outcomes McClinton S, et al. rates of acute kidney injury; similarly, no differences from systematic reviews and large RCTs which European urology. 2016 Aug 6. PubMed PMID: 27506951. were seen in the follow-up in terms of percentage of currently may cause significant confusion in the eGFR changes and progression to chronic kidney 2. Medical expulsive therapy in adults with clinical practice of urologists worldwide. disease. ureteric colic: a multicentre, randomised, In an attempt to provide support to and promote homogeneity in the clinical practice across the globe, the EAU has published a statement in European Urology regarding the formal position and view of the Association in this controversial topic1.

placebo-controlled trial. Pickard R, Starr K, MacLennan G, Lam T, Thomas R, Burr J, et al. Lancet. 2015 Jul 25;386(9991):341-9. PubMed PMID: 25998582.

3. Silodosin to facilitate passage of ureteral stones: a multi-institutional, randomized, double-blinded, placebo-controlled trial. After analysis of the evidence in literature, the authors Sur RL, Shore N, L'Esperance J, Knudsen B, highlighted that the results from the previous Gupta M, Olsen S, et al. meta-analysis were likely affected by the small size and heterogeneity of the RCTs included in the relevant systematic reviews.

European urology. 2015 May;67(5):959-64. PubMed PMID: 25465978.

4. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Annals of emergency medicine. Furyk JS, Chu K, Banks C, Greenslade J, Keijzers G, Thom O, et al.

It is a matter of fact that results from larger RCTs have been published only in the very last few months; by considering large RCT those studies with at least 200 patients, the authors identified three 2016 Jan;67(1):86-95 e2. PubMed PMID: 26194935. publications: Pickard et al. compared tamsulosin, nifedipine and placebo with regards the necessity of interventional stone removal within the 1,167 patients Selective arterial clamping recruited2. Sur et al. compared silodosin vs. placebo in 246 patients with distal ureteric stones and Furyk et and clampless partial al. randomised 403 patients to test the efficacy on nephrectomy: Are they really tamsulosin vs. placebo for the passage of distal 3,4 necessary? ureteric stone < 1 cm . All these three studies, regardless of the significant difference in the assessment of the primary end points, failed to show any benefit from the MET with respect to placebo. However, underpowered

Partial nephrectomy (PN) has been introduced for the treatment of small renal masses in order to spare nephrons of the affected kidney and reduce the risk of chronic kidney disease.

Main limitations of the study were its retrospective nature, small number of cases and limited follow-up time. These finding have been further challenged by another recent single institution study2 by Verze et al. which compared surgical, oncological and functional outcomes in patients with a high tumour complexity, defined as R.E.N.A.L nephrometry score ≥ 10. They identified a group of 68 patients undertaking laparoscopic unclamped PN which were compared with another group of 41 patients treated with a laparoscopic clamped PN. All baseline characteristics were comparable and mean tumour size was 4.7 and 5.1 cm, respectively for unclamped and clamped groups; the larger size of these tumours with respect to the Paulucci et al. study was due to the inclusion of several cT1b (n = 45 and 28, respectively) and even few cT2a (n = 1 and 1) tumours. Also in this case, authors were unable to find significant differences in terms of all the main variables in observations. The only statistical differences between unclamped and clamped groups were shown –as expected- for

EAU EU-ACME Office

European Urology Today

August/September 2016


the WIT (0 vs. 15.8 mins, p = 0) and for the estimated blood loss (165 vs. 121 follow-up mls, p = 0.018, respectively). Moreover, even if a drop of creatinine and eGFR levels were detected in the post-operative period for the clamped PN group, this difference disappeared at six-month follow-up. No changes of these parameters were recorded for the unclamped group of patients at any time point. Notably, the authors were able to achieve the TRIFECTA outcome (WIT ≤ 25 mins + no positive margins + complication Clavien grade < 2) in a high proportion of patients in both groups (94% vs. 90%, respectively for unclamped and clamped PN). Main limitations of this study were its retrospective and single-institution nature, small size of recruited patients and limited follow-up. Overall, results from these two studies may indicate that SAC-PN or clampless PN may not necessary translate to fewer traumas to health nephrons and better functional results: it appears that if WIT is limited to ≤ 25 mins -or even less, considering that in both studies mean WIT was around 15 minutes- the clamping of the main artery is not a determinant factor for functional outcomes, at least in the short-term follow-up time. It would be interesting to see whether these results will be confirmed in the long-term follow-up.

Sources: 1. BAP1 is overexpressed in black compared with white patients with Mx-M1 clear cell renal cell carcinoma: A report from the cancer genome atlas. Paulucci DJ, Sfakianos JP, Yadav SS, Badani KK. Urologic oncology. 2016 Jun;34(6):259

arm and 121 in ORP), as outcomes at this point were deemed statistically unchangeable.

Results of primary endpoints showed no benefit of RARP over ORP in terms of both functional and surgical outcomes...

PubMed PMID: 27324881.

Which are the benefits of robotic-assisted radical prostatectomy? Early results from first randomised controlled trial comparing robotic vs. open approach New technologies attract attention of both practitioners and patients simply with the notion that advances in technology imply advances in technique and outcomes. However, this paradigm does not always work and concerns may arise whether new technology is not just safe and effective but also cost-effective. Moreover, the introduction of new technology in surgery should follow standardised steps as by IDEAL recommendations1.

The outcome after living donor kidney transplantation is highly relevant, since recipient and donor were exposed to notable harm. Reliable identification of risk factors is necessary.

Baseline characteristics were comparable and patients were tested for functional, surgical and quality of life outcomes by reviewing medical records and scores from validated questionnaires at specific time-points.

366 living donor kidney transplants were included in this observational retrospective study. Relevant risk factors for renal impairment one year after transplantation and delayed graft function were identified with univariable and multivariable binary logistic regression and ordinal regression analysis.

Results of primary endpoints showed no benefit of RARP over ORP in terms of both functional and surgical outcomes: no significance difference was found for urinary continence recovery rates at six and 12 weeks post-surgery (71.10% vs. 74.50% and 82.50% vs. 83.80%, respectively). Similarly, no difference was shown for the recovery of potency (32.70% vs. 30.70%, 38.90% vs. 35%, respectively); however, no data were provided on the proportion of patients undergoing a nerve-sparing approach in the relevant arms. Though these rates can still change in the long-term follow-up, they are in contrast with those published in the previous meta-analysis2,3. Positive surgical margin rates for RARP and ORP were comparable in pT2 and pT3 prostate cancers (3% vs.2%, and 15% vs. 10%, respectively). Similar patterns were recorded for complication rates (4% vs. 9%) and physical and mental health (as by relevant questionnaires). Main advantages of RARP were found in some of the secondary end-points: length of operative time was longer in ORP patients (202 vs. 234, p < 0.0001), as well as longer hospital stay (1.55 d vs. 3.27d, p < 0.0001) even though the latter did not translate to a shorter time needed to return to work. Estimated blood loss was less for RARP but blood transfusion rates were equivalent; less pain was recorded in the immediate post-operative period (24 hrs and one week) but not at the successive time-points. Overall, this study is the first large randomised controlled trial showing no differences in the shortterm between RARP and ORP in functional and oncological outcomes; however, more conclusive data will be available once all patients will conclude the two years follow-up. Even though results of the study cannot be generalised as this was a single institution trial, it is the first providing more robust evidence with respect to the alleged advantages of robotic surgery. Indeed, it shows the benefits of the minimally invasiveness of the robotic approach; however, the most important factor for main surgical outcomes is the expertise of surgeons regardless of the approach.

Urological robotic surgery has been introduced almost In an era where costly technology may not be 20 years ago and has become popular, first in USA affordable everywhere in the world, this is good news and, eventually, in the rest of the world. for patients in need of high quality treatment and so long as expertise –rather than technology- is available. Regardless of obvious advantages for surgeons in terms of enhanced 3D vision and comfort when Sources: performing the procedures, the widespread use of 1. No surgical innovation without evaluation: the this technology has not been supported by robust IDEAL recommendations. McCulloch P, Altman evidence in literature in terms of clear benefits for DG, Campbell WB, Flum DR, Glasziou P, Marshall patients. The global financial crisis in recent years has JC, et al. Lancet. 2009 Sep 26;374(9695):1105-12. also highlighted the fact whether the robotic surgery PubMed PMID: 19782876. is cost-effective to the extent that it can justify the 2. Systematic review and meta-analysis of high cost for health providers with its purchase and studies reporting urinary continence recovery the maintenance involve. after robot-assisted radical prostatectomy. Attention has been mainly focused on roboticallyassisted radical prostatectomy (RARP) and major evidence from systematic reviews and meta-analysis of longitudinal non-randomised studies, showed advantages of RARP over open radical prostatectomy (ORP) in terms of early recovery in urinary continence and potency2,3. However, the first randomised controlled trial (RCT) comparing RARP vs. ORP has been published only very recently4. Published outcomes include ad interim results at 12 weeks of follow-up completed for 77% of the 326 recruited patients (n = 252 pts, 131 in RARP

Risk factors for renal impairment after living donor transplantation are male gender and donor age

A rigorous randomisation process was followed and data were recorded by third parties to minimised reporting bias. This was a single institution trial with two surgeons performing the radical prostatectomy with a significant and comparable experience in the relevant approach.

e9- e14. PubMed PMID: 26854086.

2. Perioperative and renal functional outcomes of laparoscopic partial nephrectomy (LPN) for renal tumours of high surgical complexity: a single-institute comparison between clampless and clamped procedures. Verze P, Fedelini P, Chiancone F, Cucchiara V, La Rocca R, Fedelini M, et al. World journal of urology. 2016 Jun 20.

Zajdlewicz L, et al. Lancet. 2016 Jul 26. PubMed PMID: 27474375.

84 patients (26.6%) suffered from renal impairment KDIGO stage ≥ 4 one year post-transplant; median estimated glomerular filtration rate was 35.3 ml/min. In multivariable ordinal regression, male recipient sex (p < 0.001), recipient body mass index (p = 0.006), donor age (p = 0.002) and high percentages of panel reactive antibodies (p = 0.021) were revealed as independent risk factors for higher KDIGO stages.

Warm ischemic time and waiting time need to be kept as short as possible to avoid delayed graft function After adjustment for post-transplant data, recipient male sex (p < 0.001), donor age (p = 0.026) and decreased early renal function at the first posttransplant outpatient visit (p < 0.001) were identified as independent risk factors. Delayed graft function was independently associated with long stay on the waiting list (p = 0.011), high donor body mass index (p = 0.043), prolonged warm ischemic time (p = 0.016) and the presence of preformed donor-specific antibodies (p = 0.043). Broadening the donor pool with non-blood related donors seems to be legitimate, but with due respect to careful medical selection, since donor age in combination with male recipient sex were shown to be risk factors for decreased graft function. Warm ischemic time and waiting time need to be kept as short as possible to avoid delayed graft function. Transplantation across HLA and ABO borders did not affect outcome significantly.

Source: Identification of patients at risk for renal impairment after living donor kidney transplantation. Kaltenborn A, Nolte A, Schwager Y, Littbarski SA, Emmanouilidis N, Arelin V, Klempnauer J, Schrem H. Langenbecks. Arch Surg. 2016 Aug 9. [Epub ahead of print]

Recipient obesity does not affect renal transplantation outcomes in a matched-pair analysis The epidemic of obesity has led to dilemmas facing all specialities caring for patients with chronic kidney disease and who must make decisions regarding whether or not the patient can undergo transplantation. The aim of the study was to assess the outcome of transplantation among obese compared to non-obese recipients. To minimize donor variability and bias, paired kidney analysis was applied.

Patients with a body mass index >30 who received transplants in the authors‘ unit between January 2000 Ficarra V, Novara G, Rosen RC, Artibani W, and December 2010 were selected. For the analysis, Carroll PR, Costello A, et al. European urology. 2012 only obese transplant recipients (OTR) and their Sep;62(3):405-17. PubMed PMID: 22749852. kidney donor pairs with a body mass index < 30 3. Systematic review and meta-analysis of (non-obese transplant recipients [NOTR]) were selected. A total of 37 pairs of patients were evaluated studies reporting potency rates after robotassisted radical prostatectomy. Ficarra V, Novara in terms of te graft function, patient and graft survival G, Ahlering TE, Costello A, Eastham JA, Graefen and number of complications. M, et al. European urology. 2012 Sep;62(3):418-30. PubMed PMID: 22749850. Groups did not differ with respect to sex and 4. Robot-assisted laparoscopic prostatectomy comorbidities. OTR were older than NOTR (53.1 vs. versus open radical retropubic prostatectomy: 46.02 years old, p < .05). One-year patient and graft early outcomes from a randomised controlled survivals were similar (100% vs. 97.29% and 100% vs. phase 3 study. Yaxley JW, Coughlin GD, 94.59% in OTR and NOTR, respectively). There were Chambers SK, Occhipinti S, Samaratunga H, no significant differences between OTR and NOTR

with respect to incidence of acute rejection (29.7% vs. 18.9%), delayed graft function (35.13% vs. 29.72%) and mean serum creatinine and estimated glomerular filtration rate assessed at discharge and after three, six and 12 months, respectively.

…obesity did not negatively influence patient and graft survival and that transplantation in obese patients should not be postponed.. OTR had a significantly longer hospitalization time (25.56 vs. 20.66 days; p < .05), and more often experienced wound breakdown (32.43% vs. 8.1%; p < .05) and new-onset diabetes after transplantation (57.14% vs. 6.25%; p < .05). The authors concluded that obesity did not negatively influence patient and graft survival and that transplantation in obese patients should not be postponed.

Source: Impact of Obesity on Renal Graft Function - Analysis of Kidney Grafts From the Same Donor. Wołyniec Z, Debska-Slizien A, Wołyniec W, Rutkowski B. Transplant Proc. 2016 Jun;48(5):1482-8. doi: 10.1016/j. transproceed.2015.12.135.

Risk factors for posttransplantation lymphoproliferative disease are recipient HLA A2 status, CMV and EBV infections/ reactivations and high initial tacrolimus dosage Post-transplant lymphoproliferative disorder (PTLD) adversely affects patients' long-term outcome. In a retrospective 1:1 matched-pair analysis including 36 patients with PTLD and 36 patients without PTLD after kidney or liver transplantation with matching criteria being age, gender, indication, type of transplantation and duration of follow-up, an analysis of potential risk factors was done. All investigated PTLD specimen were histologically positive for EBV. Risk-adjusted multivariable regression analysis was used to identify independence of risk factors for PTLD. The resultant prognostic model was assessed with ROC-curve analysis. Patients suffering from PTLD had shorter mean survival (p = 0.004), more episodes of CMV infections or reactivations (p = 0.042), and fewer recipient HLA A2 haplotypes (p = 0.007), a tacrolimus-based immunosuppressive regimen (p = 0.052) and higher dosages of tacrolimus at hospital discharge (p = 0.052).

This study suggests prognostic relevance for recipient HLA A2, CMV, and EBV infections or reactivations and strong initial tacrolimus-based immunosuppression Significant independent risk factors for PTLD were recipient HLA A2 (OR = 0.07, 95% CI = 0.01-0.55, p = 0.011), higher tacrolimus dosages (OR = 1.29, 95% CI = 1.01-1.64, p = 0.040) and higher numbers of graft rejection episodes (OR = 0.38, 95% CI = 0.17-0.87, p = 0.023). The following prognostic model for the prediction of PTLD demonstrated good model fit and a large area under the ROC curve (0.823): PTLD probability in % = Exp(y)/(1 + Exp(y)) with y = 0.671 - 1.096 × HLA A2-positive recipient + 0.151 × Tac dosage - 0.805 × number of graft rejection episodes. This study suggests prognostic relevance for recipient HLA A2, CMV, and EBV infections or reactivations and strong initial tacrolimus-based immunosuppression. Patients with risk factors may benefit from intensified screening for PTLD.

Source: Matched-pair analysis: identification of factors with independent influence on the development of PTLD after kidney or liver transplantation. Rausch L, Koenecke C, Koch HF, Kaltenborn A, Emmanouilidis N, Pape L, Lehner F, Arelin V, Baumann U, Schrem H. Transplant Res. 2016 Aug 2; doi: 10.1186/s13737-0160036-1.

Key articles

August/September 2016

European Urology Today

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www.esulasers16.org

www.esufemale16.org

3rd ESU Masterclass on Lasers in urology

9th ESU Masterclass on Female and functional reconstructive urology

In collaboration with the EAU Section of Uro-Technology (ESUT)

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

3-4 November 2016, Barcelona, Spain EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

17-18 November 2016, Berlin, Germany EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

1st ESU-ESUT Masterclass on Focal therapy for localised prostate cancer 8-9 December 2016, Paris, France www.esufocaltherapy16.org New and the first of its kind, the ESU-ESUT Masterclass on Focal therapy for localised prostate cancer will be an intensive and interactive program dedicated to Focal Therapy (FT). This premier masterclass will provide a comprehensive review of the rationale for FT and the modalities of patients selection. Focal therapy is a hot topic FT is an alternative to radical treatments in the management of localised prostate cancer (PCa). This treatment option reduces the occurrence of side effects and toxicity associated with tissuepreserving approaches. Several studies have shown promising oncological results of FT with a limited failure rate within the short and intermediate term. And in case of failure, different possibilities of salvage treatment are still possible to cure the patient, such as surgery. Core aims and objectives The inaugural masterclass aims to review the appropriateness of FT according to the characteristics of a patient’s cancer. The results of this therapy is dependent on respecting the indications and the modalities of treatment. Course Director Dr. Eric Barret said, “We want to offer an à la carte approach to patients and avoid giving all the treatments applicable to their cancer.” New developments Updates and upgrades of current treatment and technology will be covered in the masterclass such as new techniques in biopsy which is an improvement in the PCa diagnosis. The new modalities of treatment with new tools that will improve accuracy of treatment will also be introduced. And the development of new energies, such as athermal energies, to further limit the risks of side effects will be announced.

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European Urology Today

Apply now!

