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European Urology Today Official newsletter of the European Association of Urology Getting a tattoo is no longer taboo...

Emperor's new clothes Prof. B. Johansen examines the costs and benefits of MDT meetings


Prof. T.E. Bjerklund Johansen

But talking about urological diseases still is. Let’s break the silence. #UROLOGYWEEK


Vol. 30 No.4 - August/September 2018

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Early sacral neuro modulation

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Prof. Sievert looks into the impact of technology in spinal cord injury cases


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Prof. K.D. Sievert

“A journal is more than its impact factor” Prof. Catto reflects on record-high 2017 Impact Factor for EAU's European Urology journal By Loek Keizer In June, it was announced that the EAU’s flagship scientific journal, European Urology had a 2017 impact factor of 17,581, an all-time high. This makes European Urology the most highly-ranked urology journal in the world, by far. We spoke to its Editor-inChief since 2013, Prof. James Catto (Sheffield, GB) about this accomplishment, the challenges the journal faces and his experiences over the past five years. “A journal is more than its impact factor,” Prof. Catto explains. “An impact factor is a measure of your importance in the field. But there are other measures, like website traffic, the number of unique visitors, of downloads, of libraries that subscribe, and the readership. Naturally, the impact factor is also a reflection of the quality of the papers that are submitted and published.”

Prof. James Catto, Editor-in Chief European Urology

In all of these domains, Catto thinks European Urology is doing well, leading to a lot of downloads, and a strong global brand. “We are the highest scoring in our field, but I think we also do very well against competitors in bigger fields, like general oncology, or surgery as a whole. Impact factor is not everything to me, but it’s an important measure to how the journal is moving forward.” “As our platform has become more digital, we’ve managed to measure how we’ve become a more global journal. More than half of our traffic comes from outside of Europe, including North America, China, India and Australia.”

Prof. Catto is pleased by the rise in scientific quality of the journal in recent years, “but it would have been impossible without the work of my predecessor, Francesco Montorsi. We’re very much building on the foundations that he laid down.”

The European Urology Editorial Team in the years under Prof. Catto's leadership

Since taking over in 2013, Catto has identified several important challenges for European Urology: “Firstly, as we’ve become increasingly digital, I do worry that we’ve left behind some of our less IT-savvy readership and some of our authorship. We’ve tried to come up with ways to address that.” There are currently no plans to end the printed edition of European Urology, letting readers receive the journal in their preferred form. As the editorial standards and desired level of published articles has increased, there is also the risk of previous contributors who don’t have the resources for the high-quality work that the editorial team demands. Catto: “It can be hard for these authors to publish with us. Our strategy to counter this was to broaden the family of journals with the launch of EU Focus and EU Oncology. This increases our breadth and allows us to cover more topics away from the main journal.”

“We are faster to publish and we try to foresee and encourage progress in urological care.” Expanding the EU family Prof. Catto is pleased with how the two new journals are performing. EU Focus was launched in 2015 and is led by Asst. Prof. Christian Gratzke (Munich, DE). EU Oncology was launched earlier this year with Prof. Alberto Briganti (Milan, IT) as its editor.

Editorial Team Meeting in Copenhagen 2018

“Both journals are doing very well, with EU Focus about two years ahead of Oncology in its development. As the main journal has become more successful, it has gotten more oncology-driven. Focus was established as our attempt to keep and service the whole urology community. It covers the syllabus of urology, and all that matters to urologists. The journal is now on PubMed, and has a nice track record. We have an impact factor coming next year. We are eager to see how that goes.” EU Oncology has, at the time of writing, published two issues. “It has come on very quickly,” Catto says, “thanks to a very dynamic editorial team. They’re going to try to get on PubMed next year and an impact factor will hopefully follow some two years later. I know that a lot of their content comes from papers that are not quite good enough for EU. The acceptance rate transfer is quite high for both of these journals, that tells us they are perceived/received well by our authors.

Asked about how the advent of the two sister journal has affected the contents of European Urology, Catto says that it was certainly not the intention, but that he couldn’t rule it out completely. “We maintain quality as our number one brand. European Urology is the flagship and most widely-cited journal.” Each journal has a clear purpose: “I see EU Focus as being very much about the syllabus and –in their own words- ‘encompassing the whole spectrum of urology’. That means benign urology, stones, and topics where we integrate with other subjects, such as urogynaecology, paediatrics or transplantation.” “EU Oncology is about the multidisciplinary care of patients with cancers. The editorial board features medical oncologists, radiation oncologists and the goal is to encompass the multidisciplinary team that’s necessary for the best patient treatment. We also hope it attracts new readers outside of the immediate urological circle.”

Editorial challenges Reflecting on the period of his editorship, Catto sees some trends: “We’ve become much more global, more digital, much faster. We are faster to publish and we try to foresee and encourage progress in urological care. That’s because we have a young and dynamic editorial team.” All of this is also driven by a shift in contents: “We’ve brought in a statistical review, all the papers are now reviewed statistically. But more importantly, we try to target papers that we perceive as high quality and try to make them even better in the review process.”

Editorial Team Meeting in London 2013

Editorial Team Meeting in Florence 2014

ONE HAPPY FAMILY! www.eau19.org It’s been a big year for our family of journals. The launch of European Urology Oncology, a new editorial team for European Urology Focus and now an all time high for the European Urology Impact Factor. To our extended family of authors, reviewers, and readers, thank you. We really are in this together.

Our 2017 Impact Factor*

*Journal Citation Reports ® (Clarivate Analytics, 2018)

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

August/September 2018

Abstract submission now open! Deadline: 1 November 2018

European Urology Today


Update from the Guidelines Office Autumn months packed with meetings and training sessions

The Non-muscle-invasive Bladder Cancer Guidelines Panel meeting in Prague

Panel Meetings Once again, the Autumn months mark a burst of activity in the Guidelines Office as Panels meet to finalise their Guidelines texts for 2019. The Non-muscle Invasive Bladder Cancer Panel met in Prague at the end of August. September, meanwhile, sees meetings from the Prostate Cancer Panel in Amsterdam, The Urological Infections Panel in Florence, the Renal Cell Carcinoma Panel in Milan, the Urinary Incontinence Panel in Cambridge, the Male LUTS Panel in Athens, and the all new Sexual and Reproductive Health Panel in Amsterdam. Going forward, October sees panel meetings from Renal Transplantation, Urological Trauma and Testicular Cancer. Systematic Review Training Workshop Following the success of the last Guidelines Office Systematic Review Workshop, held in Amsterdam at the end of April, another workshop has been organised for the Autumn. Once again, the training session will take place in Amsterdam and will be held on the 23rd and 24th November. Attendance at the workshop is by invitation of the Guidelines Office. Those invited will include both new and established Guidelines Panel members, and young urologists enrolled on the Guidelines Office Associates programme. As usual, those attending the training workshop will come from across Europe.

European Urology Today Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Dr. F. Sanguedolce, Barcelona (ES) Dr. Z. Zotter, Budapest (HU) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL) J. Vega, Arnhem (NL) EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680 F +31 (0)26 389 0674 EUT@uroweb.org Disclaimer No part of European Urology Today (EUT) may be reproduced without written permission from the Communication Office of the European Association of Urology (EAU). The comments of the reviewers are their own and not necessarily endorsed by the EAU or the Editorial Board. The EAU does not accept liability for the consequences of inaccurate statements or data. Despite of utmost care the EAU and their Communication Office cannot accept responsibility for errors or omissions.

The intensive two-day event will see attendees participate in a packed programme of events. The training workshop will be led by members of the EAU Guidelines Office’s Methods Committee, who will give a series of presentations and lead participants in a series of practical sessions. Guidelines Office

European Urology Today

New Guidelines Panel We are delighted to announce the formation of a new working group to address the EAU Andrea Salonia Suks Minhas Guidelines on Sexual and Reproductive Health. The panel is chaired by Prof. Andrea Salonia and the Vice Chairman is Mr. Suks Minhas. This panel amalgamates the topics covered by the former Male Infertility, Male Sexual Dysfunction and Male Hypogonadism panels. The panel met for the first time in September this year to discuss the processes involved in producing new combined guidelines and the priorities for the coming years. Consensus Finding Projects The EAU Guidelines Office is currently in the process of helping to coordinate two international collaborative projects regarding the issuing of consensus statements. Deferred Treatment for Localised PCa Under the auspices of the European Association of Urology, the Prostate Cancer Guideline panel is undertaking an international collaborative project to issue consensus statements regarding the optimum approach to deferred treatment for early prostate cancer. The project involves a 2-step consensus process and is preceded by a comprehensive systematic review of the literature. The project involves all stakeholder groups involved in deferred treatment of localised prostate cancer, including patients, clinicians (including urological surgeons, oncologists, pathologists, radiologists and primary care physicians), specialist nurses, methodologists and researchers.

It is hoped that this project will result in a standardised list of strategies for the most important outcomes for active surveillance of localised prostate cancer. In time, this will make it easier for researchers to compare, contrast and combine the advantages and disadvantages of different treatments for localised prostate cancer in comparison with active surveillance. This will, in turn, help clinicians, patients and policy-makers make decisions about the most effective treatments for localised prostate cancer. Low-risk prostate cancer is a disease with minimal capacity to metastasize. Patients diagnosed with low-risk disease are at significant risk of over-treatment with associated side-effects and consequently, men with low-risk prostate cancer can benefit from close observation, with active treatment reserved for those men whose tumours show capacity for progression. International guidelines recommend that deferred treatment with curative intent (active surveillance) should be offered to men with very low-risk and low-risk prostate cancer when appropriate. However, there is a lack of good quality evidence on which to base current treatment decisions. In particular, inclusion criteria for active surveillance vary widely between different centres and might also include more aggressive prostate cancer. There is also significant uncertainty and variability in practice regarding the monitoring and follow-up of patients, what should trigger a change in management from active surveillance to curative treatment (i.e. reclassification), and how the most important outcomes should be prioritised and measured in programmes of active surveillance. The first part of the project, which has now been completed, saw a review of all published research on active surveillance in order to determine the range of criteria and thresholds regarding patient inclusion into active surveillance programmes, monitoring and follow-up, reclassification and the most commonly reported outcomes in studies of active surveillance. The second part of the project will involve a large, international online survey involving patients and healthcare professionals, with healthcare professionals taking part in the clinical aspects of the survey, and patients participating in the outcome prioritisation part. The third and final part of the project is a consensus group meeting involving a small panel of patients and healthcare professionals, where consensus statements regarding active surveillance will be issued. We will tell you more about the second project in the next issue.

Robert Pickard

Dedicated mentor and expert surgeon 1961 - 2018 It is with profound sadness that we received news of the death last July 24, 2018 of Professor Robert Pickard from Newcastle, UK. Sadness for a life that was cut short altogether too soon, but gratitude for having known such a fine man and exceptionally talented surgeon. As a leading academic urologist Rob directed many publicly funded, seminal trials on diverse topics ranging from treatment of ureteric colic, antibiotic prophylaxis in intermittent catheterisation and urethroplasty. The focus was always on questions of importance to patients, and the outcomes have led to significant and important changes in patient care. He was Chair and founding member of the British Association of Urological Surgeons’ Academic Section, and at a European level he was a highly regarded member of the EAU Urinary Incontinence Guidelines panel, as well as Chair of the EAU Urinary Infections panel. An acknowledged expert on both trial methodology and evidence synthesis, he authored numerous Cochrane reviews and had a formidable reputation as a completely dependable, robust and incisive editor. His work for the Guidelines Office exemplified his unique abilities - discussing controversial


The training will cover a diverse range of subjects aimed at underlining the importance of evidence synthesis methodology for young urologists. Topics covered will include the development of a search strategy, abstract and full text screening, assessing risk of bias, data abstraction, and data analysis and interpretation.

excellent surgeon – a rare combination in one individual. His knowledge and experience were a constant and dependable source of inspiration and clarity for others, and his willingness to share was testament to his nature. In every aspect of life he was loved for his humility, integrity, courtesy and generous spirit. “Utterly incorruptible” are words used to describe his nature, without exaggeration.

issues with a room full of experts with strong opinions, he would gently manoeuvre towards decision-making through a combination of absolute clarity of thought and expression, an unrelenting adherence to standards of evidence and due process, and unfailing courtesy. Inevitably this made him highly respected but he was never a remote figure. A man of simple tastes and with little ego, he would take the time to share a coffee or a morning run whether you were the chairman of the guidelines office, or the junior associate, without prioritising one over the other. Consequently, his company was equally treasured as his hard work and academic contributions.

It is often said in surgical circles that to be a top surgeon requires, besides professional expertise, a bit of an ego and confidence that border on arrogance, and sometimes a certain disregard for other people’s feelings. His patients, colleagues and the urological world saw the fallacy of such remarks in Professor Pickard, and his legacy will hopefully endure in the shining example he set for us all. On behalf of the EAU Guidelines Office we extend our sincere condolences and deepest sympathy to Rob’s wife and children, and the rest of the Pickard family. He will be missed beyond words.

Aside from his academic achievements, Rob was a most caring and compassionate doctor, a selfless and patient mentor, and a technically

Arjun Nambiar and Malcolm Lucas On behalf of the EAU Guidelines Office

August/September 2018

eUROGEN identifies three-year plan 2nd Annual Strategic Meeting Board in The Netherlands European Reference Networks (ERNs) are frameworks established to help professionals and centres of expertise in different countries to share knowledge and expertise. 2017 was a busy year as the European Reference Network (ERN) for rare urogenital diseases and complex conditions (eUROGEN) was approved by the European Commission in March, along with 23 other ERNs. eUROGEN comprises 29 healthcare providers in 11 Member States who collaborate to provide a diagnosis or recommendations for treatment for patients with rare urogenital or very complex conditions. eUROGEN is structured into three Workstreams, each with a dedicated lead. Workstream 1: rare congenital urogenital anomalies is led by Prof. Wout Feitz, Radboudumc in Nijmegen, the Netherlands; Workstream 2 complex urogenital conditions requiring highly specialised surgery, led

by Prof. Margit Fisch, Universitätsklinikum HamburgEppendorf and Workstream 3: rare urogenital tumours, led by Prof. Vijay Sangar, The Christie NHS Foundation Trust. The European Reference Network (ERN) for rare urogenital diseases and complex conditions held its 2nd Annual Strategic Board meeting in Noordwijk from 11-12 June 2018, with 43 attendees representing our Coordinating Team, Operational Board, Workstreams, Health Care Providers (HCPs) and European Patient Advocacy Group (ePAG), as well as the European Association of Urology (EAU) and the European Commission (EC). Prof. Christopher Chapple (Coordinator) (UK) welcomed everyone to the meeting and summarised the three-year plan for the ERN, including funding and our work packages (management, dissemination,

Apply for your EAU membership online!

Michelle Battye EAU EU Policy Coordinator Sheffield (UK)

michelle.battye@ uroweb.org evaluation, guidelines, diagnosis and expert advice, research and teaching and training). ERNs are a unique example where our patients are at the heart of all activities. Serena Bartezzati (Associazione Italiana Cistite Interstiziale) (IT), Matt Bolz-Johnson (EURORDIS) (BE) and Dalia Aminoff (Associazione Italiana Malformazioni Anorettali) (IT) delivered a report from our European Patient Advisory Group (ePAG). They explained that ePAGs (comprised of patient organisations within Europe) fit into the ERN programme by representing the wider patient community in terms of the strategic and operational delivery of an ERN. Our ePAG has had numerous achievements over the first year by raising awareness of and promoting eUROGEN, participating in and presenting at eUROGEN, EC and other meetings, and supporting the whole ERN process. They aim to continue and build on these achievements over the next years. For example, our patient organisations will play a critical role in ensuring that outcome measures that will be developed for the different disease areas covered by eUROGEN fully take into account the views of patients and parents. They have also identified transition from paediatric to adult care as an area of concern and will be working with our clinicians to write a report on how we can manage transition better for patients with a rare disease or complex condition who require highly specialised urogenital care throughout their lifetimes.

A journal is more than its impact factor. . . . . 1 Update from the Guidelines Office . . . . . . . . . 2 Obituary Robert Pickard. . . . . . . . . . . . . . . . . 2 eUROGEN identifies three-year plan. . . . . . . . 3 Multidisciplinary team meetings: The Emperor’s New Clothes? . . . . . . . . . . . . . 4 EAU RF section : NIMBUS trial recruits 250th patient . . . . . . . . 5 Announcement: Seeding Grant Application now open!. . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Stronger arguments for participation in the GPIU study. . . . . . . . . . . . . . . . . . . . . . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7

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!

eUROGEN has recently secured further funding from the European Commission to employ two staff members who will be dedicated to ensuring all our healthcare provider members are supported to use the CPMS effectively. We hope this will enable us to intensify our use of CPMS and to help more patients across Europe with a rare urogenital disease or complex condition. If you have a rare or complex urogenital case that you would like to refer to eUROGEN for expert advice, please contact Michelle Battye (michelle.battye@sth. nhs.uk) who can advise on the process for referral to the ERN.

Will Brexit impact on the ERNs?

Provide sustainable patency.





© COOK 01/2017 URO-D32084-EN-F

August/September 2018

eUROGEN is one of the leading ERNs using the Clinical Patient Management System (CPMS); CPMS is the web-based clinical software application where healthcare providers from all over the EU in our network can work together virtually across national borders to diagnose and treat patients with rare, low prevalence and complex diseases in Europe. Using CPMS, our eUROGEN healthcare providers can set up ‘virtual’ advisory panels of medical specialists across different disciplines and discuss cases in real time with advice being sent to the clinician treating the patient so that the patient does not need to travel.

Unfortunately Brexit will, of course, have a profound effect on the newly born ERNs. Six out of the 24 ERNs are coordinated by an NHS Trust in England and these six NHS Trusts have been asked to begin planning for the scenario of a ‘no-deal’ Brexit. Once the UK withdraws from the EU, it will no longer fulfil the legal eligibility criteria (membership of the EU) to coordinate an ERN. Therefore, eUROGEN has plans in place to transfer the coordination function to another healthcare provider in the EU post-Brexit. Fortunately, Prof. Wout Feitz, leader of workstream 1 and based at Radboudumc in the Netherlands, will take over the coordination function. We will be working at pace over the coming months with the EC to ensure that we plan for a smooth transition of the coordination function and that there is no negative impact on our network or patients.

Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11 Ten Questions: Mensur Selçuk Silay . . . . . . . 14 ESOU19 aims to strengthen onco-urology global community. . . . . . . . . . . . . . . . . . . . . 14 EULIS: Miniaturisation in PCNL: What has changed? . . . . . . . . . . . . . . . . . . . 15 ESUT: TURP: A treatment of choice in large prostates? . . . . . . . . . . . . . . . . . . . . . . 15 EMUC18: Joint initiatives reinforce MDT in onco-urology. . . . . . . . . . . . . . . . . . . . . . 16 ESU section: Masterclass features modern stone-disease management. . . . . . . . . . . . . 21 "SET-UP" programme is well-received in Singapore. . . . . . . . . . . . . . . . . . . . . . . . . 22 Masterclass delivers optimal learning to young urologists. . . . . . . . . . . . . . . . . . . . 23 EUSP: A fruitful clinical visit to the Fundació Puigvert. . . . . . . . . . . . . . . . . . . . . 25 ESFFU: Early sacral neuro-modulation after spinal cord injury. . . . . . . . . . . . . . . . . 27 International role yields benefits tor SIU. . . . 28 YUO section: IDENTIFY: A BURST study of haematuria referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 EUA congress addresses urologic malignancies . . . . . . . . . . . . . . . . . . . . . . . . 30 Urology training around the globe. . . . . . . . 30 EAUN section: Experiences of group support for mPCa patients . . . . . . . . . . . . . . . . . . . . . . . Nurse-led flexible cystoscopies. . . . . . . . . . . BAUS Conference Report. . . . . . . . . . . . . . . APCC 2018 Report. . . . . . . . . . . . . . . . . . . . . Join us in Barcelona for the 20th EAUN Congress. . . . . . . . . . . . . . . . . . . . . . .

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European Urology Today


Multidisciplinary team meetings: The Emperor’s New Clothes? The start of the long awaited discussion of costs and benefits of MDT meetings in urology care Being certified as urologist means that the candidate is qualified to make independent clinical decisions. Practising urologists make clinical decisions all day long, during evaluation of referrals, during ward rounds, during surgery and in the outpatient clinic. Indeed, due to the broad spectrum of patients and limited resources in most countries, urologists have to prioritise carefully between patient groups. Urologists develop a unique experience in making clinical decisions and doing it fast.

During the diagnostic work-up period, patients with prostate cancer are always seen by a urologist for one or several visits. Usually, twenty minutes are scheduled for a consultation which includes prostate biopsy tebj@medisin.uio.no and whatever The clinical judgment of urologists is undergoing examinations are Being trained as a urologist means being trained to continuous development. Most urologists will see needed. Patients are make clinical decisions. Training follows a structured established treatments being abandoned and new often also seen by an programme which is common to most surgical treatments come. Prof. John Blandy (UK) became oncologist in the disciplines and adheres to classical principles for world-famous for doing surgery on renal arteries for urological outpatient teaching. For certified urologists it is a continuous hypertension, a procedure which is no longer department. For these aim to improve clinical decisions. Urologists at the Aker Campus, Oslo University Hospital attending a MDTM performed. Most urologists are aware of aphorisms consultations one hour presented by our forefathers like the father of urologic is reserved. Usually, Recently, we saw the introduction of multidisciplinary oncology, Dr. Willet Whitmore (US), who said about no clinical or other team meetings (MDTMs) in onco-urology. MDTMs prostate cancer “Is treatment necessary when it is investigations are being performed, but the notes are There is however, a paper examining the mental mean that clinical decisions are made by a large possible and is treatment possible when it is four times as long as those prepared by the urologist. wellbeing of members of ten multidisciplinary cancer group of doctors, often sitting in front of several teams which found lower levels of psychiatric necessary?” screens and in video communication with colleagues morbidity, emotional exhaustion, depersonalisation, MDTMs were established in Oslo University Hospital in other hospitals. This form of decision-making is The benefits of prostate cancer treatment are minimal upon decisions made by the chair of the cancer board, and feelings of lower personal accomplishment than very resource-demanding and the benefit for urology and a certain amount of honest modesty is justified those of previously published UK clinician rates6. the director of the clinic, the medical director, the patients and caregivers is often questionable. The aim when clinical decisions are made together with hospital director and the chairman of the board of this paper is to introduce a long awaited discussion patients. In onco-urology, decisions have to be based all of whom are oncologists. As a consequence of Justified? in the urological community of costs and benefits of Urologists have to make many difficult clinical on examinations made by radiologists and MDTMs the urologist is no longer sitting with the MDT meetings. decisions. Some examples are: when to perform pathologists whose reports are usually signed by two patient and his wife when treatment decisions are radical cystectomy; how to treat patients with severe specialists as a means to ensure quality. made, but with oncologists. Clinical decision-making in urology: training and complications who are in critical care units; how to practice treat patients with sepsis due to multiresistant Multidisciplinary team meetings Origins It takes 5-8 years of training to become a fullybacteria; how to treat patients with Fournier’s Over the last decade I have witnessed the introduction MDTMs were introduced in response to a Scottish certified urologist. The time needed mostly depends of MDTMs for prostate cancer in two Scandinavian study on ovarian cancer which provided evidence that gangrene, chronic pain syndromes, major trauma and on the requirements for training in general surgery neurourological disorders. countries. This new way of making clinical decisions improved survival was associated with patient which varies among countries. The candidate acquires was not developed by urologists but was introduced management by a MDT and administration of clinical experience and develops his or her judgment These are decisions with significant impact on by the hospital leadership. Within a short period of platinum chemotherapy1.According to the UK and technical skills by seeing patients, working Department of Health, delegates at MDTMs shall be patients’ prognoses. There are no traditions for time most urology departments got several large alongside supervisors and attending daily discussions screens in their meeting rooms. In Oslo, 65 people able to contribute independently to the diagnostic and establishing formal multidisciplinary group meetings with colleagues. treatment decisions being made2. in these situations. Treatment decisions are usually from different medical specialties in three different made by a single urologist under considerable time hospital campuses are now being invited by a He or she acquires theoretical knowledge through This is more obvious in other specialties than in constraint who will seek discussion partners as coordinator to attend weekly conferences where structured programmes on local, national and onco-urology. In rehabilitation medicine for needed. 5-10 patients are discussed within 1-1.5 hours. international levels. No other medical specialty has as example, people from several disciplines are comprehensive guidelines on diagnosis and treatment There are no clear entry criteria, but usually, involved in the rehabilitation process like nurses, Conclusions as urology. Our guidelines are developed by physiotherapists, occupational therapists, general It is hard to believe that 20-30 people in a group, patients are being presented to the MDTM to decide multidisciplinary panels with patient representatives practitioners, neurologists and orthopaedic where only a few know the patient well, make better which well-established treatment to recommend. and are built on evidence-based medicine and surgeons. All have specific evaluation tests and clinical decisions than a single urologist who seeks A patient history is presented by a urologist or systematic literature searches. apply different principles in the execution of their advice from a fellow urologist or oncologist when oncologist who has seen the patient in the rehabilitation efforts. needed. outpatient department, or by the chairperson of the All of our courses and exams use EAU Guidelines as a meeting. Thanks to cameras all attendees see the Today MDTMs have been adopted in almost all fields Displaying pathology and radiology findings on reference. A core prerequisite for making good clinical meeting room where the speaker is. Unfortunately, of medicine but there are no generally-accepted aims screens does not add extra information to a report decisions is to have deep knowledge about the patients. what is said is not always heard and some degree of and principles for running MDTMs. Making decisions which is already signed by two specialists. The shouting is needed. Patient notes are presented on on prostate cancer treatment in the absence of the significant resources which are currently used on a separate screen by the meeting coordinator and patient and his partner or relative violates classical onco-urological MDTMs and fast track courses should Core elements of treatment decisions the results of imaging are presented on other principles. Having said this - it is hard to imagine a not be taken from other urological patients. MDTMs • Thorough knowledge about the patient screens by radiologists, specialists in nuclear patient and his wife attending a MDTM in its present • Anamnesis should however, be considered in clinical situations medicine and pathologists. form where the majority of delegates does not know • Includes assessment of patient where decisions will have significant impact on preferences and his/her competence patients’ prognoses. Then follows a discussion and usually a consensus on his history and preferences. to consent treatment is reached. The EAU Guidelines are always Resource usage • Clinical examination Urologists must learn from oncologists to seek the most important reference. The colleague who • Reliable supplementary information introduced the patient writes short minutes which are A recent Swedish study carried out among numerous positions where decisions on funding are being made medical specialties reported a mean meeting time of and to fight for urological patients for whom increased • Clinical chemistry later presented to the patient during an outpatient 1.14 (0.25–2.75) h for video-based MDTMs and mean • Imaging resources might have greater impact on quality and visit. MDTMs are also being used to authorise 12.7 cases were discussed at each meeting3.MDTM • Pathology length of life than in prostate cancer patients. experimental treatments outside research protocols duration was significantly influenced by cancer type, • Honest presentation of our understanding like extirpation of susceptible lymph nodes. This is local hospital versus university hospital, and of the disease and treatment options There are many aspects of MDTMs which should be always controversial. video-based versus non-video based meetings. • Effects discussed in the urological community. Hopefully, this • Side-effects article will initiate this discussion. All patient information in our department is stored Data on time for preparation, participation and • The patient must have the chance to ask electronically. Journals often get voluminous and post-MDTM administrative work was analysed. questions and be answered Literature finding and reading relevant documents may take Physicians reported mean times of 1.84 h for • Modesty about own qualifications and 1. Junor EJ, Hole DJ, Gillis CR. Management of ovarian 20 minutes and sometimes even more. We do not readiness to refer the patient to other cancer: referral to a multidisciplinary team matters. register routinely how many attendees have obtained preparation, 1.07 h for participation and 1.23 h for post-MDTM administrative work per MDTM. Nurses/ specialists Br J Cancer. 1994; 70: 363-370Haward, RA. deep knowledge about the patients beforehand, but others reported mean 0.89 h for preparation, 1.17 h 2. Department of Health. Manual for cancer services 2004. the impression is that only about 10-20% of MDT Department of Health, London; 20043. attendees are well prepared. Preparing might require for participation and 1.08 h for administrative post-MDTM work. Measures to improve clinical decisions 3. Alexandersson N, Rosell L, Wihl J, Ohlsson B, Steen a couple of hours. Everything that is being displayed • Extend clinical experience Carlsson K, Nilbert M. Determinants of variable resource on the screens during the meeting is already written The time required for preparation was significantly • Working alongside senior colleagues use for multidisciplinary team meetings in cancer care. in the patient journal. A lot of time is spent on longer for pathologists, mean 2.4 h and for (both in the OR and in the outpatient Acta Oncol. 2018 May;57(5):675-680. doi: answering questions from attendees who did not radiologists, mean 3.4 h compared to internists with rooms) 10.1080/0284186X.2017.1400682. Epub 2017 Dec 3. read the patient’s notes beforehand. We have no median 1.27 h and finally surgeons, who reported • Improve clinical judgment 4. Reeves S, Pelone F. Harrison R, Goldman J, Zwarenstein systematic evaluation of the MDTMs. Whether mean times of 1.55 h. There were no data from • Opportunity to consult a supervisor M. Interprofessional collaboration to improve attendees find the meetings worthwhile or not urology but the findings seem comparable to our • Structured reflections of own practice prefessional practice and healthcare outcomes. Cochrane depends on the chairmanship. experience in Oslo. Overall, 84% of the cost was together with supervisor Database of Systemic Reviews 2017, Issue 6. Art. • Honest and thorough discussions of No.:CD000072. DOI:10.1002/14651858.CD000072.pub3. MDTMs have become an integral part of what is called attributed to physician costs3. complications and unexpected events 5. Pillay B, Wootten, Crowe, Corcoran, Tran, Bowden, “packet courses” in Scandinavia. It implies that Crowe, Costello. The impact of multidisciplinary team with colleagues (root cause analyses, patients suspected of having a urological malignancy Evidence base A Cochrane review and another systematic review complication meetings etc.) meetings on patient assessment, management and are given a guarantee to be seen in the outpatient have been identified4,5.Published studies are generally • Analysing own patient series, giving outcomes in oncology settings: A systematic review of department before treatment within the next few of low or very low quality and there is no evidence for the literature. Cancer Treat Rev. 2016 Jan;42:56-72. doi: lectures and writing scientific papers weeks. The system requires prescheduled outpatient a benefit of MDTMs on the outcome of cancer 10.1016/j.ctrv.2015.11.007. Epub 2015 Nov 24. • Improve theoretical knowledge visits and OR times and actually means that these • Reading guidelines, journals and 6. Taylor, C, Graham J, Potts HW et al. Changes in mental patients are given a kind of gold card to pass through treatment. There is also no evidence for a benefit of attending courses health of UK hospital consultants since the mid-1990s. the system before other urological patients who are in fast track systems based on pre-booked slots on the outcome of cancer treatment. Lancet. 2005; 366: 742-744. the queue. Prof. Truls Erik Bjerklund Johansen Oslo University Hospital Dept. of Urology Oslo (NO)


European Urology Today

August/September 2018

NIMBUS trial recruits 250th patient Active recruitment in Germany, the Netherlands, France and Belgium. Spain, Italy and Turkey starting up Prof. Marko Babjuk Study Principal Coordinator Prague (CZ)

marek.babjuk@ fnmotol.cz

Prof. Levent Türkeri Study Principal Coordinator Istanbul (TR)

turkeri@ marmara.edu.tr 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). This European trial is actively recruiting in Germany, the Netherlands, France, and Belgium. Spain, Italy and Turkey are starting up and the first patients from these countries are expected directly after the summer holidays.

