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European Urology Today Official newsletter of the European Association of Urology


Radical cystectomy: Reducing readmissions

3D printing technology in urology What’s new in 3D printing technology

Best practices to cut readmission rates Dr. J. Baack Kukreja

Vol. 29 No.4 - August/September 2017


Dr. A. Dourado Menses


Working conditions after urology training Insights and challenges on work conditions Dr. M. Garcia Sanz

Taking the next steps in cross border urological care eUROGEN has launched with 29 centres of excellence Michelle Battye EAU EU Policy Coordinator Sheffield (UK)

michelle.battye@ uroweb.org Since the approval by the European Commission, activities of eUROGEN, the European Reference Network (ERN) for patients with rare and complex urogenital diseases and conditions, is in full swing ahead with the establishment of its network. During the first official meeting last June in Noordwijk, important steps have been taken to set the foundation for this innovative cross-border cooperation platform. Nearly 40 participants were present to bring eUROGEN to its next phase; from approved plans to execution. One of the first decisions made was the appointment of Section Leads. Besides the already assigned three Workstream Leaders, these additional volunteers were selected to assist in clinical, research and educational matters of the specific workstreams. It was also decided that for each of the fifteen disease areas a specialist needs to be appointed to coordinate the development of the disease area. These volunteers will be responsible for inputting into the development of clinical guidelines where needed, seeking out best practices in multidisciplinary patient pathways and spreading innovation across the network – all with the full input from our urogenital Patient Advisory Group.

a clinical patient management system has been developed by the European Commission and is currently being tested. Since patients with rare urogenital diseases and complex conditions often require life-long care management, this system ensures continuity of patient care from the childhood and throughout various phases in a patient’s lifetime. The healthcare professional will complete the observations and test results in the system, which will be reviewed in European virtual Multi-Disciplinary Teams (MDT) for quicker diagnosis and to identify the best treatment. Currently evidence and data is lacking for many rare conditions. Collecting information on rare and complex urogenital conditions will lead to help achieve better clinical care and research outcomes. With consent of the patient (or parent’s consent, in case of a minor), data from the clinical patient management system will be collected in a harmonised and comparable way to improve clinical care and research outcomes. Collaboration Orphanet eUROGEN has also been invited to closely collaborate with Orphanet (www.orpha.net), the European database for rare diseases. Orphanet and eUROGEN represent a common endeavour to improve the lives of European patients with rare diseases by boosting knowledge acquisition and providing equal access to expertise. By working together, we hope to coordinate our complementary activities so as to produce, improve and share information and data in the field of rare diseases. Participants of the first eUROGEN meeting last June in Noordwijk, the Netherlands

Together with the ePAG (Patient Advisory Group), eUROGEN will collaborate to update the Orphanet database by publishing a scientific paper and present this as evidence of the changes proposed to the codification. This will assist in setting a standard nomenclature of rare diseases, which will provide stakeholders with a common, controlled language to improve the interoperability between health information systems and databases and registries.

Communication To directly reach as many European patients as possible, eUROGEN recognizes the role of a solid and responsive communication strategy with a corporate branding and the right tools to properly inform patients all over Europe. The proposal for the new logo and the website was approved in Noordwijk, and What’s next together with the communication team of the EAU, a Now the boundaries are becoming more and more new website was developed in line with the corporate clear, we can fill in the gaps before eUROGEN can branding. The website, which can be found at eurogen-ern.eu, will serve as the main portal for external relations to access the latest information on various diseases, the network of health care professionals and the work flow of eUROGEN. For those involved in eUROGEN a collaborative IT platform has been launched as well. This online document management system allows all healthcare providers, patient representatives and network managers to archive and download eUROGEN-related information such as minutes of meetings, organisational documents, updates, official announcements and to work together on scientific publications. Only authorised members of eUROGEN can access this platform and share their content with the other members. The collaborative platform, however, will not contain any patient related information. Life-long patient care To implement an effective new way to use IT in supporting cross border multidisciplinary teams of the best experts in Europe to provide a diagnosis, recommendations for treatment and second opinions,

Take out the Urology Week poster inside this EUT and hang it on your wall

WEEK 2017

help its first patients, which is expected before the end of the year. In the coming months the operational board of eUROGEN will focus on launching the clinical patient management system, developing the first documentation on the different disease areas and starting the development of clinical guidelines. Thanks to the commitment and enthusiasm of its current members, eUROGEN has had a kick-start. There is still a long way to go and challenges to overcome, but we are convinced that eUROGEN will

achieve success. The Network Coordinator Professor Chris Chapple said “the ERNs are an incredible new opportunity to provide the framework for cooperation between healthcare providers and experts at European level. I am honoured to be working with so many of the best experts in Europe and I am personally committed to harness the expertise of the EAU and link it to the activities of the ERN”. If you are interested in receiving updates on the activities of eUROGEN, you can subscribe to our newsletter via the eurogen-ern.eu website (left corner).


Abstract submission now open! Deadline: 1 November 2017


August/September 2017

European Urology Today


Israeli bacterial testing chip wins award Bio-chip technology helps doctors identify effective antibiotic treatment By Jarka Bloemberg An Israeli testing technology that rapidly identifies bacterial infection in hours instead of days has won the Discovery Award, a financing grant from the United Kingdom that will enable the team to further test and expand the use of the ground-breaking bio-chip technology. The Israeli research was first presented at the 32nd Annual EAU Congress in London last March. “The grant will further advance our PRISM technology as we endeavour into assaying direct clinical samples taken from a neighbouring medical centre (Bnai Zion Medical Center in Haifa, Israel),” the team said. “The Discovery Award will aid in the fabrication and advancement of our disposable, microfluidic devices with integrated photonic sensors for continued analysis of clinical samples, such as urine, blood, sputum and cerebral spinal fluid.” The UK-based Discovery Award is a support grant and is part of the UK Nesta Longitude Prize. Led by Prof. Ester Segal (Technion Israeli Institute of Technology, Haifa), the team has developed special silicon biosensor chips which contain thousands of nano wells. The wells are coated with a material that allows bacteria to stick to the chip. Technicians use reflected visual light to count the bacteria and monitor whether the colony is growing. By adding different antibiotics in various dilutions to each chip, scientists can see which antibiotic best inhibits bacterial growth, giving them results within two to six hours.

European Urology Today

Bacterial infections are still a major cause of death worldwide, and standard tests for bacterial infection typically take around two days for doctors to finally determine the best antibiotic treatment. In Europe more than an estimated four million people acquire hospital-associated infections annually. In the UK alone at least 300,000 patients acquire infections in hospital settings each year, with over 9,000 deaths attributed to bacterial infections. In the US, around 100,000 deaths are recorded each year due to hospital-acquired infections, with around 40% caused by urinary tract infections (UTIs).

Determining the correct antibiotic for an infection in a timely manner is critical for both a patient and to prevent the spread of antimicrobial resistance; however, a typical bacteria workup procedure requires 24 hours to confirm the presence of bacteria, and at least another 24 to 36 hours to identify the correct antibiotic to use as part of antibiotic susceptibility testing (AST). In total, routine hospital lab time can take 24 to 72 hours, during which time antibiotics may be administered to facilitate the growth of resistant strains, according to the team.

"..scientists can see which antibiotic best inhibits bacterial growth, giving them results within two to six hours."

During the EAU Congress, Prof. Florian Wagenlehner of the University Clinic in Giessen, Germany and chairman of the European Section of Infections in Urology (ESUI) said the work of the Isreali team addresses an urgent medical need. “The current culture based techniques have a delay of several days in producing results, which leads, on the one hand, to inappropriate antibiotic treatment, and on the other hand to an overuse of broad spectrum, last resort antibiotics,” Wagenlehner commented. He noted there are several laboratories working on this topic, and several methods aim to reduce the antibiotic testing time. “Developing the right test will save resources and lives and slow down emergence of antibiotic resistance,” added Wagenlehner.

“We have developed a method of phase-shift reflectometric interference spectroscopic measurements (PRISM) that monitors bacterial activity on photonic silicon-based microstructures in real time,” explained co-investigators Mrs. Heidi Leonard from the Segal lab at the Technion and paediatric urologist Prof. Sarel Halachmi of the Bnai-Zion Medical Centre, Faculty of Medicine in Haifa. “With PRISM, we can rapidly determine minimum inhibitory concentrations of antibiotics using miniaturized photonic chips in a substantially faster readout time than state-of-the-art, automated AST systems, such as the Vitek 2.” The Discovery Award will help the team to fabricate and improve the disposable, microfluidic devices with integrated photonic sensors for continued analysis of clinical samples. “Preliminary results demonstrate that our system is capable of determining antibiotic susceptibility and the minimal inhibitory concentration within two to three hours. Our method provides a faster alternative for observing antimicrobial resistance and an accurate MIC readout than typical clinical methods, and serves as a rapid phenotypic antimicrobial susceptibility test that aims to require minimal sample handling,” the team said.

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


European Urology Today

EAU Patient Information: Plans and projects Exciting full-day programme at EAU18 in Copenhagen Summer is in full swing and EAU Patient Information (PI) is more inspired to undertake many promising projects for the 33rd Annual EAU Congress (EAU18) in Copenhagen. What have we been up to? Due to the increasing popularity of and demand for PI, expansion became necessary. In March of this year, PI has welcomed Dr. Giulio Patruno (IT) and Dr. Selcuk Sarikaya (TR) as co-chairs of EAU Patient Information Chairman Prof. Dr. Med. Thorsten Bach (DE). EAU18 programme Despite its rising success, PI has not been resting on its laurels. During the previous Annual EAU Congress in London, PI has met with patient support and advocacy groups. Together with the European Cancer Patient Coalition (ECPC), Europa Uomo, Fighting Bladder Cancer, the International Kidney Cancer Coalition (IKCC), and others, PI has come up with a new and exciting programme for EAU18. This programme aims to enhance the capacity of European patient advocacy groups to support their members and advocate for better care. Urologists, nurses, patient advocacy groups, patients and anyone who is interested are welcome to join the PI Session in Copenhagen on Sunday, 18 March 2018 from 9.00 until 14.30 hrs. European Reference Networks The PI programme kicks off with an update on eUROGEN, one of the 24 European Reference Networks (ERNs) approved and funded by the European Union (EU). ERNs are an exciting new form of cooperation between healthcare providers with specialised expertise to improve care for patients with rare diseases or complex conditions. And eUROGEN aims to improve diagnosis, create more equitable access to high-quality treatment and care for patients with rare urogenital diseases and complex conditions needing highly-specialised surgery.

Presently, 29 urological centres in 11 European Member States have met the criteria to become centres of excellence. Together with patient representatives, these centres are developing a lifelong, patient-care programme based on the latest available evidence so that patients can have access to the best care available. New topics and animated series After a short coffee break, the programme continues with the introduction of PI’s latest topics and informative treatment series. The series features essential videos on surgical procedures for kidney stones and drug treatment for overactive bladder (OAB). Additionally, the new PI topics include: • Cryptorchidism • Hypogonadism • Neurourology • Penile cancer • Penile curvature • Phimosis • Priapism • Primary urethral carcinoma • Renal duplication • Signs and symptoms • Testicular cancer • Urachal cancer • Urine biomarkers Feel free to check the rest of these updates at http://patients.uroweb.org. Coming soon Topics PI aims to add the new topics Congenital Malformation in the Urinary Tract, Male infertility, Renal transplantation and Vasectomy within this year.

In addition, the following topics will be updated: • BPE • Prostate cancer • Kidney stones • Urinary incontinence • Kidney cancer • Nocturia • Overactive bladder • Erectile dysfunction Animated series Visitors of the website can also look forward to more educational videos on bladder cancer. Aside from drug treatments for OAB, new topics such as cystoscopy and urodynamics will be made available soon. Call for patients EAU Patient Information is based on the EAU Guidelines for which a rigorous methodology of evidence-based literature search is in place. This year, we are looking for patients to aid in the review of our media. Through their help, PI content becomes more understandable and more conducive to educating other patients about their diseases. Website A new PI website is in the works and will be launched before EAU18 commences! The website is the culmination of the dedication and effort since the establishment of the EAU Patient Information Working Group. There will be a significant improvement in its interface; increased user-friendliness and more appealing design. PI expresses its utmost appreciation to all its working group members, Chairman and Co-chairs. These ambitious projects would not have transpired without their altruistic investment of time and expertise. We look forward to see you in Copenhagen! August/September 2017

Update from the Guidelines Office Summer Edition 2017 Recent publications from Guidelines Panels We are very pleased to announce that several papers from Guidelines Panels have recently been accepted and published by European Urology:

Panel meetings It is a busy time for Guideline Panel meetings with the Panels formalising their text to meet the fast approaching 13th October deadline for the 2018 version of the Guidelines.

• The Benefits and Harms of Different Extents of Lymph Node Dissection During Radical Prostatectomy for Prostate Cancer: A Systematic Review • Prostate Cancer and the John West Effect • What Is the Negative Predictive Value of Multiparametric Magnetic Resonance Imaging in Excluding Prostate Cancer at Biopsy? A Systematic Review and Meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel Penile Cancer Panel in Berlin

• Tract Sizes in Miniaturized Percutaneous Nephrolithotomy: A Systematic Review from the European Association of Urology Urolithiasis Guidelines Panel

And the following publications are available on-line:

In June, the Male Sexual Dysfunction Guidelines Panel met in Amsterdam. The key aims of the meeting were to discuss the progress on literature searches and text updates for the 2018 version, planned publications, and to receive an update on progress made on their 2 systematic reviews. Other meetings held were the Urinary Incontinence Guidelines Panel meeting in Noordwijk, the Penile Cancer Guidelines Panel meeting in Berlin in June (see photo), the MIBC Guidelines Panel meeting in Barcelona and the Paediatric Urology Guidelines Panel (photo) met in Amsterdam in July.

Upcoming changes to the Guidelines As of 2018, all the EAU Guidelines will begin to adopt a modified version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to measure the quality of evidence of studies included in the guidelines and to grade guidelines recommendations. The Renal Cell Cancer Guidelines Panel have already used this system in the 2017 edition of their guidelines and there will be a full roll-out of the approach across all panels for the 2018 guidelines publication. The strength of each recommendation will be determined by the balance between desirable and undesirable consequences of alternative interventions, the quality of evidence for each intervention as well as the nature and variability of patients’ values and preferences. The strength of each recommendation will be represented by the words ‘strong’ or ‘weak’. The panels will provide both ‘strong’ and ‘weak’ recommendations ‘for’ or ‘against’ each intervention. This system will be introduced across all EAU Guidelines, in a staged process, the aim being to provide transparency between the underlying evidence and a given recommendation. Conflict of Interest Policy

Taking the next steps in cross border urological care. . . . . . . . . . . . . . . . . . . . . . . . 1 Israeli bacterial testing chip wins award . . . . 2 EAU Patient Information: Plans and projects. . 2

Progressing ongoing systematic reviews and the annual text updates are standard topics included in all Guidelines Panel meeting agendas.

Update from the Guidelines Office . . . . . . . . . 3 ESFFU: Pelvic organ prolapse. . . . . . . . . . . . . 4

• The Risk of Tumour Recurrence in Patients Undergoing Renal Transplantation for End-stage Renal Disease after Previous Treatment for a Urological Cancer: A Systematic Review

Chairmen’s meeting Amsterdam

• Medical Treatment of Nocturia in Men with Lower Urinary Tract Symptoms: Systematic Review by the European Association of Urology Guidelines Panel for Male Lower Urinary Tract Symptoms.

Guidelines Office

Paediatric Urology Panel in Amsterdam

ESUT: Laparoscopic robotics. . . . . . . . . . . . . . 6

At the Chairmen’s meeting in May, a new Conflict of Interest Policy was adopted for use by the Guidelines Office and its Panels (photo). The Policy has been developed by a working group chaired by Prof. Anders Bjartell which included a number of Guidelines Panel Chairmen. It is intended to provide a reasonable and transparent system for the handling of Conflict of Interests. Once fully operational, all Panel Members will be asked to regularly update their COI through a web-based system.





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The meetin Executive 2017. people visit s are increasingly In my and represen g of care that rated on urologists allow represealso features one-on tatives of the because they offer.” the forty ntatives from -one session national of the quality members urologica s that each of l societies “Furthermore, each society the EAU Executive country to speak of Europe to individually, I believe about Europe field. We the attentio a chance to bring urology are in less their unique giving n of the EAU. EAU is also an Union Researc organ or danger of remains a versatil diversity needs h For procedure e identifying an of concern to (Brighton, closely involved in. Networks that the than, for vascular with one s and requestimpression of the one session GB) present Mr. surgeons. instance, “ESUO is s, please Board of cardiac or ed on behalf Jan Nawrocki When we program a section see page s in these one-on Urology, me of our work of the Europe that is just our goals 3. and Mr. GB) on the annual congres on the scientifi feels like Future directio beginning, is learnin an British experie Kieran O’Flynn we’re c and one and quality (Manchester, throughout Europe g more about associations!” compiling a meetins, it sometimes “I think urologyns for urology of improvement nce with (online . We would office urology situation g of ten differen ) auditin of individu in general public,” is grossly under-r love to hear t al surgeon g The discuss your country as we Prof. about the ecognis opined An Helmut Haas DK), the informal s. ed by the ion on the build a networ Prof. Jens newly-a continued (Heppenheim, importance introduce k.” audience survey of the panel Prof. Chapple ppointed Adjunc Sønksen (Herlev on the second the EAU’s of DE) was raised a membe meeting, , newest section: Urologists invited to range of day of the office urology might or culminating recognition, agreed: “We need t-Secretary Genera in Office topics where rs and the should be the day-lon l. in the ambitioNoordwijk (ESUO), as to EAU Section chairman. ‘upgrade’ well as the focusin These include urology our opinion of which In of specifi g programme at this n of having ownership d the lead g on in the near urological Germany, a sizeable he is the the cally for taking as of urology conditions that the manage future. that urologi treatment “daily practiceAnnual EAU Congre a antibiotic . It is “This is a should continu ment of urologi sts could or clinicall occurs not proportion of resistance experience ss ” urology urologist.” clear unmet be y, but in cal by e to be driven increases general with urinary . Prof. attractiv specialised need, and demographics by the tract infectio (due to it will be Chapple: urologists’ practitioners interest e for this group of urologi very of people offices. ranks of ed in “The EAU sts as more ns), the shifting who are urologists, is procedures.” the intricacies of less women enter and increas female and Week and working on this robotic the salvage ing emphas by organis paediatric Prostate ing Urology urology. Cancer Awaren is on social media A future to shape ess Day, Prof. Chapple for societies public percept and using can The meeting regional meetin summarised ion. Nationa the role of gs countries.” do the same for much of the EAU l the continued continued on Saturda Chapple the discuss in produce medical also pointed populations of their need for a white paperhis call for the Associa ion on schools, educational y, addressing societies’ to the role oncology stating that own meeting that deals stimulate tion activities of “not they their with medica to at the nationa regional s and the and bladder just on prostate meetings career choice. students’ interest could do more future of l l cancer, but in Central to Prof. Chapple in urology The Europe as well to prove and South-e the EAU’s on kidney as a announced that an astern Europe. approach, a return itself in nationaCommission generalurology is pivotal. Prof. Hein albeit with Van Poppel ly does not a differen to the regional l medical regulations Secretary t scientifi policy, involve c concept General in (Leuven, BE), EAU “After speakin need these across Europe, but and there are differen . the attentio Adjunct charge of g to you the Executi documents regional education n of medica all, it is clear European ve feels we t Prof. Haas introduc meetin to be drawn added that engage l student gs how Union and were respect es the new effectively to attendance much Office (ESUO) medical compan urology and urology, emphas s and residents must with the ed. We looked the to the assembl EAU Section of Urologis ising androlo count on figures and it was ies.” at the Informing ed represen 50-60 senior ts in much more paediatric urology clear gy, female and tatives number as areas interest. urologists, that we could The Noordw collaborating of residen that deserve but a relative ts. Meeting Prof. Haas: the EAU’s ijk meeting also ly low is essentia In the Baltic states, The aforem “These offi serves as initiatives lly a rotating between the Baltic entioned of treatme a national the many interest roundtable national nt that GPs ces fill the gap betwee societies and activities, both showcase of We would three countries, meetin discuss ing treatme and can informi This issues, n g offer and calling with EAU the kind ion raised concerned like nt that year, invited ng involvement. and South-e this model for new directio not the least of experience, requires a hospita the more intensiv speakers on their participation. (Aberdeen, the field astern Meeting the Central ns for urology which were Prof. these offi e l stay. In is changin because James N’Dow Office, and GB) on behalf of s as well.” European to conside g. concerns of the long-teces are popular with our the EAU r as Mrs. Michell and asked Prof. Chapple had National urologist, Guideli societies earlier raised and some the other e Battye the ‘familia rm care offered by patients will (Sheffield, nes EAU Executi meeting audience a single l’ atmosp in turn, with take the lead in GB) to talk offices generally on the matter. members ve organising require less here, and because scientific to voice their members support from patients, program the travel to as oppose the opinions the EAU me. The will consist reach d to (region for a joint regional Prof. Manfre al) hospita for advisor as well as of presidents of all ls.” spoke cautioud Wirth (Dresden, a the region’ y board Prof. Sønkse key opinion leader DE), EAU s Treasurer, closely with sly about urologi from each societies, n will take sts country. the lead If urologi robotic surgery. “We identifying too on behalf sts of the EAU. first, they identify themselves are organ speciali tie their fi sts. eld to technicas (robotic) surgeon seriously risk losing s surgeons their jobs al developments and obsolete.” as technol ogy makes

in Noordw


of care

Take out the Week post Urology this EUT er inside and han g it on your wall

www.eau1 8.org

W EE K 20

We are urgently looking for urology nurses!