Dr. Eric Barret Course Director

Functionality The practical side of this masterclass will be dedicated to the technical approach of diagnosis and treatment. Imaging is in tumour detection is important, therefore mpMRI modalities and different tools (e.g. MRI fusion software that is used in improving the diagnosis of PCa with targeted biopsies) will be examined. Several energy sources suitable for treatment such as cryotherapy, high-intensity focused ultrasounds (HIFU), brachytherapy, interstitial laser, vascular photodynamic therapy or the irreversible electroporation, will also be studied. Additionally, post-treatment monitoring, failure diagnostic and management will be considered as well. More learning tools For optimal understanding and for practice, pre-recorded videos of targeted biopsy and focal ablative treatments using HIFU, cryotherapy and brachytherapy will be played and reviewed during the masterclass. Moreover, hands-on-training sessions will be provided by experts in the field. Challenges, solutions and the future “The most challenging part of using FT is to target the right area where the cancer has been identified. New imaging modalities and new ways of targeting tissue, such as robotic techniques, should help us to improve results in a near future. With a significant improvement in imaging and energy, we can expect a significant decrease in radical treatment in the coming five to ten years,” said Dr. Barret. The 1st ESU-ESUT Masterclass on Focal therapy for localised prostate cancer will take place from 8 to 9 of December in Paris, France. There is limited space available. Apply now via www.esufocaltherapy16.org

August/September 2016


European Urology Forum 2017 Challenge the experts 4-7 February 2017, Davos, Switzerland Assoc. Prof. Christian Gratzke

Prof. Morgan Rouprêt

Leading urologists from every subspecialty will come together to deliberate and brainstorm at the highly anticipated ESUDavos17 meeting. To be set in the heart of the Swiss Alps, the meeting will take place from 4 to 7 February 2017 in Davos, Switzerland. Reasons to attend ESUDavos17’s comprehensive programme will include the latest developments in urological technologies, state-ofthe-art sessions and the “Urological Challenge”, which is exclusive to the meeting.

challenger and current ESU Davos faculty member, Dr. Morgan Rouprêt (Pitié-Salpêtrière Hospital, Paris) recalls, ‘’The first time I participated in the Urological Challenge was 2013. I was awarded as the winner after I presented three eclectic and different topics. I focused deeply on the challenge like anyone would for a race or a sport competition. I kept on improving my presentation every chance I got. As they say, the devil is in the details.”

The meeting is known for its intimate setting, intensive sessions and informal atmosphere. Former challenger and current ESU Davos faculty member Assoc. Prof. Christian Gratzke (Ludwig-Maximilians-University Munich) says, “The beauty of the Davos meeting is that it’s a unique blend of high-level, quality sessions with a laid back feel to it. The meeting may be relatively small but it was a good experience every time. Everyone made sure you did your best. We got along so well that I still have good contact with my fellow challengers up until now.”

Advice to future challengers As participants who have experienced the challenge firsthand, Prof. Gratzke and Prof. Rouprêt give their advice. “Talk about topics you’re truly interested in and not what others think is relevant. I remember a challenger who presented three topics in infectiology. Even though those topics were not exactly ‘mainstream’, you could tell that he knew what he was talking about. He was passionate about it. And ultimately, he made a very good impression,” says Prof. Gratzke. Prof. Rouprêt adds, “Believe in yourself and rise to the occasion. Don’t shy away; you have something to say so make sure it’s heard.”

What is the Urological Challenge? ESU Davos’ “Urological Challenge” is when up-and-coming urologists present their topics to a panel of experts which is then deliberated with counterarguments. Another former

Register now at www.esudavos17.org Expand your knowledge At the ESU Davos meeting, there are various sources that enhance your knowhow. “There is a lot to learn from everyone; from the challengers, the jury, to the audience members. It’s not because you do something in your institution and you do it well that it’s suitable for each and every patient. This is the kind of meeting where you can learn from the experiences of everybody and acquire meaningful information that you can bring home to your daily practice. ESU Davos comes with a warm, relaxed and open-minded atmosphere where every expert is available for discussion,” says Prof. Rouprêt. The upcoming ESU Davos meeting will take place from 4 to 7 February 2017 in Davos, Switzerland. Please note that there is limited space available.

www.esudavos17.org

Preliminary ESU programme in London ESU Courses Adrenals • Advanced course on upper tract laparoscopy (UPJ, adrenal and stones) • Adrenalectomy Andrology • Office management of male sexual dysfunction • The infertile couple - Urological aspects Female Urology • Prolapse management and female pelvic floor problems • Advanced vaginal reconstruction Infections • Dealing with the challenge of infection in urology Kidney transplantation • Renal transplantation: Technical aspects, diagnosis and management of early and late urological complications Male LUTS • Management of BPO: From medical to surgical treatment • Post-surgical urinary incontinence in males Neurogenic and non-neurogenic voiding dysfunction • Chronic pelvic pain in men and women • General neuro-urology • Lower urinary tract dysfunction and urodynamics • Video and imaging urodynamics

#EAU17

August/September 2016

Paediatric urology • Paediatric urology for the adult urologist: A practical update Penis/testis • Testicular cancer • Penile diseases Prostate cancer • Robot-assisted laparoscopic prostatectomy • Retropubic radical prostatectomy – Tips, tricks and pitfalls • Focal treatment in prostate cancer • Surgery or radiotherapy for localised and locally advanced prostate cancer • Prostate cancer imaging: When and how to use it • Screening and active surveillance – where are we now • Prostate biopsy - tips and tricks • Metastatic prostate cancer Renal tumours • Robot renal surgery • Small renal masses: From concepts to tips and tricks in daily management • Advanced course on laparoscopic nephrectomy • Surgery for renal cancer beyond minimally invasive approaches : Opportunities and limits Stones • Percutaneous nephrolithotripsy (PCNL) • Update on stone disease • Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips and tricks, indications

ESU Hands-on Training Courses Trauma • Urinary tract and genital trauma Unclassified and miscellaneous topics • An introduction to social media: Why this is important for urologists • Evaluation of risk in comorbidity in onco-urology • How to proceed with a haematuria • How to write a manuscript and get it published in European Urology • Surgical anatomy • Ultrasound in urology • Laparoscopy for beginners • Update renal, bladder and prostate guidelines 2017. What is changed? • A tool-kit for practising evidence based urology • Basic surgical and endo urological skills Urethral strictures • Advanced course on urethral stricture surgery Urothelial tumours • Practical management of non-muscle invasive bladder cancer • UTUC: Diagnosis and management • Laparoscopic and robot-assisted laparoscopic radical cystectomy • Management and outcome in invasive and locally advanced bladder cancer • Nerve-sparing cystectomy and orthotopic bladder substitution - Surgical tricks and management of complications

www.eau17.org

Robotic surgery • ESU/ERUS HOT in Robotic surgery intro course • ESU/ERUS HOT in Robotic surgery advanced virtual robotic procedural training Laparoscopy • ESU/ESUT HOT in Laparoscopic suturing (anastomosis) • ESU/ESUT HOT in Basic laparoscopic skills (E-BLUS training) • E-BLUS exam Diagnostics and follow-up • ESU/ESFFU HOT in Urodynamics • ESU/ESUT HOT in Fluorescence guided laparoscopic surgery • ESU/ESUT/ESUI HOT in MRI fusion biopsy Functional urology • ESU/ESFFU HOT in Women's health • ESU/ESFFU HOT in OnabotulinumtoxinA administration for OAB • ESU/ESFFU HOT in Sacral neuromodulation procedure standardisation Endoscopy • ESU/ESUT HOT in Transurethral therapy of LUTS - bipolar TURP • ESU/ESUT HOT in GreenLight laser vaporisation • ESU/ESUT HOT in HoLEP • ESU/ESUT HOT with Thulium laser for vaporesection of prostate • ESU/ESUT/EULIS HOT in Ureterorenoscopy

European Urology Today

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Education Online Education Online Improve your skills:

Improve your skills: e-learning at your own convenience e-learning at your own convenience

Guidelines E-Course Prostate Cancer (CME 3 credits) & Renal Cell Carcinoma (CME 2 credits) Guidelines E-Course Prostate Cancer (CME 3 credits) & Renal Cell Carcinoma (CME 2 credits) Risk profile-oriented management of BPE/LUTS Risk profile-oriented management of BPE/LUTS

(CME 1 credit) (CME 1 credit)

Overactive bladder: onabotulinumtoxinA as treatment Overactive bladder: onabotulinumtoxinA as treatment Overactive bladder: mechanisms & management Overactive bladder: mechanisms & management Non-Muscle Invasive Bladder Cancer Non-Muscle Invasive Bladder Cancer

(CME 2 credits) (CME 2 credits)

(CME 1 credit) (CME 1 credit)

(CME 2 credits) (CME 2 credits)

uroweb.org/education uroweb.org/education EAU Surgery in Motion School starts in September Available soon in your mobile device, tablet or pc Don’t miss it- we are officially launching our new platform, the Surgery in Motion School, at the annual EAU Robotic Urology Section (ERUS) meeting on 14-16 September. In this innovative video platform, surgical procedures in robotics, laparoscopy, endourology lower and upper urinary tract will be explained step-by-step. In a later stage, open surgery will also be added to this platform. We offer monthly updates on special techniques, tips and tricks and complications management. At your own pace and convenience, this online platform is readily accessible regardless of location and you can easily navigate, compare and share with your colleagues various procedures and techniques demonstrated by the best surgeons. A multifunctional platform, the EAU Surgery in Motion School is designed to complement your skills training. Join this innovative, online tutorial!

Improve your surgical skills with top notch videos of urological procedures performed by the best surgeons in the world

• Easy navigating by organ, procedure and/or technique • Step by step explanation in videos of 1-2 minutes • Compare different techniques and different surgeons • Connect, share and learn with colleagues

www.surgeryinmotion-school.org surgeryinmotion.org/school is a collaboration of Surgery in Motion School

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European Urology Today

A. Mottrie Editor of the EAU Surgery in Motion School

J. Palou President of ESU

J. Catto Editor of European Urology

Surgery in motion School will be available at: www.surgeryinmotion-school.org And is also available through the webpage of the European School of Urology (ESU): https://uroweb.org/education/ EAU members with an active membership automatically have access to all the content on the Surgery In Motion School platform. If you do not have an EAU membership or if you registered through the Surgery In Motion School website, please contact us to request an access key. All requests will be reviewed and if your request is approved, you will receive an email with your access key. This access key is linked to your account. In the near future we will implement the possibility to purchase a subscription to the Surgery In Motion School.

Surgery in Motion School is a collaboration of

August/September 2016


Salzburg Masterclass 2016: Bridging various viewpoints Fellows appreciate compact, insightful programme Dr. Bohdan Bidovanets Ternopil Regional Oncology Clinic Dept. of Surgery Ternopil (UA) bbidovanets@ gmail.com

Thirty-six fellows, not only from Europe, but also from Asian, Central America and Africa, attended this year’s ESU-Weill Cornell Masterclass in Urology. The scientific program included current issues in uro-oncology such as the controversies of organ- sparing in kidney cancer surgery and the treatment of locally advanced and metastatic stages including ablative technics.

The new contemporary classification of renal tumors was presented. Other topics were the benefits of prostate cancer surgery and radiotherapy in locally advanced and metastatic stages including ablative therapies and modern approaches in managing testicular cancer. Special attention was dedicated to penile cancer – its initial evaluation, epidemiology and management, particularly surgical therapies. Genomics and biomarkers in genitourinary cancer were very interesting due to the manifold evolution or changes in this field. During the last two days we

Excellent lectures in the morning presented by true experts in the field

discussed andrology issues and male infertility such as the role of varicocele, testosterone deficiency, erectile dysfunction and Peyronie’s disease, including their evaluation and management (surgical and medical). The masterclass also included case presentations by the fellows where we discovered different approaches to genitourinary diseases management and which enabled us to share our own experience. Certainly, this part of the masterclass provided very good training for us with regards presenting conference reports. Some of the reports were provocative that discussions even continued during our meal and free time. Regarding the social programme, we were treated to a great chamber music concert by Tatjana Meyer (piano) and Erin Snell (soprano) who performed some pieces from G. Puccini, R. Schumann, R. Strauss, A. Dvorák and of course W.A. Mozart. Yes, with Salzburg as Mozart’s birthplace we visited several places associated with Mozart’s life.

Hands-on training really enhanced the participants' skills

I would like to thank all members of the organisation committee and our faculty: Professors W. Aulitzky, P.N. Schlegel, H. Van Poppel, W. Albrecht, A. Bjartell, J. Hu, T.E. Keane, S. Pfeifer, A. Salonia, and Drs. W. Loidl, P. Macek and T. Tokas. We had a great time meeting new friends, sharing our opinions and gain knowledge and skills in urology while enjoying the beauty of Salzburg.

Veteran teachers inspire young urologists Nepalese view: Masterclass makes a difference in careers of young doctors Dr. Kiran Jang Kunwar Tongji Medical College of Huazhong University of Science and Technology Dept. of Urology Wuhan (NP) kjk_kunwar@ hotmail.com I am from Nepal, a small nation between two Asian giants China and India. Although Nepal is also known for Mt.Everest and the birthplace of Buddha only recent natural calamities have brought attention to my country in international news headlines. Thus, my selection to the ESU-Weill Cornell Masterclass by the European School of Urology (ESU) brought tremendous joy as I would be learning from

the likes of Professors Peter Schlegel, Hein Van Poppel, T. Keane, W. Loidl, W. Albrecht and A. Salonia, among many others, who are all pioneers and renowned experts. The programme opened with a welcome reception where American-Austrian Foundation (AAF); Director- Prof. Wolfgang Aulitzky met all the fellows and encouraged us to actively communicate with cofellows and the faculty. The backbone of the masterclass were the update lectures from the faculty and the discussions that followed. The follow-up sessions with case presentation by the fellows and thorough detailed discussions were also unique and insightful. The Hands-on Training for Laparoscopic Skills were other major highlights. The five-day course covered uro-oncology, infertility and andrology, among other topics. The sponsors and organisers also extended generous support by offering to pay for the costs of the

Impressions and reflections Multiple viewpoints in a unique masterclass Fresh perspectives in a multicultural setting I really enjoyed the case presentations session. Each Dr. Wally Mahfouz Alexandria University Dept. of Genitourinary Surgery Alexandria (EG)

"I had the pleasure to attend this extraordinary masterclass. The venue was Salzburg, an extraordinary elegant city which should be visited more than once in a lifetime. Thirty-six candidates from around the world were selected to attend this masterclass. We stayed at Schloss Arenenberg, located near the city center. From the moment of our arrival everything was well prepared and organized. Accommodation, instructions, program and the hospitality were superb. The faculty members were among the top experts from Europe and the US. The masterclass was not only compact and concise but also provided updates. The interactive discussions encouraged the participants to comment and actively join the discussions. The faculty members were not only cordial but also responded to every question that was asked. Oncological topics included renal tumors, prostate, testicular and penile cancers and genomics. Andrology topics included male infertility and male sexual dysfunctions. We participated in hands-on laparoscopy training sponsored by Olympus. It really enhanced our skills and the training was structured based on the partcipants’ level of expertise and training. August/September 2016

participant presented an interesting urological case including symptomatology, diagnosis and treatment offered. Mishaps were mentioned and the frank discussions were sometimes animated which even involved the faculty members. It was a very successful masterclass where I gained knowledge and I would recommend it to all young urologists. My thanks to all faculty members: Professors Peter Schlegel, Hein Van Poppel, Walter Albrecht, Anders Bjartell, Jim Hu, Thomas Keane, Wolfgang Loidl, Samantha Pfeifer, Andrea Salonia and lastly, special thanks to Prof. Wolfgang Aulitzky."

A masterclass that goes beyond borders Dr. Remigius Andrew Benjamin Mkapa Hospital Dept. of Urology Dodoma (TZ)

"Participating in this year’s ESU-Weill Cornell Masterclass in Urology was one of the best ever experiences in my carrier as a urologist. The course opened with a welcome reception hosted by Prof. Autzliky Wolfgang and all the faculty members. One of the main themes throughout the week included updates and experience on management of urological cancers such as testicular, renal, penile and prostate cancer and male infertility.

participants. Without the financial support (lodging, food and travel reimbursements) it would have be impossible for me to attend. Not only am I impressed with the efficient organisation but the masterclass was a wonderful oppurtunity to make new friends with the participants coming from Eastern Europe, other parts of Asia, North America and Africa, making this course a truly international gathering. With Prof. Van Poppel when saying goodbye

Indeed, the Open Medical Instiute (Salzburg Medical Seminars International- SMSI), with its sponsorship of the masterclass, fulfills a vital role and contribution to medical teaching and learning. This programme by the AAF foundation will certainly help a lot of young urologists early in their careers. Such generous philantrophy reminded me of a well-known Nepalese proverb which says: ‘Knowledge that goes to the grave without passing to others is a waste too.” I thank the ESU and AAF for this wonderful opportunity of knowledge-sharing which definitely

The workshop which featured case presentations by the fellows was fantastic and well organised and served as an eye opener regarding the management of urological patients in different countries. I presented a case on testicular tuberculosis and received enthusiastic comments from my co-fellows. The discussion also prompted us to share our hospital experiences. We had afternoon sessions on laparoscopic training (hands-on) with the tutors providing all the help we needed. I learned various laparoscopic techniques and the exposure I got will help me in my carrier and provided inspiration to seek more training in laparoscopy. The course ended with a post-seminar test and a graduation dinner. I thank the faculty for all excellent lectures and discussions. We were also provided with learning materials such as CDs and hard copies which I will share with colleagues back home in Tanzania. The week in Salzburg was certainly a memorable week, enabled me to make new friends and contacts. My heartfelt thanks to the AAF for their contribution to quality continuing medical education that goes beyond borders."

Learning from the experts

will inform and shape the direction of my career. My heartfelt thanks to Professors Peter Schlegel, Hein Van Poppel and Thomas and my co-fellows participants for showing concern about Nepal particularly in the light of the recent devastating earthquake. Prof. Wolfgang Aulitzky’s encouragement to apply for observership and a parting hug from Prof. Van Poppel have inspired me to serve back home with dedication and has motivated me to work hard and boost the influence of urology.

"It's a blessing that people like Dr. Schlegel, Dr. Pfeifer and Dr. Salonia exist, who succeed in managing these seemingly chaotic data and shape them into thoughtful, honest and comprehensive lectures." Dr. Taras Shatylko, Russia presented case discussions which prompted enthusiastic discussions on diagnostic approach and therapy options. One remarkable feature of this masterclass was its truly international audience with fellows from almost 30 different countries who shared various viewpoints and experiences. There was also easy access to faculty members, enabling the participants to discuss issues or ask follow-up questions. Other benefits included the fully covered expenses including meals, accommodation and travel costs with sponsorship from the European School of Urology. There was also laparoscopic hands-on training. I certainly will recommend this masterclass to all young urologists."

Dr. Francisco Dos Santos Botelho Hospital de Braga Dept. of Urology Braga (PT)

"I was very lucky to be selected to attend the ESU/ Weill Cornell Master Class in Urology held from June 26 to July 2 this year in Salzburg, Austria. We had excellent lectures in the morning presented by true experts in the field. Discussions of practical issues which are encountered in daily practice followed every lecture. In the afternoon the participants

"It's Salzburg, birthplace of Mozart! That's where the inspiration is born!"