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.

work to enrol in this study. Over 250 patients have been included in NIMBUS study so far in a 4-year period.

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.

The steering committee is considering every option to keep the study moving forward with research, and plans for inclusion of additional countries and sites are already in action. However, the importance of the need for continued dedication and work of our recruiting centres for the success of this study cannot be stressed enough. In an environment where scientific research is increasingly in line with industrial achievements, an investigator-initiated trial such as NIMBUS is more important than ever. If we cannot answer this scientific question, it is quite probable that it will never be answered. Therefore, we encourage all of our researchers and members of the team to continue with their increasing support for the trial and assure you that the Steering Committee will do its best to help you in this endeavour.

NIMBUS, a pivotal trial for BCG therapy in management of High-Grade NIMBC The NIMBUS Study was designed to answer a very important scientific question concerning the optimal use of BCG intravesical therapy in the management of High Grade Ta/T1 bladder tumours. The results of this study may have strong implications not only for patients in terms of compliance, therefore outcome and side effects but also for national healthcare systems in terms of medical care savings with a cost effective treatment protocol. Therefore, timely completion of this trial is of utmost importance.

Nevertheless, there have been some concerns about the slow recruitment of the trial despite the large and increasing number of recruiting centres. Unfortunately, this issue attained a critical importance lately and formed the basis of discussions for termination of the trial before its goal is reached.

We will very much appreciate any feedback relating to any topic of this study and we believe that our research teams all around Europe will make this study a landmark success.

We wish to extend our heartfelt congratulations to many centres in Europe for their dedicated and hard

Intravesical instillation of BCG is a widely-accepted strategy to prevent recurrence of non-muscle invasive Study status bladder cancer. The most accepted treatment schedule Cut-off date 6 August 2018 is induction of BCG: weeks 1 through 6 plus Country EC Approval Date maintenance (weeks 1,2,3) at months 3, 6 and 12, but it is unknown how many administrations are really Germany 18-4-2013 necessary. Scientific evidence supports the hypothesis The Netherlands 30-9-2014 that after an initial sensitisation to BCG antigens has France 5-5-2017 occurred, the number of instillations can be reduced Belgium 12-5-2018 for a proper anamnestic immune response resulting Spain 21-6-2018 in similar clinical efficacy and potentially fewer side-effects and lower costs. Italy Awaiting approval Turkey Awaiting approval

No. Centres 29 13 7 4 10 2+ 14

No. of recruiting Centres 27 12 5 1 Total

EAU Research Foundation

No. included patients 132 93 37 2 264

Study team Protocol Committee • Marko Babjuk, Prague • Luis Martinez- Piñeiro, 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 • Spain: Luis Martinez-Piñeiro • Belgium: Tim Muilwijk • Italy: TBD • Turkey: Levent Türkeri EAU Research Foundation • Anders Bjartel, Chairman • Wim Witjes, Scientific and Clinical Research Director • Raymond Schipper, Clinical Project Manager • Christien Caris, Clinical Project manager • Ilse Christ, Clinical Research Associate • Joke van Egmond, Clinical Data manager • Xandra Helmonds, Financial Officer • Hans Noordzij, Marvin Management Assistant 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 in participating 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 or check Twitter (#EAUrf) for updates.

Announcement: Seeding Grant Application now open! EAU RF supports highly innovative and original research by a junior investigator The EAU Research Foundation (EAU RF) is announcing Ethical Issues a new seeding grant, with the aim of supporting • Research involving human subjects and/or highly innovative and original research by a junior vertebrate animals must comply with the relevant investigator. The call for applications is currently European and national laws. open, with deadlines closing on October 3th, 2018 • All funded research must be conducted within the (notification of intent) and October 17th, 2018 (grant research ethics guidelines of the National Health application submission). and Medical Research Council. • Institutional approval by the appropriate ethics Applicants are invited to submit 1-year research committee(s) must be demonstrated prior to projects with a total budget up to €25,000. These release of funds. projects should be designed to collect or strengthen • Certification that approval has been given should preliminary data and to qualify for future external be forwarded with the application or as soon as competitive funding. Preliminary data is not available. required in the application. Seeding grants will be awarded in basic, translational and/or clinical The evaluation process research. Applications that are incomplete or do not comply with the requirements stated in this Call for Funding for this Call for Application amounts to a Applications will not be accepted. maximum of € 50,000 in total for 2 projects. The Applicant must be an academically active Grants will be awarded on a competitive basis. All researcher/clinician and member of the EAU and accepted Applications will undergo a two-step be younger than 40 at submission deadline. The selection process. The Review Panel will be composed total project period is one year. Successful projects of the members of the EAU Research Foundation and will start in December, 2018 and will end in an external expert reviewer, if needed. December, 2019. First step Budget Each application will be independently scored by The maximum budget request is € 25,000. Funds can three reviewers. Assignments will be made in order be spent on salaries (including the grant holder) and/ to avoid potential bias (i.e. projects will be not or consumables/reagents/subcontracts. Payment of reviewed by their own Division/Center/Institute internal facilities/clinical costs is allowed up to affiliates). € 5,000. The budget description must be accurate and every item must be justified in the appropriate section The evaluation criteria for the first step of selection of the application form. will be the following: EAU Research Foundation

August/September 2018

• Originality and innovation • Feasibility of the proposed experiments

• Potential to be competitive for larger scale funding • Qualification and research experience of the Applicant Reviewers will discuss the scoring results of individual applications and will reach a consensus ranking list. Second step The top 3-4 applicants will be invited to a personal meeting with the Review Panel, consisting of a brief presentation of their proposal (10 minutes) and a question & answer session. Reviewers will rank the candidates based on the following criteria: • Ability of the Applicant to analyse expected results in the context of a future larger proposal • Balance between innovation and feasibility How to apply Candidates are expected to submit: • • • •

Completed application form (.docx) CV and list of publications Copy of passport Written Project Proposal specifying Background, aims and objectives, project description and a paragraph with future prospects, dissemination and impact. (written project proposal should be max. 5 pages) • Specification of the costs / budget using headlines: laboratory costs, travel costs, personal hours, other expenses.

The application form can be found on www.uroweb. org/research or can be requested through the e-mail address below. All details on submission can be found on the application form. Necessary Steps to be taken by the applicant for the seeding grant: 1) All scientists intending to apply must notify the EAU Research Foundation Central Research Office by email (e.spieker@uroweb.org) no later than Wednesday October 3rd, 2018. All applicants will receive a message of receipt. 2) The above-listed documents must be completed according to the specifications above (i.e. project proposal of max. 5 pages) and sent to the EAU RF according to details on the form no later than Wednesday October 17th, 2018 at 24h Central European Summer Time by email (e.spieker@uroweb.org). All applicants will receive a message of receipt. If you miss one of these deadlines 1 or 2, your application can unfortunately not be accepted for evaluation this time. 3) The top 3-4 applicants will be invited for a personal meeting with the Review Panel on Saturday November 10th, 2018 during EMUC18, held in Amsterdam. We are looking forward to your applications!

European Urology Today


Stronger arguments for participation in the GPIU study Impressive recruitment, important achievements, new developments Prof. Florian Wagenlehner Justus Liebig University Giessen, Dept. of Urology Giessen (DE)

florian.wagenlehner@ chiru.med.uni-giessen.de

Dr. Zafer Tandogdu Edinburgh University Scotland (UK)


Prof. Truls E. Bjerklund Johansen Oslo University Hospital Dept. of Urology Oslo (NO)

allow individual institutions to bench-mark their performance against national and international peers. A proxy for antibiotic consumption is reflected by the application rates used for antibiotic prophylaxis for urological interventions. Resistance rates of most uropathogens against antibiotics are directly evaluated and the findings have great impact on our daily antibiotic use practices. The severity of healthcare-associated urinary tract infections is also increasing, with 25% being urosepsis in recent years.

Challenging UTI definitions (CDC/NHSN criteria) The ESIU has adapted and modified the CDC/NHSN criteria for special usage in urology and especially when urologists are taking part in the annual global prevalence study on infections in urology, because the same criteria have to be used, and if data of different institutions are collected/compared and if the efficacy of any intervention has to be tested.

Urosepsis During recent GPIU studies we have seen an increase in the reported percentage of urosepsis7. In 2006, the percentage of HAUTI being urosepsis was 9.3%, in GPIU is an international internet web-based study. All 2007 it was 15.4% and in 2008 it was 21.8%. The ESIU believes this might be due to more blood cultures patient information is reported anonymously to the being taken which is also in accordance with general central study file. The study is sponsored by the EAU recommendations. However, in order to avoid a too and the Merian-Iselin Foundation. high registration of urosepsis, investigators are Healthcare-associated infections in urology were seen encouraged to stick to the definitions of urosepsis in around 11%, with one-third being severe infections, presented in the ESIU guidelines. such as urosepsis or pyelonephritis. There were also Join GPIU! significant differences between regions and types of Resistance to antibiotics is continuously increasing, hospitals1,2. which is the strongest argument ever for taking part in the GPIU-study! With few new antibiotics against Collating key intelligence information gram negative pathogens in the pipeline, it is crucial The studies showed that the bacterial spectrum is that we use those we have in a prudent way. comprised of pathogens Escherichia coli (31%), followed by species of Pseudomonas (13%), The GPIU-study is the only worldwide-performed Enterococcus (10%), Klebsiella (10%), Enterobacter study in urological infections. Investigators are very (6%) and Proteus (6%). Candida spp. and welcome to publish their regional results when Pseudomonas spp. occurred significantly and more compiling with investigators of their region. This year frequently as causative agents in urosepsis than in 10-year Asian GPIU data was published8. other types of infections.

tebj@medisin.uio.no Co-authors: R. Bartoletti, G. Bonkat, F. Bruyere, T. Cai, J. Medina-Polo, B. Koves, E. Kulchavenya, T. Perepanova, A. Pilatz

The resistance rates of all antibiotics tested, other than carbapenems, against the total bacterial spectrum were higher than 10% in all regions. The resistance of E. coli, Klebsiella and Proteus spp. was below 45% for the most commonly used antibiotics. Enterococcus spp. and Pseudomonas spp. however, had resistance rates above 70% to most antibiotics3.

The Global Prevalence of Infections in Urology (GPIU) study is a worldwide point prevalence study intended to create surveillance data on antibiotic resistance, The resistance rates of most of the uropathogens type of urogenital infections, risk factors and data on against the antibiotics tested did not show significant antibiotic consumption. trends of increase or decrease, but were already high during the first study years. Resistance to almost all pathogens was lowest in North Europe and highest in Apart from the GPIU main study, several side studies are taking place: currently, the side study Asia4. evaluating prostate biopsy is amongst the most important. The GPIU study has been annually Addressing aspects of EAU Guidelines performed since 2003. As antibiotic prophylaxis is an important part of antibiotic consumption, data on routine antibiotic Due to the tremendous and enthusiastic participation prophylaxis have been evaluated showing that of more than 1000 hospitals / centres from 70 antibiotic prophylaxis in urological patients was countries, screening of 27,542 patients took place over highest in Latin America (84%), followed by Asia the last years, yielding important information about (86%), Africa (85%), and Europe (67%)3,5. The infection-related issues of urological patients. The antibiotics most frequently used for prophylaxis were collected detailed information is not available in any second-generation cephalosporins, ciprofloxacin, other sources. cefotaxime, and amoxicillin plus beta-lactamase inhibitor. Aims of the GPIU Study The primary aims of the study are to do the following “With few new antibiotics against in urology departments throughout the world: (1) Evaluate urology practice in terms of hospital infection control, which includes: a. Control programmes for catheters, antibiotics, etc. b. Antibiotic consumption practice (2) Evaluate UTI and surgical site infections (SSI) in hospitalised urological patients, which includes: a. Patient baseline characteristics b. Pathogens and their antimicrobial resistance c. Antimicrobial treatment (3) Determine the prevalence of healthcareassociated infections (HAI) for: a. Geographical regions b. Varying hospital settings c. Study years The secondary aims of the study are to offer participating urology departments and urologists: (1) an instrument for quality control of healthcareassociated infections within their institution (2) acknowledgement of active involvement in an infection control program according to European Association of Urology (EAU) /ESIU (EAU Section for Infections in Urology) recommendations (3) Certificate for infection control Through these aims, the results of the study continuously provide national and international data on UTI and SSI for use in further research and will EAU EAU Section Section of of Urolithiasis Infections in(EULIS) Urology (ESIU)


European Urology Today

gram negative pathogens in the pipeline, it is crucial that we use those we have in a prudent way.”

There were significant differences between countries/ regions and types of hospitals, both in using prophylaxis for clean procedures and in the types of antibiotics used. Antibiotic prophylaxis was not always consistent with recommended guidelines5. Data from the previous GPIU-studies indicate that in the near future both antimicrobial prophylaxis and empirical treatment will have to be tailored for each patient on the basis of risk factors, contamination category of surgical procedures and availability of effective antibiotics in the region. Prostate biopsies Especially in transrectal prostate biopsy, antibiotic prophylaxis is critical, as infection is a serious adverse effect of this procedure, and recent reports suggest an increasing incidence of post biopsy infections. For this reason a prostate biopsy side study was performed in 2010 and 2011 and followed up in 2012 and 2013. In this study, symptomatic urinary tract infections were seen in 5.2% of men, which were febrile in 3.5% and required hospitalisation in 3.1%. The most important risk factor was fluoroquinolone resistance in causative pathogens6. To expand the database and receive more information in this important field, the prostate biopsy side study will also be performed in 2018.

Box 1: Benefits for GPIU-Investigators • Online certificate of infection control • Online statistics • Recognition in GPIU publications • Slides with study results Box 2: Study days in November 2018 6-8 November 20-22 November 13-15 November 27-29 November The GPIU 2018 is registered in ClinicalTrials.gov Box 3: Practical guide for GPIU investigators: 1. Decide on the most desirable study day for your department. 2. Log on to the GPIU’s website and register yourself as an investigator and fill in the fields requested to earn EU-ACME points (http://gpiu.esiu.org/) 3. You may print out PDFs of the report forms to use as reference when making notes. 4. On the chosen single study day, at 08:00 AM local time all patients present on the ward should be included. The presence of urinary tract infections and/or surgical site infections during their entire hospital stay should be documented and audited. Thus the charts and case records of the included patients should be examined both retrospectively and prospectively and patients should be categorized as having or not having a urinary tract infection (UTI) and/or surgical site infection (SSI). 5. Fill in the electronic hospital report form. Submit your data to the study database, or store pending forms in your local computer while awaiting additional data. 6. When the results of cultures etc. are available, complete the electronic patient report forms and submit them to the study database. Remember to connect to the internet for the submission of report forms! 7. You are also cordially invited to fill in the additional questionnaire on TRUS-Bx of the prostate. 8. You will be able to compare your own results with the total mean results by January 2019. Don’t forget: You should still complete your data entry even if no hospital acquired urinary tract infection is detected in your clinic on the study day.

Box 4: Important modifications of the CDC/ NHSN criteria which will be used in the GPIU 2018 1. The time interval between the admission of the patient and the diagnosis of HAUTI is no longer a criterion for the definition of a HAUTI. It is sufficient that the patient has a negative urine culture on admission and a careful clinical evaluation suggests that there was no UTI present on admission. 2. An exacerbation from ASB to a symptomatic UTI after any intervention has to be considered healthcare-associated caused by an endogenous source. 3. Any extension of infection already present at admission with a change in pathogen, including emergence of resistance, has to be considered healthcare-associated. 4. Healthcare-associated asymptomatic bacteriuria (HAASB) should be considered as colonisation, probably as risk factor under certain circumstances, but not as infection. However, screening for ASB is always necessary before all the mucosa traumatizing urological interventions of the urinary tract, because treatment of ASB has to be initiated before any such interventions. Therefore screening for HAASB should be included into the upcoming GPIU study, but data on HAASB will be evaluated separately and not included in calculation of the prevalence of HAUTI. 5. For the GPIU, as for all routine surveillance, we recommend that the time interval for diagnosing HAUTI or HAASB should be seven days after the intervention, or in case of on-going antibiotic therapy seven days after the end of antibiotic therapy, or in case of an indwelling urinary catheter, seven days after removal of the catheter. 6. There is a new definition on sepsis, which should be based on the quick SOFA score: Respiratory rate ≥ 22/ min Altered mental function Systolic blood pressure ≤ 100 mmHg

Russian and Spanish This year, the GPIU study will for the first time be available in Spanish and Russian, which makes it even more attractive for investigators from these countries to join the study. The GPIU study is sponsored by the EAU Research Foundation (EAU RF) and Merian Iselin. References 1. Bjerklund Johansen TE, Cek M, Naber K, Stratchounski L, Svendsen MV, Tenke P, et al. Prevalence of hospital-acquired urinary tract infections in urology departments. Eur Urol 2007;51(4):1100-11; discussion 1112. 2. Wagenlehner F, Tandogdu Z, Bartoletti R, Cai T, Cek M, Kulchavenya E, et al. The Global Prevalence of Infections in Urology Study: A Long-Term, Worldwide Surveillance Study on Urological Infections. Pathogens 2016;5(1). 3. Johansen TE, Cek M, Naber KG, Stratchounski L, Svendsen MV, Tenke P, et al. Hospital acquired urinary tract infections in urology departments: pathogens, susceptibility and use of antibiotics. Data from the PEP and PEAP-studies. Int J Antimicrob Agents 2006;28 Suppl 1:S91-107. 4. Tandogdu Z, Cek M, Wagenlehner F, Naber K, Tenke P, van Ostrum E, et al. Resistance patterns of nosocomial urinary tract infections in urology departments: 8-year results of the global prevalence of infections in urology study. World J Urol 2014;32(3):791-801. 5. Cek M, Tandogdu Z, Naber K, Tenke P, Wagenlehner F, van Oostrum E, et al. Antibiotic prophylaxis in urology departments, 2005-2010. Eur Urol 2013;63(2):386-94. 6. Wagenlehner FM, van Oostrum E, Tenke P, Tandogdu Z, Cek M, Grabe M, et al. Infective Complications After Prostate Biopsy: Outcome of the Global Prevalence Study of Infections in Urology (GPIU) 2010 and 2011, A Prospective Multinational Multicentre Prostate Biopsy Study. Eur Urol 2013;63(3):521-7. 7. Tandogdu Z, Bartoletti R, Cai T, Cek M, Grabe M, Kulchavenya E, et al. Antimicrobial resistance in urosepsis: outcomes from the multinational, multicenter global prevalence of infections in urology (GPIU) study 2003-2013. World J Urol 2016;34(8):1193-200. 8. Choe HS, Lee SJ, Cho YH, Çek M, Tandogdu Z, Wagenlehner F, Bjerklund-Johansen TE, Naber K; GPIU Asian Investigators. Aspects of urinary tract infections and antimicrobial resistance in hospitalized urology patients in Asia: 10-Year results of the Global Prevalence Study of Infections in Urology (GPIU). J Infect Chemother. 2018;24(4):278-283.

August/September 2018

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

Oliver.Hakenberg@ med.uni-rostock.de

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

Case study No. 57

Case study No. 58 This 26-year-old man presented with back pain some months ago to a general practitioner. With some delay, eventually a large tumour of the right kidney was diagnosed. On the CT scans (Figs. 1 and 2) intravascular tumour extension is seen with the thrombus reaching the diaphragm. In addition, pulmonary CT scanning shows several vascular emboli on both sides. There is no evidence of metastatic disease on extensive staging.

reasonably well for his age, comorbidities are a well-controlled hypertension and he has had a cardiac stent 6 years ago.

This 86-year-old man presented with macroscopic haematuria and lower abdominal left-sided pain. Cystoscopy and transurethral resection led to the diagnosis of bladder cancer (urothelial carcinoma high grade) with muscular invasion. CT staging (fig.1 and 2) showed a lesion that has probably grown outside the bladder and reached the left pelvic wall.

Figure 1

The patient is well educated, understands the problem and would like to have curative treatment, if at all possible. His physical condition is

Figure 2

Discussion points: • Are further investigations helpful? • In view of the patients wish for curative treatment what options are possible? • What treatment would you advise? Case provided by Oliver Hakenberg, Department of Urology, Rostock University. Oliver.hakenberg@med.uni-rostock.de

Comment on clinical case study No. 57 Comments by Dr. Alberto Breda and Dr. Angelo Territo Barcelona (ES)

Dr. Alberto Breda

Dr. Angelo Territo

Nowadays, with the ageing population and the increasing number of muscle invasive bladder cancer (MIBC), optimising the management of elderly patients affected by this disease is becoming of crucial importance. According to the 2018 EAU Guidelines on MIBC, the evaluation of distant metastases is mandatory before any curative treatment. In order to detect lung and liver metastases, a CT or MRI should be performed. A bone scan and additional brain imaging are not routinely indicated, unless the patients have specific symptoms or signs suggesting bone or brain metastases1. As far as a potential curative treatment, available options include surgery (i.e. cystectomy with urinary diversion) or trimodality (radiotherapy,

chemotherapy, and transurethral tumour resection) therapy2. Although the term ‘elderly’ refers to advanced chronological age, more important factors in determining treatment are the functional status and associated comorbidities. Therefore, functional status must be seriously considered, the Karnofsky performance status being an important predictor of survival outcome in this population3. Radical treatment in patients > 80 years old (i.e. radical cystectomy with urinary diversion) leads to significant short and long-term morbidity. For these reasons, proper patient selection, assessing the performance status and psychosocial parameters seems helpful in order to optimise survival outcomes4. However, according to the current literature, acceptable survival expectancies and perioperative outcomes are reported in patients with cT4 MIBC treated with radical cystectomy5. On the other hand, trimodal therapy in elderly patients has been found to be well-tolerated with outcomes similar to that of radical cystectomy6,7. Referring to this patient, a radical cystectomy could be offered. Furthermore, as elderly patients potentially experience more post-operative complications following cystectomy with intestinal reconstruction8, a minimally invasive approach (i.e. laparoscopy or

robotic surgery) with a ureterocutanostomy could be the best choice to lower the operative time as well as the complication rate. References 1. EAU Guidelines on Muscle invasive and metastatic bladder cancer 2018. 2. Erlich A et al. Treatment of bladder cancer in the elderly. Invest Clinic Urol 2016. 3. Weizer AZ et al. Performance status is a predictor of overall survival of elderly patients with MIBC. J Urol 2007 4. Mendiola P et al. Cystectomy in the ninth decade: operative results and long-term survival outcomes. Canadian J Urol 2007. 5. Moschini M et al. The surgical management of patients with clinical stage T4 bladder cancer: A single institution experience. Eur J Surg Oncol 2017. 6. Mathieu R et al. Trimodal therapy for invasive bladder cancer: is it really equal to radical cystectomy? Curr Opin Urol 2015Rose TL et al. Management of muscle-invasive bladder cancer in the elderly. Curr Opin Urol 2015. 7. Bassett JC et al. Treating octogenarians with muscle invasive bladder cancer: preoperative opportunities for increasing the benefits of surgical intervention. Urol Oncol 2014. 8. Smith ND et al. The RAZOR (randomized open vs robotic cystectomy) trial: study design and trial update. BJU Int 2015.

Value of ureteroscopy in kidney-sparing management of UTUC Comments by Prof. Marko Babjuk Prague (CZ)

This is definitely not an easy case because of the large local tumour and the patient’s senescence. There are several details which need to be clarified to be able to make a final decision: • First we need to specify the staging of the tumour, particularly to exclude distant metastases. We must carefully evaluate the CT scan and exclude enlarged pelvic and retroperitoneal lymph nodes and liver metastasis, we must perform a thoracic CT and potentially, in the case of skeletal symptoms, also a bone scan. I usually do not use PET scans routinely, as its diagnostic accuracy in urothelial tumours is not sufficient. • Another issue is to consider the local extent of the tumour. In this particular case it is apparently reaching the left pelvic wall and the risk of positive margins or even detection

August/September 2018

of unresectable tumour during surgery seems to be significant. Bimanual examination during TURB could be helpful which sometimes indicates how rigid the fixation of the tumour to other structures is. Together with the CT scan it may help us to predict the radicality and feasibility of surgery. • A very important point is the general status of the patient. Although his condition "is reasonably well for his age", he is 86 years old which is necessarily connected with a certain extent of frailty and the risk of serious co-morbidities. Therefore, a thorough preoperative work-up should be done including the evaluation of ventilation parameters, echocardiography and comorbidity status according to ASA score and Charleston index. For the final assessment, it will be very important to know the opinion of a geriatric specialist. • Finally, we have information about the presence or absence of local complications such as pain, bleeding or hydronephrosis, as this could also influence the final decision. Based on these details, the multidisciplinary team should decide about the treatment strategy, which must be strictly individualized:

• If the patient is fit enough and the surgery with radical intent seems to be possible, the patient can even at this age benefit from radical cystectomy by improved survival and reduced risk of local complications. • Neoadjuvant chemotherapy is usually connected with significant risks in octogenerians, so I would probably not advise that in this gentleman. • The surgeon must also consider the method of diversion. In my opinion, in this case cutaneous ureterostomies are a reasonable option because of a lower burden of morbidity for the patient and a lower risk of critical complications. • In any case, the patient must be informed about the risk of surgery as we know that perioperative mortality can exceed 15% in octogenerians. • If there is a low chance of radical excision –as is probably the case here– or if the general status does not allow major surgery or if the patient is not willing to undergo surgery, radiotherapy would usually then be the treatment of choice. It may be preceded by urinary diversion in the case of hydronephrosis or intractable haematuria.