25-29 SEP TEM





n now open

! Deadline:

1 November




Promoting your meetings

The Patient Information (PI) group of the European Association Urology is looking for urology nurses in its project team. Could you be one of them?

The EAU executive is pleased to help promote any scientific meetings. However, due to the large number of requests we are receiving, we have been forced to set up some rules and regulations related to the circulation of promotional material.

If you… • have a minimum of two years’ experience in urological care • have been involved in the development of marketing materials on patient information (e.g. brochures, leaflets, etc.) • can dedicate 2 to 6 hours per month to PI

…then you are exactly what the project team is looking for!


August/September 2017

Interested? Please contact Ms. Franziska Geese (MScN, RGN) Advanced Practice Nurse and Patient Information Project Member, via email f.geese@uroweb.org for more information. Looking forward to have you on the team! Kind regards, Patient Information Group

ESUT: Tumour ablation therapy: Its advantages . . . . . . . . . . . . . . . . . . . . . . . 13 ESU section: Annual Slovak Urological Society Conference. . . . . . . . . . . . . . . . . . . . . . . . . . 14 ESU Course in Kirgizstan. . . . . . . . . . . . . . . . 14 1st ESU-ESUT Masterclass on Urolithiasis. . . 15 ESU – Weill Cornell Masterclass in Urology. . 16 Reducing readmission after radical cystectomy. . . . . . . . . . . . . . . . . . . . . . . . . . 18 EUSP: New Section Office-sponsored, specialty scholarships. . . . . . . . . . . . . . . . . . 25 EULIS: Renal stones in practice. . . . . . . . . . . 25 Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 26 EUREP – CUA Exchange Programme. . . . . . . 27


Dear nursing colleagues,

PI has considerably grown in the past few years; its website receives over 85,000 unique website visitors monthly and offers excellent resources on 19 urological conditions in 17 languages! PI needs dedicated and outstanding nurses such as yourself to aid in the reviewing process of its media (e.g. videos and leaflets).

Ten Questions: Julie Steinestel . . . . . . . . . . . 12

EBU recertifies Department of Urology in Pilsen (CZ) . . . . . . . . . . . . . . . . . . . . . . . . 28



Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11

/July 2017

EBU ensur es


Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7

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. All other urological meetings may be included in our Uroweb online calendar. Please feel free to contact us (EUT@uroweb.org) in case there are any queries or remarks related to this notice.

EBU Certification for HELIOS Marien Klinik. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Stronger arguments than ever for the GPIU!. . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Three-dimensional printing technology in urology. . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Simulation in urology. . . . . . . . . . . . . . . . . . 31 YUO section: New YAU working party: Uro-technology & Communication . . . . . . . . . . . . . . . . . . . . . . Is there a need for a Residents’ Corner in UROsource? . . . . . . . . . . . . . . . . . . . . . . . Working conditions after urology training. . Spanish urology residents compete in annual contest. . . . . . . . . . . . . . . . . . . . .

32 32 33 33

EAU-AUA Academic Exchange Programme. . 34 EAUN section: Updates from the Danish Post-EAUN Meeting. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Scandinavian biennial conference on urology. . . . . . . . . . . . . . . . . . . . . . . . . . 39

European Urology Today


Pelvic organ prolapse To mesh, or not to mesh, that is (still) the question! Prof. Elisabetta Costantini Dept. of Urology University of Perugia Ospedale Santa Maria della Misericordia Perugia (IT)

different criteria for a successful outcome, as well as studies from other sites, have shown that native tissue repairs have better success rates than previously thought6 and, therefore, not all women are in need for a prosthetic material. The “simplicity” of mesh kit insertion and the straightforwardness of mesh procedures have led to their use by surgeons with inadequate training and expertise and have, at least, contributed to the recorded complications.

ecostant@unipg.it Impact of FDA warnings The FDA warnings confirming safety concerns led to rather strong reactions from manufactures and Dr. Konstantinos physicians. Major healthcare companies, like Johnson & Giannitsas Johnson and American Medical Systems, withdrew from Dept. of Urology the area of pelvic floor surgery. Urogynaecologists’ Patras University reactions were variable depending on personal Hospital experience, volume of mesh procedures performed, as Patras University well as medico-legal issues in each particular country Patras (GR) around the world. For example, in Germany and France graft usage remained as common as one in every three anterior repairs, compared to only 15% and 3% of the cases in North America and the U.K., respectively. However, the general trend was a decrease in The debate on the optimal surgical technique for transvaginal mesh use with the largest relative female Pelvic Organ Prolapse (POP) repair is still reduction of 47% reported in the United States following FDA warnings. The decrease in transvaginal extremely engaging. The issue of using or not using reinforcing materials is the hottest. The controversy has mesh used was “compensated” by a 25.5% increase in sacrocolpopexy performed worldwide7, which is been fuelled by safety warnings of the U.S. Food and associated with a lower incidence of mesh Drug Administration (FDA) culminating to the 2014 proposal for moving transvaginal mesh to high-risk complications and higher patient satisfaction. Another effect of the FDA warnings was the inevitable devices1. “contamination” of SUI surgery with the “meshSafety issues have caused a spectrum of reactions from phobia”. Nevertheless, synthetic midurethral slings have a long history of effectiveness and safety7, and surgeons and prosthetic material manufacturers, even FDA warnings differentiate mesh for SUI from transforming the initial enthusiasm and promise of mesh implants to fear and abandonment. The European transvaginal mesh for POP. Association of Urology and the European Urogynaecological Association, trying to put the Given the turbulent situation in POP surgery, the situation into perspective, recently published a question is: “How can we get out of it?” And the “easy” consensus statement2 summarising views on the use of answer is: a) we improve the mesh-kits, b) we improve implanted meshes in the treatment of POP and stress the way we select patients for augmented repairs and urinary incontinence (SUI). Based on evidence from c) we improve urogynaecologists’ surgical skills. The published studies and opinions of experts they suggest reality is, though, that all these improvements require that careful case selection and adequate surgical skill significant effort and time. are extremely important in improving outcomes and avoiding complications. It seems that the issue is not As far as improving the mesh-kits, thorough “to mesh or not to mesh” but “how to use mesh investigation of mesh properties, host response, better”. efficacy and safety are needed. On January 5, 2016 the FDA strengthened requirements for POP mesh products, An understanding of the current situation and the stating that existing ones need both Pre-Market dilemmas regarding the use of meshes could be Approval (PMA) and post-market surveillance studies facilitated by a review of their “clinical history,” concluded by July 2018, and PMA will be mandatory highlighting reasons for their introduction in POP prior to marketing in the future8. When these surgery as well as factors associated with their requirements are met the properties of commercially complications. available products will be evaluated and confirmed and not just assumed, as it was the situation in the past. Use of mesh for abdominal POP repair began in the Manufacturers still interested in the field of 1970s but the first surgical mesh product for urogynaecology such as Boston Scientific, Coloplast and transvaginal POP repair was approved by the FDA in Acell Matristrem have started 522 clinical trials on TVM 2002. These dates indicate that transvaginal implants (with their devices) necessary to satisfy FDA for POP are rather “new.” This “new” minimally requirements. invasive management of POP stirred interest in the impact of pelvic floor dysfunction on women as well as While awaiting data from these trials careful patient on the various outcomes of reconstructive surgery. Over selection and improvement of surgical technique is the time, surgical meshes and their delivery systems only way to go. Available evidence suggests that the evolved and their number boomed to more than 100. risk of a re-operation after hysterectomy or POP repair According to data cited by the 2011 FDA increases with time after primary surgery and the communication3, out of 300,000 POP repairs in the US severity of the prolapse. It is therefore reasonable, at in 2010, one in three had mesh insertion and three out least for now, to offer mesh repairs to younger women with higher prolapse stages. Other factors predisposing of four were done transvaginally. to POP recurrence either genetic, relevant to connective tissue defects, or acquired, such as obesity and Mesh kits were introduced in the US market under the constipation are currently studied and may further help “Premarket Notification process” that demanded only us in patient selection. Urogynaecologists should “evidence” of similarity to a previously approved judiciously use mesh to improve their outcomes product. This means that meshes for POP repair were keeping in mind that traditional repairs work well for approved when considered “substantially equivalent” to meshes for hernia repairs4. Nevertheless, the vagina many patients. The potential risks and benefits of mesh should be understood by both the surgeon and the is not the abdomen and hernias are not POP: synthetic patient. material performance and safety demonstrated in hernia repairs could not guarantee POP repair Adding the third ingredient to the “recipe of success” outcomes. for mesh use, that is, improving surgical skills and Despite this, mesh kit use soon became an “epidemic” accreditation, will probably be the ultimate challenge. Experts now agree that, in contrast to what happened due to the dissatisfaction with the durability of native in the past, whoever attempts vaginal mesh insertion tissue POP repairs but also, most importantly, the must have a good knowledge of alternative surgical advertising of the efficacy and ease of placement of these products: any woman could have it, any surgeon options. The adequate amount of training, how this is could do it! certified and who supervises it remain, unfortunately, unresolved issues. The EAU Section of Female and The unsatisfactory efficacy of native tissue repairs has Functional Urology (ESFFU) could have a central role in been recently questioned. The belief of high reoperation this process helping less experienced urogynaecologists rates was largely based on the epidemiological study by to standardise their technique. Olsen et al.5. A later revision of this paper, using Moving forward In summary, we are currently facing a difficult time in EAU Section of Female and Functional Urology urogynaecology with all the uncertainties surrounding 4

European Urology Today

Fig. 1: Famous Shakespeare quote

the use of mesh in prolapse repairs and this is not in the best interest of the patients suffering symptomatic POP9. We all now realise that the unsupervised development and use of mesh kits has led us to the current predicament. But placing the blame is beyond the point: we must learn from our mistakes and move forward. Meshes for POP need to be assessed in a scientific and sound way before their widespread use by clinicians. Professional organisations should coordinate efforts to make sure that centres using mesh kits a) have training and experience in pelvic surgery, b) have specific training in the particular device and method they use, c) maintain a high volume of surgical procedures for prolapse, and d) are able to track both objective and subjective outcomes of their procedures and seek to recognise and manage complications of surgical mesh implants. With all the above actions we will hopefully turn fear to success regarding the use of mesh for POP. References 1. https://www.federalregister.gov/ articles/2014/05/01/2014-09907/surgical-mesh-

transvaginal-pelvic-organ-prolapse-repair-and-surgicalinstrumentation-urogynecologic 2. Chapple CR, Cruz F, Deffieux X, et al. Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence. Eur Urol. 2017 Apr 13. 3. http://www.fda.gov/downloads/MedicalDevices/Safety/ AlertsandNotices/UCM262760.pdf 4. Menchen LC, Wein AJ, Smith AL. An appraisal of the Food and Drug Administration warning on urogynecologic surgical mesh. Curr Urol Rep. 2012 Jun;13(3):231-9. 5. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997 Apr;89(4):501-6 6. Osborn DJ, Reynolds WS, Dmochowski R. Vaginal approaches to pelvic organ prolapse repair. Curr Opin Urol. 2013 Jul;23(4):299-305 7. Dwyer PL, Riss P. Synthetic mesh in pelvic reconstructive surgery: an ongoing saga. Int Urogynecol J. 2016 Sep;27(9):1287-8 8. https://www.fda.gov/newsevents/newsroom/ pressannouncements/ucm479732.htm 9. Roovers JP. Collaboration with the mesh industry: who needs who? Int Urogynecol J. 2016 Sep;27(9):1293-5.

Gain your CME credits at home All you need is a PC and internet access Visit www.eu-acme.org/europeanurology or http:// www.eu-acme.org/pediatric and answer a set of MCQs on-line. 80% of the answers need to be answered correctly to obtain 1 European CME credit point. Credits are attributed automatically 1 credit point per article allowing for a maximum of 50 credit points over a 5 year period.

This study method offers more flexibility where you can decide for yourself when and where you should like to study. CME is a lifelong commitment and CME credits are the ‘staples’ of staying in practice and keeping the office doors open. Good luck!

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


© COOK 01/2017 URO-D32084-EN-F

August/September 2017

#EAU18 Cutting-edge Science at Europe’s largest Urology Congress

Exclusive preview of EAU18’s Scientific Programme Distinguished members of the Scientific Congress Office (SCO) have deliberated to address the key issues in urology. As a result, a comprehensive and impactful Scientific Programme for the upcoming 33rd EAU Annual Congress (EAU18) was developed. Here is an overview of what’s new for EAU18. Plenary Sessions updates There will be a total of seven Plenary Sessions where two sessions will take place simultaneously. Due to its success during the previous Congress, the Nightmare Session on bladder cancer management will once again be part of the EAU18 Programme. Three cases will be presented, wherein each case will be cross-examined by a lawyer. Debates will ensue and the session will conclude with the best solutions for the cases.

Other Plenary Session topics will include: Evidence quality and advances in andrology; Prostate Cancer; Contemporary storage LUTS management; Precision medicine; Preventing urological disease: Future prospects and Stones. For translations for the Plenary Sessions, more languages will be considered and added. New sessions The new Specialty Session “Common problems in bladder cancer; Evidence-based debates” is designed to educate participants about the important clinical problems in managing bladder cancer and the various solutions best suited for each problem. The session will employ multiple mini-debates on common yet challenging clinical problems. For every case, two experts will propose

different solutions, which will be discussed and challenged by bladder cancer experts. Each case will conclude with a practical way forward; a fitting approach/treatment per case. The session chairmen will be Dr. Herbert Barton Grossman (US), Dr. Ashish Kamat (US) and Prof. Arnulf Stenzl (DE). In addition, a new Urology Beyond Europe session will be added in the EAU18 Scientific Programme which will be chaired by Prof. Dr. Christian Beisland (NO), President of the Nordic Urological Association (NUF), and coordinated by Prof. Jens Sønksen (DK), EAU Adjunct Secretary General – Clinical Practice. Other sessions The Scientific Programme will also include 19 Thematic Sessions. Moreover, the new EAU Section

Unwind after a Congress day at the serene and picturesque Amagerstrand Beach Park. Relax in Nokken, a charming natural hideaway devoid of the hustle and bustle of the city, and enjoy its labyrinth of gardens and hobbit-style huts. Visit the cool collection of workshops, organic

cafés, and galleries of Christiania, the city within a city built by hippies on a former military base. Then treat your taste buds with fresh, tasty meals from around the globe at the street food market in Papirøen. Or cross out “dining in the dark” on your bucket list and savour dinner on a whole new level at the Dark Waiter restaurant.

ESU Courses Organised by the European School of Urology (ESU), there will be approximately 55 courses and around 50 Hands-on Training courses at EAU18. More details on the Scientific Programme will be available shortly. Please check the EAU18 webpage regularly www.eau18.org

Important dates Congress days 16-20 March 2018

Copenhagen: More than a fairy tale Constantly ranked as the happiest city in the world, Copenhagen is host city to the anticipated EAU18 Congress. The Danish capital is also known for its flair for design, culinary revolution and Instagram-worthy destinations. Discover the Danish’s secret to happiness, the craze behind Kasper Juul and Katrina Fonsmark of the hit TV series Borgen, and all the best updates in the field of urology in one location. For a taste of unique and interesting spots in Copenhagen, read on.

of Urologists in Office will hold its first session to discuss office urology issues.

Exhibition days 17-19 March 2018

masterpiece, Jens Olsen’s World Clock at Copenhagen’s City Hall.

Abstract submission open 1 July 2017

Aside from a highly-informative Congress, Copenhagen offers plenty of must-see destinations and once-in-a-lifetime experiences. So, come join us at EAU18!

Registration open 1 October 2017

Hop on a boat ride or paddle your own kayak through Copenhagen to a tryst with The Little Mermaid. Then pass by the brightly-coloured gabled houses of Nyhavn, three of which author Hans Christian Andersen had resided in. Drop by Rundetårn, 34.8 m high tower known for its lack of stairs! Its 209-metre long spiral ramp winds itself 7.5 times round the hollow core of the tower. Check the time and even the planetary positions for thousands of years to come with the astronomical

Abstracts Submission deadline 1 November 2017 EAU Awards submission deadline 1 November 2017 Early Bird deadline 15 January 2018 Late Fee deadline 12 February 2018 Check out the programme ove

EAU Awards: Winners’ insights The EAU grants prestigious awards to innovative research and practice. Last year’s winners share their insights and aims in this article. For abstracts, at least nine prizes are given with the best selected from three categories, namely: Oncology, Non-Oncology and Video. EAU Best Papers Published in Urological Literature Awards These awards are given to young and promising urological scientists for their innovative research, which are categorised into Fundamental and Clinical Research. Fundamental Research awardee of 2017, Dr. Imran Ahmad (GB) of the CRUK Beatson Institute, has submitted “Sleeping Beauty screen reveals Pparg activation in metastatic prostate cancer”. Using an unbiased forward mutagenesis screen, Dr. Ahmad and his team were able to successfully identify candidate genes that drive advanced and metastatic prostate cancer (CaP). Alterations of peroxisome proliferator-activated receptor gamma (PPARG), encoding a crucial regulator of lipid metabolism, appear to play a role in the development of metastatic CaP in both humans and mice. “As

Apply now and win!

clinicians, fundamental research is often outside our comfort zone. However, it is vital that we take a lead to drive these translational studies and act as the link between the bench and the bedside,” said Dr. Ahmad. Clinical Research awardee of 2017, Dr. Julie Steinestel (DE) of the Universitätsklinikum Münster, together with her team have submitted “Expression of AR-V7 in circulating tumour cells does not preclude response to next generation androgen deprivation therapy in patients with castration resistant prostate cancer”. EAU Hans Marberger Award This award is given to the best European paper published on minimally invasive surgery in urology. EAU17’s awardee Dr. Riccardo Autorino (IT) of the Virginia Commonwealth University has submitted the study “Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European–American Multi-institutional Analysis”. The aim of the study was to analyse the techniques and surgical outcomes of minimally invasive simple prostatectomy — either with standard or robot-assisted laparoscopy — by using a large worldwide multi-institutional dataset. Dr. Autorino stated “We ultimately wanted to provide evidence supporting a potential role for this procedure in the surgical treatment of BPH, mostly in case of a large gland with or without associated bladder pathologies (stones, diverticula).”

www.eau18.org EAU Prostate Cancer Research Award With the goal to encourage high-quality research in prostate cancer, the EAU has launched the EAU Prostate Cancer Research Award. EAU17 awardee Dr. Masaki Shiota (JP) of the Kyushu University has submitted “Potential Role for YB-1 in Castration-Resistant Prostate Cancer and Resistance to Enzalutamide Through the Androgen Receptor V7” to reveal the expression mechanism of androgen receptor variant, which is a crucial molecule to promote the resistance to androgen receptortargeting therapeutics; and to identify the possible biomarker to predict the progression to castration resistance.

rview at

EAU Crystal Matula Award The EAU Crystal Matula Award is the most prestigious prize given to a promising European urologist under the age of 40. The current recipient of this award is Assoc. Prof. Christian Gratzke (DE) of the Ludwig-Maximilians-Universität München. How to apply Interested in applying or nominating someone you know? Please send an email to Ms. Marian Smink m.smink@uroweb.org for more information.