European Urology Today

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ESU Course in Romania ESU Course covers key updates in PCa management Dr. Radu Constantiniu General Secretary Romanian Association of Urology Fundeni Clinical Institute Bucharest (RO) raduconstantiniu@ gmail.com

cancer management, male infertility and hypogonadism. Meanwhile, Dr. Gandaglia provided updates and assessed recent developments in high-risk PCa, castration-resistant PCa, and treatment options for recurrent PCa following initial radical surgery. Both speakers shared high-quality content, visuals and clear messages, and also provided a balanced perspective on various issues. They also commented and assessed current and ongoing studies. Notably, the speakers also provided examples of management that adhere to the latest updates in the EAU Guidelines.

An ESU Course was recently organised as part of the Romanian National Congress of Urology (Romuro 2016) last June 10 in Bucharest.

www.esubpo17.org

2nd ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction 19-20 May 2017, Heilbronn, Germany EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

In line with the format of the 16 courses held in previous years, the full-day course covered topics such as current approaches in managing high risk prostate cancer (both diagnostic criteria and treatment strategies), novel treatment options in castrationresistant prostate cancer (PCa), treatment options for recurrent PCa after radical surgery, the management of primary penile cancer, male infertility in urogenital The annual ESU course draws high attendance cancers, as well as treatment options in male infertility and hypogonadism. Among the speakers were Dr. Suks Minhas (UK) â&#x20AC;&#x201C; interim Course Director who took over from Dr. Goran Ahlgren (SE) â&#x20AC;&#x201C; and Dr. Giorgio Gandaglia (IT). Dr. Minhas addressed current developments in penile

Mr. Minhas speaking on penile cancer

The conferences led to dynamic discussions between the faculty and audience, particularly during the case presentations. Two cases of distant recurrence after radical prostatectomy for localised prostate cancer were debated after the morning session, while the afternoon session ended with discussions on two cases of male infertility (a case of obstructive azoospermia, and another on bilateral varicocele), with both successfully treated using a bilateral microsurgical approach. To sum up, the organisers deeply appreciate the add-on value of the ESU courses, which respond to the needs of both academe-based and practising urologists in our community. We also extend our thanks to the EAU Central Office represented by course secretary, Melissa Van Der Krieke, for her efficient support.

www.esusalzburg17.org

www.esuurolithiasis17.org

ESU - Weill Cornell Masterclass in General urology

1st ESU-ESUT Masterclass on Urolithiasis 16-17 June 2017, Athens, Greece EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

9-15 July 2017, Salzburg, Austria EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

New Masterclass!

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European Urology Today

August/September 2016


23rd Slovak Urological Society Annual Conference ESU Course attracts high attendance in Žilina Assoc. Prof. Ivan Mincík Chairman, Urology Dept. President, Slovak Urological Society Prešov (SK) mincik.ivan@ gmail.com The 23rd Annual conference of the Slovak Urological Society (SUS) was held last June 15 to 17 this year in Žilina with the scientific programme addressing controversial issues and current trends in urology. During the opening session, the Slovak Urological Society paid a tribute to Prof. Michal Hornák who passed away on June 12. The former president of the Czechoslovak and Slovak Urological Societies, Prof. Hornák was well-known for his research studies in onco-urology.

Prof. Michal Hornák, former president of Czechoslovak a Slovak Urological Societies (16.11.1929 - 12.6.2016)

Scientific programme The structure of the scientific programme allowed sufficient time for the poster sessions, with presenters using electronic posters followed by a short Q&A. The programme took up onco-urology, functional urology, results of laparoscopic surgery of kidney tumours, complex endourological procedures and a discussion on the development of robotic surgery in Slovakia.

Currently, there is only one DaVinci robotic system, which is certainly not sufficient to serve the growing number of patients. Since we believe that minimally invasive surgeries of the kidney and prostate will be the main therapeutic method for onco-urological patients, we plan to have at least five fully equipped centres for the estimated 5.5 million Slovak population.

Urological Society lecture; the Polish Urological Society lecture on Radium 223 in mCRPC- A urologist perspective, given by P. Chlosta (PL); the Hungarian Urological The Scientific Programme consisted of 72 lectures Society lecture on the which were presented in eight sections, six sponsored role of intraoperative frozen section to symposia and a European School of Urology (ESU) course. Distinguished guest Prof. Hein Van Poppel, improve nerve sparing who represented the European Association of Urology, rates in radical gave a very interesting EAU lecture on high-risk and prostatectomy by locally advanced prostate cancer (PCa) and argued for P. Tenke (HU); Endoscopic management Awarding ceremony of the Prof. Vladimír Zvara Medal. From left: SUS president Assoc. Prof. I. the case of surgery. He gave an overview on the Mincík, Prof. J. Kliment, Prof. J. Švihra, scientific secretary and J. Mikuláš, president of the 23rd current treatment status for this group of PCa patients of non-muscle invasive Annual SUS Conference and highlighted that the main aim of therapy are both bladder cancer: oncological and functional results. He noted that open Innovations in Imaging and minimaly invasive procedures both have the same by C. Riedl (AT) and support we will certainly pursue the active links with results. Van Poppel also discussed the cooperation intraprostatic injection presented by P. Zvara (DK). the ESU in the future. between the SUS and the EAU. As an EAU executive Young Slovak and Czech urologists presented their member responsible for the Guidelines Office, he lectures such as: Current trends and changes in the During annual conference the SUS awarded its pointed out that all 28 national EAU members have conservative and surgical treatment of LUTS / BPH highest honour to Prof. Ján Kliment with the Professor one strong voice, especially when dealing with the presented by S. Vachata (CZ), and the Slovak Urological Vladimír Zvara Medal. Prof. Kliment, chairman of the European Union, the Commission and the European Urology Department in Martin, was the former SUS Parliament regarding improvements in urological care. Society lecture on complex endoscopic treatment of upper urinary tract stones by V. Kovacik (SK). president from 2010 to 2014. The award is given to urologists who have significantly contributed to Renowned speakers presented the latest findings in We also note the attendance of the Czech urologists urological advances in academic and clinical work. the following topics: Retropubic, laparoscopic and For the 23rd annual conference, there were around robot-assisted radical prostatectomy, comparison and whose active participation are not only beneficial to the scientific and professional level of the conference, 385 registered participants (250 urologists and 135 results, presented by M. Brodák (CZ) for the Czech but also reflected the friendly links among Slovak and nurses). With the number of participants, we note the Czech urologists who, until recently, worked in one growing success of the annual SUS conference, taking country. The conference was attended by 33 Czech into account that in 2015 the total number of urologists, majority of them members of the Czech registered SUS members was recorded at 321. Urological Society Board. We also welcomed the representatives of the Polish, Hungarian and Austrian urological societies.

DaVinci

Horňák

Figure 1: Map of Slovakia locating the 21 urological departments. The robotic system DaVinci is localised in the central region of Banska Bystrica

From top left: Prof. Hein Van Poppel, Dr. P. Zvara, Assoc. Prof. M. Brodák, Prof. Gakis during his lecture

Bladder cancer issues The ESU Course has been prepared in collaboration with European Association of Urology. Profs. Gakis and Burger (both from Germany) presented five comprehensive lectures regarding the management of muscle invasive and metastatic bladder cancer. The lectures were followed by case presentations and discussion. The SUS highly appreciates the regular ESU courses since they offer a wonderful opportunity for us to compare diagnostic and treatment procedures with latest evidence-based outcomes. We also value the exceptional quality of the EAU Guidelines, and together with the ESU’s educational

The Urobend, whose members are all active urologists, performs during the social programme

Katowice hosts 46th PUA Congress ESU Course tackles updates in managing prostate cancer Dr. Anna Katarzyna Czech Dept. of Urology Jagiellonian University Hospital Krakow (PL) urologia@ cm-uj.krakow.pl The 46th National Scientific Congress of the Polish Urological Association was held in Katowice from 22 to 24 June 2016 and the Scientific Programme included the European School of Urology (ESU) course on locally advanced and metastatic prostate cancer.

the audience complemented the session. The European School of Urology (ESU) Course took place on the second congress day and covered locally advanced and metastatic prostate cancer. Prof. Nicolas Mottet discussed the surgical management of locally advanced prostate cancer, adjuvant and salvage treatment options for oligometastatic disease and presented the EAU Guidelines recommendations on locally advanced and metastatic prostate cancer. Dr. Inge Van Oort discussed the staging of metastatic disease and sequencing androgen ablation and chemotherapy in metastatic prostate cancer. The lectures were followed by interactive case presentations. Prostate cancer was thoroughly discussed with the experts looking into the challenges

Oganised by the new Board of the Polish Urological Association (PUA) headed by PUA President Prof. Piotr Chlosta, the congress gathered over 1,500 participants.

Prof. Piotr Chlosta

The first Congress day opened with a Live Surgery session, a first in the history of the PUA Congress. Laparoscopic radical prostatectomy was performed and presented by three Polish laparoscopic surgeons, namely: Professors Chlosta, Tomasz Drewa and Marcin Slojewski. Commentary and questions from

August/September 2016

Impressions of the ESU course

Live surgery on the first day of the PUA congress

and issues in castration resistance and chemotherapy. The ESU Course provided an excellent overview on locally advanced and metastatic prostate cancer management including the latest updates.

We are thankful to the EAU and ESU and we look forward to future collaborations. We also extend an invitation to the next PUA National Scientific Congress. European Urology Today

19


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4th Baltic Meeting in conjunction with the EAU

EAU 16th Central European Meeting

26-27 May 2017, Vilnius, Lithuania

7-8 October 2016, Vienna, Austria EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

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Call for Abstracts Deadline: 1 April 2017

Teaching activities 2016 - 2017 European School of Urology October 4

8 20 21 21 22 29

3rd Confederación Americana de Urologia Residents Education Programme (CAUREP), Panama City (PA) ESU course at the time of the EAU 16th Central European Meeting (CEM), Vienna (AT) ESU course on Assessment and management of LUTS at the national congress of the Czech Urological Society, Ceske Budejovice (CZ) ESU course on Stone disease at the national congress of the Russian Society of Urology, Ufa (RU) ESU course on Pelvic floor dysfunction; patient selection and surgery at the national congress of the Tunisian Urological Society, Hammamet (TN) ESU course on Localised prostate cancer at the Hellenic Urological Association, Rhodes Island (GR) ESU course on Bladder cancer at the national congress of the Hungarian Urologic Association, Debrecen (HU)

November 3-4

17-18 24

25 30

3rd ESU Masterclass on Lasers in urology, in collaboration with the EAU Section of Uro-Technology (ESUT), Barcelona (ES) 9th ESU Masterclass on Female and functional reconstructive urology, in collaboration with the EAU Section of Female and Functional Urology (ESFFU), Berlin (DE) ESU courses on Multidisciplinary approach to the management of genito-urinary cancers: A clinical scenario based interactive session with the experts and Challenging the last changes in the management of advanced and metastatic prostate cancer: Multidisciplinary approach at the 8th European Multidisciplinary Meeting in Urological Cancers (EMUC), Milan (IT) ESU course on Chronic pelvic pain and chronic prostatitis at the national congress of the Lithuanian Association of Urology, Vilnius (LT) ESU course on Urooncology at the national congress of the Egyptian Urological Association, Sharm El-Sheikh (EG)

May 2017 19-20

2nd ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction, Heilbronn (DE)

June 2017 16

16-17

July 2017 9-15

ESU course on Urolithiasis at the national congress of the Ukrainian Urological Association, Kiev (UA) 1st ESU-ESUT Masterclass on Urolithiasis, Athens (GR)

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

September 2017 1-6

15th European Urology Residents Education Programme (EUREP), Prague (CZ)

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December 8-9 17

1st ESU-ESUT Masterclass on Focal therapy for localised prostate cancer, Paris (FR) ESU course on Endourology and laparoscopy in urology at the national congress of the Georgian Association of Urology, Tbilisi (GE)

February 2017 4-7

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20

European Urology Today

www.cookmedical.com

Some products or part numbers may not be available in all markets. Contact your local Cook representative or Customer Service for details. © COOK 12/2014

D13907-EN

August/September 2016


MAGNOLIA Study: Call for proposals using biological samples EAU RF accepts applications to use biological samples in MIBC Clinical trial Prof. Bill Watson Conway Institute University College Dublin Dublin (IE)

william.watson@ ucd.ie

Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ uroweb.org

The MAGNOLIA study was a randomised, double blind, placebo controlled phase II trial to evaluate the safety and efficacy of recMAGE-A3 + AS15 CI in patients with MAGE-A3 positive muscle invasive bladder cancer after cystectomy. The EAU Research Foundation is inviting basic research applications to utilise the biological samples (Tissue – FFPE and fresh frozen, Blood – Serum and Urine) that were collected as part of the MAGNOLIA study.

randomised for recMAGE-A3 + AS15 ASCI versus one patient randomised for placebo, either directly after recovery from surgery, or after recovery from adjuvant chemotherapy. The treatment scheme consisted of five doses administered at three-week intervals followed by eight doses administered at three-month intervals for a total maximum duration of study treatment administration of 27 months.

The MAGNOLIA trial was open to male and female patients with histologically confirmed transitional cell carcinoma of bladder urothelium (T2,3 N0 or N1 or N2 and M0 disease or Stage T4 N0 M0 disease after cystectomy) with expression of the MAGE-A3 antigen, and who were free of residual disease and free of metastases.

During the study, we collected FFPE block samples of at least 10mm3 of the primary tumour - or in cases where the tissue block was not possible 20-25 unstained 10 µm slides and 1 unstained 5 µm slide of the primary tumour. Fresh tissue of the resected tumour (and in case of recurrence) was also collected. Blood samples (serum) at V1 (preadministration), V3, V5, V7, V8, V10 and concluding visit were collected. Urine samples prior to cystectomy (and in case of recurrence) have also been collected.

Study Design 84 patients were randomly assigned to two treatment schedules in a 2:1 ratio, two patients Figure 1: Study design

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

MAGE-A3 + AS15 cancer immunotherapeutic product Screening

Randomisation (2:1)

Concluding visit

Applications If you have interesting basic research proposals that will utilise these samples please contact: Dr. Raymond Schipper (PO Box 30016, 6803 AA Arnhem, The Netherlands, Tel: + 31 26 3890677, Fax: +31 26 3890679, e-mail: r.schipper@uroweb.org) for further details of the MAGNOLIA study, access to the sample data base which will inform you of the numbers and types of patients and samples available and an application form. Subsequently, the completed application form will be evaluated by the basic research committee of the EAU Research Foundation chaired by Bill Watson. Literature Marc Colombel, Axel Heidenreich, Luis Martínez-Piñeiro, Marko Babjuk, Igor Korneyev, Cristian Surcel, Pavel Yakovlev, Renzo Colombo, Piotr Radziszewski, Fred Witjes, Raymond G. Schipper, Peter F.A. Mulders, Wim P.J. Witjes. Perioperative Chemotherapy in Muscleinvasive Bladder Cancer: Overview and the Unmet Clinical Need for Alternative Adjuvant Therapy as Studied in the MAGNOLIA Trial. European Urology 65, p.509, 2014.

End of study

PLACEBO

Visit 1 – Visit 5 Doses: 1 – 5 Visits: every 3 weeks Day 0

Visit 6 – Visit 13 Doses: 6 – 13 Visits: every 12 weeks Week 12

Follow-up phase Visits: every 6 months

Week 120

max Year 5

EAU Research Foundation

EAU RF NIMBUS trial recruits 100th patient Study timelines/procedures adapted to daily urological practice and BCG availability Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ uroweb.org

Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ uroweb.org The NIMBUS trial assesses whether a reduced number of BCG instillations is not inferior to standard number and dose intravesical BCG treatment in patients with high grade non-muscle invasive bladder cancer (NMIBC). Intravesical instillation of BCG is a widely accepted strategy to prevent recurrence of non-muscle invasive bladder cancer. The most accepted treatment schedule is induction of BCG: weeks 1 through 6 plus maintenance (weeks 1,2,3) at months 3,6 and 12, but it is unknown how many administrations are really necessary. Scientific evidence supports the hypothesis that after an initial sensitisation to BCG antigens has occurred, the number of instillations can be reduced for a proper anamnestic immune response resulting in similar clinical efficacy and potentially less side-effects and costs. The NIMBUS study is a multicentre prospective, randomised, parallel group, not blinded, trial to compare the efficacy and safety of two different adjuvant treatment schedules: 1) Induction cycle BCG-full dose; weeks 1 through 6 plus maintenance cycles at months 3, 6 and 12 (wks. 1,2,3); total 15 full dose BCG instillations 2) Induction cycle BCG-full dose

(reduced frequency); weeks 1,2, and 6 plus maintenance cycles at months 3, 6 and 12 (wks. 1,3); total 9 full dose BCG instillations. The primary endpoint for inferiority analysis is time-to-first-recurrence. The secondary objectives are to identify if number and grade of recurrent tumours, rate of progression to a higher stage (T2 or higher) of the disease and safety, specifically the presence of treatment related toxicity > grade 2 differ between the two study arms. Study status As of press time (cut-off date 28 July 2016), 35 centres are initiated in Germany of which 21 sites randomised, in total, 66 patients. In the Netherlands 12 sites are initiated of which nine centres randomised in total 40 patients. Randomisation of French patients is expected to start in September/ October 2016. The United Kingdom will start up in the second half of 2016. NIMBUS study presented at the 31st Annual EAU congress An update of the NIMBUS study was presented at the Steering Committee meeting, European Investigator meeting, Independent Data Monitoring Committee (IDMC) meeting and the EAU Research Foundation Special Session, coinciding with the 31st Annual EAU Congress (12-15 March, 2016) in Munich, Germany. Figure 1: Number of patients recruited

The Steering Committee decided, taking into account the advice of the IDMC and the report of the Investigator Meeting, to fine-tune the protocol in a way that study timelines and study procedures are adapted according to daily urological practices and availability of BCG. Amendment protocol: • to include patients with abnormal laboratory values indicated to be not clinically significant by investigator, and to have no maximum age for inclusion: If the treating physician decides that the patient is clinically fit enough to receive BCG treatment, the patient is eligible for study participation.