Figs. 1 and 2: Abdominal CT scans

Discussion points: 1. What treatment should be undertaken? 2. Are any special measures advisable? 3. Regarding the multiple already-existing small pulmonary emboli, what treatment is appropriate?

Case provided by Oliver Hakenberg, Department of Urology, Rostock University. E-mail: oliver. hakenberg@med.uni-rostock.de

Case Study No. 57 continued The patient underwent radical cystectomy with resection of the rectum, which was infiltrated, and construction of a terminal colostomy and an ileal conduit. The tumour infiltrated the pelvic wall and resection was therefore pathologically incomplete. Lymph nodes were positive. Postoperatively, the patient developed an insufficiency of the small bowel anastomosis which was treated by a temporal ileostomy. Postoperative recovery was extremely protracted and eventually the patient decided not to have more procedures and died under palliative care three weeks later.

European Urology Today


Key articles from international medical journals Dr. Francesco Sanguedolce Section editor Barcelona (ES)

Culture-based diagnosis was performed using routine microbiological methods. Culture-independent profiling was performed using bacterial 16S RNA profiling. E. coli strain typing was performed by amplicon pyrosequencing of the fimH gene.

fsangue@ hotmail.com

Culture-independent analysis of 38 of these samples revealed the existence of a diverse urinary microbiota

Alpha diversity in GI microbiota in men with prostate cancer It is well known that the gastrointestinal (GI) microbiota can influence the metabolism, pharmacokinetics, and toxicity of cancer therapies. Conversely, the effect of cancer treatments on the composition of the GI microbiota is poorly understood. Authors hypothesised that oral androgen receptor axis-targeted therapies (ATT), including bicalutamide, enzalutamide, and abiraterone acetate, may be associated with compositional differences in the GI microbiota. The faecal microbiota was profiled in a crosssectional study of 30 patients that included healthy male volunteers and men with different clinical states of prostate cancer (i.e., localised, biochemically recurrent, and metastatic disease) using 16S rDNA amplicon sequencing. Functional inference of identified taxa was performed using PICRUSt.

Over 2 years, 39 patients with refractory urge incontinence and coexistent rUTI were studied, yielding 9 severely affected cases. These 9 patients were carefully monitored for a further 2 years, resulting in the collection of 102 MSU samples, 70 of which were diagnosed as UTI (median of 8 UTIs/ woman). Culture-independent analysis of 38 of these samples revealed the existence of a diverse urinary microbiota. Strain typing of E. coli identified instances of rUTI caused by the same persisting strain and by new infecting strains. Patients with refractory urge incontinence and coexistent rUTI possess a diverse urinary microbiota, suggesting that persistent bladder colonisation might augment the pathology of their chronic condition.

Source: The urinary microbiome in patients with refractory urge incontinence and recurrent urinary tract infection. Chen Z, Phan MD, Bates LJ, Peters KM, Mukerjee C, Moore KH, Schembri MA.

Further analysis identified Int Urogynecol J. 2018 Jun 26. DOI: 10.1007/s00192-018significant compositional differences 3679-2. PMID: 29946828 in the GI microbiota of men taking ATT… Clinical and bacteriological cure rates of pivmecillinam in A significant difference in alpha diversity in GI UTI caused by E. coli with microbiota was found among men with, versus men without a prostate cancer diagnosis. Further analysis ESBL-production identified significant compositional differences in the GI microbiota of men taking ATT, including a greater abundance of species previously linked to response to anti-PD-1 immunotherapy such as Akkermansia muciniphila and Ruminococcaceae spp. In functional analyses, researchers found an enriched representation of bacterial gene pathways involved in steroid biosynthesis and steroid hormone biosynthesis in the faecal microbiota of men taking oral ATT. It is concluded that there are measurable differences in the GI microbiota of men receiving oral ATT. The authors speculate that oral hormonal therapies for prostate cancer may alter the GI microbiota, influence clinical responses to ATT, and/or potentially modulate the antitumour effects of future therapies including immunotherapy. It is emphasised that larger, longitudinal studies are warranted.

Source: Compositional differences in gastrointestinal microbiota in prostate cancer patients treated with androgen axis-targeted therapies. Karen S. Sfanos, Mark C. Markowski, Lauren B. Peiffer, Sarah E. Ernst, James R. White, Kenneth J. Pienta, Emmanuel S. Antonarakis, Ashley E. Ross. Prostate Cancer and Prostatic Diseases. https://doi. org/10.1038/s41391-018-0061

Persistent bladder colonisation might augment the pathology of refractory urge incontinence and recurrent urinary tract infection Urinary urge incontinence is a chronic, debilitating condition that is difficult to treat. Patients undergoing refractory to standard antimuscarinic therapy often experience recurrent urinary tract infections (rUTIs). The microbiota of these refractory patients with rUTI remains unexplored. A midstream urine (MSU) sample was collected from patients with refractory urge incontinence and coexistent rUTI during acute symptomatic episodes. Key articles


The objective of this study was to compare the clinical and bacteriological outcomes of pivmecillinam treatment for community-acquired urinary tract infections (UTIs) caused by ESBL-producing Escherichia coli versus non-ESBL-producing E. coli in an outpatient setting.

Source: Clinical and bacteriological efficacy of pivmecillinam treatment for uncomplicated urinary tract infections caused by ESBLproducing Escherichia coli: a prospective, multicentre, observational cohort study. Bollestad M, Grude N, Solhaug S, Raffelsberger N, Handal N, Nilsen HS, Romstad MR, Emmert A,Tveten Y, Søraas A, Jenum PA, Jenum S, Møller-Stray J, Weme ET, Lindbaek M, Simonsen GS,Norwegian ESBL UTI study group.

PARP inhibitors in mCRPC for the many and not just the few? Olaparib is a Poly (ADP-ribose) polymerase (PARP) inhibitor which works by trapping PARP at sites of DNA damage, causing an accumulation of DNA double-strand breaks. Previous preliminary data had shown a response as a single agent in a group of heavily pre-treated men with mCRPC. Treatment response was markedly improved in patients with tumours carrying a homologous recombination repair (HRR) mutation, presumably because of their inability to repair the DNA damage. Preclinical data suggests possible synergy between olaparib and drugs that affect the androgen receptor pathway regardless of HRR mutation status. This study assessed the efficacy and tolerability of olaparib in combination with abiraterone in patients with mCRPC irrespective of their HRR mutation status. At 41 urological oncology sites in 11 countries, 171 men with mCRPC were assessed for eligibility. Patients had to be candidates for abiraterone therapy, have a performance status of 0-2 and previous treatment with docetaxel but not second-generation antihormonal drugs. 142 patients were randomly assigned to receive olaparib 300 mg bd and abiraterone (n = 71) or placebo and abiraterone (n = 71). Cross-sectional imaging and bone scans were done every 12 weeks until week 72 and then every 24 weeks until disease progression, death or withdrawal of consent.

treatment failure for ESBL cases …

Investigators conclude that pivmecillinam given at 400 mg three times daily gave comparable clinical and bacteriological cure rates in women with community-acquired E. coli UTIs irrespective of ESBL production.

philip.cornford@ rlbuht.nhs.uk

J Antimicrob Chemother. 2018 Jun 29. DOI: 10.1093/jac/ dky230. PMID: 29982514

The primary endpoint was investigator-assessed radiographic progression-free survival (rPFS) based. In addition, blood was collected for the assessment of A prospective, multicentre, observational cohort study circulating tumour cells and plasma samples were of women aged ≥ 16 years, with pivmecillinam-treated tested for deleterious mutations in 15 HRR genes and when additional consent was obtained from community-acquired UTIs caused by E. coli with or without ESBL production, recruited from primary care whole-blood (germline) and archival tumour blocks. was conducted in the period from April 2013 to August 2016. Eighty-eight women (mean age 49.4 years) with At the data cut-off, 46 (65%) patients in the olaparib community-acquired UTIs caused by ESBL-producing and abiraterone group and 54 (76%) in the placebo group had radiographic disease progression or died. E. coli were compared with a control group of 74 rPFS was significantly longer in the olaparib and women (mean age 50.1 years). The trial was abiraterone group than the placebo and abiraterone registered at ClinicalTrials.gov, ID NCT01531023. group (median 13·8 months [95% CI 10·8–20·4] vs 8·2 months [5·5–9·7]; HR 0·65 [95% CI 0·44–0·97], p = …the subgroup treated with 0·034). However, in those patients with measurable disease at baseline there was no significant difference 400 mg pivmecillinam, showed between the groups in the proportion of patients who no significantly increased OR for achieved an overall objective response.

The median time until symptom resolution after treatment initiation was 5 days for the ESBL cases and 3 days for the non-ESBL controls (p < 0.01). The proportion of women warranting a second antibiotic prescription in the follow-up period was higher for the ESBL cases [30/88 (34.1%) versus 10/72 (13.9%), p <  0.01]. Persistent bacteriuria was non-significantly more common among ESBL cases than in the control group [15/81 (18.5%) versus 6/67 (9.0%), p = 0.10]. A pivmecillinam dosage of 200 mg given three times daily for ≤ 5 days was associated with treatment failure (OR 4.77, 95% CI 1.40-19.44, p = 0.03) for the ESBL E. coli group. For the subgroup treated with 400 mg of pivmecillinam given three times daily, there was no significantly increased OR for treatment failure between ESBL cases and the control group irrespective of treatment duration.

Mr. Philip Cornford Section editor Liverpool (GB)

This is the first study to show a significant improvement in rPFS for a combination of novel treatment In the olaparib and abiraterone group, 66 (93%) of 71 patients experienced an adverse event, compared with 57 (80%) of 71 patients in the placebo and abiraterone group. Most adverse events in both treatment groups were grade 1 or 2. The most common grade 1–2 adverse events were nausea (26 [37%] patients in the olaparib group vs 13 [18%] patients in the placebo group, constipation (18 [25%] vs 8 [11%]), and back pain (17 [24%] vs 13 [18%]). More patients had grade 3 or worse adverse events in the olaparib and abiraterone group than in the placebo and abiraterone group (38 [54%] of 71 vs 20 [28%] of 71). Grade 3 or worse adverse events that were reported more frequently in the olaparib group than in the placebo group included anaemia (in 15 [21%] of 71 patients vs none of 71), pneumonia (four [6%] vs three [4%]), and myocardial infarction (four [6%] vs none).

Serious adverse events were reported by 24 (34%) of 71 patients receiving olaparib and abiraterone (seven of which were related to treatment) and 13 (18%) of 71 patients receiving placebo and abiraterone (one of which was related to treatment). One treatmentrelated death (pneumonitis) occurred in the olaparib and abiraterone group. This is the first study to show a significant improvement in rPFS for a combination of novel treatment. This is particularly interesting as in the TOPARP-A study the efficacy of olaparib monotherapy was almost completely limited to patients with HRR mutations. More serious adverse events were observed in patients who received olaparib and abiraterone than abiraterone alone, however, the increased duration of exposure in the olaparib arm suggests that this tolerability risk might be offset by the observed efficacy. In addition there was no detriment to health-related quality of life as measured in this study. This data suggest that the combination of olaparib and abiraterone might provide an additional clinical benefit to a broad population of patients with metastatic castration-resistant prostate cancer.

Source: Olaparib combined with abiraterone in patients with metastatic castration-resistant prostate cancer: a randomised double-blind, placebo-controlled phase 2 trial. Clarke N, Wiechno P, Alekseev B, et al. Lancet Oncol. 2018; 19: 975-86.

Robotic cystectomy no better but still being adopted? Robotic surgery, originally introduced in 2000, has seen a rapid adoption across many surgical disciplines as surgeons aim to introduce the advantages of minimally-invasive surgery to ever more complex procedures. In 2016, 3,919 robotic systems were used for 753,000 procedures across the world. Increasingly this also includes radical cystectomy. Previous single centre studies found no difference in terms of positive margin rates, lymph node yield or complication rates. However, concerns have been raised about suitability for locally-advanced disease, the possibility of recurrence in uncommon locations plus the consequences of the learning curve and cost of robotic surgery. This study was designed to investigate whether robot-assisted radical cystectomy was non-inferior to open radical cystectomy. In 15 USA centres, 350 participants with biopsy proven clinical stage T1-4, N0-1, M0 bladder cancer or refractory carcinoma in situ were centrally assigned (1:1) via a web-based system stratified by type of diversion, clinical T stage, and performance status to receive robot-assisted radical cystectomy or open radical cystectomy with extracorporeal urinary diversion. Treatment allocation was only masked from pathologists. The extent of pelvic lymph node dissection and use of chemotherapy were based upon institutional preference. Perioperative morbidity was assessed using the modified Clavien-Dindo systems for complications within 90 days. Patients were followed up for bladder cancer progression or death from any cause at 4-6 weeks, then every 3-6 months for a minimum of 2 years after cystectomy. The primary endpoint was 2-year progression-free survival, with non-inferiority established if the lower bound of the one-sided 97·5% CI for the treatment difference (robotic cystectomy minus open cystectomy) was greater than –15 percentage points. The intended treatment was robotic cystectomy in 176 patients and open cystectomy in 174 patients. 17 (10%)


European Urology Today

August/September 2018

Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de of 176 patients in the robotic cystectomy group did not have surgery and nine (5%) patients had a different surgery to that they were assigned. 21 (12%) of 174 patients in the open cystectomy group did not have surgery and one (1%) patient had robotic cystectomy instead of open cystectomy.

… no significant differences in terms of major complication (Clavien-Dindo > 3), lymph node yield, positive surgical margins and patient-reported HRQoL outcomes Thus, 302 patients (150 in the robotic cystectomy group and 152 in the open cystectomy group) were included in the per-protocol analysis set. 2-year progression-free survival was 72.3% (95% CI 64.3 to 78.8) in the robotic cystectomy group and 71.6% (95% CI 63.6 to 78.2) in the open group (difference 0.7%, 95% CI -9.6% to 10.9%; Pnon-inferiority =0·001), indicating non-inferiority of robotic cystectomy. Estimated blood loss, blood transfusion rates and median length of hospital stay were significantly lower in the robotic cystectomy group although operating times were longer. Adverse events occurred in 101 (67%) of 150 patients in the robotic cystectomy group and 105 (69%) of 152 patients in the open cystectomy group. The most common adverse events were urinary tract infection (53 [35%] in the robotic cystectomy group vs 39 [26%] in the open cystectomy group) and postoperative ileus (33 [22%] in the robotic cystectomy group vs 31 [20%] in the open cystectomy group). However, there were no significant differences identified between the groups in terms of major complication (Clavien-Dindo > 3), lymph node yield, positive surgical margins and patient-reported health-related quality of life outcomes.

target dose was 137 Gy. Patients with a PSA between 10-14.9 ng/ml, > 50% positive cores or MRI evidence of extracapsular extension received EBRT (45 Gy in 25 fractions) to the prostate and seminal vesicles followed by brachytherapy boost (90 Gy). The cumulative incidences of metastasis and prostate cancer specific mortality for the NCCN very low risk, low risk and intermediate risk groups were estimated.

… less than full gland treatment for both low-risk disease and especially intermediate risk disease is not appropriate A total of 120 patients developed biochemical recurrence at a median of 4.8 years. 34/140 with very low-risk; 49/139 with low risk and 37/75 with intermediate disease. 44 patients developed biopsy-proven recurrence 9 with very low-risk disease, 18 with low risk and 17 with intermediate disease. 22 patients developed metastases at a median of 11.0 years (interquartile range, 6.9-13.9 years). The 12-year metastasis rates for patients with very low-risk, low-risk, and intermediate-risk disease were 0.8% (95% confidence interval [95% CI], 0.1%-4.4%), 8.7% (95% CI, 3.4%-17.2%), and 15.7% (95% CI, 5.7%-30.2%), respectively, and the 12-year PCSM estimates were 1.6% (95% CI, 0.1%-7.6%), 1.4% (95% CI, 0.1%-6.8%), and 8.2% (95% CI, 1.9%-20.7%), respectively. On multivariate analysis, NCCN risk category (low risk: hazard ratio, 6.34 [95% CI, 1.18-34.06; p = .03] and intermediate risk: hazard ratio, 6.98 [95% CI, 1.23-39.73; p = .03]) was found to be significantly associated with the time to metastasis. Partial gland therapies represent a treatment strategy to minimise toxicity. Alternative therapies include cryotherapy, laser, photodynamic therapy, interstitial electroporation and high-intensity focused ultrasound. Recent reviews show they are well tolerated although median follow-up is relatively short. This paper suggests that less than full gland treatment for both low-risk disease and especially intermediate risk disease is not appropriate.

Source: Long-term outcomes of partial prostate treatment with Magnetic resonance imagingguided brachytherapy for patients with favourable-risk prostate cancer. King MT, Nguyen PL, Boldbaatar N, et al. Cancer. 2018; DOI: 10.1002/cncr.31568

This study supports Robotic cystectomy as safe but was unable to assess the cost implications of an increasing number of patients/surgeons electing minimally-invasive surgery. Dependent upon pre-existing prejudice, urologists will use this paper to support their own beliefs. As a community we try to understand the true value of this surgical approach.

Source: Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Parekh DJ, Reis IM, Castle E, et al. Lancet . 2018; 391: 2525-36.

Long term outcomes suggest partial prostate treatments are not adequate Low-dose rate prostate brachytherapy involves the insertion of radioactive seeds into the prostate gland. As monotherapy, it is a recognised treatment for patients with low-risk and low-volume intermediate-risk disease. The established procedure is to implant the entire prostate with associated risk of erectile dysfunction plus urinary and rectal toxicity. A potential method of reducing toxicity is to perform a partial implant using multiparametric MRI to assist in the accurate detection and localisation of clinically significant prostate cancer. This paper presents data from a retrospective review of all men who underwent MRI-guided partial prostate brachytherapy from 1997 to 2007. 354 men with clinically T1c disease, Gleason 3+3 or 3+4 and a PSA of <15 ng/ml were recruited. Prior to implantation they all underwent an endorectal MRI at 1.5 Tesla but current multiparametric imaging was not available. The peripheral zone was then delineated as the target volume such that the minimum peripheral Key articles

August/September 2018

Biopsy follow-up after negative MRI The recent PROMIS and PRECISION trials have reinforced the role of pre-biopsy MRI in biopsy decision-making and in guiding targeted cores. One of the remaining debatable questions is the possibility of omitting standard biopsy in men at risk and with a reassuring negative MRI. In this study, Panebianco et al. followed 1,255 MRI-negative men and assessed the risk of subsequent prostate cancer on follow-up biopsies. All patients underwent 3-T MRI in one referral radiology centre to ensure a homogenous group of patients. MRI was performed between 2010 and 2015 and images were evaluated by two genitourinary radiologists with 13 and 2 year of expertise. Starting from 2012, MRI studies were assessed by the PI-RADS score. Patients were dichotomised into two groups according to their previous history of prostate biopsies. Overall, 659 patients were biopsy-naive before negative MRI. In this first sub-group, 60% of men underwent an initial biopsy within 30 days after the initial MRI. Twelve cases of clinically significant prostate cancers were diagnosed (Gleason score 6, PSA < 10, stage T1c-T2a, max 50% involvement, < 3 cores). After a median follow-up of 38 months, 85 new cancers were detected on follow-up biopsies including 36 clinically significant cases.

MRI findings should be part of the patient counselling before biopsydecision making Thus, the probability of any-grade cancer diagnosisfree survival at 2 and 4 years was 94% and 84%, respectively, in this sub-group of biopsy-naïve

patients. The probability of clinically significant cancer diagnosis-free survival at 2 years was 95%. No disease progression or cancer-specific death was reported. Usual risk factors for prostate cancer prediction (age, PSA, PSAD) remained correlated with the risk of cancer diagnosis in men with negative MRI. In the second sub-group of patients with a prior negative biopsy, the probability of any-grade cancer diagnosis-free survival at 2 and 4 years was 96%. No difference in terms of clinically-significant prostate cancer detection was noted between the two groups. The prevalence of, and positive predictive value for, clinically significant prostate cancer were 31.6% and 45.5%, respectively. The findings of this large unicentre longitudinal study tended to confirm the interesting negative predictive value of MRI for high grade prostate cancer. Few clinically significant prostate cancers were found during follow-up in men with initial negative MRI and subsequent biopsies. MRI performance still depends on various factors including the radiology experience, the estimated individual prostate cancer (assessed by age, PSA, volume, familial history), the true clinically significant prostate cancer prevalence (that could not be calculated in this study), the tumour location. The conclusions of this real-life study suggest MRI findings should be part of the patient counselling before biopsy-decision making and a negative MRI could obviate the need of systematic biopsies in low risk patients. However, in patients at high clinical suspicion of prostate cancer, mainly based on PSA, physical examination, PSA density, systematic biopsies must still be recommended in spite of a reassuring imaging. MRI as screening strategy should not be considered as a simple black and white tool but should be integrated in a shared decision-making.

Source: Negative multiparametric MRI for Prostate Cancer: What’s next? Panebianco V et al. Eur Urol 2018 ; 74 :48-54

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de The failure-free survival at 1, 3, and 5 years was 99%, 92%, and 88%, respectively. At least one repeat focal HIFU was performed in 121 patients. Eight and 36 patients underwent salvage radical prostatectomy and radiotherapy, respectively. Only 10 metastases have been detected during follow-up, and no cancerspecific death has been reported. Regarding biopsy outcomes, 222 control biopsies have been noted reporting in 18% of in-field recurrence and 12.2% of out-of-field recurrence. Two recto-urethral fistulae were reported. Urinary tract infection and epididymoorchitis occurred in approximately 10% of cases. Concerning functional outcomes, continence rate assessed by the use of 0-1 pad per day was achieved in all patients. Leak-free and pad-free status was 80% at 2-3 year after focal HIFU. Erectile domain evaluation was not available. The present study provides interesting outcomes regarding the 5-year failure-free survival after focal HIFU. Overall, 88% of men did not receive salvage radical treatment after this mid-term follow-up, with the need for re-treatment in approximately 20% for cases. Some patients developed metastasis during follow-up, even in case of pre-HIFU low-risk disease, highlighting the importance of proper patient selection, and strict and long-term follow-up. Data on oncologic efficacy and functional safety of radical salvage treatment remain scarce.

Source: A Multicentre Study of 5-year Outcomes Following Focal Therapy in treating clinically significant nonmetastatic prostate cancer. Guillaumier et al. Eur Urol 2018 doi :10.1016/j.euruol.2018.06.006

Mid-term oncologic follow-up after focal HIFU Focal therapy remains a therapeutic option under investigation in the management of localised prostate cancer. Aims are to reduce the side effects of radical treatment and to achieve similar cure rates. Although various energies are currently being tested (including high-intensity focused ultrasound (HIFU)) no prospective series with long-term follow-up are yet available.

Antimicrobial prophylaxis for vesicoureteral reflux in children

Urinary tract infection is a common cause of treatment and hospitalisation in children with vesicoureteral reflux (VUR). This management leads to significant costs for the health care system. Antimicrobial prophylaxis aims to prevent subsequent infection and In this study, the authors described the mid-term by this way, renal deterioration. The RIVUR trial was a oncologic outcomes after the former generation of 2-year multisite prospective randomised study HIFU (Sonoblate). Patients were treated between 2006 including 607 children and demonstrating a 50% and 2015 and 599/625 patients were followed more reduction rate of urinary tract infection recurrence in than 6 months. Interestingly, 84% of patients had an children (from 25.4% to 12.7%). No decrease in renal intermediate or high-risk prostate cancer at inclusion, scarring was detected. No cost evaluation has been whereas the only randomised study assessing focal performed. therapy versus surveillance recruited only low-risk patients. Nine centres were involved and cases In the present study, the authors provided a costrecorded prospectively and consecutively entered into effectiveness assessment of this antimicrobial an academic registry. prophylaxis based on the results of this trial. Cost models were created using hospital cost data, Medicare reimbursement data, and previously The present study provides published articles. A decision tree model was used to interesting outcomes regarding the compare placebo versus prophylaxis.

5-year failure-free survival after focal HIFU Disease staging was performed by pre-biopsy MRI and targeted biopsies combined with systematic biopsies (28%), or template transperineal biopsies (70%). Up to two retreatments with focal HIFU were allowed. Biological follow-up was based on PSA every 3-6 month and yearly MRI. Two rises in PSA after the nadir were investigated by MRI or prostate biopsies. Persistent clinically-significant disease could be treated by new HIFU and patients were routinely offered the option of radical prostatectomy or radiotherapy. The primary endpoint was assessed by the failure-free survival defined by the avoidance of local salvage radical therapy. Mean PSA before HIFU was 7.2 ng/ml and ISUP 2-4 cancers were detected in 72% of cases. Different schemes of focal treatment were described including mainly hemi-ablation and wide local ablation (hockey stick). Median follow-up was 56 months after excluding patients with an event.

Antimicrobial prophylaxis slightly increased costs compared to placebo with a significant decrease of infections The authors calculated that the average cost of managing children with reflux was higher in the antimicrobial prophylaxis arm ($3,092) compared to the placebo arm ($2,932). Nevertheless, 12.7 fewer infections per 100 children were observed in the treatment arm. The costs of the placebo arm remained stable even after modifying variables in the model, whereas the overall cost of the antibiotic arm decreased in case of increase in infection risk reduction. Antimicrobial prophylaxis would be cost equivalent with placebo if the rate of recurrent urinary tract infection in the placebo group increased to 32% (from 25.4%), if the antibiotic risk reduction increased to 63% (from 50%), or if the rate of pyelonephritis in the placebo was higher (48% compared to 10.6%).


European Urology Today


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

tebj@medisin.uio.no The created algorithm was only based on the RIVUR trial results and did not take into account all potential relevant factors such as gender, circumcision status, individual variations in infection management, bladder-bowel dysfunction. Despite these limitations, this cost-effectiveness analysis suggested that antimicrobial prophylaxis slightly increased costs compared to placebo with a significant decrease of infections. Slight manipulation of relevant factors (antibiotics costs, recurrent infection increase) could lead to a more cost-effective prophylaxis and should be anticipated to improve such a preventive strategy by decreasing costs and by maintaining the positive impact of antimicrobial prophylaxis in the quality of life of children and their families.

Source: Cost-effectiveness of antimicrobial prophylaxis for children in the RIVUR trial. Palmer et al. World J Urol 10.1007/s00345

Comparison of PAE versus TURP for BPH: randomised, open label, non-inferiority trial This randomised, open label, non-inferiority trial compares prostatic artery embolisation (PAE) with transurethral resection of the prostate (TURP) in the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia in terms of patientreported and functional outcomes. The procedures were performed in urology and radiology departments of a Swiss tertiary care centre. 103 patients aged ≥ 40 years with refractory LUTS secondary to BPH were randomised between February 2014 and May 2017; 48 and 51 patients reached the primary endpoint 12 weeks after PAE and TURP, respectively. PAE was performed with 250-400 μm microspheres under local anaesthesia versus monopolar TURP performed under spinal or general anaesthesia. The primary outcome was change in international prostate symptoms score (IPSS) from baseline to 12 weeks after surgery; a difference of less than 3 points between treatments was defined as non-inferiority for PAE and tested with a one sided t test. Secondary outcomes included further questionnaires, functional measures, magnetic resonance imaging findings, and adverse events; changes from baseline to 12 weeks were compared between treatments with two-sided tests for superiority.