Top tips in submitting your abstract The Annual EAU Congress presents abstract submissions from urologists and other medical professionals from around the world. For the previous congress in London, about 5,000 abstracts were submitted and only 25% (1,171 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 EAU18’s website for more information. Good luck!

You still have some weeks to go! Abstract submission deadline is 1 November 2017

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

August/September 2017

European Urology Today


Laparoscopic robotics The democratisation of robotic surgery? Dr. Stephan Hruby Tauern Hospital Zell am See Dept. of Urology Zell am See (AT)

stephan.hruby@ gmx.at

Prof. Alberto Breda ESUT Laparoscopy Group Fundacio Puigvert Dept. of Urology Barcelona (ES) abreda@fundaciopuigvert.es Robotic surgery has developed into a mega trend in surgical specialities and urology has not only pioneered this field bravely, it still is and will be one of the opinion leading core specialities. And being only at the beginning of tapping the full potential of this technology -image integration, targeted surgery, real time microscopy- most of the delicate standardised procedures can be performed equal or superior to established techniques like open or laparoscopic techniques. A further milestone was the standardisation of training curriculums around the globe with the availability of virtual reality (VR) training systems enabling -irrespective of the case load of the department- an unlimited number of training procedures and a digital objective skills scoring. EAU Section of Uro-Technology (ESUT)

Figure 1: FlexDex1

Recent developments over the last years have more or less successfully tried to translate the robotic skills into classic laparoscopy. Of course, 3D camera systems are now widely established among the community. Nevertheless two issues seemed too hard to solve. The first was to create an intuitive interface, and the second was the real-time motion translation.

Another start-up from the Netherlands has presented a market-ready haptic grasper for laparoscopy, which enables the surgeon not only to get real feedback of tissue firmness but also to feel small arteries pulsating. (Figures 1 and 2) 3D Vision, Real time Articulation and Haptic device together will be named Laparoscopic Robotics, the new laparoscopic robotic suite, which can be considered nearly equal to existing robotic systems.

Lowering the risk & mortality rate of the most frequent cancer in men 27 September 2017 from 13.30 until 17.00 hrs. European Parliament, Paul Henri Spaak (PHS) building, room P1A002, Brussels

The European Prostate Cancer Awareness Day (EPAD17) aims to set next steps to lower the risks and improve the management and care of prostate cancer. Policy makers, scientific experts, European associations, and representatives of European patient groups with an interest in cancer and prostate cancer in particular are invited to contribute to cancer control activities. The meeting will be hosted by Mr. Aloyz Peterle and Mrs. Marian Harkin of the MEPs Against Cancer group (MAC). EU Commissioner of Health and Food Safety, Mr. Vytenis Andriukaitis will respond on the EAU white paper on PCa. Registration Participation to this event is free of charge. To get the most out of this event the number of available seats is limited and registration will be assigned on a first come, first serve basis. For more info see: epad.uroweb.org


European Urology Today

Taking a closer look, this suite even outperforms the current robotic systems. The surgeon can use his standard laparoscopic approach. Moreover, the surgeon does not have to leave the operation table. The devices can be used out-of-the-box and are

With new robots reaching the market in different specialities and different indications, earlier concepts become part of the past. The emerging technology of laparoscopic robotic devices are now ready for primetime and have the potential to trigger a bottom-up revolution and make robotic technology available for every patient and in every OR at the same time at calculable costs. Laparoscopic robotic technologies have the potential to truly democratise robotic surgery, but nevertheless have to stand the test of time in terms of surgical quality, learning curve, training standardisation, and economic efficacy. Stay tuned with the upcoming ESUT live surgery sessions to learn more about the potentials of laparoscopic robotics.

Game-changing developments However, the year 2017/2018 will change the game completely. Aside from the competitors entering the “big” robotic market, there is a group of start-ups entering the market from bottom-up. Two companies (from?) have market-ready and user interface-friendly, real-time laparoscopic instruments, which will work “out of the box,” so they can be used anytime in any OR and do not require unusual port placements.


Date: Time: Venue:

available in every OR, at the same time, with no additional OR space or static requirements needed. Assuming the technology will be available with no or minimal investment, and reasonable running costs, it will spread very fast among all surgical communities; thus allowing a majority of patients all over the world to benefit from medical innovation and evolution.

But there are also downsides. Being a monopoly market for over 15 years, costs for purchasing, as well as the running costs, are still out of reach for many hospitals. Neither the pricing nor the compensation systems enable a sustainable and economically efficient use, particularly in a public-financed healthcare system. Another downside is the availability. If you can afford such a system it will be available for one operation at a time. But most hospitals have six or more OR´s running simultaneously. So the technology with its advantages will only be available for one patient at a time. The OR footprint is also a widely discussed issue which is also often a restricting factor for establishing a system. And finally, the missing feature is haptic feedback to replace the surgeon’s most sensitive instrument: his finger.

Figure 2: OptiGrip

Programme 13.30 Welcome Marian Harkin and Alojz Peterle, MEPs 13.35 Introduction on the role of patients and the importance of EPAD Francesco De Lorenzo, President European Cancer Patient Coalition (ECPC) & Ken Mastris, Chairman Europa Uomo 13.45 The EAU and its recent action on Prostate Cancer Chris Chapple, Secretary General European Association of Urology (EAU) 13.55 The European Commission’s response to the EAU’s White Paper on PCa and developments at EU level on Prostate Cancer Vytenis Andriukaitis, EU Commissioner of Health and Food Safety 14.10 Prevention of Prostate Cancer Bertrand Tombal, President of the European Organisation for Research and Treatment of Cancer (EORTC) 14.20 The role of civil society in health promotion and prevention campaigns on Prostate Cancer Lydia Makaroff, Director European Cancer Patient Coalition (ECPC) 14.30 Guidelines on Prostate Cancer screening Nicolas Mottet, Chairman EAU PCa Guidelines Panel 14.40 Prostate Cancer screening from a patient perspective Paul Enders, Europa Uomo and member EAU PCa Guidelines Panel 14.50 Recent developments in early diagnosis for Prostate Cancer Jochen Walz, Chair EAU Section on Urological Imaging (ESUI) 15.00 Prevention and early detection of Prostate Cancer Vitaly Smelov, International Agency for Research on Cancer (IARC), World Health Organisation (WHO) 15.10 Coffee break 15.25 Key treatment options and costs associated with Prostate Cancer Dominik Berthold, European School of Oncology (ESO) 15.35 The role of the nurse in the Prostate Cancer patient journey Lawrence Drudge-Coates, European Association of Urology Nurses (EAUN) 15.45 Addressing inequalities in access to care for Prostate Cancer in Europe Ian Banks, President European Men’s Health Forum (EMHF) 15.55 Will the new Joint Action include Prostate Cancer? Cancon’s vision Tit Albreht, Coordinator EU Joint Action on Cancer Control (Cancon) 16.10 How EU funds have benefited research into Prostate Cancer and future plans for FP9 Jan-Willem Van de Loo, DG Research and Innovation (EC) 16.25 The role of personalised medicine in Prostate Cancer Denis Horgan, Executive Director European Alliance for Personalised Medicine (EAPM) 16.35 What can be achieved by using Big Data in Prostate Cancer James N’Dow, Chairman EAU Guidelines Office 16.45 Call to action for EU Institutions; the view from the EAU and the European Parliament Marian Harkin and Aloyz Peterle, MEPs; Hein Van Poppel, Adjunct Secretary General EAU 17.00 Networking drink

August/September 2017

Clinical challenge Case study No. 53

Prof. Oliver Hakenberg Section editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 52 A 53-year-old man with severe Lower Urinary Tract Symptoms (LUTS) consulted an office urologist. The patient’s medical history included a gastrectomy for gastric cancer performed 10 years ago. The work-up led to the diagnosis of a carcinoma of the prostate with a Gleason score of 8 and a serum PSA of 4.9 ng/ml. While the bone scan result was normal, the MRI showed a locally advanced tumour (see Figure 1).

Fig. 1: Locally advanced tumour visible

Fig. 2: CT scan shows multiple hepatic metastases

Several months went by, local treatment options were discussed and several second opinions were sought.

vertebrae which was confirmed by a new bone scintigram. The serum neurone-specific enolase was 31.7 ng/ml (normal < 18).

Three months after the diagnosis, complete androgen blockade with an luteinizing hormone-releasing hormone (LHRH) antagonist and bicalutamide were started. A cystoscopy at this stage showed infiltration of the prostatic urethra, bladder neck and trigone. Treatment by cystoprostatectomy was proposed and as preparation, a CT scan was performed. This showed multiple hepatic metastases (see Figure 2) and also indicated bone metastases in two lumbar

This 25-year-old man was referred by an office urologist because of left flank pain, weight loss of 5 kg over the last two months and night sweats. Ultrasound showed a hydronephrotic left kidney, urinalysis was normal. A CT scan confirmed left hydronephrosis and showed a large retroperitoneal tumour (Figures 1 and 2). Clinical examination and ultrasound of both testes were normal. Serum markers were AFP 44.000 IU/l, β-HCG 10 IU/l, PLAP 480 mU/l and LDH 717 U/l. Bilateral testicular biopsy was normal on the right side and showed testicular intraepithelial neoplasia on the left side.

Discussion points: 1. Are there any further investigations needed? 2. H  ow can this patient be treated?

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

Treatment depends on final histology and tumour staging Comments by Prof. David Neal Cambridge (UK)

exclude a neuro-endocrine of the stomach because neuro-endocrine tumours are found most commonly in the gastro-intestinal tract4. Such cancers may also produce other physiologically active peptides which require treatment with somatostatin analogues5. Increased levels of NE are associated with a poor prognosis in gastro-intestinal tumours6.

This case is unusual because there is clear evidence of marked local invasion of a large tumour situated in the prostate with a low prostate specific antigen level at presentation and apparently a Gleason 4+4=8 cancer found on biopsy of the prostate. There is no evidence of any meaningful response to androgen deprivation. Three months later there was evidence of liver metastases and an increased level of neuronspecific enolase (NE) in the serum.

In addition to being confident about the histology, I would, depending on the pathology, arrange, a chest, abdomen and pelvis CT scan with contrast to exclude a primary small cell cancer of the lung. A PET CT would be useful to determine the extent of the cancer, but whether this was a regular FDG PET or a more targeted scan would depend on the histology review7. If on review of the histology a neuro-endocrine phenotype is found, I would arrange for measurement of other physiologically active peptides and ask about Clearly, careful review is required of the histology of symptoms of flushing and diarrhoea5. the biopsy by an expert uro-pathologist. Does the patient have a prostate adenocarcinoma or is there As far as treatment is concerned, this will all depend evidence of small cell carcinoma of the prostate, a on the final histology and tumour staging. Clearly the primary neuro-endocrine tumour or a tumour patient is not suitable for local radical resection. arising in the urothelium? If no evidence of The patient seems likely to have a neuro-endocrine neuro-endocrine pathology is found consideration tumour in the prostate. As primary prostate cancers, should be given to taking a larger TUR biopsy of the these are very uncommon8 and may be characterised by tumour at the bladder neck or an image-guided a dominance of large or small cells and the production biopsy of the liver secondary, although it is now of various biomarkers such as chromogranin A, recognised that neuro-endocrine differentiation can synaptophysin and NE. More commonly, cells with be difficult to identify on conventional pathology1. features of neuro-endocrine cancers in the prostate arise in the context of long-standing androgen A raised neuron-specific enolase can be found in deprivation and castration-resistant prostate cancer and several cancers such as small cell carcinoma of the may be characterised by loss of cell cycle genes such as lung, primary neuro-endocrine carcinoma of the retinoblastoma or cyclin D1,9. A neuron-specific enolase prostate, patients with metastatic prostate cancer of over 30 ng/ml is a very unusual presentation of a who are likely to do badly2,3 and patients with patient with primary adeno-carcinoma who has not had long-standing androgen deprivation2,3. extra-prostatic neuro-endocrine cancers. The patient also underwent a gastrectomy some 10 years previously and it would be useful to review the histology of the gastrectomy samples to

Early referral to a specialist medical oncologist for consideration of appropriate systemic chemotherapy is a key point here.

References 1. Tsai H, Morais CL, Alshalalfa M, Tan HL, Haddad Z, Hicks J, et al. Cyclin D1 Loss Distinguishes Prostatic Small-Cell Carcinoma from Most Prostatic Adenocarcinomas. Clin Cancer Res. 2015;21(24): 5619-29. 2. Kamiya N, Akakura K, Suzuki H, Isshiki S, Komiya A, Ueda T, et al. Pretreatment serum level of neuron specific enolase (NSE) as a prognostic factor in metastatic prostate cancer patients treated with endocrine therapy. European urology. 2003;44(3):30914; discussion 14. 3. Fan L, Wang Y, Chi C, Pan J, Xun S, Xin Z, et al. Chromogranin A and neurone-specific enolase variations during the first 3 months of abiraterone therapy predict outcomes in patients with metastatic castration-resistant prostate cancer. BJU international. 2017. 4. Modlin IM, Lye KD, Kidd M. Carcinoid tumors of the stomach. Surgical oncology. 2003;12(2):153-72. 5. Gut P, Waligorska-Stachura J, Czarnywojtek A, Sawicka-Gutaj N, Baczyk M, Ziemnicka K, et al. Management of the hormonal syndrome of neuroendocrine tumors. Arch Med Sci. 2017;13(3): 515-24. 6. van Adrichem RC, Kamp K, Vandamme T, Peeters M, Feelders RA, de Herder WW. Serum neuron-specific enolase level is an independent predictor of overall survival in patients with gastroenteropancreatic neuroendocrine tumors. Ann Oncol. 2016;27(4):746-7. 7. Chan DL, Pavlakis N, Schembri GP, Bernard EJ, Hsiao E, Hayes A, et al. Dual Somatostatin Receptor/FDG PET/CT Imaging in Metastatic Neuroendocrine Tumours: Proposal for a Novel Grading Scheme with Prognostic Significance. Theranostics. 2017;7(5):1149-58. 8. Zaffuto E, Pompe R, Zanaty M, Bondarenko HD, Leyh-Bannurah SR, Moschini M, et al. Contemporary Incidence and Cancer Control Outcomes of Primary Neuroendocrine Prostate Cancer: A SEER Database Analysis. Clinical genitourinary cancer. 2017.

Figure 1

Figure 2

Discussion points: 1. What is the likely diagnosis? 2. Are further investigations needed? 3. What treatment is advisable?

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

9. Rodrigues DN, Boysen G, Sumanasuriya S, Seed G, Marzo AM, de Bono J. The molecular underpinnings of prostate cancer: impacts on management and pathology practice. The Journal of pathology. 2017;241(2):173-82.

Liver biopsy can prove or rule out differential diagnosis Comments by Prof. Dr. CarstenH. Ohlmann Homborg (DE)

case, either metastases from gastric cancer or prostate cancer may be present. Most conclusive in this case seems to be a biopsy of one of the liver metastasis to prove and rule out differential diagnosis, which can be done by CT-guidance under local anaesthesia.

1. Are there any further investigations needed?

2. How can this patient be treated?

The differential diagnosis in this case includes late recurrence of gastric cancer, adenocarcinoma or neuroendocrine (NE)/small cell carcinoma of the prostate. The NSE-level in this patient is inconclusive and does not prove neuroendocrine prostate cancer, even in presence of the low PSA value < 5 ng/ml in this case. Additional investigations should cover tumour markers for gastric cancer (i.e. CEA, CA 72-4, CA 19-9) and chromogranin A. PSMA-PET scan might be considered; however, neuroendocrine/small cell carcinoma are often PSMA-negative and in this

In case the gastric cancer is ruled out, treatment options for this patient include local and systemic treatments. Local tumour growth will lead to hydronephrosis and/or rectal infiltration sooner or later. In case of a prostate adenocarcinoma and in view of the new systemic treatment options for hormone-sensitive prostate cancer and the resulting survival probabilities, cystoprostatectomy as a palliative treatment should still be discussed with the patient. Subsequent systemic treatment may include docetaxel-based chemotherapy in addition to ADT, which was already started. As an alternative, ADT

August/September 2017

plus abiraterone/pred may be offered instead of chemo-hormonal treatment since the LATITUDE and the STAMPEDE trial most recently reported survival benefits for this combination over ADT alone. In addition, several patient-related endpoints including time-to-skeletal-related events, time-tonext cancer therapy and time-to-symptomatic progression were in favour of the combination therapy. In case of neuroendocrine/small cell carcinoma of the prostate, prognosis of this patient is rather poor. Palliative systemic treatment options include conventional taxane-based chemotherapy for NE carcinoma or platinum-based chemotherapy for small-cell carcinoma. Local palliative treatment by cystoprostatectomy should be weighed against minimally invasive urinary diversion by nephrostomy tubes at the time hydronephrosis becomes evident. These options should be carefully discussed with the patient in this highly palliative situation.

Case Study No. 52 continued The initial pathology had been done by a dedicated uro-pathologist. Androgen blockade and ablation was continued and the patient received two cycles of docetaxel which did not result in any measurable response on repeat imaging. The patient then received six cycles of cabazitaxel which gave a very good response on imaging with shrinkage and central necrosis of the hepatic metastases. We then had a 68Ga-PSMA-PET/CT done which showed marked PSA-positivity of the prostatic tumour as well as the hepatic metastases. Therefore, the patient is currently undergoing Lu-177-PSMA treatment.

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Key articles from international medical journals Prof. Truls Erik Bjerklund Johansen Section editor Oslo (NO)


Women with symptoms of UTI but a negative urine culture The objective of this study was to examine whether or not women with symptoms of a urinary tract infection but with a negative culture (20%-30%) do have an infection. The authors performed quantitative PCR (qPCR) for Escherichia coli and Staphylococcus saprophyticus, on top of a standard culture, in urine samples from 220 women with dysuria and/or frequency and/or urgency and from 86 women without symptoms. For symptomatic women, qPCR was also carried out for four sexually transmitted agents.

Almost all women with typical urinary complaints and a negative culture still have an infection with E. coli. Use of sequencing technologies challenges principles of antibiotic stewardship In the symptomatic group, 80.9% (178/220) of the urine cultures were positive for any uropathogen and 95.9% (211/220) were E. coli qPCR-positive. For the control group, cultures for E. coli and E. coli qPCR were positive in, respectively, 10.5% (9/86) and 11.6% (10/86). In the symptomatic group, qPCR yielded 19 positive samples for S. saprophyticus qPCR, one positive sample for Mycoplasma genitalium and one for Trichomonas vaginalis. These findings suggest that almost all women with typical urinary complaints and a negative culture still have an infection with E. coli. The results of this study demonstrate that use of sequencing technologies challenges the antibiotic stewardship principle of using fewer antibiotics.