Study team Protocol Committee: • Marko Babjuk, Prague • Luis Martinez-Pineiro, Madrid • Joan Palou Redorta, Barcelona • Anup Patel, London • Levent Türkeri, Istanbul • Marc-Oliver Grimm, Jena • Wim P.J. Witjes, Arnhem

National Coordinators: • Germany: Marc-Oliver Grimm • The Netherlands: Toine Van Der Heijden • France: Marc Colombel • United Kingdom: James Green • to include patients with incidental PCa in active • Spain: Luis Martinez-Piñeiro surveillance (without PCa treatment): • Italy: Andrea Tubaro • Czech Republic: Marko Babjuk Untreated localised prostate cancer will not have any clinically significant effect on the course of the disease • Turkey: Levent Türkeri under study. EAU Research Foundation: • to extend the recruitment period with one year: • Wim Witjes, Scientific and Clinical Research Director The worldwide shortage of BCG of the last two years has hampered the start-up of new sites/countries and • Raymond Schipper, Clinical Project manager accrual of the NIMBUS trial. Therefore, the recruitment • Christien Caris, Clinical Project manager period is changed from three to four years. N per arm • Ria Janzing, Clinical Research Associate and % power are adjusted accordingly; the total • Joke Van Egmond, Clinical Data manager • Hans Noordzij, Marvin Management Assistant number patients to be randomised is 824 patients at an acceptable power of 80%. Study Principal Coordinators: • Levent Türkeri Marmara University Medical School Istanbul, Turkey • Marko M. Babjuk Charles University 2nd Faculty of Medicine Prague, Czech Republic Are you interested to participate in the NIMBUS study? Please contact: EAU RF Central Research Office PO Box 30016, 6803 AA Arnhem, The Netherlands, Email: researchfoundation@uroweb.org Phone: +31 (0) 26 38 90 677 To find out more about the EAU RF and its ongoing projects, please visit www.uroweb.org/research

EAU Research Foundation

August/September 2016

European Urology Today

21


8th European Multidisciplinary Meeting on Urological Cancers

#EMUC16

Thursday 24 November 5th Meeting of the EAU Section of Urological Imaging (ESUI) ESU Course on Challenging the last changes in the management of advanced and metastatic prostate cancer: Multidisciplinary approach ESU Course on Multidisciplinary approach to the management of genito-urinary cancers: A clinical scenario based interactive session with the experts

· · Consolidating multidisciplinary strategies

24-27 November 2016, Milan, Italy

·

Friday 25 November ESU/ERUS HOT Robotic surgery ESU/ESUT/ESUI HOT MRI Fusion biopsy

· ·

Saturday 26 November ESU/ERUS HOT Robotic surgery ESU/ESUT/ESUI HOT MRI Fusion biopsy FALCON delineation contouring workshop

· · ·

·

Uropathology Training Workshop for clinicians

Sunday 26 November EAU Young Academic Urologists Meeting

·

More information can be found at www.emuc16.org

Scientific Programme Thursday 24 November EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) From the latest novelties to guidelines and protocols 14.30-14.40

Welcome and introduction Chairs: Urologist - A. Briganti, Milan (IT) Pathologist - R. Montironi, Ancona (IT) Urologist - J. N’Dow, Aberdeen (GB) Urologist - H. Van Poppel, Leuven (BE)

14.40-15.10

Latest novelties on the WHO morphological classifications of genitourinary cancers Pathologist - J. Epstein, Baltimore (US)

15.10-15.40

The 8th edition of the TNM staging (AJCC and UICC) of the genitourinary tumors: Implications from January 2017 and beyond Pathologist - M. Amin, Los Angeles (US)

15.40-17.30

15.40-15.55 15.55-16.10

16.10-16.25

16.25-16.40

16.40-16.55 16.55-17.10

17.10-17.30

Round Table: From morphology to personalised medicine in genitourinary cancers Kidney cancer Update on molecular pathology with clinical implications Pathologist - H. Moch, Zurich (CH) How to translate advances in molecular pathology into clinical practice? Urologist - B. Ljungberg, Umea (SE) Prostate cancer Update on molecular pathology with clinical implications Pathologist - C. Magi-Galluzzi, Cleveland (US) How to translate advances in molecular pathology into clinical practice? Urologist - N. Mottet, Saint-Étienne (FR) Urothelial carcinoma Update on molecular pathology with clinical implications Pathologist - A. Hartmann, Erlangen (DE) How to translate advances in molecular pathology into clinical practice? J. Catto, Sheffield (GB) Discussion

10.15-10.30

17.00-17.15

10.30-10.45

Combined or sequential systemic treatment for castration resistant disease? Medical oncologist - C. Sweeney, Boston (US) Discussion

17.15-17.45

Discussion

10.45-11.15

Coffee break and poster viewing

17.45-18.45

Industry session

11.15-13.00

Session 2: Focus on uro-genital cancer variants Chairs: Pathologist - E. Compérat, Paris (FR) Urologist - K. Touijer, New York (US) Medical oncologist - M. Schmidinger, Vienna (AT)

Saturday 26 November

11.15-11.45 11.15-11.30

11.30-11.45

11.45-12.15 11.45-12.00

12.00-12.15

12.15-13.00 12.15-12.30

12.30-12.45

08.30-10.45

08.30-08.45

08.45-09.00 09.00-09.15 09.15-09.30

09.30-09.45 09.45-10.00 10.00-10.15

22

Welcome and Introduction Medical oncologist - T. Powles (ESMO) Radiation oncologist - P. Hoskin (ESTRO) Urologist - H. Van Poppel (EAU) Radiologist - R. Oyen (ESUR) Pathologist - R. Montironi (ESUP) Session 1: How to use combination therapies in prostate cancer Chairs: Medical oncologist - S. Osanto, Leiden (NL) Radiation oncologist - T. Wiegel, Ulm (DE) Urologist - M. Wirth, Dresden (DE) Locally advanced and high risk prostate cancer How to optimize the use of adjuvant radiation therapy after radical prostatectomy: Integrating clinical and genomic features Urologist - R. Karnes, Rochester (US) What is the role of adjuvant systemic approaches after curative treatment? Medical oncologist - K. Fizazi, Villejuif (FR) What is the best multi-modal approach for node positive disease? Urologist - K. Touijer, New York (US) Salvage radiotherapy for locally recurrent disease: When and how? Radiation oncologist - G. De Meerleer, Ghent (BE) Discussion Metastatic prostate cancer Oligo vs polymetastatic prostate cancer: Distinct tumor entities? Urologist - A. Bjartell, Malmö (SE) When to use chemotherapy in hormone sensitive prostate cancer Radiation oncologist - N. James, Birmingham (GB)

European Urology Today

Renal cell carcinoma Variants of renal cell carcinoma: The pathologist’s point of view Pathologist - H. Moch, Zurich (CH) Variants of renal cell carcinoma: Clinical implications Medical oncologist - L. Albiges, Villejuif (FR) Bladder cancer Variants of bladder cancer: The pathologist’s point of view Pathologist - A. Lopez-Beltran, Lisbon (PT) Clinical implications of bladder cancer variants: The medical oncologist view Medical oncologist - M. De Santis, Coventry (GB)

12.45-13.00

Discussion

13.00-14.15

Lunch break and poster viewing

13.15-14.15

Industry session

14.15-14.30

When science meets the clinics: Genomic profiling in primary prostate cancer Medical oncologist - L. Garraway, Boston (US)

14.30-14.45

Best of Journals: Radiotherapy Chairs: Radiation oncologist - B. Pieters, Amsterdam (NL) Radiation oncologist - P. Ghadjar, Berlin (DE)

09.00-09.15

10.30-10.45 10.45-11.15

Coffee break and poster viewing

11.15-11.55

Oral presentations of the 6 best abstracts Chairs: Medical oncologist - A. Necchi, Milan (IT) Pathologist - H. Moch, Zurich (CH) Urologist - M. Wirth, Dresden (DE)

09.15-09.30 09.30-09.45 09.45-10.00 10.00-10.15 10.15-10.30

11.55-12.10

12.10-12.30

14.45-15.00

15.00-15.15

15.15-15.30

15.30-15.45

15.45-16.15

16.15-16.30 16.30-16.45

16.45-17.00

Lecture: The role of micro-environment in GU cancers Chair: Medical oncologist - L. Garraway, Boston (US) Speaker: Biochemist - G. Van der Pluijm, Leiden (NL) A focus on consequences of pelvic radiotherapy Chairs: Radiation oncologist - P. Hoskin, Northwood (GB) Urologist - G. Thalmann, Berne (CH)

15.15-15.20 15.20-15.35 15.35-15.50 15.50-16.05 16.05-16.20 16.20-16.35

Coffee break and poster viewing

17.00-17.45

Session 6: Sports and lifestyle in uro-oncology Chairs: Urologist - S. Brookman-May, Munich (DE) Urologist - B. Tombal, Brussels (BE)

17.00-17.15

17.30-17.45

Role of physical activity, sports and lifestyle in oncology - does it impact cancer incidence, oncological outcome and quality of life? Urologist - D. Rosario, Sheffield (GB) Physiopathological impact on lifestyle on prostate health, inflammation and carcinogenesis Urologist - M. Albersen, Leuven (BE) Discussion

17.45-18.45

Industry session

17.15-17.30

Sunday 27 November 09.15-09.25

Announcement 3 best unmoderated posters Chairs: Medical oncologist - J. Oldenburg, Oslo (NO) Urologist - J.Walz, Marseille (FR)

09.25-09.40

Best of journals: Medical oncology Chairs: Medical oncologist - M. De Santis, Coventry (GB) Medical oncologist - J. Oldenburg, Oslo (NO)

09.40-11.00

Session 7: Improving active surveillance protocols in prostate cancer Chairs: Urologist - C. Bangma, Rotterdam (NL) Urologist - F. Montorsi, Milan (IT) Radiologist - O. Rouvière, Lyon (FR)

09.40-09.55

What is new in active surveillance?: Summary of the 2016 ESO meeting Urologist - P. Carroll, San Francisco (US) Role of MRI in active surveillance: Strengths and limitations Urologist - C. Moore, London (GB) Pathology and genomics for active surveillance Pathologist - S. Falzarano, Cleveland (US) Is active surveillance justifiable in 3+4 cancers (prognostic grade group 2)? Urologist - L. Klotz, Toronto (CA) Discussion

12.50-13.00

The genomic evolution of metastatic prostate cancer Genetist - F. Demichelis, Trento (IT)

13.00-14.15

Lunch break and poster viewing

13.15-14.15

Industry session

10.25-10.40

How to use imaging for the detection of clinical progression: The role of MRI and conventional imaging Radiologist - V. Panebianco, Zurich (IT) The role of PET/CT: Which tracer for which patient? Nuclear medicine physician - S. Fanti, Bologna (IT) Evaluation of biopsies from sites of prostate cancer recurrence: A new standard? Pathologist - TBC

14.15-14.30

Late breaking session Chair: Urologist - H. Van Poppel, Leuven (BE)

10.40-11.00

14.30-14.40

Announcement 3 best unmoderated posters Chairs: Urologist - A. Briganti, Milan (IT) Urologist - S. Brookman-May, Munich (DE)

14.40-15.00

The role of Progenitor cells and organoids in the translational research of prostate cancer Chair: Medical oncologist - S. Osanto, Leiden (NL) Speaker: M. Kruithof de Julio, Berne (CH)

Coffee break and poster viewing

15.00-15.15

Best of journals: Surgery Chairs: Urologist - F. Montorsi, Milan (IT) Urologist - J. Walz, Marseille (FR)

15.15-16.35

Session 5: High grade bladder Cancer: From diagnosis to progression Clinical case presentation with multidisciplinary discussion (Case presentation T1 high grade by YAU) Chairs: Radiation oncologist - P. Ost, Ghent (BE) Medical oncologist - C. Sternberg, Rome (IT) Urologist - G. Thalmann, Berne (CH)

Session 3: Recurrent prostate cancer Chairs: Radiation oncologist - A. Bossi, Villejuif (FR) Oncologist - N. James, Birmingham (GB) Urologist - H. van der Poel, Amsterdam (NL)

Imaging guided approaches for prostate cancer recurrences: When is surgery the best choice? Urologist - S. Joniau, Leuven (BE) The role of ablative radiotherapy: When and how Radiation oncologist - B. Jereczek-Fossa, Milan (IT) The role of focal therapy in the treatment of cancer recurrence Urologist - R. Sanchez Salas, Paris (FR)

12.40-12.50

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Case presentation Urologist - E. Xylinas, Paris (FR) Pathology: Are all T1 high grade created equal? Pathologist - E. Compérat, Paris (FR) How to minimize the side effects of radical cystectomy Urologist - A. Stenzl, Tübingen (DE) How to optimize patient selection for neoadjuvant chemotherapy Urologist- C. Dinney, Houston (US) Adjuvant chemotherapy Medical oncologist - G. Sonpavde, Birmingham (US) Immunotherapy in advanced urothelial carcinoma Oncologist - Y. Loriot, Villejuif (FR)

16.35-17.00

Pelvic radiation disease: From pathophysiology to therapy Radiation oncologist - M. Pinkawa, Aachen (DE) The risk of secondary cancers: An underreported clinical scenario? Radiation oncologist - C. Cozzarini, Milan (IT) Immune effects of pelvic radiotherapy Medical oncologist - G. Kroemer, Paris (FR) Discussion

12.30-12.40 14.45-17.45

Session 4: Kidney cancer: From diagnosis to progression Clinical case presentation with multidisciplinary discussion Chairs: Pathologist - A. Lopez-Beltran, Lisbon (PT) Medical oncologist - L. Albiges, Villejuif (FR) Urologist - A. Bex, Amsterdam (NL) A case of 3.5 cm tumor Urologist - T. Klatte, Vienna (AT) The role of surveillance Urologist - P. Pierorazio, Baltimore (US) Partial nephrectomy: Whenever possible? Urologist - H. Van Poppel, Leuven (BE) The role of morphology and molecular pathology Pathologist - H. Moch, Zurich (CH) Follow up in kidney cancer Urologist - A. Alcaraz, Barcelona (ES) Metastatic disease Medical oncologist - T. Powles, London (GB) Discussion

12.10-13.00

Friday 25 November 08.15-08.30

Prostate cancer Variants of prostate cancer: The pathologist’s point of view Pathologist - R. Montironi, Ancona (IT) Prostate cancer variants in the setting of mCRPCa and their clinical implications Urologist - C. Evans, Sacramento US)

09.00-10.45

What is the value of imaging guided approaches in the era of early chemotherapy? The medical oncologist’s point of view Medical oncologist - C. Sternberg, Rome (IT)

09.55-10.10 10.10-10.25

11.00-11.20

Personalized medicine and health economics: How can expensive personalized medicine finally be profitable to health economics Chair: Medical oncologist - M. Schmidinger, Vienna (AT) Speaker: B. Häussler, Berlin (DE)

11.20-11.30

EU joint action on cancer control improving prostate cancer diagnosis and care Speaker: T. Albreht, Ljubljana (SI)

11.30-12.20 11.30-11.40 11.40-11.50 11.50-12.00 12.00-12.10

Take home messages Radiologist - R. Oyen, Leuven (BE) Urologist - A. Briganti, Milan (IT) Medical oncologist - S. Osanto, Leiden (NL) Radiation oncologist - B. Jereczek-Fossa, Milan (IT) Pathologist - R. Montironi, Ancona (IT)

12.10-12.20 12.20-12.30

Closing remarks Medical oncologist - M. Schmidinger (ESMO) Radiation oncologist - P. Hoskin (ESTRO) Urologist - H. Van Poppel (EAU)

August/September 2016 www.emuc16.org


EAU RF PRECISION study recruits ahead of schedule Study compares MRI-targeted biopsy to standard trans-rectal biopsy in PCa patients Dr. Veeru Kasivisvanathan NIHR Doctoral Fellow in Urology PRECISION Study Coordinator London (GB)

Study Scheme

[SUBHEAD, BOLD] Study Scheme

[SUBHEAD, BOLD] Study Scheme

Man with no prior biopsy referred with clinical suspicion of prostate cancer Man with no prior biopsy referred with clinical suspicion of prostate cancer

Registration (n=470)

Registration (n=470)

veeru.kasi@ucl.ac.uk

1:1 Randomisation The EAU Research Foundation (EAU RF) PRECISION Trial (NCT02380027) began recruiting in February 2016. This is an international multi-centre randomised controlled study that compares magnetic resonance imaging-targeted biopsy to standard trans-rectal ultrasound guided biopsy for the diagnosis of prostate cancer (PCa) in men without prior biopsy.

1:1 Randomisation

Arm 1 (n=235)

Arm 1 (n=235)

Is the study open to new sites? Yes. Institutions with expertise in MRI-targeted prostate biopsy can take part (e.g. centres with published results of MRI-TB or audit data of detection rates of MRI-TB at their centre). If you would like to be part of this landmark study, please contact the study coordinator at veeru.kasi@ ucl.ac.uk as soon as possible. Sites must be able to complete the approvals process promptly and are expected to recruit between 30-50 men in 12 months. Anticipated trial end date is December 2017.

Arm 2 (n=235)

Multi-parametric MRI

10-12 core trans-rectal biopsy of 10-12 core trans-rectal biopsy of thethe prostate prostate

Multi-parametric MRI

MpMRIMpMRI score 1,2 score 1,2

Study status The study is recruiting ahead of schedule with 85 men recruited in six months at 14 sites (data as of July 27th 2016).

Arm 2 (n=235)

No biopsy No biopsy

MpMRI MpMRI scorescore 3,4,53,4,5 MRI-targeted biopsy MRI-targeted biopsy the prostate of theof prostate

ResultsResults given given Treatment Decision Treatment Decision Questionnaire Questionnaire

Results Results givengiven Treatment Decision Treatment Decision Questionnaire Questionnaire

Results given Results given Treatment Decision Treatment Decision Questionnaire Questionnaire

Primary Outcome:

Secondary Outcomes include:

1. Proportion of men with clinically insignificant cancer detected Secondary Outcomes include:

Chief Investigators: Caroline Moore, Mark Emberton Trial Management Group: UCL Clinical Trials Group: Chris Brew-Graves, Norman Williams, Samim Patel UCL Biostatistics: Fatima Jichi UCL CCTU: Susan Tebbs EAU Research Foundation: Wim Witjes, Scientific and Clinical Research Director Christien Caris, Clinical Project manager Joke Van Egmond, Data manager Background The classical pathway for the diagnosis of prostate cancer is TRUS biopsy of the prostate following a raised PSA. TRUS guidance is performed primarily for anatomic guidance and the ultrasound discriminates poorly between cancerous and non-cancerous tissue. Biopsies are concentrated in areas of the peripheral zone, which harbors the majority of cancer.