PAE is associated with fewer complications than TURP but has disadvantages regarding functional outcomes Mean reduction in IPSS from baseline to 12 weeks was -9.23 points after PAE and -10.77 points after TURP. Although the difference was less than 3 points (1.54 points in favour of TURP (95% confidence interval -1.45 to 4.52)), non-inferiority of PAE could not be shown (p = 0.17). None of the patient reported secondary outcomes differed significantly between treatments when tested for superiority; IPSS also did not differ significantly (p = 0.31). At 12 weeks, PAE was less effective than TURP regarding changes in maximum rate of urinary flow (5.19 vs. 15.34 mL/s; difference 10.15 (95% confidence interval -14.67 to -5.63); p < 0.001), post-void residual urine (-86.36 vs. -199.98 mL; 113.62 (39.25 to 187.98); p = 0.003), prostate volume (-12.17 vs. -30.27 mL; 18.11 (10.11 to 26.10); p < 0.001), and desobstructive effectiveness according to pressure flow studies (56% vs. 93% shift towards less obstructive category; p = 0.003). Fewer adverse events occurred after PAE than after TURP (36 vs. 70 events; p = 0.003). Key articles


The authors conclude, that the improvement in LUTS secondary to BPH seen 12 weeks after PAE is close to that after TURP. PAE is associated with fewer complications than TURP but has disadvantages regarding functional outcomes, which should be considered when selecting patients. Further comparative study findings, including longer follow-up, should be evaluated before PAE can be considered as a routine treatment.

Source: Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. Abt D, Hechelhammer L, Müllhaupt G, Markart S, Güsewell S, Kessler TM, Schmid HP, Engeler DS, Mordasini L.

with clinically significant LUTS (CSLUTS) defined by an AUA symptom score (AUASS) > 7 or mean AUASS differed significantly between the time-dependent assessments, respectively. The 15-year mean-adjusted AUASS was similar to baseline (7.00 vs. 6.85, p = 0.66). Throughout the 15 years of follow-up, the proportion of men with CSLUTS was lower than baseline with the exception of the 3-month and 15-year assessments. Among men with baseline clinically insignificant LUTS (CILUTS), the mean adjusted AUASS at 15 years was significantly greater than baseline (6.09 vs. 3.19, p < 0.001). Among men with baseline CSLUTS, ORRP led to a significant decrease in mean adjusted AUASS between baseline and 15 years (13.26 vs. 8.67, p < 0.001).

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com Moreover, the Chinese team found a significantly lower estimated blood loss for 3D LRP as well as a lower warm ischaemia time in the subgroup of articles reporting laparoscopic partial nephrectomy in favour of the 3D-led procedures.

BMJ. 2018 Jun 19;361:k2338. doi: 10.1136/bmj.k2338.

OnabotulinumtoxinA 100 U for urinary incontinence in non-catheterising MS patients The aim of this study was to evaluate the efficacy and safety of onabotulinumtoxinA 100 U in noncatheterising patients with multiple sclerosis (MS) with urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO). In a randomised, double-blind phase III study, patients received onabotulinumtoxinA 100 U (n = 66) or placebo (n = 78) as intradetrusor injections via cystoscopy. Assessments included changes from baseline in urinary symptoms, urodynamics, and Incontinence-Quality of Life (I-QOL) total score. Adverse events (AEs) were assessed, including initiation of clean intermittent catheterisation (CIC) due to urinary retention. OnabotulinumtoxinA vs. placebo significantly reduced UI at week 6 (-3.3 vs. -1.1, p < 0.001; primary endpoint). Significantly greater proportions of onabotulinumtoxinA-treated patients achieved 100% UI reduction (53.0% vs. 10.3%, p < 0.001). Significant improvements in urodynamics (p < 0.01) were observed with onabotulinumtoxinA. Improvements in I-QOL score were significantly greater with onabotulinumtoxinA (40.4 vs. 9.9, p < 0.001) and ≈3 times the minimally important difference (+11 points). The most common AE was urinary tract infection (25.8%). CIC rates were 15.2% for onabotulinumtoxinA and 2.6% for placebo.

…In non-catheterising patients with MS, onabotulinumtoxinA 100 U significantly improved UI and quality of life… In conclusion, in non-catheterising patients with MS, onabotulinumtoxinA 100 U significantly improved UI and quality of life with lower CIC rates than previously reported with onabotulinumtoxinA 200 U.

ORRP favourably affects the longterm natural history of LUTS The investigators conclude that ORRP favourably affects the long-term natural history of LUTS. The long-term economic and quality of life benefits of ORRP on LUTS should inform the risks and benefits of RP for treatment of localised prostate cancer.

Source: Long-term natural history of lower urinary tract symptoms following radical retropubic prostatectomy: A prospective 15 year longitudinal study. Xu AJ, Taksler GB, Llukani E, Lepor H. Urology. 2018 Jun 25. pii: S0090-4295(18)30579-X. doi: 10.1016/j.urology.2018.06.014. [Epub ahead of print]

Neurology. 2018 Jul 20. doi: 10.1212/ WNL.0000000000005991. [Epub ahead of print]

Long-term impact of ORRP on LUTS: A prospective 15-year longitudinal study The goal of this evaluation was to provide insights into the long-term impact of radical retro-pubic prostatectomy (ORRP) on LUTS which are age and prostate-dependent and adversely impact quality of life. 1,995 men undergoing ORRP enrolled in a prospective longitudinal outcomes study. The American Urological Association (AUA) symptom index (AUASI) was self-administered before ORRP and at pre-determined time-points after surgery. A multivariate generalised linear model was used to evaluate the association of time since ORRP with AUASS. McNemar's test and paired sample t-tests were used to assess whether the proportion of men

Source: 1. Current status of 3D laparoscopy in urology: an ESUT systematic review and cumulative analysis. Bertolo R, Checcucci E, Amparore D, et al. J Endourol. 2018 Aug 1. doi: 10.1089/end.2018.0374. [Epub ahead of print]

2. Two-dimensional versus three-dimensional laparoscopic systems in urology: A systematic review and meta-analysis. Dirie NI, Wang Q, Wang S. J Endourol. 2018 Jul 4. doi: 10.1089/end.2018.0411. [Epub ahead of print]

3D Laparoscopy: A step forward for conventional laparoscopic surgery Robotic surgery has been the most revolutionary technological advance in minimally-invasive surgery: as by the latest Intuitive report, around 4300 da Vinci systems have been sold until now in the world, most of which (> 80%) in the US and Europe. However, open and conventional laparoscopic surgeries still continue being predominant as purchase and maintenance costs of robotic systems can be afforded only in tertiary referral hospitals with large budgets. That’s why technological innovation has not (completely) stopped in laparoscopy and new devices have been introduced. Surely, the most relevant one has been in 3D cameras: the first prototypes were just an adaptation from the robotic cameras or a software conversion of 2D to 3D images. The latest devices include two cameras inside the optic which simulates stereo vision; with the aid of special glasses the vision is merged in order to obtain the depth dimension.

Relevant advantages for surgeons were expected, as experienced with robotic surgery, though cost is still an issue at more than $200,000; moreover, dizziness and eye fatigue -already seen in Source: Low-dose onabotulinumtoxinA improves urinary symptoms in noncatheterizing audiences of 3D movies- were expected “side patients with MS. Tullman M, Chartier-Kastler E, effects”.

Kohan A, Keppenne V, Brucker BM, Egerdie B, Mandle M, Nicandro JP, Jenkins B, Denys P.

These results may be in contrast to those reports highlighting the above-mentioned “side effects” of 3D vision (dizziness, eye fatigue, nausea), which may occur transitorily at the very beginning of the 3D system experience, but after the adapting period its advantages may be remarkable.

…the 3D systems seemed to provide advantages in procedures requiring intracorporeal suturing To better investigate the pros and cons of the 3D camera systems in conventional laparoscopy in urological surgery, two systematic reviews have been published almost simultaneously, one from the EAU Section of Uro-Technology (ESUT) group and another one from a Chinese team. Regardless of the different methodology used and the number of articles finally retrieved they both found similar results: though heterogeneity of studies could not allow for proper meta-analysis, the 3D systems seemed to provide advantages in procedures requiring intracorporeal suturing. This was noticed especially in the subgroups of articles dealing with radical prostatectomy where significantly shorter operative time was found in both systematic reviews; in particular, the ESUT study showed a mean difference of 35 mins (95% CI: -41.34, -28.67) less in favour of 3D laparoscopic radical prostatectomy (LRP).

Effect of ball-tip holmium laser fibre on flexible ureteroscope damage One of the most disappointing occasions for endourologists consists of breaking a costly flexible ureteroscope during a (challenging) procedure; among its most common causes there is the damaging of the working channel which usually is due to laser misfiring or to the passage of instruments during deflection, especially laser fibres. On this latter point, it is recommended to reposition a lower pole stone in the renal pelvis or in the upper calix before starting the lasertripsy. However, this manoeuvre is not always possible, especially in the case of a stuck lower pole stone in the calyx or in the presence of a narrow infundibulum, so that laser in situ is just the only option. Depending on the grade of deflection, the passage of the laser fibre may not happen or may cause the damage of the liner of the working channel. The ball-tip laser fibre has been introduced in the market to smooth the passage of the laser fibres in the working channel and reduce the risk of scope injury.

…the ball-tip holmium laser fibre may result cost-effective by using it when a lower pole stone needs an in-situ lasering A recent paper has investigated the risks of injuring a working channel liner of a scope, comparing the performance of the standard flat-tip laser fibres with the new ball-tip ones. By using plastic moulds, the authors recorded the times a liner was perforated according to the number of passages and the strengths applied when passing the fibres in the models. Moulds with different degrees of deflection (0 – 30 – 45 – 90 – 180 degrees) were used and fibres were passed 600 times through each model, with the liner changed every 150 passages for each fibre. The authors noticed that the flat-tip fibres caused a significant higher number of liner damages, with two injuries out of the four trials recorded at the 45° curvature models (passes number 94 and 117), injuries at the first pass in all the four trials at 90° deflection, and no full passes completed at 180°. No injuries of the liners were recorded in the trials with the ball-tip fibres at all deflection models.


European Urology Today

August/September 2018

Moreover, significantly less insertional force was recorded for the advancement of the ball-tip fibres in the models, with differences increasing with higher degree of deflection. Regardless of the “in vitro” nature of this study, these results are interesting as they confirm that the use of a ball-tip fibre may have a precise indication: though the cost is higher than the standard flat-tip holmium laser fibre, the ball-tip holmium laser fibre may result cost-effective by using it when a lower pole stone needs an in-situ lasering. On the other hand, it is known that the ball-tip may dissolve with intense laser firing, so that some precautions should be undertaken in order to not nullify its advantageous design: one consists of setting the laser on high frequency and low power, as it has been observed that the ball-tip may burnback more rapidly at high power; moreover, if a long firing is expected, a smart strategy may be to break the stone in smaller fragments that can be repositioned in a more favourable calyx where to continue the lasering or to complete the stone fragmentation in situ in one go (i.e. without removing and reinserting the fibre).

Source: Single-use versus reusable ureterorenoscopes for retrograde intrarenal surgery (RIRS): systematic comparative analysis of physical and optical properties in three different devices. Deininger S, Haberstock L, Kruck S, et al. World J Urol. 2018 Jun 5. doi: 10.1007/s00345-018-23659. [Epub ahead of print].

Relieving ureteric stentrelated symptoms: More evidence in favour of PDEI-5 The clinical consequences of the insertion of a JJ stent in the ureter are mostly overlooked by urologists as it is considered a non-invasive way to decompress the upper urinary tract in case of obstruction; however, it has been demonstrated that stent-related symptoms may affect a large proportion of stented patients, up to nearly an 80%. The severity of the symptoms may vary and in some cases it can cause the patients to wish for the premature removal of their stent. Many strategies have been proposed to reduce the clinical impact of the stent insertion, like developing new stent designs or testing drug-eluted stents; on the other side, the most common way to ease patients’ discomfort is by using anticholinergic -as the irritative bladder symptoms are among the most common ones-, or even NSAIs for pain control. In recent years, alpha blockers have been shown to be as effective as the anticholinergic drugs, and nowadays a combination of the two classes of drugs is the last resource for suffering patients. More recently, phosphodiesterase type-5 inhibitors (PDEI-5) have been investigated in clinical settings outside erectile dysfunction (ED), like reduction of low urinary tract symptoms, medical expulsive therapy for ureteric stones or even in case of uro-neurological disorders (like spinal cord injury) to augment bladder capacity. Furthermore, due to the potential effects on the reduction of contractility of the detrusor muscle and/ or even of the ureteric smooth muscle as well as to an alleged lowering of sensitivity of the bladder afferent nerves, a randomised controlled trial has been conducted recently in order to test the ability of sildenafil 50 mg once daily to control stent-related symptoms. The trail was not placebo-controlled, and the control arm included patients with no treatments; oral analgesics could be used by both patients groups on demand.

Advantage of sildenafil in realworld clinical practice over current treatment options still unclear A total of 94 patients with JJ stent inserted were recruited, after 4 patients in the control arm discontinued the trial because of severe symptoms and 2 patients of the sildenafil arm experienced severe side effects. A further 6 patients of the latter group experienced mild side effects which did not cause treatment discontinuation.

At 2 weeks follow-up patients were reviewed and the Arabic version of the Ureteric Stent Symptom Questionnaire was provided for them to fill up: in all domains, a significant better score was recorded for the patients receiving sildenafil, except the one in work performance. Unfortunately, no data have been provided regarding the use of analgesic; more importantly, the study design did not include a baseline USSQ evaluation (i.e. at day 1 after stent insertion) as well as the USSQ “post stent” condition, which could have controlled for subjective factors: rather than a direct comparison of scores at a specific time-point, it would have been more precise to measure score variation at different time-points. Finally, what still remains unclear is the advantage of sildenafil in the real-world clinical practice respect to the current available treatment options, especially considering that its employment will be “off-label”.

Source: A randomized controlled trial evaluating sildenafil citrate in relieving ureteral stentrelated symptoms. Tharwat M, Elsaadany MM, Lashin AM, El-Nahas AR. World J Urol. 2018 May 15. doi: 10.1007/s00345-0182339-y. [Epub ahead of print]

Does KAS attenuate the advantages of the preemptive wait-listing It is unknown whether the new kidney transplant allocation system (KAS) has attenuated the advantages of pre-emptive wait-listing as a strategy to minimise pre-transplant dialysis exposure. A retrospective study of adult US deceased donor kidney transplant (DDKT) recipients between December 2011 and December 2014 (pre-KAS) and December 2014 to December 2017 (post-KAS) was performed. The researchers estimated pre-transplant dialysis durations by pre-emptive listing status in the pre- and post-KAS periods using multivariable gamma regression models.

the impact of HLA mismatching has decreased over time due to advances including improved immunosuppression.

We prospectively assessed CMV-specific CMI predicting late-onset CMV infection at prophylaxis withdrawal and at earlier time-points , in 96 consecutive D+/R+ patients receiving either Using SRTR data, we analysed whether the association antiinterleukin 2-receptor antibody (anti-IL2RA; n = between the number of HLA mismatches and 50) or rabbit antithymoglobulin (rATG; n = 46). outcomes of first-time pDDKTs changed between 2 CMV-specific CMI was evaluated against CMV antigens (IE-1, pp65) using an IFN-γ ELISpot assay. eras: 1995-2004 (n = 2854) and 2005-2014 (n = 4643). Between eras, the median number of mismatches increased from 4 to 5 (p < 0.001). Overall graft failure risk was higher among HLA-mismatched versus HLA-matched transplants (adjusted HR 1.211.431.69 for 3-6 vs. 0-2 mismatches, p < 0.001), and this association was similar pre-2005 and post-2005 (pinteraction = 0.5). Median PRA change at relisting increased from 79 to 85 (p = 0.01), but the association between number of HLA mismatches and PRA change was similar between eras (interaction = 0.6).

HLA mismatch is as important in paediatric as in adult in transplantation Our finding that increased HLA mismatching continues to impact graft survival, with 43% higher risk of graft failure, highlights the trade-off between transplant access equity and outcomes and calls into question the de-emphasis on HLA matching in pDDKT allocation in the United States.

Source: Temporal changes in the impact of HLA mismatching among pediatric kidney transplant recipients. Ruck JM, Jackson AM, Massie AB, Segev DL, Desai N, GaronzikWang J. Transplantation. 2018, doi: 10.1097/ TP.0000000000002426 [Epub ahead of print]

Late-onset CMV infection in kidney transplant patients Whether CMV-specific cell-mediated immunity (CMI) at prophylaxis cessation predicts D+/R+ kidney transplants (KTR) at risk of late-onset CMV infection after receiving distinct induction therapies is still not well characterised.

Risk of late onset CMV infection can be predicted by measuring Immunity reactive parameters 14/96(14.6%) patients developed late-onset CMV infection and 2/96(2.1%) displayed disease. At 3 months, CMV-specific CMI frequencies were significantly lower in patients developing late-onset CMV infection (p < 0.001 for IE-1, p = 0.030 for pp65), regardless the type of induction therapy. ROC curve analyses showed accurate CMV-specific CMI cut-offs (25 and 130 IFN-γ spots for IE-1 and pp65, respectively) classifying patients into High (HR), Intermediate (IR) or Low (LR) risk (Log-rank = 0.006; H-R = 4.084 95%CI 1.431-11.651 p = 0.009) being IE-1 CMI the strongest predictor (OR = 5.554, 95% CI1.486-20.766, p = 0.011). While the profound post-transplant CMV-specific CMI inhibition among rATG-treated patients precludes its use for risk-stratification both prior and early after KT, a similar proportion of at-risk patients could be identified before month 3 within anti-IL2RA-treated patients. Monitoring CMV-specific CMI at 3-month prophylaxis cessation discriminates KTR at risk of late-onset CMV infection, regardless the type of induction therapy.

Source: CMV-specific Cell-Mediated Immunity at 3-month Prophylaxis Withdrawal Discriminates D+/R+ Kidney Transplants at risk of Late-onset CMV Infection Regardless the Type of Induction Therapy. Jarque M, Melilli E, Crespo E, Manonelles A, Montero N, Torras J, Cruzado JM, Luque S, Gil-Vernet S, Grinyó JM, Bestard O. Transplantation. 2018, doi: 10.1097/ TP.0000000000002421 [Epub ahead of print]

Pre-emptive listing significantly reduces the years on dialysis before transplantation Among 65,385 DDKT recipients, pre-emptively listed recipients (21%, n = 13,696) were more likely to be white (59% vs. 34%, p < 0.001) and have private insurance (64% vs. 30%, p < 0.001). In the pre- and post-KAS periods, average adjusted pre-transplant dialysis durations for pre-emptively listed recipients were < 2 years in all racial groups. Compared to recipients who were listed after starting dialysis, pre-emptively listed recipients experienced 3.85 (95% Confidence Interval [CI] 3.71-3.99) and 4.53 (95% CI 4.32-4.74) fewer average years of pre-transplant dialysis in the preand post-KAS periods, respectively (p < 0.001 for all comparisons). Pre-emptively wait-listed DDKT recipients continue to experience substantially fewer years of pre-transplant dialysis than recipients listed after dialysis onset. Efforts are needed to improve both socioeconomic and racial disparities in pre-emptive wait-listing.

Source: Association of the kidney allocation system with dialysis exposure before deceased donor kidney transplantation by pre-emptive wait-listing status. Harhay MN, Harhay MO, Ranganna K, Boyle SM, Levin Mizrahi L, Guy S, Malat GE, Xiao G, Reich DJ, Patzer RE. Clin Transplant. 2018, :e13386. doi: 10.1111/ctr.13386 [Epub ahead of print]

Impact of HLA mismatching among paediatric kidney transplant recipients Allocation for paediatric deceased-donor kidney transplantation (pDDKT) in the United States now deemphasises HLA matching to improve equality in access to transplantation, but other national systems still consider HLA matching due to concerns about graft survival. We hypothesised that

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Cutting-edge Science at Europe’s largest Urology Congress

Will you be an EAU Award Winner in Barcelona? EAU Crystal Matula Award 2019 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 2019 For the Best Paper published on Minimally Invasive Surgery in Urology. This paper must have been published or accepted for publication between 1 July 2017 and 30 June 2018.

EAU Prostate Cancer Research Award 2019 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 2017 and 30 June 2018. EAU Best Paper Awards 2019 For the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers must have been published or accepted for publication between 1 July 2017 and 30 June 2018.

Deadline: 1 November 2018 For more information, rules and regulations: www.eau19.org/the-congress/awards



Key articles

August/September 2018

European Urology Today


#EAU19 Cutting-edge Science at Europe’s largest Urology Congress

EAU19: More guided poster tours, case-based discussions The Annual Congress is the EAU’s flagship scientific meeting, and therefore it’s the place for innovations in how this information is communicated to its delegates. We spoke to Prof. Arnulf Stenzl (Tübingen, DE), Chairman of the EAU Scientific Congress Office, about the changes to the Scientific Programme for EAU19 in Barcelona. What can the delegates expect during the Game-Changing Session, held prior to the Plenary Session, at EAU19? The Game-Changing Session will include “hot of the press” new data from studies or from basic research, as previously seen in the “Late Breaking Abstracts” sessions. The sessions can also be used to highlight exciting data from the poster sessions. There may be several posters to the same new topic which may, altogether, underline a change for urologic practice. Speaking of Poster Sessions, this coming congress has a higher acceptance rate for abstracts, and will feature more of the Expert-Guided Poster Tours that were introduced at EAU18 in Copenhagen. Presumably the guided poster tours were a successful addition to the programme? Yes, there were unanimously positive comments. We saw very good interaction between moderators, authors and the attendees. We hope that more

posters can be discussed per session with the same (or even better) quality of discussion. In the past few years, we saw an increase in the number of poster submissions. Because we couldn’t offer any more regular poster sessions, we initiated the Expert-Guided Poster Tours. This allowed us to increase the acceptance rate which had fallen below 30% in the last few years, to around 35%. I must stress that these are all high-quality and interesting contributions! EAU19 will feature so-called ‘Tracks’: certain suggested routes through the Scientific Programme based on topics. Last year, there was a special track for Office Urologists. How will it work this year? What are some benefits? These tracks will guide delegates through the vast amount of contributions, including now 7 Plenary Sessions, 20 Thematic Sessions, more than 90 Poster Sessions, video and semi-live sessions, the live surgery day, and so on. The tracks are created according to common topics like prostate cancer, renal tumours, paediatrics, imaging, research, etc. They give delegates a suggested schedule for their congress day, based on their interests.

We are expanding our hybrid (combined poster and video) sessions and semi-live sessions. In these semi-live sessions a panel discusses surgical techniques with the presenting surgeon based on his video clips, which are raw material without additional graphics or editing.

What are some of the other changes to the Scientific Programme for EAU19?

The Guidelines Sessions now feature more cases and case-based discussion. On the Friday, we

Expert-Guided Poster Tours gave a new dimension to the conventional Poster Sessions and were successful in Copenhagen

Barcelona: A city of beauty and substance Capital of Catalonia and canvas of beloved architect Antoni Gaudí, Barcelona is host city to the largest urological congress in Europe, the 34th Annual EAU Congress (EAU19). Enrich your learning experience at EAU19 with its front-line Scientific Programme and an acquaintance with Barcelona’s renowned and yet-to-be-explored destinations. Barcelona became the first (and only) city to date to receive the Royal Institute of British Architects’ “Royal Gold Medal” for its architecture. The city boasts of nine UNESCO-protected monuments, two of which are by Modernista architect Lluis Domenech i Montaner and the rest are Gaudi’s. The Catalan capital is also the first city in the world to gain the “Biosphere World Class Destination” recognition for its commitment to responsible and sustainable tourism. Savour the experience and admire the works of Barcelona’s most famous son, Gaudí, whose first major architectural project was the Casa Vicens, the house-turned-museum with a domed rooftop and tiles painted with French marigolds. It laid the groundwork for his remarkable oeuvre and paved the way for Catalan Modernism. Gaudí’s other notable creations include Park Güell, Palau Güell, Casa Milà, Casa Batlló, the Crypt of the Church at Colonia Guell and of course, La Sagrada Família. A visit to Barcelona will never be complete without seeing this iconic architectural wonder.

Barceloneta, then onward to Nova Icària or Mar Bella. Each has its own selection of beachfront bars and restaurants, also known as chiringuitos, to get a refreshing respite and delicious tapas. Then head on to FC Barcelona club’s home stadium, Camp Nou, for a football match. The stadium covers a surface area of 55,000 square meters with a seating capacity of 99,354.

The interior of the Sagrada Família

La Sagrada Família’s design was based on the traditions of Gothic and Byzantine cathedrals; a symbiosis of the Holy Scriptures, liturgy and geometrics inspired by nature with light and colour playing the central role. The church sees an estimated 2.8 million visitors each year. Some predict its completion will be in 2026, the centennial anniversary of Gaudí’s death. Explore and discover “What was it like to be a doctor during the 18th century?” you wonder. Take a step inside the Sala Gimbernat, one of the oldest surgery theatres in Europe built for the Royal College of Surgery of Barcelona in 1762. And see where medicine meets architecture in Montaner’s opus, Sant Pau Recinte Modernista. The hospital with a 600-year history, this World Heritage site is the largest Art Nouveau complex in the world with its 27 buildings interconnected by underground tunnels. Visit the once-secret library of the Freemasons in Catalonia, the Rossend Arús Masonic Library. Revel in its luxurious marbled reading rooms and browse through its collection of important Masonic texts, rare magazines and literature. You could be fortunate to come across an enthralling spectacle of people joining hands together to form circles as they dance small, precise steps. This is the Sardana, the traditional national dance of Catalonia and a powerful symbol of national unity and identity.

Casa Batlló is adorned with roses to celebrate Sant Jordi


European Urology Today

For sun-worshippers, Barcelona’s seascape in spring is still captivating. Enjoy the view of four kilometres of beaches; from Sant Sebastià,

A must-see, albeit intriguing stop, the Calder Mercury Fountain is also worth a visit. For many years, the mines at Almadén was the world’s greatest source of mercury; it produced about 250,000 metric tons of mercury. Spain commissioned American sculptor Alexander Calder to build a fountain which, instead of water, would pump pure mercury. Your future visit to Barcelona and participation at EAU19 will bring you the best of urology and a rich cultural experience. And how apt is the Catalan expression “Salut i força al canut!” for the congress? It is to wish someone well and translates to “Good health, and strength to your balls!”

will see a new case-based session on bladder cancer, featuring a pro/con discussion by experts in the field. And finally, we will see more short industry sessions during the lunch break, in addition to the pre-existing longer industry sessions in the afternoons. These sessions fall outside of the regular scientific programme but always have the latest in healthcare or technology.

Important dates Congress days 15-19 March 2019 Exhibition days 16-18 March 2019 Registration opens 1 October 2018 Abstract submission deadline 1 November 2018 Awards submission deadline 1 November 2018 Early Bird deadline 15 January 2019 Late Fee deadline 12 February 2019 Check out the programme ove


rview at

Top tips for submitting your abstract The Annual EAU Congress attracts abstract submissions from urologists and other medical professionals from around the world. In the previous congress in Copenhagen, more than 4,600 abstracts were submitted and 1,338 (1,249 abstracts and 89 video abstracts) were accepted. Competition may be tough so here are top tips to help your abstract stand out: Your text • Write clearly and straight to the point because unnecessary words are confusing. • Adopt a neutral tone to convey objectivity. • Check your spelling and grammar, and ask someone to proofread your work. • Always double-check your facts and numbers. • Prepare well and submit on time. Waiting until the last minute may result to errors.

Your images and videos • Use high-resolution images and/or illustrations to complement your text. • Make sure that your video is in the required format. It should include the title, authors’ names, production date and running time. • Double-check if your video has audio (background music and/or voice-over). • Most importantly, 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” found on EAU19’s website for more information. Good luck!

You still have some weeks to go! Abstract submission deadline is 1 November 2018

August/September 2018

Be an ambassador for Urology Week Reach out to your community and start the conversation When people are not familiar with what urology is, they put their health at risk. Urology Week is a great opportunity for a healthcare professional such as yourself to talk to your patients and their families about the importance of urological care. Found below are some (and even fun) ways for you to start the conversation. Spread the word

Share your story

Use social media

This year, Men’s Health is the overarching theme of Urology Week. We have designed some posters that you can hang in your clinic. In this edition of EUT you will find some examples or you can download them from https://urologyweek.org/healthcare-providers/ awareness-campaign/.

When you need to talk about urological conditions with your patients and their families, how do you go about it? What is your approach? Or have you dealt with a urological condition yourself? Share your story to inspire others to talk openly. Help break the silence.

Would you like to have the posters in your language? Send us a request and the translated text via communications@uroweb.org. We will design the posters for free so you can easily download, print and share them.

Read the stories that patients and other healthcare professionals are sharing at https://urologyweek.org/stories/.