Source: Women with symptoms of a urinary tract infection but a negative urine culture: PCR-based quantification of Escherichia coli suggests infection in most cases. Heytens S, De Sutter A, Coorevits L, Cools P, Boelens J, Van Simaey L, Christiaens T, Vaneechoutte M, Claeys G. Clin Microbiol Infect. 2017 Apr 21 DOI: 10.1016/j. cmi.2017.04.004

Antibiotic resistance rates and physician antibiotic prescription patterns of uncomplicated UTIs in Southern China Whilst primary care physicians are called to be antimicrobial stewards, there is limited primary care antibiotic resistance surveillance and physician antibiotic prescription data available in southern Chinese primary care. The study aimed to investigate the antibiotic resistance rate and antibiotic prescription patterns in female patients with uncomplicated UTI. Factors associated with antibiotic resistance and prescription was explored. A prospective cohort study was conducted in 12 primary care group clinics in Hong Kong of patients presenting with symptoms of uncomplicated UTI from January 2012 to December 2013. Patients' characteristics such as age, comorbidity, presenting symptoms and prior antibiotic use were recorded by physicians, as well as any empirical antibiotic prescription given at presentation. Urine samples were collected to test for antibiotic resistance of uropathogens. Univariate analysis was conducted to identify factors associated with antibiotic resistance and prescription. Key articles


A total of 298 patients were included in the study. E. coli was detected in 107 (76%) out of the 141 positive urine samples. Antibiotic resistance rates of E. coli isolates for ampicillin, co-trimoxazole, ciprofloxacin, amoxicillin and nitrofurantoin were 59.8%, 31.8%, 23.4%, 1.9% and 0.9% respectively. E. coli isolates were sensitive to nitrofurantoin (98.1%) followed by amoxicillin (78.5%). The overall physician antibiotic prescription rate was 82.2%. Amoxicillin (39.6%) and nitrofurantoin (28.6%) were the most common prescribed antibiotics. Meanwhile, whilst physicians in public primary care prescribed more amoxicillin (OR: 2.84, 95% CI: 1.67 to 4.85, p < 0.001) and nitrofurantoin (OR: 2.01, 95% CI: 1.14 to 3.55, p = 0.015), physicians in private clinics prescribed more cefuroxime and ciprofloxacin (p < 0.05). Matching of antibiotic prescription and antibiotic sensitivity of E. coli isolates occurred more often in public than in private primary care prescriptions (OR: 6.72, 95% CI: 2.07 to 21.80 p = 0.001) and for other uropathogens (OR: 6.19, 95% CI: 1.04 to 36.78 p = 0.034). Mismatching differences of antibiotic prescription and resistance were not evident.

The 248 women in the ibuprofen group received significantly fewer course of antibiotics, had a significantly higher total burden of symptoms, and more had pyelonephritis. Four serious adverse events occurred that lead to hospital referrals; one of these was potentially related to the trial drug. Results have to be interpreted carefully as they might apply to women with mild to moderate symptoms rather than to all those with an uncomplicated UTI. Two thirds of women with uncomplicated UTI treated symptomatically with ibuprofen recovered without any antibiotics. Initial symptomatic treatment is a possible approach to be discussed with women willing to avoid immediate antibiotics and to accept a somewhat higher burden of symptoms.

The authors concluded that nitrofurantoin and amoxicillin should be used as first-line antibiotic treatment for uncomplicated UTI in Southern China. Further exploration of physician prescribing behaviour and educational interventions, particularly in private primary care may be helpful. Meanwhile, development and dissemination of guidelines for primary care management of uncomplicated UTI as well as continued surveillance of antibiotic resistance and physician antibiotic prescription is recommended.

Source: Antibiotic resistance rates and physician antibiotic prescription patterns of uncomplicated urinary tract infections in southern Chinese primary care. Wong CKM, Kung K, Au-Doung PLW, Ip M, Lee N, Fung A, Wong SYS. PLoS ONE. 2017; 12(5):e0177266 DOI: 10.1371/journal. pone.0177266

Ibuprofen vs. fosfomycin for uncomplicated UTI in women The objective of this study was to find out if treatment of the symptoms of uncomplicated urinary tract infection (UTI) with ibuprofen could reduce the rate of antibiotic prescriptions without a significant increase in symptoms, recurrences, or complications. Women aged 18-65 with typical symptoms of UTI and without risk factors or complications were recruited in 42 German general practices and randomly assigned to treatment with a single dose of fosfomycin 3 g (n = 246; 243 analysed) or ibuprofen 3×400 mg (n = 248; 241 analysed) for three days (and the respective placebo dummies in both groups).

Randomized study shows that twothirds of women with uncomplicated UTI treated symptomatically with ibuprofen recovers without any antibiotics

*The above paper was awarded the Masaaki Ohkoshi prize 2017 by the working group on UTI of the International Society of Chemotherapy for the best clinical study on urinary tract infections published during the recent two-year period.

Use of anti-depressant medication before and after renal transplantation is associated with worse overall outcomes The authors examined a novel database wherein national US transplant registry identifiers were linked to records from a large pharmaceutical claims warehouse (2008-2015) to characterise antidepressant use before and after kidney transplantation and associations [adjusted hazard ratio (aHR) 95% CI] with death and graft failure.

Kidney graft failure probably related to the development of de novo donor-specific anti-HLA antibody formation

The authors investigated 56 patients who underwent transplant procedures between 2002 to 2014 with kidney graft failure (cases), for a possible association of development of dnDSA with graft failure. The 56 patients with failed transplants were matched with 56 patients with a functioning graft for the variables deceased or living donor, transplant number, transplant year, recipient age and gender, donor age and gender, dialysis time and transplant induction therapy. All patients had at least one serum collected one year before failure (in cases) or end of follow-up (in controls).

In this retrospective case-control study, post-transplant dnDSA was clearly associated with graft loss, particularly if against HLA class II antigens

Cases and controls were very well-matched in several baseline characteristics. Post-transplant anti-HLA antibodies were found in 84% of cases and 36% of Among 72,054 renal graft recipients, 12.6% filled controls (p < 0.001). 54% of cases and 16% of controls antidepressant medications in the year before (p < 0.001) had dnDSA at the time of detection. transplant and use was more common among women Chronic active antibody-mediated rejection was and patients who were white, unemployed, and had significantly more common (p < 0.001) in patients limited functional status. Pre-transplant with dnDSA (61% vs. 12%), in 53 (47%) patients who antidepressant use was associated with 39% higher had at least one graft biopsy performed during one-year mortality (aHR 1.39, 95% CI 1.18-1.64) and follow-up. 15% higher all-cause graft loss risk (aHR 1.15, 95% CI 1.02-1.30). dnDSA was a significant risk factor for graft failure in a multivariable conditional logistic regression model (OR = 6.06; p = 0.003). dnDSA as a time…kidney transplant candidates dependent variable was also an independent predictor of graft failure in a multivariable Cox and recipients treated with analysis (HR = 2.46; p = 0.002). In both antidepressant medications should regression statistical approaches, only dnDSA-II was significantly associated with graft failure (OR = 11.90; be monitored and supported to p = 0.006) (HR = 2.30; p = 0.014).

reduce the risk of adverse outcomes

More than 50% of patients who filled antidepressants pre-transplant continued to use antidepressants post-transplant. Antidepressant use in the first year after transplant was associated with two-fold higher risk of death (aHR 1.94, 95% CI 1.60-2.35), 38% higher risk of death-censored graft failure and 61% higher risk of all-cause graft failure in the subsequent year. Pre-listing antidepressant use was also associated with increased mortality, but transplantation conferred a survival benefit regardless of prelisting antidepressant use status. These interesting associations may in part reflect underlying behaviours or co-morbidities. However, kidney transplant candidates and recipients treated with antidepressant medications should be monitored and supported to reduce the risk of adverse outcomes.

Source: Antidepressant medication use before and after kidney transplant: Implications for outcomes - a retrospective study. Lentine KL, In both groups additional antibiotic treatment was Naik AS, Ouseph R, Zhang Z, Axelrod DA, subsequently prescribed as necessary for persistent, Segev DL, Dharnidharka VR, Brennan DC, worsening, or recurrent symptoms. The primary endpoints were the number of all courses of antibiotic Randall H, Gadi R, Lam NN, Hess GP, Kasiske BL, Schnitzler MA. treatment on days 0-28 (for UTI or other conditions) and burden of symptoms on days 0-7. The symptom score included dysuria, frequency/urgency, and low abdominal pain.

g.ploussard@ gmail.com

Source: Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. Ildikó Gágyor, Jutta The role of de novo donor-specific anti-HLA Bleidorn, Michael M Kochen, Guido antibodies (dnDSA) within the pathways leading to Schmiemann, Karl Wegscheider, Eva Hummers- graft failure remains not fully understood. Pradier. BMJ 2015;351:h6544.

Nitrofurantoin and amoxicillin should be used as first-line antibiotic treatment for uncomplicated urinary tract infections (UTI) in Southern China. Development and dissemination of guidelines and continued surveillance of antibiotic resistance and physician antibiotic prescription is recommended

Dr. Guillaume Ploussard Section editor Toulouse (FR)

Transpl Int. 2017. doi: 10.1111/tri.13006. [Epub ahead of print]

In this retrospective case-control study, posttransplant dnDSA was clearly associated with graft loss, particularly if against HLA class II antigens. The authors suggested that dnDSA detection should be a tool for post-transplant monitoring of kidney graft recipients, allowing for the identification of those with a higher risk of graft failure.

Source: Role of de novo donor-specific anti-HLA antibodies in kidney graft failure: a case-control study. Castro A, Malheiro J, Tafulo S, Dias L, Martins S, Fonseca I, Beirão I, Castro-Henriques A, Cabrita A. HLA. 2017. doi: 10.1111/tan.13111. [Epub ahead of print]

Post-transplant apheresis is probably not necessary in AB0-incompatible live-donor renal transplantation ABO-incompatible live donor renal transplantation has become clinical routine. However, desensitisation strategies to safely perform ABO incompatible living donor kidney transplantations are various and still evolving. Given the successful outcome of the majority of the approaches, the current trend is focused on a minimisation of treatments.


European Urology Today

August/September 2017

Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ hotmail.com The authors described their experience with alterations of the desensitisation protocol. Starting from 2010, 58 ABO incompatible living donor kidney transplantations were performed at the University Hospital of Padua. Over the years, the initial desensitisation strategy with rituximab single-dose induction, pre- and post-transplant plasmapheresis and CMV-specific immunoglobulin administration has been shifted to a minimised approach, omitting post-transplant antibody removal in 25 cases.

The results of this reduction in post-transplant antibody removal did not affect the outcome of ABOincompatible kidney transplants in this single-centre retrospective analysis The results of this reduction in post-transplant antibody removal did not affect the outcome of ABO-incompatible kidney transplants in this single-centre retrospective analysis. There was a meaningful reduction in costs and hospitalisation time.

Source: Therapeutic apheresis in kidney AB0 incompatible transplantation. Parolo A, Silvestre C, Neri F, Rigotti P, Furian L. Transfus Apher Sci. 2017 doi: 10.1016/j. transci.2017.07.006. [Epub ahead of print]

Transperineal anastomosis for highly recurrent postprostatectomy strictures Anastomotic stricture after radical prostatectomy remains a rare complication, occurring in less than 10% of cases. Endoscopic re-interventions for this complication induce the risk for urinary incontinence caused by external sphincter damage. Moreover, the subsequent recurrences are frequent and a new endoscopic intervention will lead to a higher risk of treatment failure as compared with the first-line interventions. In the present series, the authors described the functional outcomes of transperineal anastomosis in patients suffering from a highly recurrent stricture, defined by at least three endoscopic treatment failures. The analysis was retrospective, single-centre, included a mid-term follow-up of 45 months in 23 patients. The mean number of previous endoscopic interventions was 4.7. All patients were informed of the risk of severe postoperative incontinence. An implantation of an artificial urinary sphincter three months after the transperineal anastomosis was systematically discussed with the patient. Previous pelvic radiotherapy was considered as a contraindication for such a surgery. Functional outcomes were evaluated using several validated questionnaires and the complications were assessed by the Clavien-Dindo classification. Primary endpoint was the stricture recurrence. The success was defined by the absence of repeated intervention (including dilatation and catheterization), a Qmax > 15 ml/s, and the absence of stricture after urinary tract verification. The success rate was 87% with three treatment failures that were successfully treated by new endoscopic interventions. No signs of obstruction were reported during the follow-up. Incontinence was noted in all patients pre-operatively and post-operatively. One-third of patients reported a severe aggravation of stress urinary incontinence after the procedure. An artificial urinary sphincter was implanted in 74% of men. Erectile dysfunction was worsened in 55% of cases. However, all patients did report a severe pre-operative erectile dysfunction with no erections sufficient for penetration without Key articles

August/September 2017

medical aid. One case of cystectomy with urinary diversion was reported because of severe urge incontinence.

…in patients with multiple failed endoscopic attempts, this transperineal anastomosis (and the advantage of operating in an unscarred field) should be considered as an interesting alternative to definitive urinary diversion... Two-thirds of the patients described an improvement in their health-related quality of life after the transperineal anastomosis. Results from patient satisfaction were in line with these findings, showing a 78% rate. Complication rate was less than 10%. One per-operative minor rectal injury was reported with no need for further treatment. No other grade III-IV complication was noted. As compared with the literature data, the complication rate appeared lower than that reported after other open approaches. The primary endpoint achieved in this study was clearly reached. The patients eligible for this surgery may be informed that, after the procedure, they won’t suffer from obstruction in almost 90% of cases. However, this procedure cannot be planned alone and patients should be aware of the need for subsequent interventions for severe urinary incontinence. This article shows that an artificial urinary sphincter implantation is feasible after transperineal anastomosis with acceptable mid-term functional outcomes. Nevertheless, longer follow-up is awaited. Interestingly, in spite of this worsening of urinary incontinence, the health-related quality of life was improved in the majority of patients, highlighting that highly recurrent strictures remain a very bothersome complication after radical prostatectomy.

In the present study, the authors studied the 30-d complication rate in a large national data set (ACS-NSQIP) by comparing abdominal sacrocolpopexy with or without concomitant SUI procedure. This database captures variables from patients undergoing surgery in more than 400 institutions. Audits to validate each centre were used to ensure the quality of database. From 2006 and 2013, open or laparoscopic abdominal sacrocolpopexy as well as sling placement or Burch colposuspension were retrieved from the database. Patients with previous pelvic intervention for cancer were excluded from analysis. Endpoints were 30-d complications, reoperation, and readmission. Overall, 4,793 women were identified (74% of laparoscopic approach) with concurrent sling placement in 34% of cases, and concurrent Burch colposuspension in only 1.6% of cases. Both groups were well-balanced regarding age, race and frailty index. The rate of cystoscopy performed intraoperatively did not differ in the two groups. The overall 30-d complication rate was 6.6%. The most frequent complications were urinary tract infection (3.2%) and surgical site infection (1.7%). Patients undergoing concurrent SUI procedure had a higher rate of infection (4.8% versus 2.3%, p < 0.001) and of overall complication (7.7% versus 6%, p = 0.02). Other variables (readmission, reoperation, non-infectious complications) were not different between both groups, even after adjusting for several confounding variables. Only two patients were readmitted for urinary retention, and had a sling paced at the time of surgery. Readmission and reoperation rates were only 2.4% and 1.1%, respectively. The laparoscopic approach had a protective impact on complication rate.

This population study based on a large cohort of women may help the physician to discuss about the role of concurrent SUI correction at the time of pelvic organ prolapse surgery. Thus, a woman without demonstrable preoperative SUI must be counselled on the increased risk of urinary tract infection and of complication when performing both procedures at the same surgical time. The It is worthy to note that this procedure concerns only a relative odds ratios were 2.2 and 1.8, respectively. The lower incidence of postoperative SUI must be very small proportion of radical prostatectomy balanced with this increased but moderate risk of patients. Fortunately, an endoscopic approach is postoperative complications. sufficient for treating strictures in most patients. However, in patients with multiple failed endoscopic Source: Thirty-day morbidity of abdominal attempts, this transperineal anastomosis (and the sacrocolpopexy is influenced by additional advantage of operating in an unscarred field) should surgical treatment for stress urinary be considered as an interesting alternative to incontinence. Boysen et al. definitive urinary diversion in well-informed and Urology, 2017, doi/10.1016/j.urology.2017.07.015 motivated patients.

Source: Transperineal reanastomosis for treatment of highly recurrent anastomotic strictures after radical retropubic prostatectomy: extended follow-up. Schuettfort et al. World J Urol 2017; doi 10.1007/s00345-017-2067-8

HIFU as salvage treatment after local radiotherapy failure

Complications after sacrocolpopexy are influenced by concomitant urinary incontinence treatment

Salvage HIFU is one of the recommended options to treat local recurrence after external beam radiotherapy failure, in the absence of metastatic spread of the disease. This technique offers functional complications as compared with those obtained after salvage prostatectomy.

Correction of pelvic organ prolapse by abdominal sacrocolpopexy may unmask or worsen stress urinary incontinence (SUI) that concerns up to 50% of women with organ prolapse prior to surgery. Moreover, from 10 to 50% of operated women develop SUI after sacrocolpopexy.

In the present study, the authors reported the oncologic outcomes from a large multi-institutional cohort and with a > 2.5 years follow-up. Variables were collected in a dedicated registry between 2005 and 2009, and were reviewed for this retrospective analysis. Only patients undergoing whole-gland HIFU were included in case of biochemical failure after radiation therapy, a positive post-radiation biopsy, and a negative metastatic assessment. All procedures were performed using the Ablatherm HIFU device, and the median follow-up was 3.3 years.

This population study based on a large cohort of women may help the physician to discuss about the role of concurrent SUI correction at the time of pelvic organ prolapse surgery Thus, the correction of SUI at the time of prolapse surgery is often proposed in women suffering from SUI pre-operatively. This additional procedure remains debatable in women with no symptomaticmasked SUI. The advantages of the concurrent SUI procedures are: a lower incidence of postoperative SUI and a more cost-effective procedure, as compared with a two-staged procedure. However, the risk of short-term postoperative complications has not been thoroughly assessed.

Overall, 418 patients were included in statistical analyses. Median radiotherapy dose received was 70 Gy and the mean time between radiotherapy and HIFU was five years. The mean pre-HIFU PSA was 6.8 ng/ml. No androgen deprivation therapy was continued after HIFU treatment. Two HIFU sessions were performed in 12% of patients, three sessions in only three patients. A mean of 102% of the gland volume was treated. Prostate biopsies after HIFU were reported in 254 patients with a rate of 74% of negative biopsies. The mean PSA nadir was 1.9 ng/ml (45% of patients with a PSA nadir 0.3 ng/ml) and reached 10 weeks after HIFU. After HIFU, 47% of patients received androgen deprivation therapy for persistent local recurrence or metastasis.

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk The five-year biochemical failure-free survival was 49%, ranging from 58% (in case of low-risk prostate before radiotherapy) to 36% in case of initially high-risk prostate cancer. The oncologic outcomes were also significantly influenced by the pre-HIFU PSA and the pre-HIFU Gleason score. The most favourable outcomes were achieved in patients having a Gleason score 6 and/or a PSA < 4 ng/ml before HIFU. The previous history of androgen deprivation therapy was the third major factor predictive for biochemical recurrence and salvage treatment-free survival rate. The PSA nadir post-HIFU was also highly predictive for favourable outcomes, with a salvage treatment-free rate of 56% at five years in case if PSA nadir below 0.3 ng/ml, compared with 8% when the PSA nadir was superior to 1 ng/ml.

These results from the largest case series of salvage HIFU after radiotherapy failure confirmed the role of this energy in the management of locally recurrent prostate cancer The safety profile was acceptable with a rate of moderate and severe incontinence of 19% for the most recent procedures, after the changes of HIFU parameters (specific post-radiotherapy parameters introduced in 2002). The rate of recto-urethra fistula also dropped from 9% to 0.6% in the contemporary cohort. These results from the largest case series of salvage HIFU after radiotherapy failure confirmed the role of this energy in the management of locally recurrent prostate cancer. Such a procedure provides interesting oncologic outcomes with a relatively long-term follow-up (up to seven years) with an acceptable toxicity.

Source: Salvage HIFU for locally recurrent prostate cancer after failed radiation therapy: multi-institutional analysis of 418 patients. Crouzet et al. BJU Int, 2017, 119:896-904

Effect of electroacupuncture on urinary leakage among women with SUI Electroacupuncture involving the lumbosacral region may be effective for women with stress urinary incontinence (SUI), but evidence is limited. Thus, the investigators assessed the effect of electroacupuncture vs. sham electroacupuncture for women with SUI.

Among women with stress urinary incontinence, treatment with electroacupuncture involving the lumbosacral region, compared with sham electroacupuncture, resulted in less urine leakage after six weeks A multicenter, randomised clinical trial was conducted at 12 hospitals in China, enrolling 504 women with SUI between October 2013 and May 2015. Participants were randomly assigned (1:1) to receive 18 sessions (over six weeks) of electroacupuncture involving the lumbosacral region (n = 252) or sham electroacupuncture (n = 252) with no skin penetration on sham acupoints. The primary outcome was change from baseline to Week 6 in the amount of urine leakage, measured by the one-hour pad test. Secondary outcomes included mean 72-hour urinary incontinence episodes measured by a 72-hour bladder diary (72-hour incontinence episodes).