Canada • Jewish General Hospital Finland • Helsinki University Central Hospital • Oulu University Hospital

Italy • Sapienza University of Rome, Italy • San Raffaele Hospital, Milan

Proportion of men with clinically significant cancer detected

1. 2. 3.

Participating centres: Belgium • Ghent University Hospital

France • Bordeaux University Hospital • CHU Lille, University Lille Nord de France

PrimaryProportion Outcome: of men with clinically significant cancer detected

Investigators: Christian Arsov, Manit Arya, Chris Bangma, Franck Bladou, Alberto Briganti, Silvan Boxler, Pieter De Visschere, Nicola Fossati, Jurgen Futterer, Arvin George, Maneesh Ghei, Boris Hadaschik, Giles Hellawell, Richard Hindley, Jonas Hugosson, Veeru Kasivisvanathan, Laurence Klotz, Timur Kuru, Drew Moghanaki, Francesco Montorsi, Caroline Moore, Lance Mynderse, Valeria Panebianco, Antti Ranniko, Gregoire Robert, Monique Roobol, Michiel Sedelaar, Paras Singh, Panu Tonttila, Inge van Oort, Markku Vaarala, Geert Villeirs, Arnauld Villers, Jaspal Virdi, John Ward

The potential implications of this trial: • Introduction of an alternative prostate cancer diagnostic pathway • A reduction in the number of patients undergoing prostate biopsy • A reduction in the number of biopsy cores taken per patient • A reduction in biopsy-related sepsis, pain and other side effects • A reduction in the over-diagnosis of clinically insignificant prostate cancer

2. Proportion of men with negative MPMRIcancer who avoid biopsy Proportion of men with clinically insignificant detected 3. Maximum core length of most involved biopsy core Proportion of mencancer with negative MPMRI who avoid biopsy Maximum cancer core length of most involved biopsy core

Hypothesis The proportion of men with clinically significant cancer detected by MPMRI-targeted biopsy will be no less than that detected by standard 12-core TRUS biopsy. Methods Men referred with clinical suspicion of prostate cancer who have had no prior biopsy are randomised to either standard 12-core TRUS biopsy or to a MPMRI arm. In the MPMRI arm, areas of the prostate are scored on a five-point scale of suspicion for clinically significant cancer: 1 = Highly unlikely to be clinically significant cancer 2 = Unlikely to be clinically significant cancer 3 = The presence of clinically significant cancer is equivocal 4 = Likely to be clinically significant cancer 5 = Highly likely to be clinically significant cancer Areas scoring 3, 4 or 5 will undergo targeted biopsy only. Up to three MRI-suspicious areas will be

targeted with a maximum of four cores per target leading to a maximum of up to 12 cores per patient. Visual registration or software-assisted registration may be used. In the control arm, patients will undergo a standard 10-12 core TRUS biopsy. Pathologic findings from all biopsies will be recorded and compared. Key patient inclusion criteria 1. Men at least 18 years of age referred with clinical suspicion of prostate cancer who have been advised to have a prostate biopsy 2. Serum PSA ≤ 20ng/ml 3. Suspected stage ≤ T2 on rectal examination (organ-confined prostate cancer) Key patient exclusion criteria 1. Prior prostate biopsy 2. Prior treatment for prostate cancer 3. Contraindication to MRI or prostate biopsy 4. Men in whom artifact would reduce the quality of the MRI

Germany • University Hospital Heidelberg • University Hospital Cologne • Dusseldorf University Hospital Netherlands • Erasmus University Medical Centre • Radboud University Medical Centre Sweden • University of Gothenburg United Kingdom • Basingstoke and North Hampshire Hospital • Northwick Park Hospital • Princess Alexandra Hospital • Royal Free Hospital NHS Foundation Trust • University College London Hospitals • Whittington Health Trust USA • Mayo Clinic Rochester • McGuire VA Hospital, Richmond • MD Anderson Cancer Centre, Texas • University of Michigan, Ann Arbour Funding The EAU Research Foundation provides their web-based database management system for collection of patient data and provides all sites per patient recruited funding. The study coordinator, Veeru Kasivisvanathan, is funded by a UK NIHR Doctoral Research Fellowship (DRF-2014-07-146) and UK sites are funded by the NIHR Clinical Research Network.

MPMRI reporting proforma

An alternative pathway for the diagnosis of prostate cancer in men with raised PSA is to perform a multi-parametric magnetic resonance imaging (MPMRI) to localize cancer and to use this information to influence conduct of a subsequent biopsy, known as an MPMRI-targeted biopsy. This pathway may offer advantages over the classical pathway. Study design The study is an international multi-centre randomised controlled trial, with 470 men randomised in a 1:1 ratio to one of two arms. Men will either undergo standard of care biopsy, TRUS biopsy, or will undergo a MPMRI and targeted biopsy of suspicious areas. EAU Research Foundation

August/September 2016

European Urology Today

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Young Urologists/Residents Corner First E-BLUS exam at the Spanish National Congress High passing rate recorded at initial E-BLUS exam in Spain Dr. Leonardo Tortolero Blanco Scientific Activities Manager, RAEU Spanish Residents Group Hospital Vinalopo Alicante Alicante (ES) leotor85@gmail.com For the first time, the European School of Urology (ESU) offered in Spain the standardised and validated practical exam of the European training programme in Basic Laparoscopic Urological Skills (E-BLUS) during the 81st Spanish National Congress of Urology held in Toledo, Spain.

Dr. José Gaya Sopena Fundació Puigvert Dept. of Urology Barcelona (ES)

jmgaya@ hotmail.com A total of 11 candidates with intermediate and advanced laparoscopy experience, almost all of them in their last year of their urology residency, took the exam. Before the exam, all participants had to successfully complete the E-BLUS training programme, which provides instructional videos of the exercises as

well as a theoretical module (videos of the exercises can be found at http://hot.uroweb.org/). The passing rate of 72% was considered a high percentage compared with the results from other meetings were the test is normally offered, such as during the Annual EAU Congress or at the European Urology Residents Education Programme (EUREP). Laparoscopy skills training in Toledo

The initiative was also well received by the Working Group of the Spanish Urological Association (AEU) and was considered a timely opportunity for residents and young Spanish urologists to acquire certification in basic laparoscopic skills. All the candidates who passed the exam will be issued a certificate from the ESU. Dr. Josep M. Gaya, a staff member of the Urology Department at Fundació Puigvert (Barcelona), led this

successful project as the official examiner for the hands-on-training for the EUREP. He was assisted by three experienced laparoscopists from Spain: Dr. Jacobo Arce, Dr. Diego Rengifo and Dr. Enrique Ramos. The good response from participants and remarkable results encouraged us to again offer the exam in the next national meeting which will take place in Sevilla in June 2017.

5th School on Paediatric Urology, Andrology held in Moscow Comprehensive lectures and dynamic discussions on paediatric issues Dr. Tatiana Garmanova Paediatric Urology Department State Research Institute of Urology Moscow (RU)

andrology, short case presentations by leading Russian and European experts. The main topics discussed included laparoscopic and endoscopic surgery in paediatric urology, andrology, reconstructive urology, child and adolescent outpatient urology. This year a full day was dedicated to the ESPU with a session on lower urinary tract disorders in children.

tatianagarmanova@ gmail.com

Case presentations The first day programme started with a presentation by Sergey Bondarenko on the principles of laparoscopic surgery in children with urinary tract disorders. Prof. S. G. Wroblewski SG followed with a lecture on endosurgery of hydronephrosis, focusing on operative techniques, drainage features, complications and its prevention. Most of the reports, interestingly, were devoted to the description and presentation of a fairly complex laparo- and endoscopic procedures in paediatric urology. Prof. N. R. Akramov discussed the possibilities of using single-port access during laparoscopic surgery in children, which provides not only cosmetic advantages but also functional results.

With more than 300 paediatric urologists coming from Russia, Belarus, Kazakhstan, Tajikistan and Ukraine, Moscow hosted from April 7 to 9 this year a regular school for paediatric urology. While still a resident in urology, I was involved in the preparation of the first school event. Today, this has become one of the major events in paediatric urology in our country, which is also broadcasted on Russian urological TV - Uro.TV. Held in Russian with simultaneous English translation, the guest speakers included Professors Serdar Tekgül, Guy Bogaert, Rien Nijman and Boris Chertin.

S.L. Kovarskii discussed the use of retroperitoneoscopic access with simple congenital hydronephrosis in children, which is considered quite safe and effective The European Society for Paediatric Urology (ESPU) in children. Several reports were about board was involved in previous schools notably in 2014. pneumovesicoscopy in children, with the speakers This year the school had a different format and added noting that this technique is effective but only for a to the basic lectures on paediatric urology and highly selected group of patients.

Day 2 featured a lecture by Prof. S. Tekgül regarding the regulation of the bladder function. He described brain mechanisms and the mediators of the nerve endings. His lecture provided a very understandable description of the mechanism and action of many drugs on disorders due to spinal cord injury. Prof. L. A. Deriugina lectured on the urination of foetuses and new-borns, the peculiarities of the process at an early age, and developments in the field of urinary disorders caused by adverse events during the neonatal period.

catheterisation which provides protection to the upper urinary tract. Professor S. Tekgül discussed the elimination syndrome, caused by hyper activity of the pelvic floor muscles and which leads to a disruption of the bowel movement and bladder. The afternoon session was devoted to the management of the neurogenic bladder, with treatment options that include botulinum toxin, bladder augmentation and stomas for self-catheterisation.

The final day featured discussions regarding reconstructive and plastic surgery in paediatric Succeeding lectures discussed incontinence issues urology. Interesting reports included the use of tissue with Prof. G. Bogaert presenting the latest engineering for urethral reconstruction. Other developments in the treatment of enuresis. He presentations included this author's lecture on discussed the role of tonsillectomy, disorders of bowel correcting hypospadias and epispadias. During the function and urinary incontinence, and the use of discussion it was noted that at present the most melatonin in paediatric cases. He not only stressed appropriate, safe and effective method is the the need to support and motivate these children but two-stage surgery for proximal hypospadias. also explained the causes of the disease and noted its cure rate. This event certainly gave invaluable experience to participants and with the involvement of expert speakers and opinion leaders, many in the audience Prof. R. Nijman gave a very interesting lecture on found insights and learned best practices. hypoactive bladder. Although many urologists encounter this problem in children, there is no aetiopathogenetic treatment. Possible causes for these In 2017 the school will invite ESPU experts to present on topics such as sex differentiation disorders, urgent conditions can be posterior urethral valves, Hinman syndrome, urethral stricture in boys and ureterocele in paediatric urology and children's uro-gynaecology. female children. However, in most cases, treatment of We look forward to see you next year in Moscow! these conditions is limited to intermittent self-

Novel urological evaluation system of surgical competencies Step-by-step approach provides clearer learning goals Dr. Leonardo Tortolero Blanco Scientific Activities Manager, RAEU Spanish Residents Group Hospital Vinalopo Alicante Alicante (ES) leotor85@gmail.com During the 81st Spanish Urological Congress held in Toledo, Spain in June this year, the Evaluation System of Surgical Laparoscopy in Competencies (ESSCOLAP) was introduced for the first time. ESSCOLAP is a project being developed by the Office of Continuing Education (FIU) of the Spanish Association of Urology (AEU), with the participation of Dr. Alvaro Serrano and Dr. Jaime Bachiller. The project’s main objective is to demonstrate skills assessment in laparoscopy, microsurgery and endourology. Participants in the project are committed to acquire objective, measurable and accredited skills that are transferrable to actual clinical practice, and thus 24

European Urology Today

Dr. Jaime Bachiller Burgos Head Urology Dept. Hospital San Juan de Dios de Aljarafe Bormujos (ES) Jaime.bachiller@ sjd.es

The ESSCOLAP aims to not only address all aspects of surgical training but also go beyond other evaluation systems which often look into aspects such as definition, classification and evaluation. Using technical and non-technical skills training and a step-by-step approach, the ESSCOLAP teaches laparoscopic, microsurgery and endourological procedures in urology. It establishes a series of general as well as specific skills for each surgical technique considered, next to a rating system from 1 to 5 with specific definitions of each step. For its development three levels have been considered,

contribute to better healthcare management of patients with urinary disorders or pathologies. Prof. Sanchez Margallo from Minimal Invasion Surgical Center “Jesús Usón” (CCMIJU) at Caceres-Spain has highlighted the importance of this strategic partnership. The strategic partnership has made the project possible, which links the synergies of the FIU, the Spanish Association of Urology (AEU) and CCMIJU. Currently, more than 350 urologists attend the annual seminars organised by the CCMIJU, and joint projects are expected to expand. Moreover, it is envisioned that the growing profile of scientific urology in Spain and will further strengthen the ties between the two institutions.

namely: Basic which measures basic skills on the simulator; Advanced: which evaluates specific skills using experimental animal models; and Premium which evaluates technical and non-technical skills used in a hospital setting. The implementation of this project is a great opportunity for residents and young urologists from Spain and other countries to standardise, validate and certify their microsurgery, endourology and laparoscopic skills on validated levels. Upon completing each level the urologist or resident receives a certificate as well as a brochure that explains the skills, the motivation and training necessary to prepare and achieve for the next level. The success of this project in Spain has led to the commitment to introduce this method in other European Union countries and Latin America in the near future. ESSCOLAP is already being compared by experts to already established programmes such as the OSATS system, FLS and Queen's Urology Examination Skills Training Program.

ESSCOLAP organisers and participants

We hope that you find this programme of interest and we look forward to keep you posted on future developments. August/September 2016


Young Urologists/Residents Corner 81st AEU Congress and 1st Spanish Residents Day Spanish residents and seniors unite in one common organisation Dr. Juan Gómez Rivas ESRU Secretary ESRU – YUO Board Member Chairman of RAEU Madrid (ES) juangomezr@ gmail.com

Dr. Guillermo Velilla Urology Resident Marquez de Valdecilla University Hospital Santander (ES) gvelilla10@ gmail.com

Dr. Moisés Rodríguez Socarrás Team Member RAEU NCO of Spain for ESRU Alvaro Cunqueiro University Hospital Vigo (ES) moisessocarras@ hotmail.com Toledo hosted from June 15 to 18 the 81st Spanish National Urology Congress, annually organised by the Spanish Association of Urology (AEU). The congress was deemed a success considering the number of participants and the quality of scientific contributions.

AEU president Dr. José Manuel Cózar (ES) and Confederación Americana de Urología (CAU) Secretary General Dr. Hugo Dávila (VEN) led in one of the plenary sessions, in which Dr. Alejandro Rodríguez (USA) discussed robotic radical cystectomy with intracorporal neobladder reconstruction. Rodríguez highlighted the benefits of a technique that makes the future seemed a part of the present. Participants also learned insights from the head-tohead debate between Dr. Antonio Peña (ES) and Dr. Octavio Castillo (CHI) in which both doctors gave their arguments in favour and against pedicle clamping during partial nephrectomy. Dr. Jesús Castiñeiras (ES), professor of Urology at the University of Seville, presented the AEU Universitas project, a general urology textbook for medicine students which aim to gather urology knowledge taught in the school of medicine. Dr. María José Ribal (ES), a well-known uro-oncology expert, spoke about the benefits of neoadjuvant chemotherapy in treating muscleinvasive bladder cancer. Similar to other international meetings, all the webcasts of the plenary sessions are available online on the AEU website (aeu.es). Training courses This year, the training courses were held on the first day. Directed by AEU and EAU members, the courses tackled lymphadenectomy in urological tumours, RIRS, prostate cancer, laparoscopic approach in renal cancer and andrology, to name a few. For the first time, all participants have the chance to have their laparoscopic skills assessed as required by the AEU-ESSCOLAP programme. Participants were trained in laparoscopic exercises and underwent graded evaluation, giving them the opportunity to compare and assess their skills against international standards. Also, for the first time, the E-BLUS exam was offered during the congress.

More than 1,200 urologists from all over Spain and other countries gathered in Toledo to participate in what is considered one of the most important urological meetings held in Spanish-speaking countries. During the four-day meeting 500 abstracts (310 posters, 130 videos and 130 oral presentations) were presented, reflecting the dynamic participation of the delegates. Urological issues covered included oncology, urolithiasis, andrology, pelvic floor pathology, laparoscopic and robotic techniques, among others. This year, the congress was led by Dr. Antonio Gómez and Dr. Manuel Esteban (Toledo-ES) with the organising team presenting plenary sessions that tackled urological topics of the highest scientific level.

The First Residents Day was held during the national congress

Spanish residents at the 81st Spanish National Urology Congress in Toledo

First Resident Day On Wednesday, 15 June, the first resident day was held, a result of the hard work and efforts by the Spanish residents and the Young Urologist Workgroup (RAEU) (residentes.aeu.es). The workgroup, led by Dr. Juan Gómez Rivas as chairman (also the Secretary of the European Society of Residents in Urology (ESRU) and Board Member of the EAU Young Urologists Office), was created in 2015. Since then it has become a fully operational workgroup of the AEU capable of organising a successful first resident day. Over 120 residents and young urologists attended the first Residents’ Day. The residents appreciated the support extended by the AEU board and successful meeting. Dr. Javier Angulo (ES), Scientific Activities, Publications and Congresses Manager of the CAU, talked about the benefits of being a CAU member and encouraged the residents to participate in the next CAU national meeting to be held in Panama this October. Former ESRU chairman and YOU board member Dr. Giulio Patruno (IT) presented the structure and the activities of ESRU as part of the EAU YUO. Amongst other things he talked about the last Resident Day during the EAU Congress in Munich. He also presented the European survey results regarding Social Media use among residents and young urologists. Finally, he congratulated all Spanish residents for their active participation in the ESRU-YUO surveys and for creating the RAEU. The sessions also presented lectures by renowned urologists who gave insights on several surgical techniques (TUR in bladder cancer, laparoscopic radical prostatectomy, etc.) and practical tips and tricks. The results of the national survey in urological skills of the Spanish final-year residents were also presented. The survey aims to show the training level of Spanish senior

residents and results from this survey will be published soon. Case reports of common urological conditions were also presented with experts as Dr. Ribal, Dr. Gaya, Dr. Álvarez-Maestro, among others, sharing their knowledge and expertise. Finally a “Campbell Test” took place in which the residents could test their knowledge. Drs. Fernando Vásquez Alonso and Estefanía Linares provided excellent moderation. On Saturday, 18 June, the much-awaited final of the Urology Cup took place. This national case reports competition for urology residents was developed during the past months and selects, individually or in teams, some of the best unpublished and highly interesting case reports. The Scientific Committee evaluated all the submissions and chose only the best for the competition. Every workday, three clinical cases were given to the participants who were required to answer five test questions related to the case. Depending on their correct responses and the number of case reports submitted, the participants earned a score which enabled them to move up the rankings. Rocío Barrabino won in the individual competition while the team from the Virgen de las Nieves University Hospital won the team title. We also noted the dynamic Social Media activities during the congress (#AEU16) with 1,564,981 impressions, 1,953 tweets and 213 participants. Periscopes during the Resident Day and the various conferences made it possible that participants from all over Europe and America could follow the event. We invite you to join and visit our online channels: Residentes AEU on Facebook, @ResidentesAEU on Twitter or check our website residentes.aeu.es. The RAEU is proud to mark its first year as a workgroup and we hope to continue working on new projects and pursue other challenges.