Social media is a powerful tool. Your tweet, a Facebook or Instagram post about Urology Week would reach more people. Take a selfie next to any Urology Week poster of your choice and share it for a good cause on Facebook, Twitter and Instagram. Remember to include the hashtag #urologyweek. Sharing is caring! Join us and let us raise awareness on the importance of urological care together. You can make a difference. Be a Urology Week ambassador!

Start an initiative yourself Participate in or start a local event yourself during Urology Week. Brainstorm with your peers or national society on what you can do to inform patients about urological health during Urology Week. Organise or join a marathon; volunteer to help out in your community; set up an “Open Day” at your clinic and get your colleagues involved! Already have an event planned in September? Give your event extra exposure, register it here: https://urologyweek.org/healthcare-providers/get-involved/

Join us and let us raise awareness on the importance of urological care together. You can make a difference. Be a Urology Week ambassador! For more information about Urology Week, please visit www.urologyweek.org

The European Association of Urology (EAU) and the Japanese Urological Association (JUA) offer the chance to join the fourth Japanese tour! The JUA/EAU International Academic Exchange Programme will send both Japanese faculty to Europe and European faculty to Japan. The programme aims to promote international exchange of urological medical skills, expertise and knowledge.

• •

Indicate their primary and secondary area of academic and/or clinical interest Applications should include a letter of support from department chair (must be signed and on letterhead of the institute/department)

For 2019 the JUA/EAU International Exchange Programme will provide grants to enable two EAU members to travel to Japan. The tour should take place from 7-20 April 2019 starting with visits to urological facilities in Japan, culminating with participation in the 107th JUA Annual Meeting, which will be held in Nagoya (18-20 April).

Information and application forms For all further information and programme application forms please visit http://uroweb.org/about-eau/our-partners/ and scroll down to Exchange Programmes and click on Japanese programme.

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 • Availability to travel around two weeks at the earlier mentioned time

Additionally you can contact the EAU Central Office EAU Central Office, Attn. Angela Terberg, a.terberg@uroweb.org P.O. Box 30016, 6803 AA Arnhem, The Netherlands

Application deadline: 1 November 2018

Candidates must fill out an online application and submit electronic versions of the following documents: • •

Curriculum Vitae (C.V.) Personal statement (300 words or less) describing how participation in the Programme will benefit him/her both personally and professionally

June/July 2018 August/September 2018

European Urology Today


• What do you think is the biggest challenge in urology? That would be identifying individualised treatment decisions. We have guidelines, yes, but there are a lot of scenarios and approaches for the same disease. We need to find which treatment option is the best for the patient. • If you were not a urologist, what would you be? I get inspiration working for children that’s why I’m in paediatric urology. Perhaps, if not for urology, I could have been a schoolteacher. • What is your most important piece of advice for doctors just starting out? Be a good person and always have empathy. You can be the best doctor or an average one, but if you’re a good and kind person, that by itself will make you a success. • What is the most rewarding part of being a doctor? That would be getting good feedback from the patient and their families. You feel humbled and contented when you see that they are happy with the treatment results. • What is your advice to other physicians on how to avoid burnout? Spend time with your family and loved ones. Have some hobbies to get you out of stress. After work I just enjoy the time with my family and play basketball and table tennis. • If you could change something in the healthcare system, what would it be? One goal is to make changes that will allow free healthcare to everybody regardless of their economic status. • What´s the last wonderful book you have read? I like reading stories to relax… The last I’ve read was a Turkish book titled ‘Nur’ by Mustafa Kutlu. • What’s the last thing that surprised you? My kids. Every single day they surprise me. Every day they come to me with a surprising observation as if made by a grown-up. • What’s your favourite hour in a day and why? Again, I will say the time spent with my family after work, and that’s usually the evening hours and just before bedtime. • What is the one thing you wished you had said to your patient but did not? I wish I could say to all my patients that they will perfectly recover a hundred percent after the surgery with no complications, but this doesn’t happen often in real life.

TEN QUESTIONS Interview by Joel Vega


Age: 38 Specialty: Urology City: Istanbul (TR) Current Position/Awards: Chairman & Urology Professor, Division of Paediatric Urology, Dept. of Urology, Istanbul Medeniyet University, Turkey; Chairman, Young Academic Urologists (YAU); Director, Paediatric Robotic Surgery Programme, Mehmet Akif Ersoy Training and Research Hospital, Istanbul; Winner, 2018 EAU Crystal Matula Award.

ESOU19 aims to strengthen onco-urology global community Meeting offers relevant updates in diagnosis, treatment and follow-up Prof. Maurizio Brausi Azienda USL di Modena Modena (IT)

mauriziobrausi@ gmail.com

New technologies and developments in diagnosis, treatment and follow-up in prostate, bladder, renal, testicular and penile cancers are some of the topics to look forward to at the 16th Meeting of the EAU Section of Oncological Urology (ESOU19).

The principal aim of this meeting is to further strengthen the onco-urology global community; give the participants the opportunity to connect, exchange new ideas and strategies in the development of knowledge; and innovate and improve patient care. The meeting, which is set to take place in historic Prague from the 18 to 20 January 2019, will explore and investigate the benefits of multi-parametric magnetic resonance imaging (mpMRI) in the diagnosis of prostate cancer (PCa); new drugs in the treatment of muscle-invasive bladder cancer (MIBC) and renal cancer; the role of genetics in PCa; updates on checkpoint inhibitors; and bladder-sparing approaches in MIBC. ESOU19’s scientific programme will also offer opportunities for debates, discussions and cutting-

ESOU19 16th Meeting of the EAU Section of Oncological Urology 18-20 January 2019, Prague, Czech Republic In conjunction with the European School of Urology (ESU)

Complete Scientific Programme at www.esou19.org


European Urology Today

edge lectures such as using artificial intelligence in biopsy decision-making. A workshop on mpMRI interpretation for PCa treatment is also organised for the meeting. Participants can also expect insightful case presentations, and educational videos of robotics, laparoscopy, nephrectomy and more. One of the most important characteristics of the ESOU meeting is its goal to involve and support young European urologists. Now in its 9th year, the successful STEPS (Sessions To Evaluate ProgresS in the management of urological cancers) programme will continue to boost links with promising young clinicians specialising in urological cancers. The programme allows selected young urologists to discuss cases with established international experts. Join the ESU course I highly recommend participating in “Treatment of localised and locally advanced prostate cancer” course by the European School of Urology (ESU). The course aim is to provide practical tips and tricks, taking into account the most recent developments in the field. During the course, the management of recurrent disease will be reviewed, and the ability of new developments in multimodal treatment to improve cancer control will be assessed critically as well. Current challenges in onco-urology In my opinion, the current major challenges include how to treat PCa and bladder cancer (both MIBC and non-muscle invasive) through genetics; more expansive application and advancement of focal therapy for PCa; and new therapy for renal cancer in combination with checkpoint inhibitors. However, I think the most imminent challenge is the prevention of bladder and prostate cancers. And because of this, I initiated and promote the international Bladder Cancer Prevention Programme. This has been adapted already in Italy and other countries such as Canada and Brazil, to name a few.

EAU Bladder Cancer Prevention Programme poster

Expected future breakthroughs I think use of surgery, even mini-invasive, will be minimised in five to ten years. Genetics will have a greater role in diagnosis together with new imaging technologies such as a more sophisticated MRI. Focal therapy will probably be the leading treatment for PCa and kidney cancer. Fellow urologists should be more aware of these potential breakthroughs. They need to be prepared to update what they know and apply said new knowledge. And one of the ways is to do so is be part of the ESOU meetings.

Register now for the early fee! Deadline: 26 October 2018 August/September 2018

Miniaturisation in PCNL: What has changed? New sheath design improves irrigation and fragment retrieval Prof. Guohua Zeng EULIS Board, international member Director, Dept. of Urology The First Affiliated Hospital of Guangzhou Medical University Guangzhou (CH) gzgyzgh@vip.sina.com Percutaneous nephrolithotomy (PCNL) has become a well-established treatment for stones in the kidney and upper ureter.

stones as early as 1992 in a medical journal from China. MPCNL would become the most commonly used miniaturised PCNL technique in China. The instruments are an 8/9.8F semi-rigid ureteroscope or a specially-designed 8.5/12.5F mini nephroscope, and a pulsatile high-pressurised endoscopic perfusion pump. The dilation of the percutaneous tract is serially performed with scaled fascial dilators from 8 to 14–20F. The fragments during the operation are mainly pushed out with the pulsed perfusion pump. My centre has performed nearly 30,000 cases of MPCNL during the past decade. Nowadays, the indication for MPCNL can be broadened to all the upper urinary tract calculi that need standard PCNL intervention with lower complication rates while maintaining good stone-free rates.

angle or stones in a calyceal diverticulum. But this procedure does not allow for stone extraction. In this respect, stone analysis can be difficult.

space of the nephroscope which allows the utilisation of larger instruments (as 550 um laser fiber or 1.0 mm lithotripter) without reducing the irrigation efficacy. The another major difference between SMP and traditional mini-PCNL is the way the fragments are managed. In traditional mini-PCNL, the stone fragments are removed using either pressurised irrigation or left in situ for spontaneous passage by the patient. In SMP, stone fragments are actively removed by negative pressure aspiration. The use of negative pressure aspiration facilitates irrigation drainage but at the same time maintains a low average renal pelvic pressure throughout the procedure.

A percutaneous nephrostomy tube inside the kidney

Furthermore, the SMP system provides a more efficient hydrodynamic mechanism for retrieval of fragments as compared to traditional mini-PCNL Improvements “...miniaturised PCNL techniques systems. In traditional mini-PCNL systems, the inflow Although miniaturised PCNL procedures have gained and outflow take place in the same lumen of the increasing popularity in the recent years, there are have further expanded, and can sheath. The inflow can partially offset the effect of also disadvantages of miniaturised PCNLs using currently be classified into minioutflow and push the stone fragments back into the smaller tract sizes. These include limited continuous collecting system, which can lead to migration of the irrigation due to reduced working tract size, difficult PCNL, minimally-invasive PCNL stone and lengthening of the operation time. The stone fragment extraction, and the theoretical risk of (MPCNL or MIP), ultramini-PCNL persistently elevated renal pelvic pressure during the irrigation-suction sheath in the SMP system allows operation. To overcome these deficiencies, Prof. Kemal the inflow and outflow separately and creates a (UMP), micro-PCNL, and superone-way flow. So this resolves the problem of low Sarica’s team and I developed the SMP technique to The distinguishing feature of the mini-PCNL technique mini-PCNL (SMP).” improve the critical limitations of miniaturised PCNLs. efficiency of stone removal in the traditional is the use of smaller instruments through smaller mini-PCNL systems, leading to a more successful diameter sheaths. The use of a variety of endoscopes The basic components of the SMP system are an 8.0F surgery. has been described by various authors for stone Recent developments miniaturised nephroscope with an irrigation-suction disintegration and removal, using working tract size More recently, a further advancement has been Innovative ideas, techniques, and technology will sheath available in either 12 or 14F. In traditional as small as 4.8F. Recently, miniaturised PCNL proposed in UMP, utilising a 3F telescope with a continue to evolve further in the future. The safety and mini-PCNL, the main irrigation is delivered through techniques have further expanded, and can currently special 7.5F nephroscope introduced through a 11–13F the same channel used for working instruments. This efficacy of the mini-PCNL techniques have been be classified into mini-PCNL, minimally-invasive PCNL sheath. A further significant step towards demonstrated in either adult or paediatric caused a dramatic reduction in irrigation efficiency (MPCNL or MIP), ultramini-PCNL (UMP), micro-PCNL, miniaturisation, now at the end of the spectrum of populations. An SMP system using an irrigationonce the laser fiber or pneumatic lithotripter probe and super-mini-PCNL (SMP). diameters of percutaneous access, is represented by was inserted. To solve this problem, we designed the suction sheath is associated with better irrigation and the micro-PCNL procedure. The technique utilises a a more efficient hydrodynamic mechanism for irrigation-suction sheath to improve the irrigation MPCNL in China 4.8F “all-seeing” needle. The major advantage of retrieval of fragments. However, the “new kids on the Actually, my centre had described the MPCNL micro-PCNL is reduced risk of blood loss. Besides, the efficiency in the SMP. The sheath is a two-layered block” in the mini-PCNL family, including UMP, structure. The space between the two layers of the technique to manage all the upper urinary tract renal access and PCNL are performed in one single micro-PCNL, and SMP, still need to undergo the rigors sheath forms an independent irrigation channel. step under direct visualisation, which offers a of prospective randomised comparative studies to particular advantage for difficult-to-access calculi, and Using this sheath, the irrigation is delivered through EAU Section of Urolithiasis (EULIS) prove their worth. impacted lower pole calculi with an acute infundibular the sheath, thereby freeing up a working channel PCNL has the advantage of achieving a high stone-free rate, but it is also a more invasive procedure. To improve the outcomes of PCNL, a “minimally invasive percutaneous nephrolithotomy” (also called “miniPCNL”) technique was first developed for children and introduced by Jackman et al. In 2001, a specially designed mini-nephroscope for mini-PCNL in adults was first made by Lahme et al. in Germany. Since then, the “mini-PCNL” technique has developed rapidly and has become increasingly popular worldwide.

TURP: A treatment of choice in large prostates? Laser prostate enucleation- an effective and safe technique Dr. Benedikt Becker Dept. of Urology Asklepios Hospital Barmbek Hamburg (DE)

ben.becker@ asklepios.com Transurethral resection of the prostate (TURP) has been considered as the gold standard for transurethral treatment of lower urinary tract symptoms due to benign prostatic obstruction (BPO) over the last decades. Considering the worldwide distribution of different transurethral therapies, TURP is performed most often with good short and long-term results.

The most important criteria that underline the quality of a transurethral procedure to treat BPO are a surgery-free, long-term durability combined with a low complication rate. The answers to the question why (laser)-enucleation should be favoured can be found in the guidelines of the American Urological Association. On the one hand, it shows that open prostatectomy (OP) has the lowest rates of secondary surgery due to the completeness of its surgical principle. On the other hand, OP is associated with the highest rate of blood transfusions compared to minimally-invasive transurethral therapies. Laser enucleation of the prostate combines both advantages of an anatomical enucleation in the layer of the pseudocapsule and the minimally-invasiveness due to the transurethral access path.

Although, TURP and laser enucleation are both transurethral-performed techniques, the surgical principle differs completely. During TURP small tissue chips are created from the inner layer of the In 2008, Reich et al. published a series of 10,654 adenoma towards the peripheral zone. Due to this patients undergoing TURP. The morbidity and mortality technique, all blood vessels that arise from the rates for prostates <60 ml showed an effective and safe peripheral zone are chopped open with every single way to relieve patients of their obstructive symptoms. resection, consequently leading to bleedings However, patients with prostates >60 ml had a throughout the whole procedure. The great significant higher risk of bleeding complications and advantage of laser enucleation is the opportunity to the need of surgical revisions associated with a higher adopt the surgical technique according to individual prostate configurations. Depending on the lobe overall mortality rate. configuration and the size of the prostate, a 2-, 3- or During the past years, there has been an incredible even 1-lobe technique can be performed. race in modern urology for minimally-invasive laser techniques to treat BPO. Nowadays, the thulium The 2-lobe technique is usually started with a 5- or (Tm:YAG), holmium (Ho:YAG), and greenlight (KTP) 7-o’clock incision down to the surgical capsule. laser have been established to perform prostate Then, the single lateral lobe is enucleated followed enucleation (Tm:YAG/Ho:YAG/KTP), prostate by enucleation of the other lobe together with the vaporisation (Tm:YAG/Ho:YAG/KTP) or prostate median lobe. The 3-lobe technique is commonly performed in cases of large prostates with a large resection (Tm:YAG/Ho:YAG). Meanwhile, all lasers have been adopted to the guidelines of the European median lobe. After 5- and 7-o’clock incisions, the Association of Urology with an increasing use of middle lobe is enucleated and afterwards the lateral lasers in urological departments. lobes have to be dissected at the layer of the surgical pseudocapsule and pushed into the bladder. With the 1-lobe technique, all three EAU Section of Uro-Technology (ESUT) prostate lobes are enucleated and pushed into the August/September 2018

bladder in which the adenomatous tissue can be morcellated. Regardless of each enucleation technique, the blood vessels are just seen once and coagulated immediately in the layer of the pseudocapsule, thus leading to less bleeding. At the end of surgery, a three-way Foley catheter is inserted for continuous bladder irrigation, which is stopped based on the individual department protocols.

“Laser enucleation of the prostate combines both advantages of an anatomical enucleation in the layer of the pseudocapsule and the minimally-invasiveness due to the transurethral access path.” To verify whether laser enucleation is superior to TURP in large glands, Netsch et al. performed a subgroup analysis of 74 patients (group 1 >100 ml gland size, group 2 <100 ml gland size) using a 120-W thulium laser. The authors could show that the intra- and postoperative complication rates as well as the functional outcome parameters after a follow-up of six months are comparable without an increase of morbidity and mortality in patients with large prostate glands compared to TURP as mentioned above.

differences after six months with respect to complication rates and functional outcome parameters. In a retrospective analysis of 2,648 patients undergoing either TURP, photoselective vaporisation of the prostate (PVP) using a greenlight laser or ThuVEP in different urological departments in a German city, the study revealed an immediate improvement in voiding parameters with comparable results among all techniques. However, the hospitalisation rate after ThuVEP was significantly less compared to TURP and PVP. Logically, the efficiency of tissue retrieval (g/min) was comparable for prostate glands <40 ml, however, with an increasing size of the prostate adenoma, the efficiency was significantly higher during ThuVEP compared to TURP. The analysis of all procedures showed a distribution of 52.2% (ThuVEP), 30.1% (TURP) and 17.7% (PVP), respectively. This multicentric analysis of this single German city shows the current shift from TURP to enucleation of the prostate. Therefore, the answer to the question whether TURP is still the gold standard to treat LUTS due to BPO is “no”. Laser enucleation of the prostate is the most effective and safest technique to perform with long-lasting micturition improvement assessed by functional voiding parameters.

In a recently published randomised controlled study comparing thulium vapoenucleation of the prostate (ThuVEP) and holmium laser enucleation of the prostate, Becker et al. showed that regardless of the energy source used for enucleation, both techniques are safe and effective to perform without significant European Urology Today


EMUC18: Joint initiatives reinforce MDT in onco-urology Updates on multidisciplinary strategies in genitourinary cancers hosted by Amsterdam Multidisciplinary team (MDT) work, although a widely-accepted practice in medicine, still has a long way to go in actual clinical and research work considering new challenges encountered by physicians such as the introduction of new diagnostic and treatment agents and their impact on standard therapies.

(IMRT), image-guided radiotherapy (IGRT), stereotactic body radiotherapy (SBRT) and brachytherapy, and ensuring good quality assurance and adopting optimal schedules based on clinical trial data, are crucial aspects in our field,” he said. Hoskin also reiterated the need to properly execute clinical trials. Experts often raised the issue that the core activities of a clinical trial are mostly perceived as supplemental responsibilities. These so-called ‘peripheral’ activities are then assigned to a variety of staff which are obligated to accommodate them besides their full-time work.

In onco-urology— and similar to developments in other medical fields— the difficulties in establishing clinical trials for new agents is one such challenge often faced by researchers. The most recurrent questions are issues in prioritising clinical research questions and the gap between clinical research and actual practice. Complicating these matters are the rate of drug development and their entry into the healthcare system. “Clinical trials become more complex with every new agent. Close collaboration between specialties is essential to ensure appropriate case selection and that each study maximises its potential to enhance knowledge,” said Prof. Peter Hoskin, consultant clinical oncologist of the Mount Vernon Hospital Cancer Centre in Northwood (UK). Hoskin represents the European SocieTy for Radiotherapy & Oncology (ESTRO) at the 10th European Multidisciplinary Congress on Urological Cancers (EMUC18) which will take place in Amsterdam, The Netherlands, from 8 to 11 November. He will speak on the European CanCer Organisation’s (ECCO) essential requirements for quality cancer care (ERQCC), a project that aims to improve outcomes for cancer patients through the adoption and the implementation of essential requirements for quality cancer care across Europe. The annual EMUC is a collaboration of the European Society for Medical Oncology (ESMO), ESTRO and the European Association of Urology (EAU) to boost professional links and provide scientific updates in genitourinary cancers within the context of multidisciplinary synergies. Hoskin said that an international and interdisciplinary platform such as EMUC offers an excellent opportunity not only to introduce key changes in clinical practice but also to highlight issues that affect MDT work. “The management of urological cancers is a multidisciplinary effort and optimal treatment is best achieved by a close collaboration among diagnostic and therapy specialties, which are all represented at the EMUC,” he added.

Register now for the late fee! Deadline: 8 November 2018 ERQCC for prostate cancer Hoskin will provide an update on the ECCO’s ERQCC project, particularly on the final drafts of

With regards to MDT work in hospitals, Hoskin said MDT composition and the time given to these teams are also of equal importance.

Prof. P. Hoskin speaking at EMUC17

the Breast Cancer and Prostate Cancer manuscripts. The manuscripts are expected to be finalised in time for the ECCO 2018 European Cancer Summit in Vienna in September.

"The management of urological cancers is a multidisciplinary effort and optimal treatment is best achieved by a close collaboration among diagnostic and therapy specialties..." “The work of ECCO in producing the ERQCC documents, which will be presented at EMUC18, is an important step to define the basic requirements for modern cancer care based on multidisciplinary teams,” according to Hoskin. “This provides an authoritative document for countries within Europe to aspire and aim for a minimum standard across the wide range of healthcare systems.”

Join the conversation at #EMUC18 and #ESUI18 Using new technology Regarding novel developments, Hoskin noted the rate of adopting new technologies in cancer treatment can make a crucial difference in the delivery of optimal care. Although financial costs and reimbursement systems widely differ across Europe, cancer experts are convinced that using innovative approaches are essential in early diagnostic tests, patient selection and in predicting disease progression. “Harnessing state-of-the-art techniques including intensity-modulated radiotherapy

Programme at a glance

“One of the main challenges for many is an efficient organisation which ensures that all

specialties are represented at the MDT and that there is sufficient time for case discussion,” he said. At EMUC18, the Scientific Programme will look into the various clinical and research dilemmas confronting onco-urology experts. Addressing core topics in prostate, kidney and bladder cancers, expert lecturers and speakers from both sides of the Atlantic will present insights on best practices, look into decision-making dilemmas and anticipate prospects in drug development and their use in specific patient populations. Interactive voting and collating the various views of the participants, and presenting them within the context of how it affects MDT work is one of the features of EMUC.

For the complete Scientific Programme visit www.emuc18.org

8-11 November 2018, Amsterdam, The Netherlands

Implementing multidisciplinary strategies in genito-urinary cancers

10th European Multidisciplinary Congress on Urological Cancers In conjunction with the • 7th Meeting of the EAU Section of Urological Imaging (ESUI) • EAU Prostate Cancer Consensus meeting on Active Surveillance (EPCCAS) • EAU-ESMO Bladder Cancer Consensus meeting • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) • European School of Urology (ESU) • EAU Young Academic Urologists Meeting (YAU)



ESUI18 7th Meeting of the EAU Section of Urological Imaging 8 November 2018 Amsterdam, The Netherlands In conjunction with the 10th European Multidisciplinary Congress on Urological Cancers

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

Thursday, 8 November 08.30 - 18.45 09.00 - 12.00 14.00 - 17.00

7th EAU Section of Urological Imaging ESU Course 1: Daily practice in the management of metastatic prostate cancer ESU Course 2: Immunotherapy for urological tumours

14.30 - 17.30

EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics

Friday, 9 November 08.30 - 17.30 17.45 - 18.45 Various slots

10th European Multidisciplinary Meeting on Urological Cancers Uropathology Training Workshop Hands-on Training Courses

Getting it right: Indications for modern urological imaging

Saturday, 10 November 08.30 - 17.30 14.00 - 16.00 Various slots

10th European Multidisciplinary Meeting on Urological Cancers FALCON Contouring Workshop Hands-on Training Courses

Sunday, 11 November 08.00 - 12.00

10th European Multidisciplinary Meeting on Urological Cancers

June/July 2018 16 European Urology Today

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Masterclass features modern stone-disease management Second edition delivers intensive theoretical, practical and hands-on training Dr. Iason Kyriazis Dept. of Urology General University Hospital of Patras Patras (GR)


Prof. Evangelos Liatsikos Dept. of Urology General University Hospital of Patras Patras (GR)

liatsikos@yahoo.com We, urologists, manage a diverse range of clinical scenarios in our day-to-day practice. It is crucial that our knowledge and skills are up-to-date. When treating stone disease, we need to keep up with the rapid evolution of available instrumentation that offers novel treatment options, as these options help increase the efficacy of stone surgery and reduce morbidity. Our continual learning is essential but it can get demanding. A frontline masterclass dedicated to stone disease is essential.

offer urologists the latest updates in a two-day event. Field experts designed the masterclass to offer a comprehensive theoretical, practical and hands-on training to surgeons who want to master and update his/her stone-management practice. Second edition topics Last June, the Greek city of Patras was host to the recently-concluded second edition of the masterclass. A total of 41 delegates participated and the faculty of 10 internationally-known experts shared their know-how on the investigation and diagnosis, conservative and interventional treatment options for stone disease. The masterclass emphasised on the metabolic evaluation of urolithiasis, indications, equipment, tips and tricks for the most commonly employed operations. Complications and troubleshooting in stone surgery, and special management of demanding cases were also covered. Programme enriched with surgeries Four live surgeries provided an insight on lege-artis operative management of stones in a real-life clinical setting. These surgeries included a supine endoscopic combined intrarenal surgery performed by Dr. Cesare Marco Scoffone (IT) and Assoc. Prof. Andreas Skolarikos (GR); a prone percutaneous nephrolithotomy operated by Prof. Evangelos Liatsikos (GR); a single-use ureteroscopic lithotripsy by Prof. Palle Osther (DK); and a flexible ureteroscopic lithotripsy by Prof. Olivier Traxer (FR).

The programme also offered several pre-recorded surgeries such as semi-rigid ureteroscopy by Seitz The European School of Urology (ESU), in conjunction (AT) and bladder stone lithotripsy by Prof. Liatsikos which aimed to deliver tips and tricks of every with the European Section of Urotechnology (ESUT), organised the ESU-ESUT Masterclass on Urolithiasis to operation in urolithiasis management.

Delegates and faculty of the ESU-ESUT Masterclass on Urolithiasis

Practical application The delegates participated in three jam-packed hours of hands-on training. Nine endoscopic stations were used for the training in laser lithotripsy wherein delegates learned more about lithotripsy efficacy via various low- and high-power lasers setup and equipment. Seven endoscopic stations were dedicated to basic endourologic training in semi-rigid and flexible ureteroscopy; and three stations for the training in percutaneous nephrolithotripsy focused on fluoroscopic- and ultrasound-guided percutaneous access, and ultrasonic lithotripsy. New and exciting developments await future delegates of the 3rd ESU-ESUT Masterclass on Urolithiasis in 2019. Come join us! We look forward to seeing you there!

Dr. C. Scoffone (IT) during HOT fluoroscopic guided percutaneous puncture


Demonstrating laser lithotripsy during HOT

Prof. P.J.S. Osther (DK) during HOT flexible ureteroscopy

Testimonials from masterclass participants Dr. Sani Raji Aminu (GB) Uroandrol services Ltd, UK “The masterclass was concise and well organised with a good balance between lectures and live/ video demonstrations. It offered excellent opportunities to learn about varied techniques from different lecturers. My message to those who will participate next year is to come with an open mind and to listen well.” Dr. Paul Soava (FR) Centre Hospitalier de Beauvais “For me, the highlight of the masterclass was the live PCNL regardless of the technical options employed by various surgeons. It was a great opportunity to see the masters at work. Albeit, PCNL remains a less familiar option than ureteroscopy in most centres, it was educational to see how each surgeon demonstrated his technique while the faculty would point out the specific differences from their own. I felt fortunate to be in the same room with experts in the field, get their insights and brainstorm with them. Another advantage of this masterclass is to be able to clarify some less obvious aspects of stone surgery to achieve a clearer insight and get the details right. I am very grateful to have been a part of this masterclass. It answered questions I never knew I had. My advice to future participants is to have well-defined objectives and make a list of questions for the faculty. Also, stick around when

August/September 2018

1st ESU-ESTU Masterclass on Kidney transplant 15-16 November 2018, Madrid, Spain An application has been made to the EACCME® for CME accreditation of this event

Prof. Traxer is handling the HOT modules as he is a source of great wisdom. Seriously.” Dr. Vlad Pantea (DE) Katholisches Klinikum Essen “What I appreciate about the masterclass is that we can talk directly to the faculty and ask them questions. They were engaging and interested in explaining things to us. Overall, the atmosphere was informal and relaxed. The programme included numerous live and semi-live surgeries. To those who are interested in going to this masterclass, I say to them that it’s definitely worth attending!” Dr. Anastasia Polykarpova (RU) N.A. Lopatkin Research Institute of Urology and Interventional Radiology “The masterclass was an enlightening experience for me and my colleagues. Many interesting topics were covered and presented and it enriched what I know. The new information I’ve acquired will be included in my PhD work. In my opinion, the main feature of the masterclass was the hands-on training. It was a great opportunity to try different ureteroscopes under expert supervision and guidance. I received plenty of advice, tips and tricks.