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Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de Among the 504 randomised participants (mean [SD] age, 55.3 [8.4] years), 482 completed the study. Mean urine leakage at baseline was 18.4 g for the electroacupuncture group and 19.1 g for the sham electroacupuncture group. Mean 72-hour incontinence episodes were 7.9 for the electroacupuncture group and 7.7 for the sham electroacupuncture group. At Week 6, the electroacupuncture group had greater decrease in mean urine leakage (-9.9 g) than the sham electroacupuncture group (-2.6 g) with a mean difference of 7.4 g (95% CI, 4.8 to 10.0; p < .001). During some time periods, the change in the mean 72-hour incontinence episodes from baseline was greater with electroacupuncture than sham electroacupuncture with between-group differences of 1.0 episode in Weeks 1 to 6 (95% CI, 0.2-1.7; p = .01), 2.0 episodes in weeks 15 to 18 (95% CI, 1.3-2.7; p < .001), and 2.1 episodes in Weeks 27 to 30 (95% CI, 1.3-2.8; p < .001). The incidence of treatment-related adverse events was 1.6% in the electroacupuncture group and 2.0% in the sham electroacupuncture group, and all events were classified as mild. Among women with stress urinary incontinence, treatment with electroacupuncture involving the lumbosacral region, compared with sham electroacupuncture, resulted in less urine leakage after six weeks. The authors concluded that further research is needed to understand long-term efficacy and the mechanism of action of this intervention.

Source: Effect of electroacupuncture on urinary leakage among women with stress urinary incontinence: A randomized clinical trial. Liu Z, Liu Y, Xu H, He L, Chen Y, Fu L, Li N, Lu Y, Su T, Sun J, Wang J, Yue Z, Zhang W, Zhao J, Zhou Z, Wu J, Zhou K, Ai Y, Zhou J, Pang R, Wang Y, Qin Z, Yan S, Li H, Luo L, Liu B. JAMA. 2017 Jun 27;317(24):2493-2501. doi: 10.1001/ jama.2017.7220.

Role of BMI in school-aged children with lower urinary tract dysfunction Lower urinary tract (LUT) dysfunction comprises a large percentage of paediatric urology referrals. Childhood obesity is a major health concern, and has been associated with voiding symptoms. The investigators assessed the impact of body mass index (BMI) on treatment outcomes of children presenting with LUT or bladder-bowel dysfunction (BBD). Children aged five to 17 years diagnosed with non-neurogenic LUT dysfunction and no prior urologic diagnoses were identified. Patient demographics including BMI, lower urinary tract symptoms, constipation, medical and psychologic comorbidities, imaging, and treatment outcomes were evaluated. BMI was normalised by age and gender according to percentiles: underweight < 5th, healthy 5th to < 85th, overweight 85th to < 95th, and obese > 95th percentile. Uni- and multivariate analyses were performed to identify predictors of treatment response.

Children with LUT dysfunction and elevated BMI are significantly less likely to experience treatment response During an 18-month period, 100 children (54 girls, 46 boys) met the inclusion criteria. The mean age at diagnosis was 7.7 ± 2.4 years, and mean length of follow-up 15.3 ± 13.1 months. Sixty-nine patients were a normal weight, 22 were overweight, and nine were obese. Fifteen percent of the children had complete treatment response, 63% partial response, and 22% non-response. On univariate analysis, children with Key articles


elevated BMI (p = 0.04) or history of urinary tract infection (p = 0.01) were statistically more likely to not respond to treatment. Controlling for all other variables, children with BMI > 85th percentile had 3.1 times (95% CI 1.11-8.64; p = 0.03) increased odds of treatment failure (Table).

association is unlikely to be causal and should not preclude the use of vasectomy as a long-term contraceptive option.

Source: The association between vasectomy and prostate cancer: A systematic review and meta-analysis. Bhindi B, Wallis CJD, Nayan M, Farrell AM, Trost LW, Hamilton RJ, Kulkarni GS, Finelli A, Fleshner NE, Boorjian SA, Karnes RJ.

BBD management includes implementation of a bowel program and timed voiding regimen, with additional treatment modalities tailored on the basis JAMA Intern Med. 2017 Jul 17. doi: 10.1001/ of the prevailing symptoms. We observed that jamainternmed.2017.2791. [Epub ahead of print] school-aged children with a BMI ≥ 85th percentile were over three times more likely to experience treatment failure when controlling for all other patient A microscopy on the scope characteristics including constipation and a history of the characterisation of the urinary tract infection. Nearly one-third of school-aged children presenting to our institution with LUT or BBD were overweight or obese when normalised for age and gender. Children with LUT dysfunction and elevated BMI are significantly less likely to experience treatment response.

Source: Role of body mass index in schoolaged children with lower urinary tract dysfunction: Does weight classification predict treatment outcome?. Arlen AM, Cooper CS, Leong T. J Pediatr Urol. 2017 Apr 25. pii: S1477-5131(17)30177-8. doi: 10.1016/j.jpurol.2017.03.033. [Epub ahead of print]

Link between vasectomy and prostate cancer Despite three decades of study, there remains the ongoing debate regarding whether vasectomy is associated with prostate cancer. The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched for studies indexed from database inception to March 21, 2017, without language restriction. Cohort, case-control, and cross-sectional studies reporting relative effect estimates for the association between vasectomy and prostate cancer were included. Two investigators performed study selection independently. Data were pooled separately by study design type using random-effects models. The primary outcome was any diagnosis of prostate cancer. Secondary outcomes were high-grade, advanced, and fatal prostate cancer. Fifty-three studies (16 cohort studies including 2,563,519 participants, 33 case-control studies including 44,536 participants, and four crosssectional studies including 12,098,221 participants) were included. Of these, seven cohort studies (44%), 26 case-control studies (79%), and all four cross-sectional studies were deemed to have a moderate to high risk of bias. Among studies deemed to have a low risk of bias, a weak association was found among cohort studies (seven studies; adjusted rate ratio, 1.05; 95% CI, 1.02-1.09; p < .001; I2 = 9%) and a similar but nonsignificant association was found among case-control studies (six studies; adjusted odds ratio, 1.06; 95% CI, 0.88-1.29; p = .54; I2 = 37%).

This review found no association between vasectomy and high-grade, advanced-stage, or fatal prostate cancer Effect estimates were further from the null when studies with a moderate to high risk of bias were included. Associations between vasectomy and high-grade prostate cancer (six studies; adjusted rate ratio, 1.03; 95% CI 0.89-1.21; p = .67; I2 = 55%), advanced prostate cancer (six studies; adjusted rate ratio, 1.08; 95% CI, 0.98-1.20; p = .11; I2 = 18%), and fatal prostate cancer (five studies; adjusted rate ratio, 1.02; 95% CI, 0.92-1.14; p = .68; I2 = 26%) were not significant (all cohort studies). Based on these data, a 0.6% (95% CI 0.3%-1.2%) absolute increase in lifetime risk of prostate cancer associated with vasectomy and a populationattributable fraction of 0.5% (95% CI 0.2%-0.9%) were calculated. This review found no association between vasectomy and high-grade, advanced-stage, or fatal prostate cancer. There was a weak association between vasectomy and any prostate cancer that was closer to the null with increasingly robust study design. This


upper tract urothelial cancer: Confocal laser endomicroscopy Conservative management of upper tract urothelial cancer (UTUC) is becoming more and more popular: the key is the correct selection of UTUC patients at low-risk UTUC based on size (≤1 cm), focality (single lesion), stage (< T2) and grade (low grade). While the first three of the above mentioned criteria can be identified at CT scan before the endourological manoeuvre, the latter is based on selected cytology and/or histology of biopsy, with results available days after surgery. Moreover, the inability to have proper tumour features during endoscopic surgery may prevent patients to receive, contextually, a treatment, if suitable for conservative management. Finally, cytology sensitivity for high-grade UTUC is around 70%, and biopsy may be inconclusive in up to 25% of the cases because of inadequate sampling or misrepresentation of the tissue taken: the former issue may be related to the small portion of tissue that can be biopsied with endoscopic forceps, whilst the latter may be related to the portion of lesion biopsied as distal papillae which may not represent the actual grade at the tumour core.

Based on their experience, the authors have suggested that the main potential of CLE employment could be the real-time treatment decision-making, especially for patients suitable to endoscopic nephrons-sparing management The confocal laser endomicroscopy (CLE, CellvizioTM) is a new 3 Fr device consisting of a probe acquiring 12 frames per second at a 150 X magnification; the system consist of a low-power laser light which reacts to fluorescein, a topical fluorescent dye, so that resolution of cellular architecture and surrounding blood supply can be augmented. The dye is previously injected locally in the ureteric lumen on the top of the lesions; than the probe can be inserted through the working channel of ureteroscopes (both semi-rigid and flexible ones) and according to predefined criteria, a dynamic microscopic characterisation of UTUC lesions can be performed just by scrolling the probe over the surface of the tumours. A disorganised structure of the cellular pattern and a dense representation of cellular nuclei, are among the main features which are represented in a high-grade UTUC. Recently, a group of researcher from Spain has tested this technology in a group of patients with clinical diagnosis of UTUC by correlating surgeon’s readings (low vs high-risk UTUC) to either final histology (in patients subsequently undergoing nephroureterectomy or segmental ureterectomy) or ureteric biopsy. They found a concordance of 100% and 83% in successfully characterised low and high-risk UTUC, respectively (Cohen’s k= 0.64). No complications were recorded intra-, peri- or post-operatively related to the technology. Based on their experience, the authors have suggested that the main potential of CLE employment could be the real-time treatment decision-making, especially for patients suitable to endoscopic

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de nephrons-sparing management. Another field of application could be the follow-up of patients initially treated conservatively to confirm suitability to this approach. A further and even more ambitious application of the technology would be the ability to detect CIS not visible with white light. On the other hand, the low number of patients recruited (only 14) could not allow for any robust recommendation: large, multi-centric series may in the future confirm preliminary impressions of the technique’s utility and eventual cost-effectiveness.

Source: Correlation between confocal laser Endomicroscopy (Cellvizio®) and histological grading of upper tract urothelial carcinoma: A step forward for a better selection of patients suitable for conservative management. Breda A, Territo A, Guttilla A, et al. Eur Urol Focus. 2017 Jun 4. pii: S2405-4569(17)30127-X. doi: 10.1016/j.euf.2017.05.008. [Epub ahead of print]

Retrograde intrarenal surgery vs. miniaturised percutaneous nephrolithotomy in lower pole renal stones < 1.5 cm Improvements of technology and techniques in endourology in the last two decades have been changing the paradigms and guidelines of the treatment modalities for renal stones. On one hand, the miniaturisation of scopes and devices, increased flexibility and better visibility have made retrograde intrarenal surgery (RIRS) progressively very popular worldwide. On the other hand, smaller and smaller nephroscopes for percutaneous nephrolithotomy (PCNL) have been introduced to combine low-risk of comorbidity with the high stone-free rate (SFR) proper of the technique. MicroPerc has been the latest of these latter technologies to have being introduced: with a 4.85 Fr outer calibre, it is the least invasive of the miniaturised PCNL, even though it only enables fragmentation of stones without the extraction of fragments. Miniaturised PCNL has been proposed as the real competitor to RIRS: comparison between microPerc and RIRS have been investigated through some systematic reviews pulling results from small cohort series; one randomised controlled trial (RCT) has also been performed. Overall, results have shown comparable pros and cons for the two techniques.

Regardless of the potential (randomisation modalities) and/or intrinsic (small sample of patients per arm) flaws, this study still provides more evidence on the indications of microPerc… Another RCT has been carried out recently focusing on the safety and efficacy of the two techniques in the setting of lower pole stones, a challenging condition for both techniques: anatomical characteristics may limit efficacy of RIRS in the case of difficult access of ureteroscopes to the targeted calyx/stone, as well as fragmentation without extraction of fragments may turn micro-Perc in just a more invasive shock wave lithotripsy and with all the limitations that this latter approach implies. In the span of 32 months, the authors recruited 60 patients with single lower pole renal stones < 15 mm, equally split in the two arms of treatment.


European Urology Today

August/September 2017

The head-to-head comparison included surgical outcomes like fluoroscopy time, operative time and hospital stay, functional outcomes, intra and post-operative complication rate, three-month SFR, and auxiliary procedure rate. In all the 60 patients, access to the targeted calyx/stone was successful. Main results included a fluoroscopy time significantly longer with microPerc and with respect to RIRS (158.48 vs. 26.58 sec, p = 0.001), as well as the mean hospital stay (54.2 vs 19 hours, p = 0.001): this latter finding is quite counter-intuitive and in contrast with previous evidence, as the significantly reduced invasiveness of microPerc should allow even a day-case management. No differences were recorded in terms of operative time, complication rate, insertion of JJ stent, drop of haemoglobin and decrease of creatinine. Threemonth SFRs with non-contrasted CT scan were also similar (83.3 vs. 86.7%, p = n.s.), but three patients of the microPerc group received a second look whilst RIRS patients with residual fragments were just followed up. Regardless of the potential (randomisation modalities) and/or intrinsic (small sample of patients per arm) flaws, this study still provides more evidence on the indications of microPerc: no superiority has been demonstrated either in terms of safety or efficacy with respect to RIRS for the treatment of renal stones, even in the subset of patients with lower pole stones < 1.5 cm. Finally, a proper cost-effectiveness evaluation is still lacking in order to really assess whether there is a future for microPerc in the management of renal stones.

On the other hand, two of the principal investigator of the SUSPEND trial argued the lack of robustness of previous systematic reviews on the basis of which MET treatment has been widely adopted, and that the results from the three -largely expected- RCTs did not find benefit of alpha-blockers in all the primary end-points (difference in stone passage rate or clinical surrogate), as well as the potential benefit in the silodosin trial for the distal ureteric stones resulted from an underpowered sub-analysis. As a consequence, the authors urged the EAU Guidelines panel to change the indication of MET for ureteric stone passage as not appropriate. In this still uncertain scenario, another group of researchers queried a group of patients in to assess their preference if offered MET in the case of ureteric stones; the patients were interviewed with a tailored questionnaire which included a description of current evidences in literature and potential side effects of alpha-blocker as well as of corticoids. During the 12 weeks of the study, 200 questionnaires from outpatient clinic were collected. Main results included that 71% of patients would have undertaken MET regardless of the current conflicting data, before considering any eventual surgical treatment option. This study, regardless of the multiple limitations, shows that with pathological (benign) condition patients may be more prompt to undertake a more conservative management even if evidence in support of the latter is conflicting. Overall, in the absence of other medical options, MET may still be considered a treatment alternative in fully informed patients who are unwilling to undertake surgery, especially in the setting of distal ureteric stones > 5 mm.

Source: A prospective randomized comparison of micropercutaneous nephrolithotomy (Microperc) and retrograde intrarenal surgery (RIRS) for the management of lower pole kidney Sources 1) Medical expulsive therapy in adults with stones. Kandemir A, Guven S, Balasar M, et al. World J Urol. 2017 Jun 6. doi: 10.1007/s00345-017ureteric colic: a multicentre, randomised, 2058-9. placebo-controlled trial. Pickard R, Starr K, MacLennan G, et al.

Medical Expulsive Therapy for ureteral stones: “Yes” party, “against” party…and “patient” party After the publication of the SUSPEND randomised placebo-controlled trial in 2015 showing no clinical benefit of alpha-blocker for the passage of ureteral stones, many discussions have argued whether this high-level of evidence was enough to overrule previous level 1 evidences, international guidelines and clinical practice consolidated worldwide. Furthermore, two large RCTs have been published with primary end-points showing –again- no overall benefit of alpha-blockers for the passage of ureteral stones. Several articles and editorials have been published by prominent experts in the main urological Journals. In the latest European Urology Focus volume dedicated to urolithiasis, main aspects of the “pro” party and “against” party have been highlighted. T. Knoll and C. Turk -from the EAU Guidelines Office- pointed out the potential weakness of the SUSPEND trial, such as the lack of imaging at a definite time-point of follow-up to assess efficacy of medical expulsive therapy (MET) or the large number of patients (75%) with small (≤ 5 mm) ureteric stones which are expected to pass spontaneously in a high rate. They also highlighted the benefit of silodosin in a subgroup of patients with stones in the distal ureter in the relevant RCT.

This study, regardless of the multiple limitations, shows that with pathological (benign) condition patients may be more prompt to undertake a more conservative management even if evidence in support of the latter is conflicting

Lancet. 2015 Jul 25;386(9991):341-9. doi: 10.1016/ S0140-6736(15)60933-3. Epub 2015 May 18.

2) Silodosin to facilitate passage of ureteral stones: a multi-institutional, randomized, double-blinded, placebo-controlled trial. Sur RL, Shore N, L'Esperance J, et al. Eur Urol. 2015 May;67(5):959-64. doi: 10.1016/j. eururo.2014.10.049. Epub 2014 Nov 20.

The NCDB is a national cancer registry established in 1989 and captures approximately 70% of all newly diagnosed cancer cases from >1500 Commission on cancer-accredited cancer programmes across USA and Puerto Rico. Patients diagnosed with AJCC stage II–III urothelial carcinoma of the bladder between 2004 to 2013 were identified. Patients undergoing BPT were stratified as having received any external-beam radiotherapy (any XRT), definitive XRT (50-80 Gy) and definitive XRT with chemotherapy (CRT). Multivariate logistic regression was used to assess the association between receipt of definitive XRT with chemotherapy and patient/tumour factors including age, sex, race, ethnicity, payer group, income quartile, education, urban/rural location, facility volume (in tertiles) histologic type and tumour grade. OS was defined as time to death or loss to follow-up was compared between RC and each BPT cohort.

The current study results must be assessed, understanding the challenges of using retrospective administrative databases 32,300 patients with stage II-III urothelial carcinoma and survival data were identified. Radical cystectomy was performed in 22,680 patients, of which just 14% had neoadjuvant chemotherapy) whilst 2,540 patients had definitive XRT of which 1,489 had CRT. RC patients were more likely to be younger, to have less comorbidities, but also to have stage III disease. Over the study period there was a steady increase in the number of patients undergoing CRT (p = 0.0011). Improved OS was observed for propensity score matched patients undergoing RC (3-yr OS = 58.5%, 5-yr OS = 48.3%) when compared to patients having Definitive XRT plus chemotherapy (3-yr OS = 43.6%, 5-yr OS = 29.9%) (HR 1.4, CI 1.235-1.6, p < 0.0001). The current study results must be assessed, understanding the challenges of using retrospective administrative databases. However, until a randomised prospective trial is available patients will need to be counselled using well-designed observational studies such as this.

Source: Contemporary use trends and survival outcomes in patients undergoing radical cystectomy or bladder-preservation therapy for muscle invasive bladder cancer. Cahn DB, Handorf EA, Ghiraldi EM, et al.

3) Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Cancer. 2017; http://dx.doi.org/10.1002/cncr.30900. Multicenter Trial. Furyk JS, Chu K, Banks C, et al. Ann Emerg Med. 2016 Jan;67(1):86-95.e2. doi: 10.1016/j. annemergmed.2015.06.001. Epub 2015 Jul 17.

4) The Role of Medical Expulsive Therapy for Ureteral Stones: Pro MET. Against MET. Eur Urol Focus. 2017 Feb;3(1):3-6. doi: 10.1016/j. euf.2017.01.002. Epub 2017 Jan 20.

5) A survey of patient preferences regarding medical expulsive therapy following the SUSPEND trial. Bell JR, Penniston KL, Best SL, Nakada SY. Can J. Urol. 2017 Jun;24(3):8827-8831.

Survival outcome in muscle invasive bladder cancer: Cystectomy versus bladder preservation

Making decisions with Decipher Randomised trials have demonstrated a progressionfree survival benefit for adjuvant radiotherapy (ART) after radical prostatectomy for men with extracapsular extension, seminal vesicle invasion or a positive surgical margin. However, the impact on overall survival is less clear. Moreover, radiotherapy early after surgery may arrest the return of sexual and urinary function and impose new bowel related-side effects. As a consequence many urologists delay radiotherapy and might welcome a biomarker to inform clinical decision-making. The Decipher test is a genomic classifier that predicts the five-year risk of clinical metastases after radical prostatectomy. Decipher evaluates the activity of

genes in the tumour that have been shown to be involved in the progression of prostate cancer. This paper assessed the recommended management from the treating provider, as well as patient and provider decision effectiveness before and after viewing the results of a Decipher test. Men who had prostate cancer previously treated with radical prostatectomy and being considered for either adjuvant (150) or salvage radiotherapy (SRT) (115) received Decipher testing. This report is to compare the treatment recommendations without the Decipher test results (visit 1) with those made after reviewing the Decipher test results (visit 2). This change in treatment recommendation is measured from observation to any treatment and vice versa or from a treatment to a higher magnitude treatment (e.g., RT to RT with ADT). Decision effectiveness was assessed using the Decisional Conflict Scale (DCS) for each patient-provider pair and prostate cancer-specific anxiety assessed using the Memorial Anxiety Scale for Prostate Cancer (MAX-PC).