ESUT16 kick-starts ESRU-ESU collaboration Junior tutors acquire first experience in teaching at ESUT Dr. Juan Vasquez Chair Elect ESRU EAU-YUO Board Member Copenhagen (DE)

jlvm33@yahoo.com Co-author: Dr. Juan Gómez Rivas, Madrid, Spain Athens was an ideal venue for the 5th Meeting of the EAU Section of Uro-Technology (ESUT) held from July 8 to 10 this year which attracted more than 600 delegates. The three-day event examined the newest techniques and technologies, presented Live Surgery sessions and high-quality video and prompted lively discussions among urology experts and their peers. The latest technologies were highlighted including emerging trends in prostate, bladder and stone surgeries, laparoscopy and laser treatments. However, it was clear that experience August/September 2016

and technique are more important than having and using the newest tools. Thus, one the objectives of the ESUT are to provide a structured Hands-on Training (HoT) where participants can efficiently acquire and refine their skills. Hands-on-training is always attractive for residents and young urologists which allow the trainee to benefit from a one-hour simulation console practice on diverse techniques under the direct guidance of an expert tutor. This training approach provides the opportunity for the participants to sharpen their skills and to interact directly with experts. For ESUT16, we had hands-ontraining for laparoscopy, ureterorenoscopy, Green Light laser vaporization and bipolar TURP. Moreover, during this year’s ESUT event, the European Society for Residents in Urology (ESRU) as part of the EAU Young Urologist Office (YUO) begun a new collaboration with the European School of Urology (ESU) by inviting young and experienced residents to serve as junior tutors during the training.

Maria Rothmann (Roskilde, Denmark), Ahmet Ürkmez (Istanbul, Turkey), Juan Gómez Rivas (Madrid, Spain) who served as junior tutors in laparoscopy. Leonardo Tortolero (Alicante, Spain) served as tutor for ureterorenoscopy while Juan Luis Vásquez (Roskilde, Denmark) acted as tutor for bipolar TUR-P. Not only are we excited and eager to take on this challenge, but we also welcome this unique chance to gain new skills in tutorship and mentoring. Teaching as an ‘art’ is not easy since one has to put skills, knowledge and expertise to a major test, and which makes the teaching a productive and dynamic experience for both student and teacher. Prof. Ali Serdar Gözen introduced us to the key points of being a good tutor, such as the following:

1. Flexibility which requires adapting your techniques and approaches to meet the learning styles of the different students; 2. Patience: what’s easy for you is not necessarily so for your student; 3. Being a good and emphatic listener who can pick up cues from the student’s speech and actions, The idea is to provide teaching skills to the participating enabling a tutor to respond to the student’s residents. For this latest ESRU-YOU’s initiative the needs; and exciting collaboration involved five candidates, namely: 4. Having the ability to inspire.

ESRU Junior Tutors during HOT sessions at ESUT 2016

The experience we have had from the ESUT HoT was very rewarding for all the junior tutors since we managed to get familiar with the different systems and consoles, provide coaching to our younger colleagues, while at the same time picking up valuable tips and tricks from our senior colleagues. The junior tutor programme will continue in future EAU meetings with the goal to contribute to the knowledge-sharing and skills refinement of a new generation of hands-on training tutors. Certainly, the ESRU and the YUO is committed to contribute to the development of young promising talents. European Urology Today

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EAU Statement on “Brexit” referendum The European Association of Urology (EAU) understands that a referendum in the United Kingdom (UK) has suggested that there is a majority view (by a narrow margin) in support of the UK leaving the European Union (EU). The vast majority of colleagues within urology and members of the EAU feel that this is an extremely retrograde step. As clinicians and scientists working within the EAU, we are committed to collaborative working practice across Europe for the benefit of our patients.

As it currently stands, there will be no change to the status of the UK within the EU until the British government formally requests withdrawal from the EU under Article 50. The EAU will continue to monitor the situation as the outcome of the referendum is translated into political consequences.

encourage and support cross-border research, especially for young researchers. The EAU membership of British urologists is not in question. Together, we will continue to work to ensure an equal level of healthcare throughout Europe and beyond. On behalf of the EAU Board

Where possible, we will work with national and international bodies to ensure that science and the quality of care does not suffer. We will continue to

Prof. Chris Chapple EAU Secretary General

Azerbaijan Urology Association holds 2nd congress Baku congress focuses on best practices, developments in urology Dr. Parviz Nasirov Modern Hospital Dept. of Urology Baku (AZ)

pnassirov@ hotmail.com

established by the association with international groups such as the European Association of Urology, noting that one of the meeting’s goals is to share urological experience and best practices. At the start of the congress, an agreement memorandum on collaboration, guideline policy and exchange of training programmes has also been signed by the Turkish Oncourology Association, the Azerbaijan National Oncourology Centre and the Azerbaijan Urology Association. Dr. Fuad Guliyev,

Baku hosted last April 30 the 2nd Congress organised by the Azerbaijan Urology Association which gathered over 500 qualified urologists, nephrologists, radiologists and pathologists from government and private hospitals across Azerbaijan.

During the scientific programme, Prof. Bob Djavan presented a lecture on “Ischemic technique in partial nephrectomy,” followed by a presentation from Prof. Sumer Baltaci (Ankara University) regarding “Management algorithm of non-muscle invasive bladder cancer.” Participants appreciated the evidencebased materials and data that both lecturers presented. Treating male LUTS, management of BPH and prostate cancer, urolithiasis and paediatric urology were among the highlights. Dr. Rashad Sholan discussed the topic “Minimal invasive urology – the way from open to robotic surgery” which provided motivation for young urologists to seek proper training in expert centres thereby gaining valuable experience in laparoscopic and robotic surgeries.

In his welcome remarks, association president Prof. Samir Cavad-zade noted the enthusiastic participation of both national and overseas urologists who attended the meeting. He also highlighted the growing links EAU International Relations Office

head of the Urology Department of the National Oncourology Centre, also announced the launch of the association’s website – www.uroweb.az.

Prof. S. Cavad-zade updates journalists

One of the healthcare challenges in Azerbaijan is the current economic recession which has negatively impacted many private hospitals. The author discussed “Organization and management of urology

Prof. B. Djavan answers questions on ischemic technique in nephrectomy

practice at private hospitals” which provides insights on how to keep a urological practice up-to-date and improve patient care. The organisers are delighted by the response of the congress participants as they expressed appreciation for the compact scientific programme and insightful lectures which have led to open discussions, knowledge transfer and networking.

American Urological Association (AUA)

A chance to join the ...

International Academic Exchange Programme American Urological Association (AUA) in collaboration with the European Association of Urology (EAU)

2017 American Tour To date 12 American and 12 European tours have been organised and each of those proved extremely successful. Therefore the European Association of Urology (EAU) and the American Urological Association are pleased to announce the 2017 American tour! The AUA/EAU International Exchange Programme will send American faculty to Europe and European faculty to the United States. The programme aims to promote international exchange of urological medical skills, expertise and knowledge. This upcoming 2017 American Tour will provide grants which will enable 3 EAU members to travel to and attend the AUA congress in Boston (May, 12-16, 2017) and to participate in an extended ten days travel programme, taking them to several urology centres in the United States. EAU Section of Urolithiasis (EULIS)

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Eligibility criteria • Less than 42 years of age • Minimum academic rank of assistant professor • Letter from the departmental chairman of the applicant’s commitment to academic medicine • Membership of the EAU Information and application forms For all further information and programme application forms please visit www.uroweb.org, and select 'our partners' at the bottom of the page, AUA-EAU International Academic Exchange Programme or contact the EAU Central Office, T +31 (0)26 389 0680, F +31 (0)26 389 0674, E: a.terberg@uroweb.org. We look forward to receiving your application before 1 December 2016. EAU Central Office, Attn. Secretariat, P.O. Box 30016, 6803 AA Arnhem, The Netherlands

August/September 2016


Japanese Tour 2016 Academic Exchange Programme A glimpse of Japanese traditions and culture for European urologists Dr. Géraldine Pignot Institut PaoliCalmettes Marseille (FR)

with how time is divided up within the context of properness, courtesy and tradition. This is reflected in their attitude toward taking up other people’s time or in the unhurried contemplation that takes place in Japanese gardens. We left Fukuoka just a day before the devastating earthquake occurred, and I felt the warning tremors that night.

The next stop was at the Okayama University. Prof. Nasu and his colleagues welcomed us and shared his expertise. We also explored this beautiful city with its castle and popular gardens. We also had the chance In April 2016, I participated in the Japanese Urological to visit Hiroshima where we made a tribute in this Association (JUA)-EAU Exchange Programme and had historical city ravaged by war. The visit was impressive the great opportunity to travel to Japan. It was a very and reminded us of the lasting impact and destruction interesting experience for me to discover another caused by international conflict. We also had the way of living and establish new contacts. chance to share a great meal with Prof. Nasu in a noodle restaurant and it was a real challenge for me The programme begun at Kyushu University in to eat with chopsticks! We also discovered the famous Fukuoka where Prof. Eto and his colleagues Bizen pottery, just before leaving for Tokyo. welcomed Dr. Otakar Capoun and me after a long flight from Europe. We toured the urology unit with the staff, and discussed some cases with them. The therapeutic approach was very similar to ours. I was pleasantly surprised to know that all urologists could With invited foreign professors at Presidential Dinner during the 104th JUA Annual Meeting in Sendai also manage medical oncology therapies such as chemotherapies or anti-angiogenics agents in very good conditions. We were pleased that several international sessions Discovering Tokyo At Jikei University in Tokyo, Prof. Egawa spent a lot of were conducted in English, as part of the meeting’s Prof. Naito welcomed us at the Harasanshin Hospital aims to encourage and promote academic as well as time with us and discussed the points of view and where we got a briefing about new technological cultural exchanges of urologists from around the different cultural aspects amongst countries. We approaches such as Greenlight laser for TUBA. We world. The scientific programme was very interesting visited the operating rooms and shared our opinions visited Fukuoka and its many temples and we were and we also viewed the special exhibition dedicated on robotic surgery, a procedure which is also fortunate to have a special meditation session with a to the 2011 earthquake and tsunami victims held on expanding in Japan. The Japanese authorities have temple master. The temple master introduced us to the sidelines of the congress. recently validated the use of the robotic approach for Eastern ideas on the passage of time, which is seen in partial nephrectomy, which is remarkable considering a particularly different light. The Japanese are more With the hospitality of our hosts, we learned a lot that legislation on new surgical technologies is very concerned not with how long something happens, but Dr. Capoun and me with Prof. Nonomura, IJU Editor-in-Chief about Japanese culture and traditions and we hope to cautious. offer the same warm hospitality in return. This amazing experience was made possible thanks to the “The Japanese authorities have dynamism of the EAU and we are proud to be chosen as participants. We hope that this is just the recently validated the use of beginning of a sincere and lasting cooperation the robotic approach for partial between the two associations. gg_pignot@yahoo.fr

nephrectomy, which is remarkable considering that legislation on new surgical technologies is very cautious.”

Apply for your EAU membership online!

We also visited the Tokyo Imperial Palace, the official residence of the Emperor of Japan, and saw for ourselves the impressive contrasts between traditional architecture such as the old castle and Tokyo’s very modern buildings right in the middle of the city. In Tokyo we again enjoyed typical Japanese food and tasted excellent sake. At the end of our trip, we participated at the 104th Annual Meeting of the Japanese Urological Association (JUA) in Sendai, chaired by Prof. Arai.

Me with the President of JUA, Prof. Fujisawa from Kobe

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! European Association of Urology

With Profs. Eto, Nasu, Egawa and Fujisawa after receiving certificates and presents from JUA in Sendai

August/September 2016

European Urology Today

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Never stand still. Our goal is to take you forward, faster. We will continue to drive positive change with papers on innovative treatments, in the quality of data we publish and with new models to assess the efficacy of surgical procedures. We will build on past success with a focus on the future – for the benefit of our authors, readers and their patients.

european urology

europeanurology.com

Forward faster. Together.

european urology Forward faster. Together.

Only a few weeks to go european and it’s Urology Week! urology

WEEK 2016 26-30 SEPTEMBER

Urology Week is an initiative of the European Association of Urology to raise awareness on the importance of urological care. It aims to start relevant discussions, and introduce new technologies and insights through events, social media and personal stories.

Even if you weren’t able to organise an event or participate in one, you can still show your support! There is still time! There are many ways to get involved in Urology Week and every effort counts.

Step Up, Join the Campaign!

Our mission, your Quality of Life

#urologyweek

Join our social media campaigns Urology Week has three social media campaigns: Selfie time!, Quality of Life and Thunderclap campaigns. • Selfie time! is taking a selfie with the “I Support Urology Week” sign that you can download from the website. Put the hashtag #urologyweek in your caption. • The Quality of Life campaign is taking a photo of whoever or whatever you value the most, and including the phrase “Quality of Life” in the photo. Then use the hashtag #urologyweek in your caption. • Thunderclap is about simultaneously sending Urology Week’s main message on the social media accounts of supporters. This is a great way to give Urology Week more visibility. If you would like to join go to https://www.thunderclap.it/projects/ 45041-i-support-urologyweek.

Forward faster. Together.

Share your stories Shared stories and experiences can help others see urology in a different light. Mr. Lawrence Drudge-Coates (Uro-Oncology Clinical Nurse Specialist and Hon. Lecturer at Kings College Hospital NHS Foundation Trust), Dr. Lionne Venderbos (Erasmus MC), Ms. Jeannette Verkerk [MScN and RN] (Groene Hart Ziekenhuis) and clinical nurse specialist Ms. Anneke Meerkerk (Beatrix Ziekenhuis in Gorinchem) have shared their stories. If you would like to share your story, please let us know! Events Events have been organised for Urology Week to further spread the importance of urological care. Some notable examples are a conference on advanced technology in urology, live operations during Radical Laparoscopic Cystectomy Week (Saint Petersburg, Russia), and the Urology Week Opening Run (Szczecin, Poland), to name a few.

For more ideas, please visit www.urologyweek.org/getinvolved/how-to-contribute. Check out what’s new using the hashtag #urologyweek on Twitter and Instagram. Remember to follow EAU @uroweb, too.

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August/September 2016


EAU Best Papers published in Urological Literature Awards

Apply now!

To be awarded at the 32nd Annual EAU Congress in London, 24-28 March 2017 The two EAU Prizes for Best Paper published in Urological Literature are tools through which the EAU encourages young and promising urological scientists to continue their work and to communicate their achievements to the European urological community. Two awards of € 5,000 each will be made available for the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers have to be published or accepted for publication between 1 July 2015 and 30 June 2016. The awards will be handed out at the 32nd Annual EAU Congress in London, 24-28 March 2017. Rules and Eligibility • Eligible to apply for the EAU Best Paper published in Urological Literature are urologists, urologists-intraining or urology-related scientists. All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • The paper must be written in English (or translated into English).

• The subject of the paper must be urological or urology related. • The deadline for submission is 1 November 2016. How to apply • Please send your paper by e-mail to m.smink@uroweb.org, indicating clearly the category in the subject line: “EAU Best Paper on Clinical Research” or “EAU Best Paper on Fundamental Research”. • Include a copy of your curriculum vitae. • Supply a list of all authors who have significantly contributed (if relevant). • Mention any financial support by companies, government or health organisations. • A publisher’s letter of acceptance has to be submitted along with your paper. A review committee consisting of members of the EAU Scientific Congress Office will review all submitted papers and select the winner of the two EAU awards for Best Paper published in Urological Literature.

EAU Hans Marberger Award 2017 For the best European paper published on Minimally Invasive Surgery in Urology The EAU Hans Marberger Award will be handed out for the best European paper published on Minimally Invasive Surgery in Urology. The award, annually given since 2004, is named after Prof. Hans Marberger to honour his pioneering achievements and contributions to endourology and the development of urologic minimally invasive surgical procedures. The award will be handed over at the 32nd Annual EAU Congress in London, 24-28 March 2017 during the Opening Ceremony. Rules and Eligibility • All urologists and scientists are invited to send in papers. • The topic of the paper should deal with Minimally Invasive Surgery in Urology. • The paper must have been published or accepted for publication in a European Journal between 1 July 2015 and 30 June 2016.

Apply now!

• All papers must be submitted in English. • All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • Deadline for submission is 1 November 2016. A review committee, consisting of members of the EAU Scientific Congress Office, will select the winning paper. How to apply Please send your paper to the EAU Central Office at m.smink@uroweb.org and mention “EAU Hans Marberger Award 2017” in the subject line of your e-mail.

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

August/September 2016

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#ESUR16

ESUR16

23rd Meeting of the EAU Section of Urological Research 20-22 October 2016, Parma, Italy Prof. Kerstin Junker ESUR Chair

Cutting-edge Urological Research comes to Parma For three days in October, Parma will be the centre of research in urology as the EAU Section of Urological Research (ESUR) holds its annual meeting there. Its broad scientific programme examines the latest developments, while also taking into account clinical applicability. Registration is still open for the 23rd ESUR Meeting (ESUR16), which will take place at the Grand Hotel De La Ville in Parma on 20-22 October. Prof. Saverio Bettuzzi (Parma, IT) is the Meeting Chair. Research is a huge driving force for innovation in urological care, making ESUR16 a not-to-be-missed meeting for urologists, who are looking to get informed on upcoming innovations in their field. When devising the scientific programme for ESUR16, the organising committee wanted to make it attractive for experimental and clinical researchers working in the field of urology, but also for young urologists who are interested in research but did not start their own research. The programme reflects several important research fields in urology, especially within onco-urology. ESUR16 aims to stimulate the discussion between researchers and clinicians, and will also present â&#x20AC;&#x2DC;hotâ&#x20AC;&#x2122; fields in experimental research in general, not necessarily focused on urology. This is done in order to show techniques and a general understanding in molecular and cellular biology, both of which are important for urological research. Urologists who are not directly involved in research can also expect to gain a lot from attending ESUR16, including the following talks:

More info: www.esur16.org

Tumour heterogeneity in kidney cancer: The molecular genetic picture Dr. Samra Turajlic (London, GB)

Diagnostic challenges of clonal heterogeneity in prostate cancer Dr. Michael C. Haffner, (Baltimore, USA)

Identifying and understanding the genomic events that drive cancer is fundamental for delivering precision medicine. In addition to identifying recurrent genomic driver aberrations across multiple tumour types, next-generation sequencing (NGS) studies have revealed extensive intra-tumour heterogeneity (ITH) evidenced by genetically distinct subclones existing within a single tumour.