Register now!

Words can't really describe how thankful I am and how motivated I feel after participating in this masterclass. I highly recommend it to young urologists!”

European Urology Today



"SET-UP" programme is well-received in Singapore Programme offers participants optimal setting for learning By Erika De Groot The successful EAU KARL STORZ ‘’SET-UP’’ programme which took place from 11 to 13 July in Singapore provided the participants a rich, high-level experience and an optimal setting for familiarisation with procedures. A training course such as this shortens the learning curve, boosts development of skills, and reduces the risks of complications when performing procedures. Participants have rated it 4.6 out of 5, illustrating an overall good impression and satisfaction with the programme.

certain urological indications; and management of critical details related to urological procedures. On the last day of the programme, participants took the European-Basic Laparoscopic Urological Skills (E-BLUS) exam at the Urofair18 congress venue. The exam is designed to measure skills such as depth perception, bimanual dexterity, and general confidence and efficiency. A participant’s speed and accuracy were tested with the peg transfer, circle cutting, needle guidance, and knot-tying tasks. There were four exam sessions which had six participants per session. A total of six stations were utilised under the supervision of six mentors.

“Teaching for the “SET-UP” programme was rewarding. The participants were enthusiastic to learn and determined to pass the exams. For me, this shows how much they value the accreditation programme,” shared Dr. Sim.

“A structured programme such as the E-BLUS would certainly play an important role in increasing the adaption of laparoscopy in this region.”

The mentors’ impressions International experts such as Prof. Evangelos Liatsikos (GR), Prof. Dr. Christian Schwentner (AT) and Dr. Allen Sim (SG), were some of the esteemed faculty members who guided the participants.

“I witnessed the success of the programme first-hand when I saw the exam results. To me that was fulfilling as a faculty member,” added Prof. Schwentner. When asked about the best parts of the programme, Prof. Schwentner said it was the talks he had with the participants and the one-on-one mentoring. “We’ve met young urologists who were eager to learn To Dr. Sim, it was the collaboration between the EAU and the local faculties, and the hands-on session prior laparoscopy, and quickly adapted the tips and tricks to the exams. For Prof. Liatsikos, it was the entirety of we gave them. We were impressed with their progress and I commend their drive and enthusiasm,” the programme; how every component came together. said Prof. Liatsikos.

Honing her skills with various tasks

We hope to conduct this programme in different parts of Asia through a regional laparoscopic urologic society,” concludes Dr. Sim.

Prof. Liatsikos looks on as participants cuts a circle

Programme in a nutshell Held at the Tan Tock Seng Hospital, the "SET-UP" programme was a joint venture of EAU’s European School of Urology (ESU), EAU Section of UroTechnology (ESUT), Urological Association of Asia (UAA), and KARL STORZ. It was comprised of hands-on training sessions, and semi-live surgery sessions. Participants were familiarised with the setup and organisation of the operating area, and management of equipment. The programme offered standardised technical approach of a urological procedure; surgical strategy and benchmarks for

Future plans “The programme was well-received in Singapore. We have plans to expand it to other Asian countries and of course, beyond that region as well,” shared Prof. Liatsikos. “We hope to conduct this programme on a regular basis. Laparoscopic surgery in urology is substantial as robotic surgery is still not widely available in many parts of Asia. Open surgery is still the gold standard treatment in many countries due to lack of specialty skills in laparoscopy. A structured programme such as the E-BLUS would certainly play an important role in increasing the adaption of laparoscopy in this region.

Participant is pleased with her progress



5th ESU-ESUT Masterclass on Lasers in urology

3rd ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer

22-23 November 2018, Barcelona, Spain This Masterclass is designated for up to 12 hours of European external CME credits.


Dr. Sim observes participant perform needle-guidance task

European Urology Today

13-14 December 2018, Paris, France This Masterclass is designated for up to 8 hours of European external CME credits.

August/September 2018


Masterclass delivers optimal learning to young urologists Salzburg participants share their impressions, experiences and perspectives By Erika De Groot Tailored for young urologists, the ESU-Weill Cornell Masterclass in General urology (ESU Salzburg) offers participants a high-level programme under the guidance of an expert faculty. This masterclass is a collaborative programme between the European School of Urology (ESU) and Weill Medical College of Cornell University.

year. The intimate setup promoted learning, and the highly-condensed programme included the recent EAU Guidelines. The masterclass covered a third of our urology curriculum and I wish I can attend two more ESU masterclasses to complete the rest.”

In-depth programme Mornings were filled with state-of-the-art lectures, whereas afternoons had interactive sessions based on case presentations submitted by the participants. Last July, the week-long masterclass took place at “I truly enjoyed these case presentations, which Schloss Arenberg in Salzburg, Austria under the provided good practice for what I might encounter auspices of the Open Medical Institute, a programme someday,” said Cozman. Hüttl added, “For me the of the American Austrian Foundation. The Scientific case presentations were a highlight of the Programme included topics on bladder cancer masterclass. There were many interesting cases that (urothelial carcinoma), paediatric urology, stones, and resulted to productive discussions. The faculty gave plenty more. extensive feedback and shared their insights on the technical aspects of the cases.” “Medicine requires life-long learning, dedication and enthusiasm; the masterclass was a perfect example of “It definitely pushed me to become that,” said Dr. András Hüttl (HU) of Semmelweis a better doctor.” University. “The lectures provided useful insights which were highly beneficial to my daily clinical practice. We were encouraged to ask questions during The masterclass also offered opportunities to or after the lectures. The faculty were present at each participate in hands-on training in laparoscopy in the other’s lectures which I think amplified the impact of afternoon. “The hands-on training allowed us to learn their presentations.” according to our level of expertise. Each participant Dr. Claudiu Cozman (IE) of the University Hospital Waterford stated, “Part of what made the masterclass attractive and successful was having a well-known faculty of European and American academics. The manner in which the lectures were presented and the test at the end made me realise how much I’ve learned and which areas I still need to work on.” Dr. Kareim Mohamed Khalafalla (QT) of Hamad General Hospital said, “This is the first masterclass I’ve ever attended and it was spectacular from the way it was organised, the venue, to punctuality. I wish this masterclass was held more than once a

The esteemed faculty of the masterclass

The delegates together with the faculty

was assigned to one instructor during the training. This gave us a chance to ask questions and learn about laparoscopy on a one-on-one basis.” New relationships “The setup of the masterclass was well balanced with the social programme. I made new friends with varied cultural backgrounds,” said Cozman. Hüttl shared, “I noticed a great cultural diversity of young urologists attending the masterclass. Young doctors hailed from countries beyond Europe from as far as Mexico, Tanzania and Mongolia. And one of the best things about this masterclass was when participants and faculty ate together, exchanged ideas and conversed about cultures, healthcare systems, urology and politics. I’ve made new friendships through these conversations that I hope to maintain in the future.” Khalafalla agreed, “We have gotten to know each other better even in a short period of time. Enjoying daily meals together also became a masterclass highlight.” Final words and Austrian scenes “Once I got off the train in Salzburg and walked

along the Salzach River, I immediately knew I was in the right place,” said Hüttl. “Vibrant Salzburg and Schloss Arenberg with its marvellous architecture and garden set the tone for those who are eager to learn like me.” Cozman added, “I strongly recommend this masterclass to anyone who’s interested in spending an amazing week in a beautiful city with incredible people and learning from top lecturers.” Khalafalla stated, “My message to future participants of this masterclass is that you chose well. Learn, study, and ask as much as you can. Update your practice, continue to spread the knowledge, and of course, make new friends along the way.” Hüttl concludes, “I feel fortunate to have been able to attend this masterclass. I’m truly grateful for the experts who took the time to teach us and to do this without a honorarium. Participating in the masterclass was good professional and personal experience. It definitely pushed me to become a better doctor.”


2nd ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer 7-9 February 2019, Berlin, Germany

21-22 February 2019 Prague, Czech Republic An application has been made to the EACCME® for CME accreditation of this event

August/September 2018

European Urology Today


ESU Event Calendar

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


Event name



Check out the new Guidelines E-course on Thromboprophylaxis

ESU course on Update in urology at the national congress of the Armenian Urological Society


Coming soon: • Sexual dysfunction, Infertility & Hypogonadism and LUTS (Lower Urinary Tract Symptoms) • NMIBC (Non-Muscle Invasive Bladder Cancer)


ESU course on Clinical and histopathological basics and main research questions in prostate cancer at the 25th Meeting of the ESUR

Athens (GR)


E-BLUS at the EAU Central European Meeting

Cluj Napoca (RO)


ESU course on Recent developments and broadening indications in treatment of urolithiasis at the national congress of the Hellenic Urological Association

Athens (GR)


ESU course on Urodynamics in daily practice: How to perform and how to interpret at the national congress of the Czech Urological Society

Ostrava (CZ)

18 ESU course on Percutaneous nephrolithotripsy (PCNL) at the national congress of the Tunisian Urological Society

High standard, up-to-date courses

Yerevan (AM)

Free access with MyEAU account

Guidelines and topic-specific courses All information is in line with the EAU Clinical Guidelines

18-20 E-BLUS at the Tunisian Urological Association Annual Congress 27

ESU course on Update on prostate and bladder cancer at the national congress of the Turkish Association of Urology

30-31 5th Confederación Americana de Urologia Residents Education Programme (CAUREP)

Prepared by urologists from all over Europe All accredited courses comply with the EU-ACME and UEMS/EACCME guidelines for e-learning

Hammamet (TN)

Hammamet (TN) Bafra (CY)

Punta Cana (DO)



Men’s Health


ESU courses on Daily practice in the management of metastatic prostate cancer and Immunotherapy for urological tumours at the 10th EMUC

Amsterdam (NL)


ESU course on Urinary tract infections and erectile dysfunction at the national congress of the Russian Society of Urology

Yekaterinburg (RU)

15-16 1st ESU-ESTU Masterclass on Kidney transplant

Madrid (ES)


ESU Urology Bootcamp

Lisbon (PT)


ESU course on Paediatric urology at the national congress of the Iraqi Urological Association

Baghdad (IQ)

22-23 5th ESU-ESUT Masterclass on Lasers in urology

Barcelona (ES)


New Guidelines E-course on Men’s Health Includes:

Free access with MyEAU account

Sexual Dysfunction

Infertility & Hypergonadism

LUTS (Lower Urinary Tract Symptoms)


ESU course on Paediatric urology at the national congress of the Egyptian Association of Urology

Cairo (EG)


ESU course on Office management of male sexual dysfunction at the national congress of the Georgian Association of Urology

Tbilisi (GE)


ESU course on Actual aspects in the management of metastatic prostate cancer and urinary incontinence at the national congress of the Algerian Association of Urology

Algiers (DZ)

13-14 3rd ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer

Paris (FR)

JANUARY 2019 18-20 ESU course on Treatment of localised and locally advanced prostate cancer at the occasion of the 16th meeting of the ESOU

Prague (CZ)

FEBRUARY 2019 High standard, up-to-date courses


URO Berlin Skills Teaching and Training (UROBESTT)

Berlin (DE)


Hands-on training skills programme on Laparoscopy and Endourology

Caceres (ES)

Guidelines and topic-specific courses All information is in line with the EAU Clinical Guidelines Prepared by urologists from all over Europe All e-courses are accredited and comply with the EU-ACME and UEMS/EACCME guidelines for e-learning

22-23 2nd ESU-ESOU Masterclass on Non muscle invasive bladder cancer

Prague (CZ)



European Urology Today

August/September 2018

EUSP: A fruitful clinical visit to the Fundació Puigvert Inspiring fellowship in a fertile learning environment with patient and witty teachers Dr. Francesca Vedovo Resident in Urology Dept. of Urology Azienda Sanitaria Universitaria Integrata di Trieste Trieste (IT) francesca.vedovo@ gmail.com From 29 March to 29 June 2018, I undertook a clinical visit to the Uro-Oncology and Kidney Transplant Divisions, at the Fundaciò Puigvert in Barcelona, Spain. The clinical visit was sponsored by the European Urological Scholarship Programme, EUSP.

Europe. Its chairman of the urological service is Prof. Joan Palou, who leads 33 consultants and 13 residents. Prof. Palou is also Chairman of European School of Urology (ESU). The Fundació Puigvert has 124 beds for inpatients, and four operating theatres equipped with the latest technology in endoscopic, endourological, laparoscopic and robotic surgery. The Urological Service is divided into 6 units: the uro-oncology unit under Dr. Alberto Breda, the urolithiasis unit under Dr. Oriol Angerri, paediatric urology (Dr. Anna Bujons), reconstructive urology (Dr. Caparros Joan), renal transplantation (Dr. Alberto Breda) and the functional urology unit led by Dr. Araño Pere.

Dr. Breda using Cellvizio

endourology. He has an international approach that gives the opportunity to his collaborators to be likewise. He is a doctor who really cares about the patient's good. Dr. Breda is also a patient teacher. He gave me the chance to take part in several open, laparoscopic and endo-urological procedures. He taught me confocal laser endomicroscopy by using the Cellvizio system, how to perform an en-bloc resection of bladder tumour and the prostatic cryoablation procedure. I also attended, for the first time in my life, open and robotic renal transplantations. I sincerely thank Dr. Breda for all he has taught me and he has advised me on in these months.

The host centre Fundació Puigvert is one of Europe’s leading centres for the provision of specialised medical care in urology, nephrology and andrology. The centre is located on the grounds of the Hospital Sant Pau, the largest modernist building in the world designed by the Catalan architect Lluís Domènech i Montane and a museum since 2014. The urology centre was founded in 1961 by Professor Antoni Puigvert and is focused on urological, nephrological and andrological diseases. It has a highly-trained, experienced and prestigious medical staff working within comprehensive multidisciplinary teams. Nowadays Fundació Puigvert is among the most renowned urological centres in Spain and in European urological scholarship programme report Francesca Vedovo

The clinical visit Fundaciò Puigvert is a well-organised centre, fully prepared to receive international guests. All the staff proved to be immediately efficient, kind and helpful. The centre provides up-to-date educational material and offers many opportunities to learn. In these months I had the great privilege of participating in different courses of international interest.

During my visit to the Fundaciò Puigvert, I also had the privilege of meeting Prof. Palou. He is a bright and witty person with a great attitude. Prof. Palou is a world-leading expert in uro-oncology with immense expertise, he does not miss any opportunity to teach. I will not forget his drawings on the blackboard during the uro-oncological meetings. It was a real honour for me to have the opportunity to learn from him. Experiences In this period I had the chance to be involved in several clinical trials about prostatic salvage cryoablation, the predictive value of clinical classification of bladder carcinoma in situ, and en-bloc resection of bladder tumour. I also wrote my specialisation thesis titled : “En-bloc bladder tumour resection prospective randomised evaluation of monopolar, bipolar and thulium energy: preliminary data”.

This experience gave me the chance to create new professional and personal connections with learned and smart people: consultants, residents and fellows. These new friendships, I hope, will lead to future international collaborations. This experience made me realise that I would like to continue to deal with uro-oncology and minimally invasive surgery and I'd like to do it in my own country. I will carry with me the scientific and multidisciplinary approach that I learned at the Fundaciò Puigvert and I will invest it in my Italian centre. Perhaps it would be easier to stay abroad where things are already state-of-the art, but I embrace the challenge of working towards similar facilities in Italy. Everyone has their own mission, one of mine will be to leave this world a little better than I found it. Conclusion I strongly recommend Fundaciò Puigvert as a place to learn and improve oneself. I will remember this period as one of the most beautiful in my life. I would like to thank Mr. Ricard Pellejero, librarian of the Fundaciò Puigvert, as he was incredibly helpful throughout my clinical visit, assisting me in solving any problems and making my stay as comfortable as I could imagine. Finally, I would like to thank Dr. Gavrilov, Dr. Gaya, Dr. Sanguedolce, Dr. Gausa, Dr. Rodriguez Faba, Dr. Pisano, Dr. Rosales, Dr. Parada, Dr. Huguet, Dr. Angerri, Dr. Emiliani, Dr. Territo, all residents, nurses and administrative staff that have contributed to my excellent stay.

One of the strengths of this centre is the way it operates with multidisciplinary teams. Getting in touch with highly-trained specialists was a huge opportunity for me that made me aware of my training and of the issues in which I am lacking. Over the course of my clinical visit, I passed the European Board of Urology oral examination. I consider it a privilege to have had the opportunity to study urology in this fertile environment and with the help of such experienced colleagues. Collecting data in OR European Urological Scholarship Programme Office

In these months my tutor was Dr. Alberto Breda. Dr. Breda is a leader, a very learned doctor, and a skilled surgeon in open surgery, robotics, laparoscopy and

Pr. Palou, Dr. Breda, me, Dr. Regis, Dr. Corsi FPuigvert fellows

With Dr. Angerri

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.

Editorial Policy Manuscripts are submitted with the explicit understanding that the decision to include material will be made by the Editor-in-Chief in conjunction with his Section Editors. All authors have read and approved the manuscript subject to submission. It is the author’s responsibility to obtain permission to reproduce any parts of other publications (i.e., tables, figures). Precise reference to the original work must be given in the legends. Statements in articles or opinions expressed by any contributor in any article are not the responsibility of the editors or the publisher. The publisher is not responsible for the loss of manuscripts through circumstances beyond their control.

August/September 2018

The publisher will commit itself to make judicious use of the article in accordance with the aims and objectives of the association and make the article available to medical professionals at no cost.

Proofs must be returned within the deadline specified by the publisher.

Manuscript Submission

Original articles

Manuscripts and questions regarding manuscript submission may be directed to: European Urology Today Editorial Office E-mail: EUT@uroweb.org Submission of an article signifies the author’s consent to transfer copyright to the EAU, publisher of European Urology Today.

Submission platforms All material is to be submitted in English, as Word file for text and JPG, TIFF, PPT, PDF for illustrations (minimum 300 dpi). For files over 10 MB WeTransfer can be used. Word count for authors is available on request at the EUT Editorial Office.

Types of Articles Original articles may be solicited by the editorial board or submitted to the editorial board for consideration. In case of doubt, authors are encouraged to check with the editorial board describing the content of their article before submission. Maximum word count for original articles is approximately 1,800 words, exclusive of references and illustrations. In case authors provide large reference files, the Editorin-Chief may decide to either limit the total number of references included in the print, or make references available on request through EUT@uroweb.org.

Meeting Reports

Maximum word count for submitted articles is approximately 1,000, exclusive of illustrations. Proofs Only reports of EAU related meetings accompanied by Accepted manuscripts will be copy-edited to bring them high resolution photos will be published. All material is into conformity with the journal’s style. to be submitted initially to the EUT Editorial Office, Unless otherwise indicated, proofs are sent in PDF format EUT@uroweb.org via e-mail to the corresponding author.

Young Urologists/Residents Corner This section is reserved for articles of which the first author is a resident in training. All material is to be submitted for consideration to the Section Editor responsible for this section, Zsuzsanna Zotter, zotter.zsuzsanna@gmail.com

Reports General reports and papers on interesting developments/urology departments/accreditation etc. may be submitted for consideration to the Editorin-Chief. Illustrations are welcome. Word count for reports are approximately 900/1,000 words.

Reviews of books and new media Books and new media to be considered for review may be sent to the EUT Editorial Office.

Letters to the editor Authors are welcome to submit letters to the editor. The text of letters should be limited to 500 words. Letters to the editor will be published as space permits.

European Urology Today


A chance to join the ...

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

2019 American Tour To date 13 American and 13 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 2019 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 2019 American Tour will provide grants which will enable 3 EAU members to travel to and attend the AUA congress in Chicago, IL (3-6 May 2019) and to participate in an extended ten days travel programme, taking them to several urology centres in the United States.

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, a.terberg@uroweb.org. We look forward to receiving your application before 1 November 2018. EAU Central Office, Attn. Secretariat, P.O. Box 30016, 6803 AA Arnhem, The Netherlands



4th ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction

EULIS19 5th Meeting of the EAU Section of Urolithiasis 3-5 October 2019, Milan, Italy

17-18 May 2019, Heilbronn, Germany

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

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

Save the date!


European Urology Today

August/September 2018

Early sacral neuro-modulation after spinal cord injury Technology of ever-smaller implants can be updated as knowledge increases Prof. Karl-Dietrich Sievert Section Chair Neuro-Urology Klinikum Lippe Dept. of Urology Detmold (DE) kd_sievert@ hotmail.com Control of the lower urinary tract involves the peripheral and central nervous systems1,which suggests electrical pulses to the nerve to address this issue. For the non-neurogenic patient, sacral nerve modulation (SNM) has become a wellestablished treatment modality for refractory non-obstructive chronic urinary retention, urgencyfrequency syndrome and urgency incontinence after conservative therapy failed or was not as effective or as expected2-5. In terms of level of evidence, SNM is equivalent to the use of Onabotulinum toxin A (Botox®). In a recently published comparison study (ROSETTA6), of those two treatment options, both seem to have a similar outcome although the dosage of Botox® was doubled to the approved 100 IU7,8. For the long-term adherence to continue one of the therapies, a recent study reported an advantage for the neuromodulation8. Similar treatment options have been investigated for those with neurogenic bladder dysfunction, but the investigated treatment cohorts are significantly smaller. Patients with spinal cord injury (SCI) or diseases (divided into incomplete and complete) seem to have even more complex bladder issues (e.g.: urinary urgency, frequency, incontinence and retention, and/or bowel disorders)9,10,11. Commonly, patients undergo conservative treatment before they are even offered any invasive or surgical treatment options12. Early experiences with unilateral SNM in neurogenic patients have been disappointing13. Besides the previous range of symptoms, there has been no clarification of the optimal time point to initiate any treatment14. Shi et al. reported that the early phase after the SCI is the optimum point to start SNM, despite the fact that they found an intra-individual pattern of stimulation to cause the best effect. They confirmed, as seen in the initial clinical trial in the rodent model by Sievert et al, the particular importance of initiating the SNM prior to the development of detrusor overactivity (DO). However, they performed SNM only unilaterally, which has proven not to be effective in humans to suppress DO and eventually detrusor-sphincter-dysynergia (DSD) in the long- term15. As a result, different approaches such as drug (fesoterodine fumarate (FF)16, Resiniferatoxin [Effects of early intravesical administration of resiniferatoxin to spinal cord injured rats in the prevention of neurogenic detrusor overactivity. Oliveira. R. et al, submitted for publication.])

PNS-pudendal nerve stimulation17, or SNM18 have been investigated during the initial shock phase to investigate the different aspects to the optimal time point and setting in an animal model. Although some drugs might influence the base level, neuromodulation offers the opportunity to attain an even closer physiological stimulus to control bladder function. Bladder filling is necessary to register and communicate to ensure the optimal filling with the stimulator to initiate micturition. Mendez et al. investigated afferent nerve fibres of the pelvic nerve roots and were able to pick up the relative bladder fullness at 25%, 50%, and 100% of capacity19. Karam et al. developed an algorithm for real-time bladder event detection based on a single in-situ sensor, creating a closed-loop control of stimulation systems for sensor and treatment of bladder malfunction. The sensor for bladder events made it possible to recognise the event and to use this information in real-time for the treatment of certain unwanted events (e.g. overfilling, urinary incontinence). This led to an implantable pressure device which has been recently evaluated in the large animal model (cow)20,21. All these investigations are based on the data of normal volunteers and validated again the common based urodynamic data. EAU Section of Female and Functional Urology

August/September 2018

Surprisingly, this kind of ‘closed-loop feedback’ would allow to adapt the actual SNM to the momentary needs. Such a sophisticated approach might not be needed in all cases, but definitely in those patients without sensory feedback such as the complete SCI patient. Patients with incomplete SCI were investigated in the long term follow-up as published by Lombardi et al.22 Patients who had a pure chronic neurogenic nonobstructive urinary retention (N-NOR) have the highest likelihood to be successful in the medium term. The unsatisfying long-term outcome might be related to the fact that those patients received unilateral SNM; whereas other investigations have suggested performing a bilateral implant and stimulation as well in non-neurogenic bladder dysfunction. While there are patients with complete SCI injury, even in this group the treatment options and outcome depends on the level of the injury23,12. The number of published studies remains small. The only clinical study published included 10 patients with a complete SCI in the early phase were compared to those patients who declined SNM. As long as the electrode remained in place, the effect of high capacity was administered to the patient. If one of the electrodes shifted out of its optimal position, the effect was that the ‘until then’ prevented Detrusor-Sphincter-Dysenergia (DSD) was comparable to those without SNM who developed DSD after the shock phase developing DO15. This data was confirmed in a large animal model (pig) study performed by Froditsch et al.24 Opposite to the pudendal nerve stimulation they confirmed in those spinalized animals stimulated at the sacral root, the outcome functionally and, even more important, histologically. The SNM prohibited the change in the ratio of muscle to extracellular tissue and, even more importantly, the density of nerve fibres distal to the spinal cord injury were significantly higher after SNM, compared to SCI alone and even to the pudendal nerve stimulation (PNS). These are magnificent research results but the financial burden to run these necessary experiments is unbelievably high and difficult to fundraise.

1194-1201. 15. Sievert. K. Early sacral neuromodulation prevents urinary incontinence after complete spinal cord injury. Ann Neurol 2010;67:74-84. 2010. 16. Biardeau X. Early Fesoterodine Fumarate Administration prevents neurogenic detrusor overactivity in a spinal cord transected rat model. Plus One. 2017;Jan 2, 2017. 17. Li. P. Early low frequency stimulation of the pudendal nerve can inhibit detrusor overactivity and delay progress fibrosis in dogs with spinal cord injuries. Spinal Cord; 51: 668-672. 2013. 18. Kumsar. S. Effects of sacral neuromdulation on isolated urinary bladder function in a rat model of spinal cord injury. Neuromodulation. 2015;Jan;18(1):67-74. 19. Mendez. A. Estimation of bladder volume from afferent neural activity. IEEE transactions on neural systems and reha bilitation engineering. IEEE Engineering in Medicine and Biology Society. 2013;21:704-15.L6. 20. Karam. R. Real-Time Classification of Bladder Events for Effective Diagnosis and Treatment of Urinary Incontinence. IEEE Trans Biomed Eng. 2016 Apr;63(4):721-9. doi: 10.1109/ TBME.2015.2469604. Epub 2015 Aug 18. 21. Majerus. SJM. Suburothelial bladder contraction detection. POLS ONE, Doi: 10.1371/journal.pone.0168375, Jan 2017. 22. Lombardi. G. sacral neuromodulation for neurogenic non-obstructive urinary retention in incomplete spinal cord patients: a ten-year follow up single-centre experience. Spinal Cord (2014) 52, 241–245; doi:101038/sc2013155. 23. Panicker, J.N., et al. Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. Lancet Neurol, 2015. 14: 720. 24. Froditsch E et al., Effect of erly sacral and pudendal neuromodulation in spinal cord and lower urinary tract in spinal cord injured minipigs, INUM, Zurich Swizerland, 27-29 Aug. 2015. 25. Redshaw JD et al. Protocol for a randomized clinical trail investigating early sacral nerve stimulation as an adjunct to standard neurogenic bladder management following acute spinal cord injury, BMC Urology (2018) 18:72 with the referral to the FDA protocol: https://clinicaltrials.gov/ct2/show/ NCT03083366.