Use of a genomic test that delineates a patient’s risk of clinical metastasis after radical prostatectomy led to changes in treatment recommendations. It reduced but did not eliminate decisional uncertainty…. Before the Decipher test, observation was recommended for 89% of patients considering ART and 58% of patients considering SRT. After Decipher testing, 18% (95% confidence interval [95% CI], 12%-25%) of treatment recommendations changed in the ART arm, including 31% among high-risk patients; and 32% (95% CI, 24%- 42%) of management recommendations changed in the salvage arm, including 56% among high-risk patients. Decisional Conflict Scale (DCS) scores were better after viewing Decipher test results (ART arm: median DCS before Decipher, 25 and after Decipher, 19 [p < .001]; SRT arm: median DCS before Decipher, 27 and after Decipher, 23 [p < .001]). PCa-specific anxiety changed after Decipher testing; fear of PCa disease recurrence in the ART arm (p = 0.02) and PCa-specific anxiety in the SRT arm (p = 0.05) decreased significantly among low-risk patients. Decipher results reported per 5% increase in five-year metastasis probability were associated with the decision to pursue ART (odds ratio, 1.48; 95% CI, 1.19-1.85) and SRT (odds ratio, 1.41; 95% CI, 1.09-1.81) in multivariable logistic regression analysis. Use of a genomic test that delineates a patient’s risk of clinical metastasis after radical prostatectomy led to changes in treatment recommendations. It reduced but did not eliminate decisional uncertainty and as such additional decision aids may be required to clarify which patients are optimally selected for observation.

Source: Decipher test impacts decision making among patients considering adjuvant and salvage treatment after radical prostatectomy: Interim results from the multicentre prospective PRO-IMPACT study. Gore JL, du Plessis M, Santiago-Jimenez M et al. Cancer. 2017; 123: 2850-9.

Bladder cancer accounts for about 5% of all new cancers in the western world and is the fourth most common cancer in men. Between 20 and 30% of patients are diagnosed with muscle-invasive disease which carries a 24-month overall survival (OS) without treatment. The current standard of care is neoadjuvant chemotherapy followed by radical cystectomy (RC) including lymphadenectomy.

However, this treatment is associated with significant procedure-related morbidity. Trimodal bladder preservation therapy (BPT) with maximal TURBT, chemotherapy and radiotherapy is an alternative option, which aims to maintain the patients native bladder, with a smaller effect on quality of life. There are no large randomised trials to compare the outcomes of these different treatment options so this paper uses a large national tumour registry to examine trends in the As a consequence, the authors still recommend the use of BPT and compare survival outcomes of patients with stage II and III urothelial carcinoma use of alpha-blockers, especially in the subset of distal ureteric stones > 5 mm, as reflected in the latest attempting to adjust for measurable difference edition of EAU Guidelines on Urolithiasis. between the treatment groups.

European Urological Scholarship Programme (EUSP) Do not forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme, before the next deadline of 1 January 2018! For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website http://www.uroweb.org/education/scholarship/

Key articles

August/September 2017

European Urology Today


• What do you think is the biggest challenge in urology? On the individual level for doctors, communication with patients can be quite a challenge. In general, the healthcare system is burdened with obstacles and doctors and the work that we need to do are affected. • If you were not a urologist, what would you be? I have always wanted to be a doctor and urology is very multi-faceted. The speciality is challenging due to its scope. But if I would have to start all over again maybe I would have gone into foreign studies and languages. • What is your most important piece of advice for doctors just starting out? That would be to broaden their perspective and expand one’s views. By looking at a problem through different viewpoints or a diversity of opinions, one can find creative solutions. • What is the most rewarding aspect of being a doctor? When you see that the patient trusts you and you find the right words for them in very difficult situations. It’s also a special experience to have a crucial role in their treatment and help them face the crisis of being sick. • What is your advice to other physicians on how to avoid burnout? That’s a tough question. Burnout is caused by many underlying reasons especially for young doctors. It is important to first look at the underlying problem and solve it. In my case, taking a break with my non-medical friends and engaging in sports help. • If you could change something in the healthcare system, what would it be? I would love to have less paperwork and instead have more time for patients. A commercialised system does not benefit anybody. Documentation of course is needed but there has to be a balance. • What´s the last wonderful book you have read? It’s a long time ago I’ve read a book or a novel. Mostly I read books on medicine. But I like watching films and have seen a lot of Quentin Tarantino films. He always has brilliant actors. • What do you most often wish you could say to patients, but didn’t? I wish I could tell them I have all the time they need. Every doctor I guess would like to tell their patients that they have a cure, but that, of course, is rare. Patients need more of our time but we can’t just give it. • What’s the last thing that surprised you? The election of Trump in the US was a surprise but not in a good way (laughs).

TEN QUESTIONS Interview and Photography by Joel Vega

• What’s your favourite hour in a day and why? The evenings or the last hours of the day… I always have a difficult start in the early hours and I like sleeping longer in the mornings. Age: 33 Specialty: Uro-oncology City: Muenster (DE) Current Posts: EAU17 Congress Winner, Best Paper on Clinical Research; UKM Universitätsklinikum Münster, Dept. of Urology


NEW! Awareness Campaign for Urology

WEEK 2017

These new Urology Week 2017 awareness campaign posters were created to inform the public and encourage them to visit a urologist, whether to seek treatment for urological conditions or to prevent them by asking about symptoms to watch out for.


European Prostate Cancer Awareness Day 27 September 2017

Urology Week is an initiative of the European Association of Urology, which brings together national urological societies, urology practitioners, urology nurses and patient groups to create awareness of urological conditions among the general public.

Step up! Join the campaign! 1. Reach out to your community and spread the word. 2. Organise an event and register it at www.urologyweek.org. Big or small, every effort counts! 3. Share your stories via social media and remember to use the hashtag #urologyweek.

European Prostate Cancer Awareness Day 4. Join27 the Thunderclap campaign in September 2017

European Urology Today

Give us one good reason not to get checked out!

You don't have to lose sleep over your prostate!

Don't settle for discomfort! loved ones, your urological life and to spend quality time with When your main priority is to enjoy of prostate cancer. Ask now to know more about the prevention health becomes priority, too. Start source. Talk to a Urologist. your questions direct from a trusted



About 1 in 7 men will be diagnosed with prostate cancer (PCa) during his lifetime. It’s understandable why this statistic might worry you. But you can do something about it. When you learn more about your prostate, you help prevent the onset of PCa. Be informed. Talk to a Urologist.



Do you lose urine when you cough, sneeze, go for a run, or even when you’re just lifting groceries? Do you have the sudden urge to go to the restroom and can’t really hold it in? If you’ve said “yes” to either question, you might have urinary incontinence (UI). It’s not easy to talk about it. But there is nothing to be embarrassed about, millions worldwide are affected by UI. Don’t wait any longer. Visit a Urologist.



Go viral!

September. 5. Download campaign materials or use the Urology Week poster in this EUT issue.

Created your own educational posters on urological health for Urology Week 2017? Seen an informative video on prostate cancer awareness? Discovered a new, creative campaign on urinary incontinence? Or read an interesting article on bladder cancer?

Let’s do this together!

Let us know! We’d love to share and retweet it on our social media channels. Let’s make it viral!

For more information and inspiration, go to www.urologyweek.org


Feel free to download these and post them at the office, in your clinic or wherever they could grab attention. And if you would like to have these posters in your language, please let us know and we’ll make them for you! Send us your request and translated text via communications@uroweb.org.



August/September 2017

Tumour ablation therapy: Its advantages With development of focal therapy, ablative therapy gains more attention Dr. Eric Barret Chair ESUT Ablative group Dept. of Urology Institut Montsouris Paris (FR)

eric.barret@imm.fr There has been a growing interest for quite some time in the new minimally invasive ablative therapy (AT) for the treatment of kidney and prostate cancer (PCa). The principle of this therapy is based on using an energy source delivered under imaging guidance for the ablation of a targeted tissue, with a combined objective of optimal effectiveness and minimal risks of complications1.

To qualify for a trial, the patient's characteristics would include: a PSA < 15 ng/ml, a clinical stage T1c–T2a, a Gleason score of 3 + 3 or 3 + 4 (Group 1 or 2), a life expectancy of > 10 years and any prostate volume, as defined by a recent international multidisciplinary panel3.

Radiotherapy (Cyberknife, brachytherapy): Variants of radiotherapy such as Cyberknife or brachytherapy could be considered for FT of localised PCa. During radiotherapy procedures, the multiple ionisations induced via the Compton Effect cause DNA damage, cell cycle arrest and ultimately cell death.

The possibility of preserving both urinary and sexual functions is an important reason for choosing FT over other whole gland treatments. The strategy will depend on the multiparametric MRI data and the prostate biopsy results. Depending upon the volume and location of the tumour, many treatment modalities are possible (ultra-targeted ablation, a lumpectomy, a hemi-ablation or a sub-total ablation) and, once decided upon, in most cases the energy will be then delivered under ultra sound guidance4.

Focal laser ablation (FLA) is defined as the thermal destruction of tissue by the photothermaI effect of a laser. The thermal action results from the absorption of radiant energy by tissue-receptive chromophores inducing heat energy in a very short time. Due to the weak absorption by water or haemoglobin, wavelengths in the infrared spectra (700–1064 nm) are traditionally used to effect a deeper penetration of the tissue. The intraprostatic laser fibre insertion is achieved through transperineal approach using a brachytherapy template under TRUS or MR guidance.

oncological outcomes are promising with a median rate of significant residual disease within the treated area at the control biopsy ranging from 0% to 13.4% at one-year follow-up (4). The ESUT Ablative Group The ESUT Ablative Group is composed of expert members working together in the field of the Ablative Therapy for the purpose of ensuring a better understanding of AT and providing an adequate training for an optimal patient care.

Within this work group, we write review articles on the different aspects of AT. For urologists who want to learn more about this approach, we have also organised a masterclass on FT for localised prostate cancer that provides a comprehensive review of the rationale for FT and the modalities of patient selection and treatment. Hands-on training is featured and live After the specific limitations and complication profile surgery is performed to illustrate the theoretical of the patient's prostate have been determined, various Photodynamic therapy (PDT) is based on the activation educational programme. The 2nd ESU-ESUT-ESUI energy sources are currently available to ablate the Masterclass on Focal Therapy for Localised Prostate prostatic tissue, which is why we recommend an “a la of a photosensitiser (PS) administrated intravenously Over the past several decades, AT such as and which is activated by using a laser with a specific Cancer will take place in Paris later this year on 7 and radiofrequency ablation (RFA) and cryoablation (CA) carte” approach, and the one chosen will depend 8 December. wavelength in the presence of oxygen. The light were used to ablate kidney cancer as an alternative to a exclusively on the tumour location within the gland5. moves the PS into a higher energy state, which is then partial nephrectomy (PN), especially in elderly patients released from the activated PS in different ways. This References The several energy sources to treat PCa6 include: with severe comorbidities. Several authors reported therapy induces cell death by necrosis and/or High-intensity focused ultrasounds (HIFU) which is a that PN and percutaneous AT for small (< 7 cm) renal 1. Ahmed M, Brace CL, Lee FT Jr, Goldberg SN. Principles of apoptosis, and causes the destruction of the tumour masses are associated with similar rates of local trans-rectal approach producing ultrasound waves and advances in percutaneous ablation. Radiology. 2011 vasculature and produces an acute inflammatory generated by a spherical transducer. The ultrasonic recurrence and a decreased morbidity in favour of AT2. Feb; 258(2): 351-69. response. energy is focused on a fixed point. HIFU allows 2. Thompson RH, Atwell T, Schmit G, Lohse CM, Kurup AN, With the development of Focal Therapy (FT) for depositing a large amount of energy into the tissue, Weisbrod A, Psutka SP, Stewart SB, Callstrom MR, Irreversible electroporation (IRE) corresponds to a localised PCa, AT has recently gained in popularity. The which results in its destruction through cellular Cheville JC, Boorjian SA, Leibovich BC. Comparison of non-thermal ablation modality that uses electric main objective of this technique is to combine a disruption and coagulative necrosis in the targeted Partial Nephrectomy and Percutaneous Ablation for cT1 pulses to create irreversible pores in the cell minimal morbidity with satisfactory cancer control as area while preserving the surrounding tissue. Two Renal Masses. Eur Urol. 2015 Feb; 67(2): 252-9. membrane, thereby causing cell death. Electrical well as to maintain the possibility of re-treatment. If the mechanisms of tissue damage occur with HIFU: 3. Tay KJ, Scheltema MJ, Ahmed HU, Barret E, Coleman JA, disruption of the cell membranes in the target area is target tissue can be accurately identified, FT could be thermal and cavitation effects. Dominguez-Escrig J, Ghai S, Huang J, Jones JS, Klotz LH, generated by local application of repetitive heavy an ideal method of treatment for low or intermediate Robertson CN, Sanchez-Salas R, Scionti S, Sivaraman A, current pulses via electrodes placed transperineally. Cryotherapy consists of the cellular destruction of risk localised small-volume cancer. However, because de la Rosette J, Polascik TJ. Patient selection for prostate The number of needles used is directly correlated to of a lack of validated data, EAU Guidelines has tissue through freezing. The cellular damage caused focal therapy in the era of active surveillance: an determined that FT “cannot be recommended as a can vary including direct (membranes disruption) and the tumour size. International Delphi Consensus Project. Prostate Cancer therapeutic option outside clinical trials”. indirect effects (ischemia and coagulative necrosis). Prostatic Dis. 2017, In Press. Whatever the energy is being used, FT for PCa is Cryotherapy is feasible by the insertion of interstitial needles using a transperineal approach under image feasible with an acceptable morbidity and a low References 4, 5 and 6 are available on request at EAU Section of Uro-Technology (ESUT) complication rate ranging from 0 to 17%. The early guidance. eut@uroweb.org.

Education Online


Improve your skills: e-learning at your own convenience

2nd ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer

New EAU Education Online course:


7-8 December 2017, Paris, France An application has been made to the EACCME® for CME accreditation of this event

Introduction to Upper urinary tract endoscopy for stones New E-Course This course is a new e-learning activity from the EAU’s European School of Urology in collaboration with the EAU Sections of Urolithiasis and Uro-Technology. The course allows participants to develop skills and gain practical insights on urolithiasis. It was developed as part of the training programme in ureteroscopic diagnostic and therapeutic surgery.


August/September 2017

An application has been made to the EACCME® for CME accreditation of E-Learning Material (ELM)

European Urology Today


Annual Slovak Urological Society Conference ˇ Trencianské Teplice hosts 24th congress Assoc. Prof. Ivan Mincík Chairman, Dept of Urology President, Slovak Urological Society Prešov (SK)

procedures, and minimally invasive surgery. There were nearly a hundred lectures divided into eight sections, six sponsored symposia and an ESU course.

Among the distinguished guest speakers was Prof. James N´Dow, Chairman of the EAU Guidelines. He delivered a very interesting lecture titled ”Conflict of Evidence - How the EAU Guidelines can improve your practice.” In Europe this is an important topic since mincik@ there is a need to unify levels of urological care across fnsppresov.sk the region. Prof. Shahrokh Shariat presented the EAU Lecture on “Upper urinary tract urothelial cancer The 24th Annual conference of the Slovak Urological Diagnosis and Treatment. Prof. Shariat gave an Society (SUS) took place last June 7 to 9 in the overview on current treatment status for patients with Slovakian spa city of Trencianské Teplice, known since this aggressive oncological disease and highlighted the 14th century for its historical legacy, natural that the main aim of therapy is surgical access, which environment and spa facilities. could be conservative in small papillary lesions. He stressed that open and minimally invasive procedures The Scientific Programme, prepared by the SUS Board, have the same oncological results with regards small included the electronic posters with the abstract papillary UTUC. Renowned speakers also presented presenters given three minutes followed by a short the latest findings such as Dr. Matoušková who discussion. This streamlined structure of the Scientific delivered the CUS lecture regarding immunotherapy Programme allowed sufficient time for all planned in managing bladder tumours. sections. The main topics were onco-urology, functional urology, laparoscopic surgery, endourological Young Slovak and Czech urologists presented their lectures, discussing topics such as “Proximal ureterolithiasis management - grey zone of guidelines

The Slovak Urological Society awarded Prof. Ján Dvorácek with the highest honour, the Professor Vladimír Zvara Medal. From left: SUS president Assoc. Prof. I. Mincík, Prof. J. Dvorácek and Prof. J. Švihra, scientific secretary

Prof. Piotr L. Chlosta presented his lecture titled “Bladder cancer minimally invasive surgery: reality or mirage?”

ESU Course speaker Prof. Verze (Napoli, IT) receives a special gift of appreciation from conference president Dr. Roman Sokol. The t-shirt was autographed by the famous Slovak football player, one of FC Napoli’s best players.

Dynamic discussions during the ESU course with Prof. Kocvara from the Czech Republic giving his comments

(Tomáš Hradec, Prague) and from the Slovak Urological Society Dr. Kubas Banska (Bystrica) discussed minimally invasive partial nephrectomy for renal cell carcinoma. As in previous years, Czech urologists actively participated. We also welcomed the representatives of the Polish, Hungarian and Austrian urological societies. Well-attended ESU Course The well-attended ESU course has been prepared in collaboration with the EAU. Prof. P. Verze (Naples, IT) and Prof. Margreiter (Vienna, AT) presented five comprehensive lectures on current andrology topics followed by case presentations and discussions. Prof. P. Verze clearly summarized the EAU guidelines recommendations on erectile dysfunction and premature ejaculation. He emphasised the influence of life-style and modifiable risk factors on erectile dysfunction, as well as the interventions that may improve erectile function. Prof. Margreiter discussed the current status and future perspectives of medical treatment of erectile dysfunction. He focused on

Prof. James N´Dow, Chairmen of EAU Guidelines, discusses the benefits of EAU Guidelines for daily urological work

non-PDE5 inhibitors agents, which are targeted on alternative pathways in the erectile process. This comprehensive and insightful ESU course provided as the opportunity to compare our diagnostic and treatment procedures with the latest evidencebased medicine data presented by expert speakers. The 24th Annual SUS Conference gathered around 410 registered participants, including 280 urologists and 130 nurses.

ESU Course in Kirgizstan Insights on BPH, PCa and chronic pelvic pain Dr. Cosimo De Nunzio Division of Urology, Sant’ Andrea Hospital Sapienza University Dept. of Urology Rome (IT)

on the aforementioned topics and led an interesting discussion. They also highlighted the unmet urological needs in the country, the need to adapt international guidelines within the context of local practice and the available urological technology, whilst understanding the experience and best practices in other countries.

cosimodenunzio@ virgilio.it

The participants responded positively to the ESU course, while as faculty members we had the opportunity to meet colleagues and enjoy the social programme. We saw the beautiful countryside such as the Issyk-Kul Lake in the northern Tian Shan mountains in eastern Kyrgyzstan. We had a taste of the local food including the kymyz or horse’ milk. We also participated in a game of Buzkashi, a Central Asian sport where horse-mounted players attempt to place a goat carcass in a goal. It was certainly a unique experience!

For the first time the European School of Urology (ESU) organized a course in Kirgizstan during the National Congress of the Kirgizstan Society of Urology which took place in Cholpon Ata from June 29 to July 1 this year. There were more than 150 participants from several countries in the region (Russia, Georgia, China, Kazakistan and Uzbekistan). The programme, besides general urology, included several lectures on uro-oncology and therapeutic treatments of urological malignant and benign diseases. Among the participants was Prof. Bob Djavan who discussed the potentials of urological practice in Kirgizstan. He also mentioned that a Central Asia Congress of Urology will help better define the unmet needs in the region.