The clinical presentation of prostate cancer is very heterogeneous and can range from indolent localised disease to lethal metastases. This variance in disease severity has made it difficult to choose appropriate treatment regimens.

ITH is a significant hurdle for precision medicine, not least through the effect of tumour sampling bias on prognostic and predictive biomarker development. ITH is an emerging theme in ccRCC. Our group has demonstrated profound ITH in a cohort of ccRCCs revealing branched tumour evolution. Critically, the majority of known driver events and potential therapeutic targets are found to be subclonal suggesting that they are under-represented in single biopsies. The impact of ITH on the course and treatment of ccRCC is an area of unmet scientific and clinical need. Multi-disciplinary approaches to decipher evolution in ccRCC, allow us to examine: (1) the association of ITH with disease progression (informing the management of small renal masses); (2) the relationship between the clonal architecture of the primary tumour and its metastases (helping to define the role of nephrectomy, lymph node clearance, metastasectomy and thrombectomy in the setting of early or advanced disease); and (3) the routes to treatment resistance (potentially informing systemic therapy combinatorial approaches). To this end we have set up TRACERx Renal (TRAcking Renal Cell Carcinoma Evolution Through Therapy (Rx)), a multi-site, multidisciplinary study which aims to collect and analyse a large number of cases which reflect a range of ccRCC stages and metastatic patterns.

ESUI16

The use of whole genome sequence and integrative molecular analyses allows us to study tumour samples spanning the entire spectrum from the primary tumour to distant metastases, characterise clonal relationships of individual lesions and evaluate clinically relevant biomarkers. Such analyses contribute important insights into the complex clonal constellation of prostate cancer progression and provide a strong rational for a molecular approach to prostate cancer pathology. This presentation will discuss potential diagnostic challenges that arise from clonal intra-tumour heterogeneity in prostate cancer, highlight results from recent integrative profiling efforts and discuss ancillary diagnostic strategies. Late-breaking abstract submission The ESUR is accepting late abstracts for ESUR16. Scientists are encouraged to submit definitive results of well-conducted basic, translational, and clinical research. The ESUR Board discourages the submission of case reports and abstracts reporting routine clinical observations and procedures which are outside the scope of the meeting.

Late-breaking abstract deadline: Sunday, 18 September 2016, 23:59 CET http://abstracts.uroweb.org

#ESUI16

5th Meeting of the EAU Section of Urological Imaging

Imaging and shifting paradigms in urology

In conjunction with the 8th European Multidisciplinary Meeting on Urological Cancers

24 November 2016, Milan, Italy

Jochen Walz (FR) ESUI Chairman

5th ESUI: Imaging and shifting paradigms in urology Milan meeting to highlight MRI/ultrasound fusion biopsy and fusion biopsy Hands-on Training The use of Magnetic Resonance Imaging (MRI) has expanded in prostate cancer diagnosis and management due to its increasing diagnostic performance. Indeed, MRI is now considered a key element that is about to change the paradigms in prostate cancer diagnosis. With regards to the use of MRI data for targeted biopsies, the information needs to be transferred from radiologist to urologist and from MR-imaging to ultrasound based imaging. Both steps are prone to systematic errors. Currently, most of the promising data is published by centers of excellence, pioneering the use of MRI in clinical pathways. To expand the use of this approach and help with the task of information transfer, specific systems were developed that integrate or fuse the MRI information into ultrasound imaging for the daily clinical workflow of transrectal or transperineal prostate biopsies. Many different systems are commercially available and several methodological approaches are possible. There is electromagnetic navigation or tracking, software-based navigation or tracking, mechanical navigation or tracking, or stepper-based navigation or tracking. There is also

the possibility to do the so-called cognitive fusion, which means the operator performs a fusion of MR data with the ultrasound imaging in his mind. All the above approaches will gain increasing importance in the future and it is of utmost significance that urologists are familiar with these technologies. The 5th ESUI meeting puts an emphasis on these technologies and has dedicated an entire session to the topic MRI/US fusion, where internationally renowned experts will share their techniques and best practices in doing such biopsies and discuss the advantages and drawbacks of various methods. The ESUI also offers during the 8th EMUC meeting handson-training courses for MRI/ultrasound fusion biopsy during the two days following the ESUI meeting. This course will provide the basics of MRI reading and the different types of fusion technologies will be critically reviewed and discussed. Moreover, the participants will have the possibility to simulate hands-on prostate biopsies using different systems to acquire first-hand experiences and become familiar with the required workflow.

For additional information visit the ESUI meeting website at www.esui16.org 30

European Urology Today

The ESUI meeting will also cover several other fields of urological imaging where current paradigms are about to change. These are the fields of bladder cancer, imageguided therapies and molecular imaging. For instance, a joint meeting between the European Association of Nuclear Medicine (EANM) and the ESUI will address the latest developments in PET imaging in urology.

The ESUI meeting will precede the 8th EMUC meeting, which will integrate additional topics in imaging and urological oncology.

Late fee registration deadline: 24 November 2016

August/September 2016


www.esgurs16.org

www.eulis17.org

ESGURS16

EULIS17

8th Meeting of the EAU Section of Genito-Urinary Reconstructive Surgeons

4th Meeting of the EAU Section of Urolithiasis 5-7 October 2017, Vienna, Austria

In conjunction with the Spanish Genito-Urinary Reconstructive Surgery Group (CRU-AEU)

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

7-8 October 2016, Madrid, Spain EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

Download the EAU Events app

www.esou17.org

ESOU17 14th Meeting of the EAU Section of Oncological Urology

Instant access to all meeting info

20-22 January 2017, Barcelona, Spain EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

Events

August/September 2016

Search for ‘EAU Events’ in your App or Play store!

EAU Events

European Urology Today

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Send your nominations today!

EAU Crystal Matula Award 2017 For a young promising European urologist The EAU Crystal Matula Award 2017 is the most prestigious prize given to a young promising European urologist under the age of 40 who has the potential to become one of the future leaders in academic European urology. The award will be presented at the Opening Ceremony of the upcoming 32nd Annual EAU Congress in London from 24 to 28 March 2017. The list of previous awardees includes many well-known names: A. Briganti (2016), M. Rouprêt (2015), S.F. Shariat (2014), P. Boström (2013), P.J. Bastian (2012), S.G. Joniau (2011), J.W.F. Catto (2010), M.J. Ribal (2009), V. Ficarra (2008), M.S. Michel (2007), A. De La Taille (2006), M.P. Matikainen (2005), P.F.A. Mulders (2004), B. Malavaud (2003), M. Kuczyk (2002), B. Djavan (2001), A. Zlotta (2000), G. Thalmann (1999), F. Montorsi (1998), F.C. Hamdy (1996). Nomination Process National Societies can nominate a candidate by supplying the following documents: • Letter of endorsement • Motivation letter • Complete curriculum vitae

• List of publications in the below sequence: 1. Peer reviewed papers (including the impact factors of the journals) • Original articles • Reviews • Case reports 2. Book chapters or editor of books • Overview of grants received from (inter-)national institutions or from the industry • List of received Awards • The deadline for nomination is 1 November 2016. Please note that eligible candidates can also apply for this award by contacting their national urological society directly. The candidate is then expected to supply his/ her national society with a CV and the above mentioned documents, requesting a letter of endorsement. How to apply Please send your nominations to the EAU Central Office at m.smink@uroweb.org and mention “EAU Crystal Matula Award 2017” in the subject line of your e-mail.

The EAU Crystal Matula Award is supported by an educational grant of €10,000 from LABORIE.

Apply now!

LABORIE

EAU Prostate Cancer Research Award 2017 For the best paper published on clinical or experimental studies in prostate cancer With the goal to encourage innovative, high-quality research in prostate cancer, the EAU has launched the EAU Prostate Cancer Research Award. Supported by an unrestricted educational grant from the Fritz H. Schröder Foundation, an expert jury will select the best paper dealing with clinical or experimental studies in prostate cancer. The award will be handed over at the 32nd Annual EAU Congress in London, 24-28 March 2017 during the Opening Ceremony. Join this competitive search and help boost the quality of prostate cancer research in Europe! Rules and Eligibility • The topic of the paper should deal with clinical or experimental prostate cancer research.

• The paper must have been published or accepted for publication in a high-ranking international journal between 1 July 2015 and 30 June 2016, and submitted in English. • Applicants must be a member of the EAU. • The submitting author must be the first author of the paper or, by exception, the corresponding senior last author. • Applicants should only submit one paper. • Deadline for submission by e-mail is 1 November 2016. A review committee will screen all entries and an independent jury will select the best paper based on quality and merits. How to apply Inquiries and correspondence should be addressed to the EAU Central Office, at m.smink@uroweb.org, with “EAU Prostate Cancer Research Award 2017” in the subject line of your e-mail.

The award is supported by an educational grant of €5,000 from the FRITZ H. SCHRÖDER FOUNDATION. www.fhsfoundation.eu

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August/September 2016


• What is the most rewarding aspect about urology? In urology we are with patients from diagnosis, treatment to follow-up care while combining research activity whether it’s clinical or transitional research. Certainly, urologists are able to treat patients in a holistic way which also requires multi-disciplinary approaches. • If you were not a urologist, what would you be? Since I was a kid I wanted to be a tennis player. My second ambition was to be a doctor and a third option in my mind then was to be a lawyer. • How do you avoid burnout? It’s certainly a difficult profession but the secret of avoiding burnout is to rely on your family and friends and have that ability to maintain a private life. It’s easy as a doctor to bring your work back home, but one should really set a time for family and the people you love. • How would you persuade a young doctor to specialise in urology? I will not convince but show him that urology is a unique specialty and that it’s a fantastic field to combine both surgery and non-surgical activities. Urologists can also combine their medical work with a wide range of research activities. • What do you think is the biggest barrier to practising medicine today? It is important for doctors to remain updated and be continually in the forefront of developments. We should not miss the opportunities to be innovative in our field. Certainly, there are many challenges in research. • What do you most often wish you could say to patients, but didn’t? That’s a difficult question. As doctors we are responsible for many things and the interaction with patients demands a lot of psychology. Many doctors put a lot of energy in what they do and we also have a lot of passion that is not seen or recognised by patients. • What’s the last thing that surprised you? When I learned my wife was pregnant and we were in the hospital doing the ultrasound it was an amazing thing… It may sound cliché but in that moment one indeed becomes more aware of the mystery of life. • What’s the last wonderful book you have read? When I’m not in a good mood and I need a boost, I read the novels of Pirandello, an Italian dramatist, poet and short story writer. He wrote like a painter and he has that ability to describe the characters in his stories in an amazing way. I would recommend not one but several of his books. • What’s your favourite hour in a day and why? The early morning hours when I can concentrate much more on the work I’m doing. When I was younger I preferred the late afternoon, but that has changed and now I can do much more in the early morning.

TEN QUESTIONS Interview and Photography by Joel Vega

Age: 38 Specialty: Onco-urology City: Milan, Italy Recent Awards & Current Post: 2016 Winner, EAU Crystal Matula Award; Professor of Urology, IRCCS San Raffaele Hospital, Dept. of Urology, Milan; Member, EAU Guidelines Office, Faculty member, European School of Urology

• What is your biggest fear? To lose curiosity. One of the driving forces in the work we do is curiosity. Not losing curiosity is important since it prompts us to push and go beyond our limits.

Alberto Briganti

Cutting-edge Science at Europe’s largest Urology Congress

Apply now and win!

Featuring the SIU-ICUD Joint Consultation on Urologic Management of the Spinal Cord InjuredCongress Patient 36th the 36thofCongress of Symposium the and the 2nd SIU Nurses’ Educational Société Internationale d’Urologie

Société Internationale d’Urologie

Hilton Buenos Aires Hilton Buenos Aires

October 20–23, 2016

October 20–23, 2016 Why You Should Attend • SIU represents a close-knit community of international urologists, and the Congress features world experts presenting the latest and most relevant advancements in urology that YOU need to know about.

Will you be an EAU Award Winner in London? EAU Crystal Matula Award 2017 For a young promising urologist under the age of 40 who has the potential to become one of the future leaders in academic European urology. National Societies can nominate a candidate for this award or eligible candidates can apply by contacting their national urological society directly. EAU Hans Marberger Award 2017 For the Best Paper published on Minimally Invasive Surgery in Urology. This paper must have been published or accepted for publication between 1 July 2015 and 30 June 2016.

www.siu-urology.org

EAU Best Paper Awards 2017 For the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers have been published or accepted for publication between 1 July 2015 and 30 June 2016.

For more information, rules and regulations: www.eau17.org/the-congress/awards

August/September 2016

• The condensed format of SIU Congresses gives you a one-of-a-kind opportunity for more high-quality interactions with leaders in urology.

EAU Prostate Cancer Research Award 2017 For the Best Paper on Clinical or Experimental Prostate Cancer Research. The paper must have been published or accepted for publication in a high-ranking international journal between 1 July 2015 and 30 June 2016.

Deadline: 1 November 2016

www.eau17.org

• Buenos Aires, known as the “Paris of Latin America”, is a vibrant, cosmopolitan, and stylish metropolis.

#EAU17

#SIU16

SIU Academy reaches over 43,000 users. Are you ONE OF them?

www.siu-urology.org

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EAUN provides insightful training to Danish nurse A fellowship exchange at UZ University Hospital Ghent, Belgium Annette Hjuler, Rn Centre for Continence Disorders Århus University Hospital Århus (DK)

annehjul@rm.dk I visited the UZ University Hospital in Ghent last 24 to 27 November as part of a fellowship programme of the European Association for Urological Nurses (EAUN). The EAUN, which sponsors the travel, accommodation and daily allowances, offers two application rounds per year. In my daily work at the Centre for Continence Disorders, we provide urological nursing to a diverse group of patients. We see men suffering from Hypertrophia prostatae who have an indwelling catheter following a period of urinary retention. We see the same group of patients for urodynamic examinations in order to establish which treatment is more suitable for each individual. Another large group are younger patients suffering from various continence disorders. It is particularly satisfactory when we succeed in helping this group of patients getting back to everyday life with "normal" urination, which many of them have never previously experienced.

The week concluded with a visit to the Rehabilitation Centre, comparable to Centres for Brain Damage and Centre for Spinal Cord Injuries in Denmark. Patients are admitted immediately following an accident/ injury. The rehabilitation is conducted similar to our practice in Denmark and patients are hospitalised as long as necessary. The centre has “test” apartments where patients can live, including with family, one month prior to being discharged. If any aspects of managing everyday life requirements appear difficult for the patient to handle, there is time to address them. There is also a small garden with a greenhouse where training can take place as well as a car where patients can train how to get in and out and how to place the wheelchair, among others.

he supervises nurses in the outpatient clinic, the recovery room and the ward. In addition, staff from other departments called him for assistance such as providing training for clean intermittent catheterisation. I was also present during several urodynamic examinations of children, men, women and "neuropatients." Technically, the examination is conducted a bit differently from the way we do it in Denmark. A three-way catheter is used, with the urethral sphincter examined during filling. EMG (electrodes for measuring muscle activity) is not used and a profile is not established as we do it back home. An X-ray is made in order to control the position of the catheter and a picture is made of the urination to help improve diagnose and if the patient suffers from cystocele and reflux. Provided that the patient is sufficiently stable to stand up, both sitting and standing filling is made and "cough leaking" is also tested. The bladder was not emptied in case of residual urine before the second filling; instead it was noted that the filling had started with X ml. The "neuro-patients" were examined in the same manner as we do it. All examinations were observed by a doctor and the patient got feedback and treatment was initiated immediately after the examination. Treatment with anticholinergics, Betmiga (Beta 3 agonist) and clean intermittent catheterisation training is initiated with the same indications as we use; however the approach is less pedagogical – often basic assessment has not been made prior to the urodynamic examination resulting to instances when patients are sent home to fill in liquid/urination scheme and, in rare instances, the use of diapers.

In conclusion, I benefited from a good and useful experience regarding specialised nursing practice in another country. I would encourage colleagues to take the same opportunity since it provides a great chance to reflect, learn and gain inspiration. And my thanks to Ronny Pieters who guided me during the wonderful fellowship in Ghent. Annette Hjuler and Ronny Pieters

Several unsuccessful attempts were made at changing a double J catheter via a urostomy, despite the involvement of several doctors. But fortunately we have an operation ward! Suprapubic catheters were placed as well; when the patient’s bladder does not contain sufficient urine, salt water is instilled by catheter. The balloon contains 10 ml water and when Another group of patients which I am specifically there is a sufficient volume in the bladder, the nurse interested in are those suffering from "Bladder Pain draws it to prevent the water from leaking in case of Syndrome." Sometimes it is possible to treat these bladder cramps. At the same time, the bed was patients with the instillation of Chondroitin sulphate, elevated at the feet end and the doctor placed the either by self-instillation or by receiving the treatment An annual subsidy of 150 euros for buying diapers etc. catheter easily and quickly. at the hospital. The so-called "neuro-patients" who is provided for all patients suffering from continence are suffering from spinal cord injury, patients who disorder, including the period prior to the medical At the ward, nurses are responsible for everything have had a Clam operation and where the bladder is intervention. When the medical assessment has been relating to patient car. The nurse has a mobile rack enlarged and with Mitrofanoff / Monti operations – finalized and diapers are established as one of the containing utensils that might be needed, the are another important group of patients. remedies to treat the condition, the patient will patients’ medicine and a computer. One nurse is receive a 100% refund of the cost. As for catheters, responsible for four to eight patients but depending It is a great challenge to help these patients get the public funds will cover four catheters per day and on the demands of the individual patients. competent care and assistance. In our small unit there in case of a need to extend the frequency, the patient is a very good collaboration with our secretary and must rely on the catheter manufacturer to donate the the doctors in charge of the patients suffering from rest. To my understanding, it is possible for each highly complex continence disorders and from spinal individual patient to choose the best fit among cord injury. available catheters.