3. Herbison. G. Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults. Cochrane Database Syst Rev 2009; 15: CD004202. 2009. 4. vanKerrebroeck. P. Neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol 2007; 178:2029–2034. 2007. 5. Burkhard. F.C. et al., EAU Guidelines on Urinary Incontinence. https://uroweb.org/guideline/urinaryincontinence/ 6. Amundsen. C. OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial. JAMA 2016 Oct 4;316(13):1366-1374. 2016. 7. Fontaine. C. Patient treatment preferences for symptomatic refractory urodynamic idiopathic detrusor overactivitiy. Urol Ann 2017 Jul-Sep;9(3):249-252. 2017. 8. Tam J. PD32-06 Patients have Poor Compliance with repeat onabotulinumtoxin A injections for overactive bladder. April 2018, Volume 199, Issue 4, Supplement, Pages e646-e647. 2018. 9. Stohrer. M. The standardization of terminology in neurogenic lower urinary tract dysfunction with suggestions for diagnostic procedures. Neurourol Urodyn 1999; 18: 139–158. 10. Paris. G. Management of neurogenic bowel dysfunction. Eur J Phys Rehabil Med 2011; 47: 661–676. 11. Chen. G. Sacral neuromodulation for neurogenic bladder and bowel dysfunction with multiple symptoms secondary to spinal cord disease Spinal Cord 16 September 2014; doi:101038/sc2014157. 12. Blok. B. EAU Guidelines on Neuro-urology. Edn. presented at the EAU Annual Congress Copenhagen 2018. ISBN 978-94-92671-01-1. http://uroweb.org/guideline/neurourology/#6 13. Hohenfellner. M. Chronic sacral neuromdulation for treatment of neurogenic bladder dysfunction-long term results with unilateral implants. Urology 2001:58:887-92. 2001. 14. Shi. P. Bladder response to acute sacral neuromodulation while treating rats in different phases of complete spinal cord injury: a preliminary study, . Int Braz J Urol 2015; 41: StimGuard EUT-KD ad (MD0896)-PRINT.pdf



10:24 AM

Recently, the group at the University of Utah (USA) received FDA approval to perform a similar clinical study as previously described25. This is the longexpected and much-needed follow-up to confirm the above reported outcome, although the published protocol deviates significantly from the original protocol and programming of the IPGs15. With the newest developments in the miniaturisation of implants it seems that StimWave® might have the possible best implant currently on the market. The company is now preparing a similar study to the group from Utah, with an stimulation setting identical to the study previously performed by Sievert et al.15, but with an external, rechargeable device. The injectable implant will most likely be accepted by the potential candidates, which is manipulated through an external rechargeable device. Other devices became available in the last year with initial experience in the iDOA but not yet in the neurogenic area. C


In recent years we have not seen a huge number of clinical introductions of a change in SNM for SCI patients; however, this approach in addressing the issue has recently undergone a significant shift. In basic research the evidence has been made that early treatment – within the spinal shock phase – and definitely prior to the development of the DSD is necessary to maintain influence or even control. Major steps have been made to get closer to a closed-loop feedback, which allows, with the information of healthy volunteers, to identify the individual needs and probably to control those malfunctions by SNM. Y






The implants made a major technology change, not only minimising the size but also by providing technology which can be continually updated with increasing knowledge about physiology, as well as increasing ways to have a working neuroprosthesis in the patient; probably not only for the urinary bladder, but also for bowel function. With a joint effort, not only will SCI patients benefit, but also all other patients who are currently dealing with the diagnosis of iOAB, pelvic pain and other diagnoses. References 1. Fowler. C. The neural control of micturition. Nat Rev Neurosci 2008; 9: 453–466. 2. Oerlemans. D. Sacral nerve stimulation for neuromodulation of the lower urinary tract. Neurourol Urodyn 2008; 27: 28–33.

European Urology Today


International role yields benefits for SIU


Società Italiana di Urologia-EAU: Stronger links through the years


By Joel Vega

Online & Printed Agreements

En bloc membership also brings financial benefits since national or regional societies which have signed



ion of Uro logy



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EAU offers two types of en-bloc agreements: the Online agreement and the Printed agreement. Members of these two agreements are entitled to: ission now

open! Dead



line: 1 Nove


mber 2018




Notification: Entitlements Online Agreement: • Downloading of the online version of the EAU Guidelines • Access the online translations of the EAU Guidelines • Online access to European Urology and supplements

• • •

Scholarship Programme Eligibility CME Credits EAU ID Card

Promoting your meetings

Online access to European Urology Focus & Extra Entitlements Printed Agreement: The EAU executive is pleased to help promote European Urology Oncology • Hard copy the EAU Pocket Guidelines any scientific meetings. However, due to the these agreements are entitled to specially reduced further deepen their alliance. With Italyofaccounting for access to UROsource • Hard copy of the EAU Extendedlarge Guidelines collected at receiving, we rates •(SeeAdvanced Table). Thus, the SIU’s pivotal move in 2003 one of the biggest urological associations in Europe, number(to of be requests we are have been forced to set up some rules and to avail of en bloc membership has provided an the tie-up between the organisations is a prime • Discounted fees for all EAU Events (incl. Annual EAU the Annual EAU Congress) example to other national urological groups, and example on how urological associations can combine regulations related to the circulation of Congress) • Hard copy of European Urology Today promotional material. paved• theOnline way for similar arrangements. their efforts and benefit from each other’s strengths. profile to collect all personal information • Hard copy Historia Urologiae Europeae • Grant & Award Eligibility •

In return, EAU activities and projects such as the EAU Better partnership Guidelines are adopted by SIU and the latest edition is Today, the SIU and the EAU continue to nurture the being translated into Italian for adaption into the close partnership and are now exploring ways to country’s healthcare system, putting into concrete steps the EAU’s goal to raise the quality of urological practice across Europe. Pricing & Conditions “The enthusiasm of SIU members to contribute and boost knowledge and skills-sharing exemplify the shared goals of both organisations. This close cooperation is significant since it serves as a catalyst to improve urological practice,” said the EAU Membership Office.

National Two-day Societies meeting addresses Meeting urology common concerns in


The treatme the most nt landscape of bladder lethal urologi at such a cal maligna cancer, one of fast pace that speciali ncies, is evolvin dilemmas g and sts only to re-asse challenges which encounter clinical prompt them ss current anticipate not new therape guidelines but the delivery also to utic options of optimal that may care. enable Following the 8-9 June update meetinglaunch of a dedicat 2018 Munich, ed prostate last year on Bladder Germa www.bca1 ny Cancer (BCa18)in Vienna, the EAU cancer bladder cancer 8.org Update to be offeredis the first meeting to educate on which is cancer experts by the EAU biased With 275 across Europe with the aim participants, level of evidenc by poor data quality and from around and beyond including e in the guidelin the came from 48 countries, some faculty and exhibito . es,” he explainlow Prospects as rs, of the cancer ed. South Africa. far as China, Burkina in molecu experts immunotherapy lar classifi From across Faso, Germany cation and Europe, host Mexico and accounted On Day 2, country urologist Italy, the for many Seth Lerner United of Powles (UK) amply represe Kingdom, Austriathe participants, (US), with new develop and urologist Maurizi oncologist Thomas and Spain specialists. nted by urologi ments in o Brausi sts and other also treatme bladder (IT) BCa18 gathers nt. Lerner cancer classifi took up medical tackled nearly 300 practice, Powles discusse genomics’ impact cation and participa Held in Munich nts in Munich metastatic on clinical d immuno from for the latest compact BCa, format with 8 to 9 June, the meeting in bladder management and Brausi examin therapy’s role in Rodolfo Montiro cancer updates lectures issues in ed had a preceding succinct overvie unresectable palliative classification. ni (IT) discuss w update the interact discussions MIBC tumour ed “MIBC is ive breakou non-invasive “The correct charactthe WHO 2016 s. associa exchange to allow a more inclusiv t case betwee and the mutatio ted with a very “We are e and direct prognostic and invasive neo-pla erisation of the point-by-point n faculty and high mutatio moving forward n process and therape Lerner in the sms has biologic n es affect impacting . his voting system review of standar participants. With survival,” rate… managementutic implications, diagnostic, prospec al predictors that We now have a lot as express lecture in which d treatme a said. said significantly of new are not he knowledge on key questio ion-based of individu tive random nts and a Ashish ns urinary tract molecular covered topics such ised trials, yet confirmed in going to on immun Kamat (US) present al patients,” he BCa18 is and clinical practice that test the be implem but probab otherapy ed a concise comprehensive how it may tumours, progno subtypes, upper s of the ented giving ly are in to further stic biomar inform clinical and detailed participants, boost multidiNMIBC and undersc overview musclenew adjuvant or in the decision when expression-bas kers and decision added . neoadju ored The opening sciplinary -invasive there vant therapi disease,” treatments,” ed subtypes defi -making. “mRNA partnership. its role more integrating are still hurdles es in data coming Bellmunt bladder cancersession on high ne unique He said Lerner immunotherap to face and risk non-mu said. mutation up about for exampl as he undersc biology and (NMIBC numbers questions scle invasive the benefi “There is y in urology overcome in e, adjuvan ored are fusions such as the ) brought to the ts linked who that of t . chemotherapy Among the giving, may fail new high fore key both the to surviva relevant issues he EAU l rates. “These therapy,” render a patient in patients changes another type adjuvants. This capability mentioned sensitive needed in he added. Dr. Joan Palou and ESMO guidelin means we of chemot to to targeted is retrosp switch to herapy. Althoug population, maintain an applica are the urologist’s discrepancy (ES) tackling issueses on NMIBC with ective, not and the clinical ble patient Powles discuss between h everyth way, we prospective. practice setting clinical practice guidelines such as the ing can appropriatenes ed immun Perhaps licensed and adherence additional select specific patients in this e checkpo . in metasta and actual Educational (CME) demographic conside s of therapy, int inhibito just to give tic urothel atezolizumab, and outcomes,” strategies rs an evolving rations. ial “In a 2017 and he added. maybe we can improve durvalumab nivolumab, pembrocancer such as IO, study by own challen treatment landsca adaptability within Hendrik 87% of the the and avelum lizumab, pe also present ges. PD-L1 as respondents sen (Eur Urol Necchi, meanw ab- drugs targets for but only Focus, their say they with PD-1 40 to 69% hile, describ inhibition. immune use the guidelin2017), “Urolog landscape therapy correctl factors. Re-TUR ed the treatme On single-a and as “contin ists Powles mention in platinum gent the next BT were y identified progno es, part when should be not too patients,” 18 months ually evolving” and nt stic ed the followinrefractory disease guarded it • Immun said Palou. performed in low agents such durvalumab, said or shy of management.comes to systemi e checkpo low-risk g key points: , as ramucir that in pembrolizumab and under-m “There is over-m risk It is a multidi c immuno-oncol being avelum chemotherapy int inhibitors umab, teamwo onitorin added to ab, onitoring , atezoliz have superse ogy sciplina and rk and we in platinum illustrate • All of the umab, of high risk,” g of These agents nivolumab are have to collabo ry effort, it is ded medical -refractory the guidelines drugs the drugs oncolog disease rate with and actual gap between observi he durable remissi are associated and results are undergoing to watch. are our patients ists. Another the clinical practice testing in with long-te ; ng the are to be message on; • Pembro various trials for which months, expected rm is that these follow-up . Palou took lizumab with we have in and surveill is the only up been doing randomised last quarter nivolumab’s expectethe following that since agent with (TUR), adjuvanrisk strategies, the of 2019. the immun ance. It’s not fair d outcom transurethral • The biomar phase 3 study; a positive t chemot to patients someone es by the e-oncology and disease, kers are else, we among others. herapy and T1-High resection is adminis 'consistently' Necchi’s send them patients necessary key would feel inconsistent. somewhere. tered by in patients “Re-TUR may not grade “PD-L1 shouldmessages include lost,” Kamat The tissue is be d present in with T1HG/G3, if said. there is value be tested with the role of PD-L1. Surgical Continu muscles the specim differences clinical assessm and ed on page muscle en. in high patients for both mono Following systemic approa 22 ent as specific survivarecurrence, progres There are no and combo ches the case and value , determined by sion and in l (CSS), “ discussions, in MIBC moved on rational for cancertolerability PD-L1 for combo he said, to surgica concerns, in PD-L1 muscle invasive l and systemithe afternoon session pointed out. tumours re-TUR is due to the noting the initial low During patients left behind bladder cancer c approaches neoadjuvant the case disease, is more evidenc after the high number of discussions ,” he in with and adjuvan first re-TUR. adjuvant on e, we guidelines Joaquim Bellmu (MIBC) and advance t therapies, which is chemot nt on MIBC mandatory have to re-TUR T1 Until there new and Andrea (ES) assessing the d should be offeredherapy is the first Necchi said tumour to improve drugs and option that Necchi to patients the first TUR. s, therapeutic clinical trials advanced “Doing a . “There sequences (IT) tackling stages. better first are multipl trials should available in chemot in locallyavoid in e the near TUR is more importa intervention be the first to be herapy. Clinical An estimat future to with T1 disease nt. We can 7-9 Februa offered after instead of re-TUR so ed ry 2019, the the usual muscle-invasiv75% of bladder many a small tumour . If we have a Berlin, Germa chemotherapy first cancers are patient with patients e bladder are either Page 19 nonny this patient, , and perform a solitary muscle-invasiv cancer, and the or stage then a second a good first New Even needed. e or metasta remaining where the TUR is probab TUR with These factors t! disease become tic disease Bellmunt a procedu ly not reduce the ,a said s lethal. re number current standarneoadjuvant chemot For MIBC, patients,” which also has a psychologicalof re-TURs, and he explain herapy (NAC) d, but the ed. ESMO are guidelin impact on is the such as the still lacking when es of both the EAU it comes “There is management of variant to issues also the histolog lack for NAC in both guidelinof predictive biologic ies. al es,” said www.eau1 Bellmunt. factors In the ESMO 9.org after NAC Guidelines, there failure, wherea are suggest these are ed options s in the missing. He also noted EAU Guidelines integration on (UUT) tumour the management that there is a lack ESMO these s in the EAU Guideliof upper urinary of tract are not address nes, while gaps, he in the ed noted the June/July prospects at all. Despite these markers. 2018 in new biologic Abstract subm al

Strengthening international links can pay dividends to national societies as it enables their members to actively network with colleagues from overseas and be in the forefront of urology. This has been the experience of the Società Italiana di Urologia (SIU) which has carefully cultivated its links with the European Association of Urology.

With this en bloc agreement, the SIU succeeded to further raise its international profile and provide distinct advantages to its members. Moreover, by closely collaborating with the EAU, the SIU benefitted from the synergies such a link provides which means direct EAU participation in the SIU annual meetings. Courses organised by the European School of Urology (ESU), training and skills workshops, and keynote or state-of-the-art lectures, among others, are regular features during the SIU’s annual congresses.

n Urolo gy Toda y

er of the Europea n Associat

2018 EAU



The SIU is the first national European urological society to seal an en bloc membership agreement in 2003 with the EAU, a milestone in the relations of both societies and which also reflects the outwardlooking approach that underpins the SIU’s core goals.



Prof. Walter Artibani, the current SIU Secretary General, and Prof. Vincenzo Mirone (former SIU Secretary General) have previously served in key positions within the EAU. Prof. Giuseppe Vespasiani is the current president of the SIU.

The pricing for the agreements is as follows: Agreement


Non European

1 - Printed*



2 - Online*



3 - Residents Printed*



4 - Residents Online*



All EAU related meetings (Section Offices either full members or partners) and national societies meetings with which we have a special alliance, may be promoted by e-mail (e-mail newsletter or separate e-mail communication), in addition to the other available channels.

In order to benefit from an en-bloc agreement the national Indeed, national urology is All other urological meetings may be included society is required to provide with a list of names of all multi-faceted particularly in the EAU in our Uroweb online calendar. its themembers. EuropeanFurthermore setting wherethe national society will bring at least 80% of itsinmembers into the EAU. Please This isfeel excluding senior borders medical science free to the contact us (EUT@uroweb.

org) in case there are any queries or remarks are expanding andnon-urologists. long-term urologists and the

* Individual members can receive the hard copy version of European Urology for an additional annual fee of 100 Euros.

Membership Office

related to this notice. strategies becoming more inclusive. In this sense, the The payment of the EAU membership fees should be executed by SIU has been a pioneer in the national society, not by each member personally. international relations, thanks to its outward-looking vision and approach.

Interested? Would you like your members to benefit from all the EAU advantages?

Call for: ‘Nightmare Cases’

Deadline online or printed membership agreement. If all parties agree with the contents and the agreement is signed, you will be requested extended to provide the EAU with theuntil contact details of your members within the agreement in order to keep them up to date of all EAU events. 1 October! Contact our EAU Membership Department at membership@uroweb.org or +31 (0)26 389 0680 to receive a draft copy of either a

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

For a new series in the YUO section of European Urology Today we need your contribution! Have you ever encountered a patient case that was extremely challenging but were able to resolve it despite the odds? Have you ever had a case which seemed common at first but the situation changed in an instant and you had to deal with every urologist’s worst nightmare? Have you ever attended a Nightmare Case session and although you felt that the presented cases were truly problematic, you encountered an even worse case yourself? If so…

• What was the case? Join us today and become part of the • What did you do? • Was it resolved? If yes, how? world’s most vibrant urological community! We can learn from these cases to help us treat our patients better and enhance our everyday practice in the future. Please send the details of your personal Nightmare Case and photos to: Dr. Zsuzsanna Zotter, eut@uroweb.org

NGage®: Reach for the original. NGage Nitinol Stone Extractor


© COOK 01/2017 URO-D32084-EN-F


European Urology Today

www.urosource.com August/September 2018

Young Urologists/Residents Corner IDENTIFY: A BURST study of haematuria referrals Collaborative study to develop optimal, individualised diagnostic strategy Mr. Sinan Khadhouri BURST committee Urology Resident, Aberdeen Royal Infirmary, NHS Grampian, UK sinan.khadhouri@ doctors.org.uk

Dr. Kevin Gallagher BURST committee MRC Clinical Research Fellow & Urology Resident, University of Edinburgh kevin.mjgallagher@ gmail.com

Dr. Veeru Kasivisvanathan BURST Chair Urology Resident, West Herts NHS Trust and University College London, UK veeru.kasi@ucl.ac.uk Who are we? Founded in the UK, the British Urology Researchers in Surgical Training (BURST) research collaborative is now an international group of trainees and urologists with the aim of delivering high-quality international research and audit. (Appendix A). What do we do? Collaborative research is a novel research model. Traditional research models have major challenges including a risk of producing underpowered studies. Collaborative research has a unique ability to deliver large-scale multi-centre studies that can change clinical practice. The model developed by BURST1,2, demonstrates how this works to deliver fast, high-quality research with definitive answers. This is embodied by the success of our MIMIC study3. A guiding principle is that scale can be reached quickly with relatively small workload from each individual. As American writer Helen Keller once said, “Alone we can do so little, together we can do so much.” We are passionate about recognising the input of our collaborators, with PubMed indexed collaborative authorship. Furthermore, opportunities to present the study and join the writing team for papers are offered to all collaborators. The Prize-winning MIMIC study: an example of a large-scale trainee-led research collaborative project MIMIC2 launched in October 2016, recruiting 4,181 patients from 71 sites in seven countries in four months. MIMIC showed that in patients treated conservatively with acute ureteric colic, white cell count (thought to be a predictive marker of stone passage) was not associated with spontaneous stone passage. The study provided the largest contemporary analysis of stone passage predictors and Table 1: Top recruiting sites and collaborators (information correct as of 16 July 2018) Records Country

Hospital name

Collaborators Nicola Pavan










Royal Derby Hospital


Vancouver General Hospital

August/September 2018

Francesco Claps Matteo Boltri Prof Carlo Trombetta Tara Sibartie Nkwam Nkwam Kevin Murtagh Simon Williams Miles Mannas Peter Black

Table 2: List of countries registered Country UK Spain USA France Australia Italy Ireland China Portugal Poland Argentina Turkey Germany Netherlands Hungary Uruguay Canada Hong Kong Slovenia Croatia Czech Republic Belgium Japan Malaysia Sri Lanka Iraq Nigeria Mexico Brazil Paraguay Denmark Greece Singapore

Number of registered hospitals 73 14 13 10 8 7 6 5 3 3 3 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1

individuals and sites will be recognised, having priority of authorship as well as being invited to present the study at international conferences. IDENTIFY updates were already presented at major international conferences including the 33rd Annual EAU Congress (EAU18) and the 2018 BAUS Annual Scientific Meeting, with some interesting preliminary data emerging. Videos of these can talks can be seen on our YouTube channel, BURST Urology: https:// www.youtube.com/watch?v=YhsdGrmHbV8&t=965s. We would like to thank those who have taken part in the study so far. We aim to complete data collection by December 2018. Full results will be presented at international conferences in 2019 and 2020. We thank The Urology Foundation, Rosetrees Trust and Action Bladder Cancer UK for the funding and support. More information about BURST and the IDENTIFY study is available on our website (http://www.bursturology.com/p/identifyoverview. html) Further questions and queries can be sent to identifystudy@gmail.com. Committee members Veeru Kasivisvanathan, Ben Lamb, Taimur Shah, Sinan Khadhouri, Kevin Gallagher, Arjun Nambiar, Matthew Jefferies, Kenneth MacKenzie, Eleanor Zimmermann, Eric Edison, Chuanyu Gao, Sacha Moore,

Advisory board Hashim Ahmed, Ben Challacombe, Mark Emberton, Graeme MacLennan, Robert Pickard, Stephen Hughes References 1. Kasivisvanathan V, Kutikov A, Manning T et al (2018). Safeguarding the Future of Urological Research and Delivery of Clinical Excellence by Harnessing the Power of Youth to Spearhead Urological Research. Eur Urol 2018; 73 (5):645-647 2. Kasivisvanathan V, Ahmed H, Cashman S et al (2017). The British Urology Researchers in Surgical Training (BURST) Research Collaborative: an alternative research model for carrying out large scale multi-centre urological studies BJU Int doi:10.1111/bju.14040 3. Shah T, O’Keefe A, Gao C et al. A multi-centre cohort study evaluating the role of inflammatory markers in patients presenting with acute ureteric colic (MIMIC) Eur Urol Suppl 2017; 16:e723-4

demonstrated that medical expulsive therapy was not associated with stone passage. MIMIC is now being used to develop a risk calculator for stone passage. How to get in touch with BURST We at BURST are involved with numerous projects, and we welcome new ideas for future projects as well. Email us at bursturology@gmail.com, visit www.bursturology.com and follow us on Twitter @BURSTUrology to stay updated. If you are interested in representing your country in our current or future studies, please send us an email. What is the IDENTIFY study? The Investigation and DEtection of Neoplasia in paTIents reFerred with suspected urinarY tract cancer: a multi-center analysis (IDENTIFY) is our currently active international collaborative study of haematuria referrals in secondary care. IDENTIFY is a global study with over 450 collaborators from 33 countries (see Table 2) on six continents across 172 hospitals. It has over 8,000 records and still rising! The study aims to determine current prevalence rates of urothelial cancer in specific subgroups and to analyse the diagnostic value of different diagnostic strategies in patients with haematuria. The aim is to develop an optimal, individualised diagnostic strategy. This will take into account patient specific factors such as demographics, presentation and risk factors. The advantage of such a well-powered large-scale multi-centre study will be two-fold: Firstly, the ability to investigate individualised diagnostic strategies in subgroups of patients and secondly, the ability to analyse the diagnosis of rarer urothelial cancers such as upper tract transitional cell carcinoma. The study has undergone rigorous internal and external peer review by medical experts in the field, statisticians and methodologists who specialise in diagnostic strategies. This is an observational study collecting anonymous data from routine patient assessment. It does not require ethical approval in most countries, and it facilitates a fast recruitment rate. All collaborators will be PubMed indexed collaborative authors for any publications. Furthermore, the highest recruiting

Figure 1: BURST members at National Research Collaborative Meeting 2017, EAU18 and 2018 BAUS

European Urology Today


Young Urologists/Residents Corner EUA congress addresses urologic malignancies A report on the biggest uro-oncology meeting in the Eurasian region Dr. Taha Uçar Istanbul Medeniyet University Goztepe Research and Training Hospital Elected-Chairman of ESRU Turkey Istanbul (TR)

collaboration of medical oncologists, urologists, radiation oncologists and radiologists by Sabahattin Aydin and Selçuk Guven. The congress commenced with the Friends of Georgia meeting, then continued with the B2B Renal Cancer session. The lecture “Molecular pathways in RCC” presented by Dilek Telci was one of the most interesting topics in the session.

ucartaha@gmail.com Prof. Archil Chkhotua (GE) once said, “Tbilisi, Georgia is where Europe meets Asia”. The Georgian capital was host city to the 8th Eurasian Uro-Oncology Congress, the official annual congress of Eurasian Uro-Oncological Association (EUA). It was the biggest uro-oncology meeting in the region organised in cooperation with the Georgian Urological Association and the Turkish Society of Medical Oncology.

“Participants had access to extensive knowledge about urological malignancies, from the molecular level to the most advanced techniques for diagnosis and treatment.” Internationally-known faculty

About 600 participants, 135 speakers, panellists and moderators from 25 countries attended the congress where 243 abstracts have been accepted and presented. Participants had the opportunity to receive the latest updates in uro-oncology and explore the beautiful city of Georgia.

The Opening Remarks and the award ceremony took place on the second day of the congress. Dr. Erbil Ergenekon (TR), Prof. Sudeyif Imamverdiyev (AZ) and Prof. Mehmet Arslan (TR) were honoured with lifetime achievement awards. Prof. Ckchotua became the first honorary member of the EUA.

Esteemed speakers from all over the world who shared their insights during the congress included Prof. Jean De La Rosette (NL), Dr. Ignacio Duran (ES), Prof. Steven Joniau (BE), Dr. Jose Karam (US), Dr. Makarand Khochikar (IN), Dr. Aytekin Oto (US), and Dr. Iraklis Poulias (GR). Participants had access to extensive knowledge about urological malignancies, from the molecular level to the most advanced techniques for diagnosis and treatment. To achieve this, a multidisciplinary scientific programme was created through the

Interesting and educational deliberations

education provided for residents. During Education, Prof. Kural offered valuable insights in his lecture “The path, residency to mastership”. Later on, Prof. Maria Pilar Laguna (NL) gave amazing tips and tricks for young urologists in her The Residents Meet Masters session was well prepared presentation “How to write a paper”. by European Society of Residents in Urology (ESRU) In addition to the scientific programme, the European Turkey. The session was divided into two: Opportunities and Education and a total of ten training in basic laparoscopic urological skills international speakers presented, some of whom (E-BLUS); workshops on advanced laparoscopy and were Dr. Karam, Dr. Simon Tanguay (CA), Prof. Ali Rıza clinical research; and courses on prostate biopsy and multi-parametric magnetic resonance imaging Kural (TR), Prof. Onder Yaman (TR). (mpMRI) attracted numerous residents and young During Opportunities, the European Association of urologists. Urology, Société Internationale d'Urologie, Endourological Society, and the Turkish The congress was eventful and productive in many ways, and we look forward to next year’s EUA19! Association of Urology introduced the training and

During the congress, the sessions, social events and ceremonies were shared via Twitter @avrasyauroonko account, and by the social media team of the EUA.

Urology training around the globe Focus on Canada Dr. Andrea Kokorovic Chief Urology Resident Dalhousie University Dept. of Urology Halifax, NS (CA) @drandreakoko akokorovic@dal.ca While Canada as a country is known for being geographically harsh and cold, I can assure you that Canadians as people and citizens of the world will invariably find themselves on the opposite end of that spectrum. Canadians are some of the nicest, most welcoming and friendly people you will ever encounter. A prime example of this is our national icon, the beaver. Most countries want to be represented by ferocious animal warriors, but not Canadians! We would rather give you a warm welcome with a friendly, flat-tailed, buck-toothed creature. I am a first-generation immigrant to this wonderful country, and find myself extremely lucky to be completing my urology residency training here.

yearly), and is based on grades, exam scores, extracurricular activities and an interview. Interestingly, pre-medical classes are not requisites for medical school admission. This means that one could, theoretically, complete a degree in art history or music before beginning his or her medical studies. Hence, Canadian medical students come from many backgrounds and represent the diverse patient population encountered in our country. Medical school takes four years to complete. The first two years are spent in the classroom and the third year is clinical clerkship training. In the fourth year, students choose the specialty they would like to pursue in residency. They complete electives in this specialty across the country, and participate in the Canadian Resident Matching Service (CaRMS). This is a very complex process wherein students are “matched” to a training programme based on a computer-generated algorithm.