The ESU course was a success, thanks to the efforts of the local organizing committee and, in particular, the work done by Associate Prof. Khakimkhodzhaev and his staff who carefully arranged for our visit. And our thanks to Ms. Claudia Van IJzendoorn of the EAU Central Office who gave wonderful support not only during the preparation but throughout the whole process.

A day was dedicated to the ESU course in which issues in managing benign prostate hyperplasia (BPH), prostate cancer and chronic pelvic pain were discussed. Regarding prostate cancer (PCa), topics included investigational risk factors, new imaging modalities for PCa diagnosis and innovation in hormonal and chemotherapy treatments. The second part focused on updates and current evidence on LUTS/BPH diagnosis and medical treatment, as well as a thorough evaluation of the standard and investigational treatments for chronic pelvic pain. Participating as ESU faculty members were Dr. Roderick Van Den Bergh (NL), Dr. Rui Almeida Pinto (PT) and the author. They presented their experience 14

European Urology Today

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

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


Surgery in Motion School is a collaboration of

Participants and faculty members of the ESU course

August/September 2017

1st ESU-ESUT Masterclass on Urolithiasis Masterclass provides advanced theoretical and practical knowledge Dr. Iason Kyriazis Fellow of Endourology University of Patras Patras (GR)

jkyriazis@gmail.com Under the collaboration of the European School of Urology (ESU) and the EAU Section of Uro-Technology (ESUT), the first ESU-ESUT Masterclass on Urolithiasis took place on June 16 to 17 this year at the University of Patras in Greece. Around 40 urologists and leading experts participated in the two-day masterclass which aimed to deliver advanced theoretical and practical knowledge in managing stone disease. The masterclass offered highly-informative theoretical courses as well as debates on the pathophysiology, diagnosis and conservative treatment of lithiasis, and extracorporeal and interventional management options which covered all established variations of retrograde and antegrade approaches. To further enhance the educational value of the masterclass, several live surgery operations were performed by renowned experts at the University Hospital of Patras and broadcasted live to the conference centre. Live surgery events included an endoscopic combined intrarenal surgery operation performed in supine position by Prof. A. Skolarikos (Athens, GR) and Dr. C. Scoffone (Torino, IT); a fluoroscopic-guided prone percutaneous nephrolithotripsy case performed by Prof. E. Liatsikos (Patras, GR); a single use flexible ureteroscopic lithotripsy case performed by Dr. O. Wiseman (Cambridge, UK); and a retrograde intrarenal surgery

operation using a high power holmium laser performed by Prof. O. Traxer (Paris, FR). In addition, several important tips and tricks on stone surgery were demonstrated in pre-recorded videos. Prof. C. Seitz (Vienna, AT) presented a case of semi-rigid ureteroscopic lithotripsy, Prof. A. Papatsoris (Athens, GR) a case of a large bladder stone operated by a high power Holmium laser, and Prof. T. Knoll (Sindelfingen, DE) presented a percutaneous nephrolithotripsy case using mini-percutaneous instruments. The programme also offered an extensive hands-on training course using various simulators that provides exercises on many aspects of stone surgery, such as single and multi-use flexible ureteroscopy navigation, ureteroscopy and percutaneous access establishment, ureteral basket handling using flexible instruments and laser use in bladder, ureteric and kidney stones.

"Participating in a quality masterclass to improve skills is invaluable!" At the end of the course, panel experts shared their experience during an interactive roundtable on ureteroscopic and percutaneous surgery complications and troubleshooting. Prior to that, video demonstrations of common and rare perioperative adverse events were also presented. The response from the participants was enthusiastic and the general opinion was that this first ESU-ESUT masterclass provided a great training opportunity to all attending urologists who are specialized on stone disease. Following the success of this event, the second urolithiasis masterclass is planned on June 22 to 23 June next year.


2nd ESU-ESUT Masterclass on Urolithiasis 22-23 June 2018, Patras, Greece An application has been made to the EACCME® for CME accreditation of this event

Application open from 1 October 2017

August/September 2017

Comments of participants Dr. Wally Mahfouz (Egypt) I had the pleasure to attend this excellent masterclass led by some of Europe’s top endourology experts. It was a compact, wellorganised, two-day course that examined recent advances in endourology. There were open and interactive sessions that involved the faculty members and the participants. The faculty gave tips and tricks in a simplified and straightforward manner. Hands-on training (four hours) on flexible URS and lasers was carefully supervised by the mentors who were very helpful. The trainees were also mentored based on their skills level. Thanks a lot to the organizers and to the faculty members. I would definitely recommend this masterclass to those who are interested in endourology. Dr. Sebastián Valverde Martínez (Spain) The masterclass was an excellent opportunity to received guidance from experts who gave the latest developments in urolithiasis and updates on current technology. The lecturers have not only provided important tips for clinical and surgical practices but also presented complex clinical cases. We learned insights on various topics such as trouble-shooting and management of complications.

retrograde intra-renal surgery (C. Seitz, AT) and ESWL (A. Papatsoris, GR). An introduction was presented regarding the new Moses LASER effect mainly when treating bladder stones. This technique allows a reduction of the retropulsion phenomenon during stone fragmentation. A. Breda (ES) described semi-rigid ureteroscopy (Breda A., Barcelona) highlighting how to manage very specific and challenging situations such as re-implanted ureters. C. Seitz (AT) and O. Traxer took up optimisation of LASER settings to obtain dusting, fragmentation or pop-corn effect while recognizing some features and nature of the stones. The debate on the use or non-use of the access sheath (T. Knoll, DE) was very interesting and was supported by consistent data. The concluding statement favoured the use of the access sheath to reduce the intrarenal pressure. Bladder stones treatment and mini-micro PCNL surgery were covered in the presentations by A. Papatsoris and T. Knoll.

The half-day hands-on training provided the opportunity for the trainees to try several LASE machine and scopes including the Moses. The concluding session included an overview on how to perform the step-by-step procedures, plus tips and trips from the experts. This was followed by the Dr. Peter De Bruyne (Belgium) The masterclass was a great success as it delivered presentation on single- use scope by O. Wiseman who highlighted the potential advantage of the a wealth of information on the different aspects of single-use scope in terms of infection control and stone disease and management. What also made possible cost reduction. Data on PCNL and flexible this course valuable was its clinical relevance. ureteroscopy were presented with regards <2 cm> Moreover, the tutors focused and gave perceptive reviews on theoretical knowledge that matter to our stone for a comparison of the successful rate and number of surgical sessions required for the two patients. This is an excellent course that is not to procedures. The last session took up complications miss. Thank you to the organisers. management with clinical cases discussion and the final closing remarks by the faculty members. Dr. Ioannis Leotsakos (Greece) My gratitude to the staff for their professional work Definitely, this is a masterclass not to be missed by urologists! in the masterclass and a special word of appreciation to Prof. Liatsikos for his hospitality. The Dr. Kiran Jang Kunwar (Nepal) masterclass offered the opportunity to examine The masterclass is a wonderful learning experience interesting topics and learn from the experts. The regarding recent advancements in managing event was efficiently organised and the scientific urolithiasis. The enthusiastic discussion among the programme was comprehensive. Participating in a quality masterclass to improve skills is invaluable! I faculty and participants made this meeting more relaxed. An educational program like this will be look forward to another chance to participate. very beneficial for young urologists since the expert guidance that was available helps in identifying Dr. Dejan Simic (Serbia) I highly appreciate the opportunity to attend the 1st modern approaches in diagnosis and treatment. ESU-ESUT Masterclass on Urolithiasis. Aside from The tutorials on urolithiasis included dedicated the fact that it was a well-organized meeting, my lectures by experts, live surgeries and hands-on experience benefited my everyday practice. The topics were carefully selected and useful for clinical training. The major highlight of this masterclass is the guidance provided by experts such as the practice. I also appreciate the practical hands-on distinguished faculty members, namely: Professors training, and the skills I learned were very useful. Olivier Traxer, Evangelos Liatsikos, Thomas Knoll, Once again, thank you for the opportunity to participate, gain knowledge, and I hope to take part Alberto Breda and Christian Seitz and many more. again in similar courses in the future. As the only non-European participant, I greatly appreciate my participation in this masterclass and Dr. Michela Pisani (Italy) would like to thank the EAU, the European School The masterclass provided an in-depth look into of Urology and the ESUT for the opportunity. I also stone’s disease and the major issues were all thank by Prof. Liatsikos for his encouragement for well-articulated in sessions that focused on me to join as a short-term trainee in his institution diagnosis, metabolic assessment, surgical in the future. treatment, and complemented by live-surgery sessions and hands-on training. Dr. Alexei Plesacov (Moldova) It was a great event, full of valuable information Updates on diagnosis and radiological features which can help in everyday practice. Tips and tricks were presented by A. Papatsoris (GR) followed by were given during the live and semi-live surgeries, metabolic assessment of the stones with O. Traxer and these tips have practical use which is usually (FR) emphasising the importance of performing stone analysis besides routine blood and urine tests not found in books. Thank you for organising this meeting. to address more specific and individualised treatments, particularly in conditions such as hyperoxaluria and hypercalciuria. The first live surgery session was on supine ECIRS procedure dome C. Scoffone (IT), which prompted a discussion on two different approaches - papillary versus supine non-papillary PCNL. A live surgery was also conducted with enthusiastic commentary from the audience. There were also tips and tricks from the experts on how to perform a successful Participants at the 1st ESU-ESUT Masterclass on Urolithiasis PCNL (O. Wiseman, UK),

European Urology Today


ESU – Weill Cornell Masterclass in Urology A joint seminar diary Dr. Veronika Šturcová Kaliská Charles University 2nd Faculty of Medicine Motol University Hospital Dept. of Urology

Prague (CZ) veronikakaliska@ yahoo.com

Sunday, July 9 Although I was tired after the long trip to Salzburg I took the public transport instead of a taxi knowing the bus would take me through the beautiful city centre on the way to the castle. Finally, the iron gate of wonderful Schloss Arenberg came into view. The reception staff was very friendly and helpful. My single room was comfortably equipped and offered a lovely view of the green Würth sculpture garden. At 7 pm we all met for the evening welcome drink with the faculty member. We were also introduced to the other participants. After the dinner, most of us spent the rest of the evening pleasantly chatting in the lounge before we called it a night in the late hours. It is going to be a long day tomorrow. Monday, July 10 The first day started with a 30-minute pre-seminar test, which covered the entire scope of seminar themes. We will take the same test again for reference at the end of the week. The theme of the day was prostate cancer. Dr. Walz talked about the role of imaging in the diagnostics, active surveillance and treatment of prostate cancer. He mentioned the indication for MRI-targeted biopsy

of patients with prior negative biopsy. Prof. Barbieri discussed risk stratification, patient evaluation and new biomarkers. The coffee break is essential for our brains, so after short refreshment we were ready for radical prostatectomy with Prof. Scherr and his tips and tricks for nerve-sparing surgery enriched with techniques for optimising the return of continence. In my opinion, it was a perfect presentation and very helpful. The rest of the lectures were dedicated to treatment of locally advanced as well as metastatic cancer. After a delicious lunch, we continued with the first group of case presentations by seminar fellows. We all engaged in very fruitful discussions and - as we were all coming from different countries - many cases are really unique and interesting such as a case of echinococcus bladder cyst. After the wrap-up of the presentation session, some of us went for a short walk around Salzburg. After the dinner we met again in the lounge for a couple of drinks and conversation. Tuesday, July 11 Urinary tract infections day. The morning session with Dr. Grabe was focused on the new EAU guidelines classification of UTI and sepsis followed by investigation possibilities. One of the slides surprised me. Does each of our bodies really contain 2.5 kilograms of bacteria? Interesting idea. Prof. Aulitzky talked about the impact of urogenital infection on male fertility and described several methods of sperm retrieval techniques used in treating an infertile couple, including microsurgical repair of iatrogenic injury of the vas. Nowadays, a highly pressing topic, since nearly 20% of couples has difficulty conceiving. After the coffee break, we discussed UTI, its management and the importance of rational antimicrobial prophylaxis.


3rd ESU-ESUT Masterclass on Operative management of benign prostatic obstruction

After a well-deserved lunch and discussions over a cup of coffee, we continued with the second part of case reports presented by participants, which was followed by another intensive and enthusiastic discussion. During my free time, I went to the train station to buy a return ticket to Prague. I cannot help but admire Salzburg with its picturesque narrow streets lined with small shops and cafes. The rainy weather made us sleepy so after dinner I went to bed early.

Dr. Artur Leminski Pomeranian Medical University Szczecin (PO)

artur.leminski@ gmail.com Wednesday, July 12 After a nourishing breakfast we started the day dedicated to urolithiasis. It’s hard to believe we’re almost half way through, but everyone stays on alert even though the evening lasted quite long. We began with prof. Oliver Traxer’s (FR) lecture on lasers in the treatment of urinary stones. Everyone was impressed with his profound understanding of lasers, and found his lecture (and visuals!) very informative. Dr. Richard Lee (Weill Cornell, NY, USA) gave updates on the evolution of percutaneous nephrolitotripsy and ESWL. It may seem that these procedures are slowly becoming obsolete, due to the rapid progress in flexible ureteroscopy; however their robustness and cost-effectiveness makes it possible that they become the mainstay of endourology in the coming years. Prof. Traxer presented the concluding lecture on retrograde intrarenal surgery, with lots of technical information, very nice visuals and practical tips. Unfortunately, only very few have access to flexible ureteroscopes on a daily basis. The hands-on training in laparoscopy took place in the afternoon and consisted of basic exercises on dexterity using trainers. Frankly, even though there were numerous training stations available, there was not much to do for more skilled laparoscopic surgeons. A RIRS training could be an attractive alternative for participants who won’t benefit from basic laparoscopy.

The last and most pleasant part of the programme was the farewell dinner with the faculty, during which the fellows were granted their certificates. I was very pleased to acknowledge that together with two colleagues from Bulgaria – Drs. Petar Antonov and Kremena Petkova we were awarded Certificates of Academic Excellence for the results of the postseminar test. The dinner and drinks lasted well into the night, but since this is our last day everybody stayed longer for conversation. I made many new friends and I certainly look forward to seeing them again.

ESU-ESUT Masterclass: Surgical skills training

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

Following the success of last year’s masterclass, the European School of Urology (ESU) and the EAU Section of Uro-Technology (ESUT) will again collaborate for a two-day masterclass from May 4 to 5, 2018 in Heilbronn, Germany to offer a comprehensive skills training on the operative management of Benign Prostatic Obstruction (BPO).

routine procedures such as TURP and had the opportunity to discuss pros and cons of each procedure with the experts’ panel. I really appreciated the theoretical session on Day 2 on prostate surgery details such as catheter use and small tips and tricks, which are valuable and could help you out in a difficult scenario."

The goal is to provide not only theoretical knowledge but also a comprehensive and practical approach and skills training on surgically managing BPO. In particular the course will focus on minimally invasive techniques recently introduced and incorporated in current guidelines.

Dr. Alexandru Iordache (RO) “It was a very interesting meeting and I am sure that all information provided will increase the quality of patient care and my skills and professional expertise. All of us had a good time in Heilbronn with the guidance of our host, Prof. Rassweiler.“

Tips and tricks on various types of TURP, enucleation techniques, pre- and intra-operative management, post-operative care and two modules on skills training using hands-on models and actual instrumentation are part of the programme.

Dr. Zhivko Siromahov (BG) “The masterclass was really useful and the SLK Kliniken is a perfect venue for the Masterclass. This kind of event is very useful for young urologists like me. We do not only meet but also learn a lot from each other. The lecturers and the course mentors are really good teachers. Their presentations were great!”

The masterclass has earned the recommendations of participants who appreciated the insightful mentorship and step-by-step guidance. Here are some enthusiastic comments on the 2017 Masterclass: Dr. Petros Sountoulides (GR) "I really enjoyed the ESU-ESUT Masterclass on the surgical treatment for BPH for more than one reason. The course offered an exhaustive overview of all available surgical procedures for small to very large BPH and was supported by very didactic live cases. We all had the chance to refresh our knowledge on European Urology Today

Friday, July 14 The calm and relaxing atmosphere of the Schloss Arenberg could not stop the time from passing quickly. Although I missed my family, kids and friends, the hospitality we received from our hosts made us feel at home. The last lectures focused on urethral strictures (Prof. Chapple), stress urinary incontinence (Prof. Cruz) and pelvic organ prolapse (Dr. Roger P. Goldberg). The morning session ended with a consensus discussion among the faculty and fellows on the use of meshes in stress urinary incontinence. The afternoon session consisted of cases presentations by fellows, followed by a post-seminar test. After the comprehensive week of learning, the test proved to be less difficult.

Operative Management of BPO

4-5 May 2018, Heilbronn, Germany


Thursday, July 13 I had my jogging routine along the the Salzach river and ran towards the centre, as this provided amazing views of the old town, with the Hohensalzburg Castle overlooking the city from the top of the Festungsberg mountain. The lectures were largely devoted to functional urology with top-notch lecturers like Prof. Chris Chapple (UK), Dr. Robert Lee and Prof. Francisco Cruz (PT) addressing the issues of medical assessment of male LUTS, surgical management of BPH, bladder underactivity and the pharmacology of urinary tract. With many experts in functional urology available for discussion, the fellows enthusiastically ask questions and participated actively in debate. After the lunch we enjoyed a free afternoon, with the other half of the group engaged in laparoscopy training. I took the opportunity for sightseeing and visited the old town, Schloss Mirabell and the neighboring gardens, where I spent a pleasant afternoon. We met again at a Grand Hall in the evening for a chamber music concert performed by artists from the Mozarteum University: pianist Tatyana Meyer and soprano Erin Snell.

Dr. Aleksandar Spasic (RS) “During the masterclass I finally resolved some doubts that I have regarding endourological procedures. My experience gave me a positive impression due to the efficient and well organized programme led by experts. The technologies that were examined were also new and represent future possibilities in urology. Heilbronn is a beautiful town and the hospitality of our hosts was memorable. Thank you very much!” August/September 2017

Teaching activities 2017


European School of Urology September 25 30

ESU-ERUS courses at the 15th Meeting of the EAU Robotic Urology Section (ERUS), Bruges (BE) ESU course on Recent developments in diagnosis and treatment of stone disease at the national congress of the Urological Section of Serbian Medical Association, Belgrade (RS)

October 12 12 12-13 13 17 19 27

ESU course on The management of small renal masses at the national congress of the Tunisian Urological Society, Hammamet (TN) ESU course on Clinical and histopathological basics in bladder cancer: unmet needs at the 24th Meeting of the EAU Section of Urological Research (ESUR), Paris (FR) 10th ESU-ESFFU Masterclass on Female and functional reconstructive urology at the European Lower Urinary Tract Symptoms meeting (ELUTS17), Berlin (DE) ESU course on Update on Uro-oncology at the national congress of the Turkish Association of Urology, Girne (CY) 4th Confederación Americana de Urologia Residents Education Programme (CAUREP), Santa Cruz (BO) ESU lecture at the national congress of the Czech Urological Society, Pilsen (CZ) ESU course on Recent developments in diagnosis and treatment of urolithiasis at the national congress of the Hungarian Urologic Association, Pecs (HU)

1st ESU Masterclass on Non-musle-invasive bladder cancer 2018 Prague, Czech Republic


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

November 6

ESU course on The current role of laparoscopy in urology at the national congress of the Scientific Society of Urologists of Uzbekistan, Tashkent (UZ) 10 ESU course Management of surgical complications in urology at the national congress of the Russian Society of Urology, Moscow (RU) 16 ESU courses on Bladder and Kidney cancer: A clinical scenario based interactive session with the experts, at the 9th European Multidisciplinary Meeting in Urological Cancers (EMUC), Barcelona (ES) 23-24 4th ESU-ESUT Masterclass on Lasers in urology, Barcelona (ES)

December 2 6 7-8 8

ESU course on Metastatic and castrate resistant prostate cancer at the national congress of the Georgian Association of Urology, Tbilisi (GE) ESU course on Erectile dysfunction at the national congress of the Egyptian Association of Urology, Cairo (EG) 2nd ESU-ESUT Masterclass on Focal therapy for localised prostate cancer, Paris (FR) ESU course on Bladder cancer and endoscopic stone management: 2017 update, at the national congress of the Algerian Association of Urology, Algiers (DZ)

Contact: esu@uroweb.org

4th ESU-ESUT Masterclass on Lasers in urology


23-24 November 2017, Barcelona, Spain ESU Lasers Masterclass delivers laser-technology essentials Modern medicine has made great strides in recent years, and this includes the conception and advancement of laser technology. When inexplorable by hand or scalpel, lasers became the well-suited alternative to navigate within the human body. Over the years, this versatile tool has drastically and positively influenced the field of urology. The much-awaited masterclass on lasers, the 4th ESU-ESUT Masterclass on Lasers in Urology (esulasers17), will take place from 23 to 24 November in Barcelona, Spain. Organised by the European School of Urology (ESU) and the EAU Section of Uro-Technology (ESUT), esulasers17 will deliver the must-know in laser technology: mastering the basic concepts of laser treatments, identifying the suitable candidate per approach, managing commonly encountered complications and other essentials. Fundamental laser techniques Learn from the best as key opinion leaders share relevant insights along with the best practices exclusively offered during the masterclass. The masterclass aims to provide reliable information on laser technology and its applications in urology. Use of contemporary laser systems such as the Holmium laser, 532-nm laser, Thulium laser, Diode laser, Neodidium and other lasers will be examined; and various techniques will be evaluated and explored in detail. Masterclass setup The masterclass will feature in-depth lectures, riveting discussions, and live surgeries – an effective format designed

August/September 2017

for optimal learning. Participants are guaranteed to learn how to further optimise laser efficacy, and successfully apply it in their clinical practice. Participants can look forward to educational sessions such as the state-of-the-art lecture “Which is the best laser for TCC/ bladder/upper tract?” by Prof. Dr. Olivier Traxer (FR); the round table with case presentation; and the lecture “Lasers for BPH: Different techniques for different prostates” by Dr. Fernando Gomez Sancha (ES). Highly-informative live surgeries The interactive feature of the operating rooms during the live surgery sessions will enable participants will be able to observe various operations simultaneously. Moderated by Dr. Oriel Angerri (ES) and Asst. Prof. Evangelos Liatsikos (GR), the initial set of live surgeries will focus on stones. Two operating rooms will be demonstrating RIRS + Holmium Laser for lower pole stone, and mini-PCNL + Holmium laser for renal stone.