EAUN Board Chair Past Chair Board member Board member Board member Board member Board member Board member Board member

Stefano Terzoni (IT) Lawrence DrudgeCoates (UK) Paula Allchorne (UK) Simon Borg (MT) Linda Söderkvist (SE) Corinne Tillier (NL) Susanne Vahr (DK) Jeannette Verkerk (NL) Giulia Villa (IT)

www.eaun.uroweb.org

Application open for EAUN17 Travel Grant

Urodynamic examinations During my time at the Centre for Continence Disorders, I was interested in experiencing and learning how the nursing of comparable patients is conducted at another university hospital in Europe. I chose Gent since the group of patients matched that of the Centre for Continence Disorders. My contact point, Ronny Pieters, helped me find accommodation near the hospital, which was very comfortable. I spent a weekend as a tourist in Ghent with its historical centre and the many beautiful canals. The first day of the week, I observed the daily routine of Ronny who is a clinical urological nursing specialist. He workes full days at the hospital where

Beautiful houses and charming waterways European Association of Urology Nurses

34

European Urology Today

At the operation ward I observed how test electrodes for InterStim Neurostimulation Therapy were placed by sacral nerves 2-3. This method is applied to different kinds of continence disorders, but the best results are observed with patients suffering from an overactive bladder. The test period is between one to four weeks and if the patient period is satisfactory to lessen the patient’s symptoms, a small battery box is inserted into the right part of the loin. Once the box is adjusted, the patient should go to the toilet based on the need and the problem is solved. Later, when the patient is in the recovery room, Ronny Pieters – as part of his supervisory tasks – comes by and adjusts the intensity of the electricity with a small remote control. Hexvix (Blue-light cystoscopy), instilled about one hour before trans resection of the bladder, is also used as well as the instillation of Mitomycin C in the bladder after resection. It is given when the urine is nearly clear, and the procedure as done in the recovery room by Ronny Pieters. Catheter removal Nephrostomy catheter removal is done in the outpatient clinic. The new catheter is guided by ultrasound and guidewire. A plaster is placed on the catheter where it meets the skin which makes it easy to detect if it is displaced; a thread fixed to the skin is also used. The bandage is placed over the catheter as we know it, but in order to avoid pulling and cracking of the hose, it does not cross the abdomen. The hose is placed over the hip and along the outer side of the leg which makes it impossible to lie on the side without irritation. The patient also has a supra-pubic catheter which was changed in the same session – the nurse made the necessary preparations, pulled out the old catheter and the doctor inserted the new one- a very smooth procedure.

The Annual EAUN Travel Grant allows nurses based in Europe to participate in the EAUN Meeting by providing €500 towards the cost of towards travel, registration and accomodation (provided the receipts have been submitted). Candidates will be required to be working in urology and be current members of the EAUN. Non-members can apply for the grant provided they have submitted a paid membership application. Submission deadline: 1 November 2016 For detailed information please visit www.eaun17.org This grant was made possible through an unrestricted educational grant from ASTELLAS.

Call for Papers The International Journal of Urological Nursing - The Official Journal of the BAUN The International Journal of Urological Nursing is clinically focused and evidence-based and welcomes contributions in the following clinical and nonclinical areas: • General urology • Clinical audit • Continence care • Clinical governance • Oncology • Nurse-led services • Andrology • Reflective analysis • Stoma care • Education • Paediatric urology • Management • Men’s health • Research There are many benefits to publishing in IJUN, including: • Broad readership of papers—all published papers will be available in print and online to institutional subscribers and all members of the British Association of Urological Nurses • Fast and convenient online submission— articles can be submitted online at http://mc.manuscriptcentral.com/ijun

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

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

August/September 2016


Improving follow-up care after nephrectomy Experience from a Dutch cancer institute nuclear grade and histological tumour necrosis. The Leibovich prognosis score gives a score ranging from 0 to 11 and is categorised into three groups dependent of the risk of recurrence after surgery: low- (0–2), intermediate- (3–5) or high-risk (≥6) groups (Table 1).

We implemented a standardised follow-up according to the evidence based in August 2015. We divided the patients into three groups depending on the risk of recurrence after partial/radical c.tillier@nki.nl nephrectomy (low, intermediate and high-risk groups). The follow-up is alternately done by the Similar to worldwide trends, renal cell carcinoma urologist and the clinical nurse specialist urology. (RCC) in the Netherlands comprises 2% of all the The follow-up after partial nephrectomy and malignancies1. The Netherlands Cancer Institute is a nephrectomy is, respectively, five and nine years. specialised institute where many cases of Four weeks after the surgery, the patient has a nephrectomies and partial nephrectomies are consultation with the urologist who explains the risk performed in localised and locally advanced RCC. of recurrence and reviews with the patient the medical issues one month after surgery. The patient The follow-up after surgery was until 2014 done by receives from the urologist an overview of the the urologists only. There were no common guidelines follow-up for the next years. A few days after the for the follow-up. In 2014 we decided to develop a clinical nurse specialist calls the patient and asks if standardised follow-up after partial and total everything is clear. The nurse explains his/her role nephrectomy where the clinical nurse specialist could in the follow-up as the permanent contact person play an important role. The goal was to have a who is accessible for the patient when needed. standardised follow-up and to decrease the consultations by urologists. A personalised follow-up depending on risk of recurrence is linked with the digital file of the patient We evaluated that performing the follow-up (Table 2). This means that all the requests for CT scans, alternating with urologist and a clinical nurse ultrasounds and blood tests are computerised. The specialist could generate a decrease of the urologist’s urologist or the clinical nurse specialist has to fill at consultations by about 58%. We decided to include the time of the follow-up (for example month 42) and the Leibovich prognosis score2 which is dependent of all the imaging tests and laboratory tests needed for the risk of recurrence in order to perform an adapted/ the next consultation are automatically included and personalised follow-up after partial or radical scheduled (Table 3). If the patient develops metastasis nephrectomy. The score takes into account the during the follow-up, we end the follow-up in the pathological T stage, nodal status, tumour size, digital file and we refer the patient to the oncologist. Table 1: Leibovich prognosis score after partial/ radical nephrectomy2 Characteristics Tumour

Dimension Lymph node status Fuhrman

Tumour necrosis

pT1a pT1b pT2 pT3-pT4 <10 cm >10 cm pNx/pN0 pN1-pN2 1-2 3 4 absent present

Points 0 2 3 4 0 1 0 2 0 1 3 0 1

European Association of Urology Nurses

Preparing for the consultation (Self-Management) During the follow-up, the patient has the opportunity to prepare the consultation with the urologist or clinical nurse specialist. The patient can log-in through his patient portal (www.mijnavl.nl) and can ask questions or report physical/mental complaints after surgery. When the urologist/nurse clinical specialist prepares the consultation (a few days before), the questions/complaints appear in the

Nephrectomy: Intermediate risk Follow-up Consultation Laboratory test Imaging test

Send a letter to the GP

25-27 March 2017, London, UK

With the EAUN’s commitment to support innovative work, we invite you to submit a research project proposal for the EAUN Nursing Research Competition. The topics that have to be included in the project plan and examples can be found on our website. During the 18th International EAUN Meeting in London (25-27 March 2017), all projects of the nominees will be discussed in a scientific session, enabling all participants to learn through feedback and discussions. A winner, chosen from the final nominees selected by a jury, will receive € 2,500 to (partly) fund the research project. Detailed submission criteria and rules for both submissions can be found at the congress website www.eaun17.org For more information please contact the EAUN at eaun@uroweb.org.

August/September 2016

The patient is very satisfied to have the opportunity to prepare her/his consultation because in this way the patient will remember to ask a question to the urologist/clinical nurse specialist. We have to admit that we are also very satisfied since it makes the consultation easier. We can already prepare the answers to the questions/complaints. We have evaluated the follow-up after partial or radical nephrectomy (one year after implementation). The patient expressed satisfaction on the following: • The alternating consultation urologist/clinical nurse specialist. They do not mind who is giving the results of CT Scans/ultrasounds/ laboratory results; • Receiving a schedule of the visits for the next five to nine years; • Having the same urologist/clinical nurse specialist; and • Having the opportunity to prepare the consultation.

Year 1 4w 3m Urologist x x Clinical Nurse Specialist x (call) x x CT abdomen x CT lung x Ultrasound x

Nursing research may bring the most amazing results

in conjunction with

patient’s digital file. The most common questions/ complaints are: Is my cancer hereditary? Is it normal that I am still very tired? Do I have to follow a special diet after nephrectomy? Can I live with one kidney without health problems?

The urologist has fewer consultations after partial/ radical nephrectomy (for example 28% less consultations for low-risk after nephrectomy). We noticed that compared to the follow-up before the standardisation, we perform less CT scans. Moreover, the clinical nurse specialist appreciates providing counselling and support to the patients and is able to give the results of the CT scan or other exams. Feasible scheme The personalised follow-up after partial and radical nephrectomy based on the Leibovich prognosis score is feasible, efficient and can be alternatively done by the urologist and the clinical nurse specialist. It saves consultation time for the urologist and also reduces financial costs (less CT scans). The computerisation of the orders depending on the moment of the follow-up avoids unnecessary CT scans and allows a standardised follow-up. References 1. Dutch Cancer Registration 2015: http://www. cijfersoverkanker.nl/selecties/Dataset_2/img578bcb8073d2d 2. Leibovich BC, Blute ML, Cheville JC et al. Prediction of progression after radical nephrectomy for patients with clear cell renal cell carcinoma: a stratification tool -for prospective clinical trials. Cancer 2003; 97: 1663–71.

Table 2: Schedule Follow-up after nephrectomy- intermediate risk

Share your experience and ambition in London

Submission deadline: 1 December 2016

Table 3: Example of computerised orders

6m 9m x x x x x x

Year 2 12 m 18 m 24 m x x x x x x x x x x x x x

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

Year 3 30 m 36 m x x x x x x x x

Year 4 42 m 48 m x x x x x x x x

Year 5 54 m 60 m x x x x x x x x

Year 7 Year 9 84 m 108 m x x x x x x x

x x x

www.eaun.uroweb.org

Corinne Tillier, CNS, MANP Clinical Nurse Specialist Urology The Netherlands Cancer Institute Amsterdam (NL)

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 European Urology Today Nurses

35


Monitoring patients on abiraterone Experience of a regional cancer centre in New Zealand Kirstin Unahi Nurse Practitioner Southern District Health Board Dunedin (NZ)

Kirstin.Unahi@ southerndhb.govt.nz Prostate cancer is the most common cancer among men in New Zealand. In 2012, 3,129 men were diagnosed with prostate cancer and 607 died from metastatic or castration-resistant disease (MoH, 2015). The Southern District Health Board (DHB) is a publically funded regional health service covering the lower half of the South Island of New Zealand, servicing an estimated resident population of 304,260. It is the largest geographical area of any of the district health boards in New Zealand covering 62,000 km2, which in itself can present barriers to care in terms of distance and accessibility for its large rural population (www.southerndhb.govt.nz). But perhaps, more significantly in the setting of prostate cancer, it has an aging population many of whom live in rural areas. Introduction of abiraterone In New Zealand, abiraterone was publically funded for patients with metastatic resistant prostate cancer (mCRPC) in May 2015. Relatively intense monitoring of side effects is required at the start of abiraterone therapy. This includes potential for hepatic toxicity and hypokalaemia, hypertension or fluid retention due to mineralocorticoid excess caused by CYP17 enzyme inhibition (Pointer, 2016). Within Southern DHB a joint decision was made to place the primary use of abiraterone after European Association of Urology Nurses

bicalutamide and before taxanes for those patients who were chemotherapy naive. This was not a wholly clinical consideration but took into account societal and economic considerations (Pointer, 2016). Care of these patients was centralised within Radiation Oncology at the Dunedin Cancer Centre with a preference for managing patients at home in the primary care setting by making use of existing monitoring systems, including the OncologyHaematology Assessment Unit (OHAU) and MOSAIQ, an electronic monitoring programme, both described below (Pointer, 2016). Oncology Haematology Assessment Unit The Oncology Haematology Assessment Unit is a nurse-led virtual clinic developed at the Southern District Health Board, just over two years ago with the primary aim of promoting appropriate use of services and resources and reducing avoidable hospital admissions. Secondary aims of this project included: • Improving patient safety and care by monitoring symptoms and side effects of cancer treatment in a timely manner; • Reducing avoidable treatment delays and dose reductions; • Standardising the advice given to patients using evidence-based assessment tools; • Providing a single point of contact for patients from throughout the region; and • Ensuring calls are triaged safely and appropriately. A 24-hour a day, free phoning number is given to all patients receiving oncology/haematology therapies when they first present for treatment. Incoming clinical enquiry’s to this number are triaged according to a set protocol and patients are either given advice and education over the phone; the patient may be referred to another health care practitioner, including the patient’s general practitioner, district nurse, emergency department or oncologist, or the patient can be bought into the unit for an advanced nursing assessment and appropriate treatment. Key to the success of OHAU is that nurses are able to proactively monitor high risk

patients on treatment; for example those with complex co-morbidities, elderly patients or those with mental health issues. Patients on oral cancer treatments such as abiraterone are also proactively monitored through the unit via scheduled phone calls. MOSAIQ: Electronic monitoring programme MOSAIQ is a comprehensive electronic information management system used within OHAU. It can be used to review, prescribe, dispense, treat, and document patient data in a single database solution. Customisable electronic records can be viewed online from multiple sites, with integration from external diagnostic laboratories and pharmacies. Appointments can be scheduled, and letters, reports and documents created (www.elekta.com/softwaresolutions/care-management/mosaiq-medicaloncology). What happens when a patient is started on abiraterone? Patients are seen in clinic by a radiation oncologist and abiraterone is electronically prescribed in MOSAIQ. Approval of the prescription automatically generates an electronic memo to OHAU nursing staff to prompt scheduling of abiraterone phone calls. MOSAIQ also automatically prompts the consultant to prescribe Lucrin (a gonadotropin releasing hormone agonist) if appropriate, to apply for a special authority for the abiraterone (required by the New Zealand drug funding agency PHARMAC) and an electronic request for a DEXA bone scan is generated. Patients are educated either on-site or over the phone not long after they have seen the oncologist and the patient’s general practice nurse is contacted to arrange for recordings of blood pressure, weight and blood tests. This is then followed up by the nursing staff in OHAU initially two weekly and then monthly at the time of phoning the patient, along with screening for other side effects, including oedema, diarrhoea, breathlessness and any other treatment or disease related complications. If the patient has any complex issues such poor mobility or financial constraints, a

plan is individualised to their circumstances. Any concerns regarding a patient or their side effects are discussed with their oncologist as they arise. Strengths and limits of the OHAU Abiraterone Monitoring Programme It has been a pleasure working with men commencing on abiraterone. The number of patients reporting improved quality of life with reduction in pain and improved mobility is particularly satisfying. Many patients will be on opiates at the start of their treatment and within a few weeks have been able to wean themselves off. It also reassuring to know that a system is in place to ensure patients do not slip through the cracks in terms of follow up. MOSAIQ has made this process all that much easier for nurses. The monitoring programme is reliant on the team, not an individual, with all patients’ notes available electronically with no requirement for hand-over between staff. OHAU provides early identification of toxicities and has provided remarkable outcomes in providing supportive care to oncology and haematology patients; patients report that they feel well supported. The only real limitation is managing the high volume of patients, which has become easier over time as the process is refined. I would like to acknowledge the fabulous oncology team I work with, in particular Jo Tuaine, Lynda Dagg and Simon Pointer, who were pivotal in the development of the abiraterone monitoring system. References • Ministry of Health, Cancer: New registrations and death 2012. • Pointer, S. 2016. MOSAIQ to Manage Patients with Metastatic Castrate-Resistant Prostate Cancer. Unpublished Power Point Presentation. • www.elekta.com/software-solutions/caremanagement/mosaiq-medical-oncology, retrieved 27 July 2016. • http://www.southerndhb.govt.nz/index. php?page=654, retrieved 27 July 2016

Abstract, Research Project, Difficult Case and Video Presentation deadline: 1 December 2016 Early registration deadline: 16 January 2017

25-27 March 2017, London, UK Stefano Terzoni, Chair EAUN

‘London Calling’ – 18th International EAUN Meeting, 25-27 March 2017 The planning for the anticipated 18th International EAUN Meeting is at its advanced stage! The Scientific Committee is hard at work putting together a relevant and informative scientific programme to support the practice of urological nursing in Europe. Many of the features that give the EAUN meeting its distinctive flavour will be retained such as the Plenary Sessions, Thematic Sessions, European School of Urology courses, Difficult Cases, state-of-the-art lectures, and the increasingly popular Research Poster sessions. Full details of the programme will be available on the EAUN London website www.eaun17.org soon so please regularly check it for updates. Patient-centred urological nursing care The EAUN meeting will focus on patient-centred urological nursing care and sessions to analyse current issues such as uro-oncology in older people, the role of renal function in health, the emerging challenges in testicular cancer care, lymphedema following pelvic lymph node dissection, and the future trends in urodynamics, to name a few. Additionally, the critically important issue of the emergence of drug-resistant microorganisms in urology will be revisited in the “Is an Avalanche Coming?” session.

Recognising our role as educators to our patients, we will examine their health literacy to see how we can improve our effectiveness in communicating vital information and guidance to them. Furthermore, we will concentrate on the role of ethics in urological care through the interactive “House of Commons” session, which promises to be both interesting and enjoyable. We, urology nurses, are increasingly required to demonstrate the value of the service we provide our patients, employers, and clinical colleagues. Therefore, we research and seek ways to persuade others about the importance of our role and clinical professionalism. To aid us in getting our message to a wider audience, there is also an EAUN session about the role of social media in urological nursing.

Corinne Tillier, Chair SCO

Location London is truly an exciting city to visit. Despite its size, it is remarkably easy to travel around. The venue, London ExCel, has two on-site rail stations and it is only five minutes away from the London City Airport. This year’s EAUN Meeting is in the heart of London and our programme is in the heart of evidence-based, urological nursing care. We look forward to seeing you in London and to sharing our future in European urological nursing! Corinne Tillier Chair SCO

Advantages EAUN Travel grants are NOW available for EAUN members. Have a look at www.eaun17.org > Registration and see how you can benefit. Do you have something to share? Join the growing number of contributors by submitting an Abstract, Video Abstract, Difficult Case or Research Plan. The process is easy. Submissions can be made online or by e-mail until 1 December 2016. For more information, please visit www.eaun17.org > Scientific Programme.

For detailed information and updates of the Scientific Programme, visit the EAUN’s meeting website at: www.eaun17.org

#EAUN17 in conjunction with

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European Urology Today

www.eaun17.org August/September 2016

European Urology Today - August/September 2016  

European Urology Today (EUT) August/September 2016. EUT is the official newsletter of the EAU.

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