The applicant ranks (in numerical order) the programmes he or she would like to match to (specialty and location) and the programmes also independently rank the applicant. Then, boom, magic happens – the applicant presses “submit”, the programme presses “submit”, and a few weeks later your computer tells you where you will be spending the next five years of your My quest for becoming a urologist started fourteen (!) life! (I suppose the process itself is a little more years ago. Without being too revealing of my age, I will sophisticated, but this is what it feels like for the student, take you through the journey of becoming a Canadian- anyway). For most applicants, the highly-anticipated trained urologist, which I believe represents the Match Day is a happy day, however unexpected surprises experience of the majority of trainees in this country. can, and do happen with this type of system. Medical school In Canada, one must complete a minimum of three years of university studies prior to applying to medical school. Most undergraduate degrees take four years to complete, and therefore many applicants have obtained a Bachelor of Science degree before being accepted into medical school. Acceptance into a Canadian medical school is rigorous and competitive (13,500 applicants for 3000 positions 30

European Urology Today

Residency In 2018, there were 72 applicants for 29 urology residency positions in Canada. I was very lucky to match to the Dalhousie University residency training programme in 2014, where I am currently in my final year of training. (Side note – if you are a math wizard you would have calculated that my journey thus far does not add up to 14 years. I also completed my Master of Science degree prior to medical school, which added an additional two years to my training.)

There are only 13 urology residency training programmes across the country. Each programme differs slightly, however our professional regulatory college, the Royal College of Physicians and Surgeons of Canada, oversees the medical education and professional development of all Canadian residents and sets national standards to maintain high-quality training for all residency programmes. Hence, a Canadian trained urologist that passes the certification examination (more on that later) will have met strict requirements set forth by the Royal College regardless of where his or her training was completed. Urology residency is a five-year programme. The first two years are mostly spent off service on general surgery, vascular surgery, intensive care, pathology, anesthesia and nephrology; we also complete several months of core urology training. In the third year, we finally become real urology residents and complete the remainder of our rotations on the urology service.

Canada (By E Pluribus Anthony [Public domain], from Wikimedia Commons)

Post-training career After completing residency, one must choose between a career path at an academic university hospital or the community (Canada does not have a private health care system). Regretfully, many graduating residents have a difficult time finding employment. This is especially true for aspiring academic urologists. Our universal health care system simply does not have the resources to open more positions, despite a rise in the number of highly trained urologists available for hire.

Exposure to the operating room starts early. At Dalhousie, there is a graduated level of responsibility in surgical training. Junior residents (years 1-3) become proficient at completing endoscopic and smaller general urology procedures, while the senior residents take on more complex open and laparoscopic cases. All residents have on-call duties and complete urology clinic and emergency department rotations.

I believe that my experience as a Canadian urology resident has been nothing short of outstanding. Following residency training, I will be completing my urologic oncology fellowship at MD Anderson Cancer Center in Houston, Texas. My long-term career goal is to work at a Canadian academic center of excellence, with a focus on treating urological malignancies and contributing to research advancements in the field.

Our fifth year of training is our “Chief” year – something that I personally have been looking forward to since my first day of residency (Chief Andrea has a nice ring to it, no?). Chief year means you are essentially the boss of the surgical service and are given the power to choose whatever case you want to assist in. Chief year is also known as Exam year – the Royal College urology certification examination is in the fifth year and requires many long months of preparation and study. Combined with long hours of operating, it can be a grinding, rigorous year but the end reward is worth it.

To the junior residents reading this article – regardless of your background or what country you are training in, your residency experience is a reflection of the work you decide to put into it. You are your own best advocate, and only you can pave the way to live your best life. My personal outlook on urology residency has been the following: to put my head down and work hard, be a sponge and learn as much as I can from the wonderful urologists I am lucky enough to train with, and lastly to become the best surgeon and advocate for my patients I can possibly be. August/September 2018





25th Meeting of the EAU Section of Urological Research

EAU 18th Central European Meeting in conjunction with the national congress of the Romanian Association of Urology

4-6 October 2018, Athens, Greece

12 October 2018, Cluj Napoca, Romania In collaboration with the EAU Section of Uropathology

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BALTIC19 6th Baltic Meeting in conjunction with the EAU 24-25 May 2019, Tallinn, Estonia An application has been made to the EACCME® for CME accreditation of this event

EAU Update on Bladder Cancer

17 -18 May 2019 Turin, Italy


August/September 2018

EAU onco-urology series

Call for Abstracts Deadline 1 April 2019

European Urology Today


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EAU Prostate Cancer Research Award 2019 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 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 34th Annual EAU Congress in Barcelona, 15-19 March 2019 during the Opening Ceremony.

• The paper must have been published or accepted for publication in a high-ranking international journal between 1 July 2017 and 30 June 2018, 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 2018.

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

A review committee will screen all entries and an independent jury will select the best paper based on quality and merits.

Rules and Eligibility • The topic of the paper should deal with clinical or experimental prostate cancer research.

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 2019” in the subject line of your e-mail.

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

Send your nominations today!

EAU Crystal Matula Award 2019 For a young promising European urologist The EAU Crystal Matula Award 2019 is the most prestigious prize given to a young promising European urologist aged 40 or under 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 34th Annual EAU Congress in Barcelona from 15-19 March 2019. The list of previous awardees includes many well-known names: S. Silay (2018), C. Gratzke (2017), 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 2018. 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 2019” in the subject line of your e-mail.

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


European Urology Today


August/September 2018

EAU Best Papers published in Urological Literature Awards

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To be awarded at the 34th Annual EAU Congress in Barcelona, 15-19 March 2019 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 2017 and 30 June 2018. The awards will be handed out at the 34th Annual EAU Congress in Barcelona, 15-19 March 2019. 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 2018. 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 2019 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 34th Annual EAU Congress in Barcelona, 15-19 March 2019 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 2017 and 30 June 2018.

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 2018. 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 2019” in the subject line of your e-mail.

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

August/September 2018

European Urology Today


Experiences of group support for mPCa patients Specialist nursing role in advanced PCa is multi-faceted and requires careful planning Louisa Fleure, MSc Urology Lead Nurse Guys and St Thomas NHS Trust London(UK)

Louisa.Fleure@ gstt.nhs.uk

Men with metastatic (advanced) prostate cancer have a variety of supportive care needs including physical issues, communication, physiological/emotional needs, intimacy and sex, and information (Patterson et al 2017). In addition, we know from the work presented by Afshar et al at the EAUN Meeting in Copenhagen in 2017 that patients with a urological malignancy are five times more likely to commit suicide than those in the general population and that the ratio of suicide attempts to completed suicides was lower in patients with prostate cancer than that in the general population (1:7 vs. 1:25). The specialist nursing role in advanced prostate cancer is varied, but may include: • Support at diagnosis and regarding treatment decisions; • Improving adherence and managing nonadherence to treatment; • Monitoring treatments, response or progression and referral as appropriate; • Proactive management of side effects and metabolic effects; • Crisis management and rescue work; • Support groups and education events; • Finance and practical advice; and • Advanced care planning and palliative care Provision of supportive care can take place in a variety of ways, depending on patient preference and service demands. These may include face to European Association of Urology Nurses

face in consultations, nurse-led clinics, via assessment tools, by phone or email, through groups or seminars or other support-based activities The use of seminars and support-based activities can be an efficient and cost-effective way of reaching men. At Guys and St Thomas NHS Trust in London (UK) we have had a successful support group for many years and have also been using seminar-based events (“Healthy on Hormones”) to provide specific support and information for men on androgen deprivation therapy. We have also recently obtained charity funding for an associated project called the “Advanced prostate Cancer Club”.

“Providing forums where men can get information and support has been successful and rewarding for staff as well as patients.” Support group Our support group (Prostate life!) has been running for over 10 years at Guys Hospital and is open to any man who has been treated for prostate cancer at our hospital (regardless of treatment or stage). The sessions are popular and numbers of attendees have increased year on year. The group also has an email distribution list where members are kept up to date with information about meetings, news and information The meetings have a standard format: we start with an educational topic followed by the support element where members are able to talk amongst themselves or ask for specific advice. Refreshments are provided which adds to the relaxed and friendly environment. Some of the attendees have sent in their comments about what the support group has meant to them. Below are some testimonials: “I have found the Support group extremely useful… The ability for new patients to be able to talk with men who have undergone treatments and explain how they have been affected and how they feel afterwards, is invaluable and offers reassurance.”

“Since coming to the support group over the past seven years the group has been very supportive towards each other. Through shared experiences the group has helped me overcome the fear, anxiety and anger that having cancer gives you. The lectures have helped us understand our condition at the various stages we are at.” “The support group has made up for a major gap in my experience as, until diagnosed, I had no friends or relations with the disease and no prior knowledge of it. The group meetings have provided a very friendly and supportive framework and I am very grateful for the help and encouragement given by other members and all the professionals involved.” Staying Healthy on Hormones Seminars We know that there is a need for support and education for men on ADT around side effect management and metabolic effects. However, most education and support is given 1:1 in consultations or over the phone, often in the context of a nurse-led clinic also dealing with treatment response or disease progression. Information given in this way is not always retained and referrals were often not taken up when advice regarding side effects and heathy living were given in the context. The aims of the seminar were to understand treatment and its side effects, and offer advice regarding side effect management, to suggest simple lifestyle changes to mitigate longer term metabolic effects, and, finally, to empower men to engage with primary care and take an active part in their monitoring and care (improve self-efficacy) A total of 306 men and 74 friends/partners have attended the seminars and 289 evaluations have been completed. The evaluations have been extremely positive with most men finding the sessions useful, and all men saying that they would recommend the seminars to other men on hormone therapy Advanced prostate cancer club We received a legacy donation from one of our patients for support for men with advanced prostate cancer. The donation was specifically for “palliative care”. We have set up a project to use the donation to provide Healthy on Hormones seminars, but also

run a selection of small groups and workshops specifically for men with advanced prostate cancer based on palliative care principles. Palliative care aims to treat or manage pain and other physical symptoms. It also aims to help with any psychological, social or spiritual needs. The goal is to help patients and everyone affected by a diagnosis to achieve the best quality of life. To inform the project, we ran a focus group for men and partners and also canvassed ideas from staff working with men with advanced prostate cancer. We asked what would be useful, whether there were unmet information needs, ideas for activities and groups, and where and when it should take place. The themes discussed by the groups included, emotional support, understanding what support was available, help and advice with getting affairs in order including advanced care planning, financial help, physical issues including managing pain and fatigue, and activities where men could meet other men such as art and photography, day trips and gym and social events The first events organised are two-day trips and a course on art classes in order to build a community of men. We are working with palliative care to set up some more challenging events to discuss issues around death and dying, but the initial groups are around building a safe and supportive community where, through activities such as art and exercise, we can start to gain trust, peer support and open up some important lines of communication. Providing forums where men can get information and support has been successful and rewarding for staff as well as patients. The advanced prostate cancer club builds on our experience with support groups and seminars and will be a valuable addition to the support we can offer to men, as we use non-medical locations and activities to provide a safe space to get support and discuss challenging issues. Reference Patterson et al 2017 Unmet Supportive Care Needs of Men with Locally Advanced and Metastatic Prostate Cancer on Hormonal Treatment: A Mixed Methods Study. Cancer nursing 40(6)

Nurse-led flexible cystoscopies Reducing anxiety in patients, building trust in disease management EAUN Board Chatterton Kathryn, BSc (Hons) Bladder Cancer Clinical Nurse Specialist Guy's and St Thomas' NHS Foundation Trust, London (UK) kathryn.chatterton@ gstt.nhs.uk As a nurse cystoscopist, some of the most vital aspects in care management of surveillance patients with non-muscle invasive bladder cancer (NMIBC) include continuity of care, timely follow-up, and having a specific point of contact. These allow patients to have trust and confidence in the management of their disease.

for their flexible cystoscopy. The doctors’ posts continually change and their clinical demands are high. Having a nurse cystoscopist, whom the patients already know perform the “dreaded check cystoscopy”, can reduce their anxiety. There are no studies specifically dedicated to determining patient anxieties regarding nurse-led flexible cystoscopy. Data from a personal cohort initially demonstrated that 97% of patients said that they were happy with a nurse specialist to perform the cystoscopy again in the future. The 97% became 100% as the patient who was unsure at first changed his mind, and confirmed that if the same nurse performed the procedure, he would be more than happy.

cystoscopy video and give them as much or as little information as they require, based on the assessment during the preliminary meeting. When patients have sufficient preparation, psychological care, continuity, and a point of contact, I am confident that nurse-led surveillance cystoscopies can significantly reduce their anxieties. Certainly in the United Kingdom, only senior and experienced clinical nurse specialists should be selected for flexible cystoscopy training as specified in the British Association of Urological Surgeons (BAUS) and British Association of Urological Nurses (BAUN) guidelines. It is recommended that the nurse will have had two years’ experience in urology and have the support of a consultant urologist to undertake flexible cystoscopies. This is imperative for the training process to be successful.

As a specialist bladder cancer nurse, I feel fortunate to meet the patients at the beginning of their bladder cancer journey – from initial diagnosis, administration During training, it is advised that a nurse of intravesical treatments, to surveillance flexible completes a comprehensive in-house training I carry out a weekly flexible cystoscopy list solely for cystoscopy (if that is the follow-up route taken). programme led by a consultant urologist. NMIBC patients who require surveillance post Additionally, they should demonstrate their treatment and have undergone transurethral resection Questions have been raised about the costknowledge and competence by completing a effectiveness of nurse-led flexible cystoscopy. of bladder tumour, intravesical Bacillus CalmetteHistorically, it has been documented that a nurse may training booklet and undergoing assessment, Guérin (BCG), chemotherapy and radiotherapy so both nurse and consultant urologist are not see as many patients as a doctor would, but this follow-up. This group of bladder cancer patients satisfied that the nurse can work independently. number will increase as the nurses gain more requiring surveillance are unique; they adhere to experience. It has also been recognised that nurses strict follow-up guidelines and need regular The Training Tool I used was adapted from the BAUN/ surveillance flexible cystoscopies, which can lead to can be trained to carry out cystoscopy and identify BAUS guidelines and endorsed by the local trusts abnormalities as accurately as urologists could. It lifelong care. clinical governance team and the heads of nursing could be argued that the nurse provides a more and urology department. The tool was divided into holistic approach by allowing more time for their Hospital attendances can involve the fear of the consultation. four sections. These were: Theoretical, Observational cancer recurring, anxiety and worry about pain. (minimum 10), Practical (minimum of Having spoken to regular surveillance patients, During my cystoscopy consultations, I always ensure 50 supervised as recommended by BAUN), I am aware that they find comfort in knowing they and Consolidation of practical competence that the patient understands the procedure and feels see the same person every time they go to the clinic relaxed. When needed, I distract them by engaging in (30 unsupervised) with confirmation of the accuracy different topics of conversation unrelated to the of findings overseen by the supervising urologist. European Association of Urology Nurses procedure. I recommend to let patients watch a These findings were retrospectively reviewed using 34

European Urology Today

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

Susanne Vahr (DK) Paula Allchorne (UK) Stefano Terzoni (IT) Jason Alcorn (UK) Paula Allchorne (UK) Linda Söderkvist (SE) Corinne Tillier (NL) Jeannette Verkerk (NL) Giulia Villa (IT)


video data to ensure consistency. A nurse cystoscopist report was devised for the nurses’ portfolio to keep a log and evidence of training using video cystoscopes. The theoretical component comprised of a SelfDirected Learning Package which includes the anatomy and the physiology of the bladder; investigations of haematuria; bladder cancer overview; principles and workings of a cystoscope; complications and antibiotic prophylaxis; follow-up protocol; and up-to-date literature for reference. Are you interested in learning how to be a nurse flexible cystoscopist? Do you want to provide highquality service, and consistency for your patients? Or would you like to know how to hold a scope and learn the principles of cystoscopy? Come and join us at the flexible cystoscopy workshop at the 20th International Meeting of the European Association of Urology Nurses (EAUN19) in Barcelona. Grab the opportunity to learn the basics and apply your new skills in your local hospitals. August/September 2018

BAUS Conference Report Updates on haematuria, urinary tract cancer and new BCa studies Sue Osborne Urology Nurse Practitioner Auckland (NZ)

sue.osborne@ waitematadhb.govt.nz Recently, I attended the BAUS conference held at the BT Convention Centre in Liverpool, England last June 25 to 27. I was joined by a few urological colleagues from New Zealand and Australia, but accents were predominantly British and European. There were around 950 names on the published delegates list but I was unable to ascertain the breakdown of medical staff, nursing and allied health workers. I was very much looking forward to this, my first British conference given the similarities between the New Zealand healthcare system and the National Health Service. I was not disappointed, finding the conference sessions stimulating and relevant to our healthcare environment. I particularly enjoyed the thought provoking session hosted by BURST Research Collaborative. This is a trainee-led research group comprised primarily of urological registrars, supported by consultants, junior trainees and medical students. The aim of the collaborative is to produce high impact multi-centre audit and research that can improve patient care. They also offer on-line education series aimed at honing the research skills of health care practitioners. At the conference, the group updated us on their project called ‘MIMIC.’ This is a multi-centre cohort study designed primarily to establish the relationship between White Blood Cell (WBC) on admission and European Association of Urology Nurses

spontaneous stone passage (SSP) in patients discharged from emergency department after initial conservative management. The hypothesis of the study is that a raised WBC is associated with decreased odds of SSP and it is hoped that the evidence from this study will guide clinicians on the management of patients who present with acute renal colic. MIMIC has closed for recruitment and its primary data analysis is underway. A BURST poster was presented at the conference on the secondary aim of the MIMIC study, evaluating the role of Medically Expulsive Therapy (MET) in SSP in patients with acute ureteric colic. The protocol included all patients admitted with acute renal colic with CT-KUB confirmed obstructing ureteric stone. Statistical analysis was used to explore the effect of age, gender, stone size and position, (upper, middle or lower ureter) on whether MET use had an effect on SSP.

clinic protocols in the UK. I felt disappointed not to have been aware of the study earlier, especially when I noted that around six Australian sites were participating in the data collection. To date, 7500 patients have been recruited in just six months, a testament to the power and organisation of BURSTS international trainee network. This study is designed to inform the creation of haematuria risk stratification pathways, beyond patient age and type of haematuria (visible/ non visible). These pathways can be incorporated into urology guidelines utilised to determine the need for and type of haematuria screening investigations.

The session presenters informed us that of the 73 United Kingdom Hospitals participating in the study 82% have a one-stop haematuria clinic and 52% did routine PSA screening as part of their work-up. 52% utilise renal tract ultrasound scan as their first-line Data was collected from 4181 patients. 75% (3127) imaging for visible haematuria, with 45% using CT were discharged with conservative management. scan. Preliminary findings (may change after final 80% of these (2516) later spontaneously passed their data analysis) reveal a renal cancer diagnosis rate of calculus and were included in the multivariate 1% (78) and upper tract Urothelial Carcinoma of 1% analysis. Results indicated that 44% (952) were (79). Bladder cancer was diagnosed in 14.6% of prescribed MET in the form of Tamsulosin and 56% patients (970) and prostate cancer in 0.8% (51). This is were not (1234). The rate of SSP in the two groups from referrals for both visible and non-visible was 78% and 72%, respectively. Although this is a 6% haematuria and other referral symptoms, the data not difference in favour of MET use, this effect yet stratified. disappeared when confounders such as stone size ad position were adjusted for in the multivariate One interesting interim finding is that there was a 5% analysis. The study therefore concluded that MET has cancer detection rate in under 45-year-olds, a group no benefit in SSP regardless of stone size or position. which the NICE guidelines excluded from the recommendation to refer to secondary care for renal IDENTIFY’s interim findings or bladder cancer investigations. If this statistic is The BURST Research Collaborative also presented confirmed it will be interesting to see if it is interim findings from IDENTIFY, a protocol that is incorporated into an updated NICE guideline going recruiting until the end of this year. IDENTIFY is the forwards. acronym for study: Investigation and Detection of urological neoplasia in patients referred with suspected The BURST team outlined the ‘next big idea’- an RCT of urinary tract cancer: a multicentre analysis. IDENTIFY is a personalised investigative pathway for haematuria vs standard of care. The hypothesis is that personalised a study dear to my heart as the centre where I practice investigation will result in no worse cancer detection collects a very similar data set on individuals that are rate with lower investigative burden than standard of seen at our one-stop haematuria clinic, modelled on

Results from the IDENTIFY study were presented by the BURST Research Collaborative

care. This concept was greeted with much enthusiasm from BURST Twitter followers, leaving me feeling inspired by the idea of how these large, speedy recruitment multicentre studies really have the potential to inform practice in a timely manner. The session wrapped up with a ‘Dragons Den’ where three finalists presented excellent research study proposals. The study designs were critiqued by the ‘dragons’ with questions from the audience. Twitter and in-house voting picked the winning proposal. The author said his study would challenge the “there’s no harm in exploring” mentality that often leads to scrotal exploration in acute scrotal pain. The runners-up aimed to investigate the outcomes resulting from the different practices of ‘ureteric stenting with delayed definitive stone treatment’ versus ‘immediate acute ureteroscopy’ for obstructing calculi, with the third finalist’s protocol designed to try and ascertain optimal stent duration postureteroscopy. I found all proposals thought-provoking along with the constructive critique they received from the dragons. I left the session feeling the future of urology continues to be in good hands. In my next column I will share some other conference highlights that confirm this view. Until then, be well.


The International Journal of

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August/September 2018

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European Urology Today


APCC 2018 Report Excellent prostate cancer care Down Under Dorien Andof Urology Ward Nurse Prostate Cancer Nurse Urology hospitals Leuven Leuven (BE) dorien.andof@ uzleuven.be Last week I participated at the Asia-Pacific Prostate Cancer Conference in Brisbane to prepare for my nursing fellowship at the Australian Prostate Centre in Melbourne. It was a great opportunity to meet my future colleagues at the centre and acquire new knowledge about prostate cancer. I also welcomed the opportunity provided by the EAUN to pay for the registration fees in return for a conference report. I’ve been working as a urology ward nurse for four years, and two years ago I started a prostate cancer nurse specialist programme at the University Hospitals Leuven. In Belgium, nurse specialists are still relatively ‘new,’ which makes the Brisbane meeting a great opportunity to learn from experienced colleagues Down Under.

The first day took up the history and future of urology followed by the role of genetic screening and prostate cancer prevention. During the discussion on active surveillance, I realised it is a subject I could further pursue. One controversial subject discussed was lymph nodes in prostate cancer, and the lecture by Professor Walsh discussed the benefits, barriers and long-term outcomes of a lymph node dissection. He noted that there are a lot of risks when performing a lymph node dissection with little evidence that shows benefit.

“…there are a lot of risks when performing a lymph node dissection with little evidence that shows benefit.” Following the lunch break was a lecture on patients’ expectations and quality of life. Although

The conference itself was not as big as I expected, but it was a lot easier to network with the Australians and participants from other countries. The conference had a professional but warm atmosphere and during the breaks I got to talk to nurses, doctors, researchers and physiotherapists. I also had the chance to talk with the speakers during lunch breaks lunch to discuss some details in their lectures. One of the topics discussed was the differences in health care systems and how they affect patient care.

European Association of Urology Nurses

ask a patient who has a problem with, for instance, erectile dysfunction. During a 1.5-hour workshop, the participants shared experiences, dilemmas and knowledge, and It was good to realise that we basically struggle with the same clinical issues and challenges.

With a very varied programme, I attended as many sessions as possible including those that tackled nursing issues. Many of the speakers were nurses and their lectures were not only remarkable but also inspired me.

The lectures on sexual health stressed the importance of asking the patient the right questions

Helen Crowe and Prof. Tony Costello of the Royal Melbourne Hospital (middle) with me and Christophe Orye, both from Belgium and doing a fellowship there.

patients nowadays have access to better information they still often have unrealistic expectations, for example, regarding the efficient management of incontinence. The session made me realise that I have to provide guidance to patients without taking away their hopes. Patient education certainly involves preparing them for what might come and properly informing them of realistic outcomes. Running a nurse-led clinic The second day took up the topic of the value of a well-run nurse-led clinic. Speaker Ms. Louisa Fleure has 25 years of experience with nurse-led clinics in the UK and gave good and practical examples on various management strategies. I noted many of her tips which I can use back home in my clinical practice, putting theory into actual practice. The rest of the day included lectures on sexual health with many helpful recommendations and insights from the speakers. One of the most significant things I picked up was the importance of carefully listening to patients. Some questions to consider are: What is the goal? What is the patient expecting? What does the partner want? Do they want the same thing? How far would they go? Do they have the right information? I will definitely have better questions to

The last day in the nursing and allied health programme provided lectures on postprostatectomy incontinence, a subject which I am very familiar with. The session was not only inter-disciplinary but also covered many aspects comprehensively, with insights from doctors, nurses and physiologists. To summarise, my experience at the APCC Conference in Brisbane was very remarkable for its high quality programme and the warm collegial atmosphere. It is one of the rare meetings where I felt very welcomed and which made networking very easy. Lastly, I would like to thank the EAUN and the APCC for giving me the opportunity to attend this amazing conference. I intend to participate in next year’s conference and stay longer for the nursing fellowship. I certainly look forward to both!

The Conference Gala Dinner took place at the stunning Queensland Art Gallery

Join us in Barcelona for the 20th EAUN Congress Share your clinical practice or research insights in the video, abstract or difficult case sessions The EAUN extends a very warm Mediterranean invitation for you to join us in Barcelona for the 20th International EAUN Congress from 16 to 19 March 2019.

Abstract submission now open! Deadline: 1 December 2018

The EAUN19’s Scientific Programme is as exciting, diverse and vibrant as Barcelona itself. We will not only be looking back to recent achievements and assess how our practice has evolved until today, but will also explore the prospects that will help us meet the urology needs of tomorrow.

The EAUN Scientific Office aims to offer a programme that recognises the changing face of Dedicated to promoting ever higher standards of urology nursing. Participants can again expect a very diverse programme that will take up issues urology nursing knowledge and care, EAUN19 is the such as patient protection, renal stones, sexual largest gathering of urology nurses in Europe. The health and well-being, urostoma management, congress provides an unparalleled opportunity to examine and discuss evidence, technologies and male incontinence, pain management and practice across the urology care spectrum. We also antimicrobial resistance, as well as emerging issues in transgender nursing care and the offer the opportunity for participants to link up with colleagues from across the globe in one of the world’s urological care needs of refugees and migrants. most dynamic cities. Taking off from our discussions during EAUN18 in Copenhagen, we will report on the views expressed and work undertaken regarding the development of a urological nursing education curriculum in Europe. We will also be asking the question – ‘Where is urology nursing in our changing world?’ as we seek ways to support each other and ‘future-proof’ our practice. Expect all these activities besides our regular offer of dedicated nursing poster sessions, special interest groups in both bladder cancer and continence, discussion of difficult cases, video sessions, ESU Courses and the Research Competition segment. We have hospital visits, the well-attended Guided Nurses Walk and Congress Dinner, among other activities.

For the complete Scientific Programme visit www.eaun19.org

build an ever stronger community of urology nursing professionals.

Save the date! Details of EAUN19 can be found at www.eaun19.org. Check the link for information on the venue, the Scientific Programme and links for submitting abstracts. Abstract submission is now open, so don’t delay! You can also find details on how to apply for the EAUN Travel Grant worth €500. Registration opens 1 October 2018 (the early fee deadline is 15 January, 2019).

Come and join us at EAUN19 Barcelona, it would not be the same without you!

20th International EAUN Meeting

16-18 March 2019, Barcelona 16-18 March 2019, Barcelona, Spain www.eaun19.org Submit your Abstract, Video, Difficult Case or Nursing Research Project proposal Deadline: 1 December 2018

Join the top of Urology Nursing!

All in all, EAUN19 will be a very tasty urological nursing tapas and we want you to join us! Share your clinical practice or research insights by submitting an abstract. Innovation, when shared, will 36

European Urology Today

August/September 2018

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European Urology Today August/September 2018  

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

European Urology Today August/September 2018  

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

Profile for uroweb