More information at www.esulasers17.org carcinoma of the upper urinary tract (UTUC). Moderated by Dr. Jose Maria Gaya Sopena (ES) and Dr. Cesare Marco Scoffone (IT), these will comprise of two live surgeries and one semi-live surgery. The live surgeries will include RIRS + Holmium for UTUC, and en bloc laser resection of bladder TCC/Holmium, and the semi-live surgery will illustrate RIRS + Thulium for UTUC. The final set of live surgeries will take place on the last day of esulasers17 which will be moderated by Asst. Prof. Liatsikos and Dr. Javier Ponce De León (ES). Two live surgeries will concentrate on HoLEP and Vaporization 180-W; and two semi-live surgeries will demonstrate ThuLEP and ThuVEP techniques. Secure your place Interested in participating? Apply now to secure a seat at this anticipated masterclass. Please note that application should be done online before 15 September 2017. Only limited seats are available and on a first-come, first-served basis. Selection of the participants will be decided upon by the Course Directors. It is mandatory that applicants are EAU Members. For questions concerning membership, please contact the membership department at membership@uroweb.org.

The second set of live surgeries will centre on urothelial

European Urology Today


Reducing readmission after radical cystectomy First two weeks post-discharge are crucial in reducing readmission Dr. Janet Baack Kukreja Urologic Oncology Fellow MD Anderson Cancer Center Houston (US)

Dr. Ashish Kamat Prof. of Urology Wayne B. Duddlesten Prof. Cancer Research MD Anderson Cancer Center Houston (US) akamat@ mdanderson.org

Table 2: Phases of care and the ERAS framework: Illustrating using ERAS framework to integrate into a associated symptoms with the readmission programme to decrease readmissions diagnosis as early as five days after initial discharge11. 4) Readmissions lead to care fragmentation, and this Preoperative Intraoperative Postoperative is also underestimated12. Readmissions and care Early complication identification Practice guidelines for surgical site Consistent education fragmentation are often associated because the Address early complications as an infection prevention (normothermia, Preoperative optimisation readmission often is not at the index hospital; this increases care transitions and unnecessary outpatient when possible (nutrition, cardiac, pulmonary) AUA guideline antibiotics) complexities. One of the biggest challenges Venous Thromboembolism Prophylaxis Early follow-up with primary care Prehabilitation includes not being able to obtain medical records Standard information Smoking cessation counselling Standard information (daily during care transions13. Reducing care Telephone follow-up instructions, discharge instructions, fragmentation should ultimately improve the care communication with other providers) provided to patients8. Skilled nursing facility (SNF) or rehabilitation admissions are surprisingly associated with a larger incidence of readmissions compared to those discharged home or with home-health14,15.Thus, current readmission prevention strategies are ineffective. All these findings can be used to guide strategies to reduce readmission rates.

Unknown readmission effects Current practices to improve patient care have not been able to directly reduce readmissions. Both Radical cystectomy is a complex procedure with minimally invasive (MI) surgery and ERAS inherent complications and potential for prolonged programmes improve quality and patient care hospital stay as well as frequent readmission after provided. However, this has not yet translated into a discharge. Herein, we present a summary of demonstrably decrease – nor thankfully an increase components of the enhanced recovery after surgery – in readmissions. Notably, large readmission (ERAS) paradigm which can advance the database studies do not differentiate ERAS patients. perioperative care for patients undergoing major This is important because the ERAS patients may urological surgery, reduce perioperative morbidity have different readmission timing and different care and enhance post-surgical outcomes. acuity associated with their readmissions. ERAS framework can be used for readmission prevention Enhanced recovery after surgery is a multimodal approach centred on the needs of patients undergoing when the studies are available for the ideal timing major surgical procedures. This was first championed to intervene. by our surgical colleagues in colorectal surgery, Strategies to reduce readmissions where enhanced recovery has successfully reduced Efforts to afford lower readmissions should centre on length of stay and complications. This paradigm is the period of the highest readmission frequency after especially relevant to the radical cystectomy cystectomy, the first two weeks post-discharge. The population, where perioperative morbidity is goal of readmission improvement is not only to considerable and length of stay stagnates at an decrease the rate, but also the acuity if a readmission average of 11 days at most centres. Furthermore, is required9. readmissions continue to be prevalent in the United States for an attributable $15 billion in healthcare Table 2 mirrors the ERAS principles throughout the costs1. care cycle. Using the ERAS framework we can better Enhanced Recovery After Surgery (ERAS) understand and ultimately implement programmes ERAS pathways involve multimodal care protocols to which can be successful in readmission reduction. improve patient preparation for the physical and emotional stress of having a major operation2. While All three phases of care are areas suitable for ERAS programmes have been most commonly intervention to avoid readmissions and should be implemented for radical cystectomy patients, the developed or revised in ERAS programmes16. principles apply to most major urologic surgeries. Interestingly, while urologists often self-report that Preoperative care optimisation allows for the patient to improve their overall health status, thus they are providing ERAS care, there is a significant resulting in an improved response to surgical gap in actual implementation. This gap may be the stress. Areas commonly associated with outcome reason why the full spectrum of ERAS benefits have not been realised3. Most pathways incorporate ERAS improvement in this patient population are prehabilitation, nutrition and cardiac.16 Patient tenets in Table 14-6. education with consistent information decreases patient anxiety17. For many reasons, successful Current readmissions and associated risk factors Readmissions are a reality and frustrating for most smoking cessation counselling can also lead to a surgeons. Of all major surgeries (urologic and reduction in readmissions18. non-urologic), radical cystectomy has the highest 90-day readmission rates at 40%7,8.Unfortunately, Additionally, care coordination starting before there are not many consistent predictors or risk admission must become a focus to improve discharge factors which are realistically modifiable to prevent and follow-up care15. It is of paramount importance to readmissions (i.e. gender). set expectations early – not only for the patients but also for their families and allied health care Three large studies have looked at cystectomy personnel. readmissions and revealed the following facts: Strategies to maximise in-hospital programmes 1) Two-thirds are readmitted by Week 2 after utilising clinical practice guidelines provide benefits discharge, with mean time to readmission of throughout the care cycle leading to a reduction in 11.5 days9. related readmissions. Relevant guidelines available 2) Any complication during the index stay remains include: prevention of venous thromboembolism, associated with readmissions9,10.Importantly, the optimisation of co-morbid conditions and surgical site infection prevention16. leading cause of readmission was serious infections, where 26% required intensive care Vigilance is needed for follow-up care in these unit (ICU) admission9. 3) While readmissions might occur in the first two patients, where early follow-up is an essential key in weeks after discharge, patients often have reduction of readmissions. Models have been

developed to target interventions and found some Recovery (QUICCER Study). BJU international. 2016. readmissions can be detected by an office visit (16%), 7. Stitzenberg KB, Chang Y, Smith AB, Nielsen ME. but detection can increase with the addition of followExploring the burden of inpatient readmissions after up telephone calls – in this model the readmission major cancer surgery. Journal of clinical oncology : was averted with four phone calls11. Early recognition official journal of the American Society of Clinical of warning signs associated with developing Oncology. 2015;33(5):455-464. complications can be addressed early and hence 8. Chappidi MR, Kates M, Stimson CJ, Bivalacqua TJ, potentially eliminate readmission or decrease acuity19. Pierorazio PM. Quantifying Nonindex Hospital Primary care providers involvement can provide early Readmissions and Care Fragmentation after Major outpatient support20.Communication upon discharge Urologic Oncology Surgeries in a Nationally is an essential tool to provide key information, Representative Sample. The Journal of urology. 2016. especially with SNF facilities14,19.The use of 9. Hu M, Jacobs BL, Montgomery JS, et al. Sharpening the standardised discharge templates can aid in primary focus on causes and timing of readmission after radical care provider transitions as well. cystectomy for bladder cancer. Cancer. 2014;120(9):1409Conclusion ERAS framework can be used to build and improve strategies in readmission prevention. Radical cystectomy accounts for many readmissions, however, improvements can serve as a model for other urologic surgeries if successful reductions in readmission are realised. Early complication identification can be useful in reducing critical care needs and should remain a priority in follow-up care. The first few weeks after discharge seem to be the most at risk for readmissions. Thus, known prevention strategies should be employed with a focus on improving the care coordination and follow-up during this period, including frequent follow-up contact with the patient via telephone. References 1. Downs TM. Reducing readmissions and mortality after radical cystectomy. The Journal of urology. 2015;193(5):1461-1462. 2. Danna BJ, Wood EL, Baack Kukreja JE, Shah JB. The Future of Enhanced Recovery for Radical Cystectomy: Current Evidence, Barriers to Adoption, and the Next Steps. Urology. 2016. 3. Baack Kukreja JE, Messing EM, Shah JB. Are we doing "better"? The discrepancy between perception and practice of enhanced recovery after cystectomy principles among urologic oncologists. Urologic oncology. 2016;34(3):120 e117-121. 4. Francis N KR, Ljungqvist O, Mythen MG. Manual of fast track surgery recovery for colorectal surgery. Springer:New York; 2012. 5. Patel HR, Cerantola Y, Valerio M, et al. Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy? European urology. 2014;65(2):263266. 6. Baack Kukreja JE, Kiernan M, Schempp B, et al. Quality Improvement in Cystectomy Care with Enhanced

1416. 10. Skolarus TA, Jacobs BL, Schroeck FR, et al. Understanding hospital readmission intensity after radical cystectomy. The Journal of urology. 2015;193(5):1500-1506. 11. Krishnan N, Liu X, Lavieri MS, et al. A Model to Optimize Followup Care and Reduce Hospital Readmissions after Radical Cystectomy. The Journal of urology. 2016;195(5):1362-1367. 12. Chappidi MR, Kates M, Stimson CJ, Johnson MH, Pierorazio PM, Bivalacqua TJ. Causes, Timing, Hospital Costs, and Perioperative Outcomes Of Index vs. Non-Index Hospital Readmissions Following Radical Cystectomy: Implications For Regionalization of Care. The Journal of urology. 2016. 13. Noyes K, Baack-Kukreja J, Messing EM, et al. Surgical readmissions: results of integrating pre-, peri- and postsurgical care. Nurs Open. 2016;3(3):168-178. 14. James AC, Izard JP, Holt SK, et al. Root Causes and Modifiability of 30-Day Hospital Readmissions after Radical Cystectomy for Bladder Cancer. The Journal of urology. 2016;195(4P1):894-899. 15. Minnillo BJ, Maurice MJ, Schiltz N, et al. Few modifiable factors predict readmission following radical cystectomy. Can Urol Assoc J. 2015;9(7-8):E439-446. 16. Raman JD. Hospital readmission following urologic surgery. Can J Urol. 2015;22(1):7647. 17. Chandrasekaran A, Anand G, Sharma L, et al. Role of in-hospital care quality in reducing anxiety and readmissions of kidney transplant recipients. J Surg Res. 2016;205(1):252-259 e251. 18. Hemal S, Krane LS, Richards KA, Liss M, Kader AK, Davis RL, 3rd. Risk factors for infectious readmissions following radical cystectomy: results from a prospective multicenter dataset. Ther Adv Urol. 2016;8(3):167-174. 19. Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-485. 20. Brooke BS, Stone DH, Cronenwett JL, et al. Early primary care provider follow-up and readmission after high-risk surgery. JAMA Surg. 2014;149(8):821-828.

Provide sustainable patency.



Table 1: ERAS Principles





Preoperative education Prehabilitation Carbohydrate Loading Preoperative evaluation and optimisation (nutrition, cardiac, pulmonary)

Avoidance of hypervolemia Normothermia Local Analgesia Venous Thromboembolism Prophylaxis AUA Guideline antibiotic

Prevention of ileus Opioid sparing pain control Early oral nutrition Early mobilisation Venous Thromboembolism Prophylaxis


European Urology Today


© COOK 01/2017 URO-D32084-EN-F

August/September 2017

Bladder Cancer

Right ureter Peritoneum

Left ureter



Muscle layers

Opening of left ureter

Fat layer

Trigone of bladder Urethra


European Urology Today

August/September 2017


When your main priority is to enjoy life and to spend quality time with loved ones, your urological health becomes priority, too. Start now to know more about the prevention of prostate cancer. Ask your questions direct from a trusted source. Talk to a Urologist.


August/September 2017

European Urology Today


Give us one good reason not to get checked out! August/September 2017

European Urology Today




Patient Information - Bladder Cancer



This poster is a part of the EAU Patient Information on Bladder Cancer and can be used during consultations.



August/September 2017

European Urology Today


Right ureter

Apply now!

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 a grant from the Fritz H. Schröder Foundation, an expert jury will select the best paper dealing with clinical or experimental studies in prostate cancer. The award will be handed over at the 33rd Annual EAU Congress in Copenhagen, 16-20 March 2018 during the Opening Ceremony.

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

• The paper must have been published or accepted for publication in a high-ranking international journal between 1 July 2016 and 30 June 2017, 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 2017. A review committee will screen all entries and an independent jury will select the best paper based on quality and merits.


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

Bladder Cancer

EAU Prostate Cancer Research Award 2018

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 2018” 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


EAU Crystal Matula Award 2018 For a young promising European urologist


Nomination Process National Societies can nominate a candidate by supplying the following documents: • Letter of endorsement • Motivation letter

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.

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The list of previous awardees includes many well-known names: 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).

• 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 2017.

How to apply Please send your nominations to the EAU Central Office at m.smink@uroweb.org and mention “EAU Crystal Matula Award 2018” in the subject line of your e-mail.

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

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The EAU Crystal Matula Award 2018 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 33rd Annual EAU Congress in Copenhagen from 16-20 March 2018.

Muscle layers

Opening of left ureter

Fat layer

Trigone of bladder

Send your nominations today!


European Urology Today


EAU Best Papers published in Urological Literature Awards

Apply now!

To be awarded at the 33rd Annual EAU Congress in Copenhagen, 16-20 March 2018 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 2016 and 30 June 2017. The awards will be handed out at the 33rd Annual EAU Congress in Copenhagen, 16-20 March 2018. 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 2017. 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 2018 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 33rd Annual EAU Congress in Copenhagen, 16-20 March 2018 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 2016 and 30 June 2017.

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 2017. 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 2018” in the subject line of your e-mail.

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


European Urology Today

August/September 2017

New Section Office-sponsored, specialty scholarships EUSP links up with Section Offices for scholarships Prof. Vincenzo Mirone Chair EUSP Naples (IT)

“break the infertility code” by strengthening the collaboration between partners at hospitals, universities and educational institutions working in reproductive medicine.

The ESAU, together with Repro Union, is funding a total of four joint post-doctoral degree scholarships of €20,000 each. These scholarships offer young researchers interested in reproduction medicine the ability to collaborate and share scientific knowledge mirone@unina.it among various medical areas in reproduction and fertility medicine by accessing the specially created The European Urological Scholarship Programme networking platform set up for PhD and post(EUSP) has entered into a number of strategic doctorate students, research assistants and other collaborations with three of the 12 EAU section offices young researchers. The ultimate aim is to unite to offer specialty-focused scholarships, aside from scientific and medical expertise for further the existing clinical visits and research scholarships development of this medical specialty area. awarded each year. Some of the key clinical capabilities of the Repro Since the section offices themselves are the most Union network include: knowledgeable and capable of identifying future • High standard IVF and ICSI treatment including needs for specialty skills and research within their use of recent methods for embryo selection; own fields, interested and qualified candidates • Extended evaluation of the male partner to find now have the chance to get an early start on the best treatment options for the couple and launching their careers in the area that most prevent long term squeal of infertility; interests them. Moreover, they will be guided and • Sperm DNA analysis; supported by the section offices which created the • Andrological surgery and treatment of ejaculatory scholarships. dysfunction; • Gonadal cryopreservation; As the conduit and funding office for EAU • Gamete donation; and scholarships, the EUSP’s role in these newly created • Assessment and counselling regarding specialty scholarships, includes assistance in environmental reproductive risks at the individual developing research proposals, receiving and and the group level. processing applications, evaluating and interviewing potential applicants, selection of scholarship Thus far two scholarships have been awarded to EAU recipients and management and disbursement of urologists at the Department of Growth and funding to candidates who wish to study abroad at Reproduction Medicine at the University of EAU-sponsored host institutions, which are amongst Copenhagen and the Department of Reproductive the most prestigious in the European Union if not in Medicine at Lund University in Sweden. Two more the world. scholarships are being offered in 2018 (application deadline December 2017) with scholarships Reproductive medicine scholarship commencing on February 2018. The first of these scholarships, offered in conjunction with the EAU Section of Andrological Urology (ESAU), Robotic surgery scholarship is in the burgeoning area of reproductive medicine. Another new series of scholarships on offer are in the These joint EAU-EU sponsored scholarships are the field of Robotic Surgery in collaboration with the EAU product of a multi-disciplinary Reproductive Medicine Robotic Urology Section Office (ERUS). ERUS is research network known as Repro Union, which offering a number of certified Curriculum ERUS consists of 13 clinical and research units throughout Robotic Training courses with a value of €8.000 each, Denmark and Sweden. Repro Union’s mission is to on behalf of their Working Group on Education & Training. The six to 12-month fellowships in robotic surgical training will take place at ERUS-designated robotic host centres and will cover travel and lodging European Urological Scholarship Programme Office expenses.

The fellowships are intended to train surgeons to perform robot-assisted prostatectomies independently and will include theoretical sessions, skills training in dry and wet laboratories, real-case observation in a robotic training centre, bedside assistance, and mentored training at the console. Scholarship recipients will train at recognised host-centres that are set up to properly train robotic surgeons and will allow trainees’ access to the robot giving them the skills to perform several urological procedures robotically in a high-volume setting under the tutelage of the ERUS training curriculum. For the first six months, training will be conducted in a step-by-step manner in a modular, staged curriculum, under the guidance of a local mentor starting with tableside assistance, advancing to modular training on the console and culminating in an advanced robotic skills course in the final month. At the end of the fellowship, the fellows will perform a case of radical prostatectomy independently with a fully recorded procedure and will be assessed by two blinded independent international experts. Upon completion of the curriculum, surgeons will be certified as ERUS Robotic Fellows. All fellowship applicants must have a robot at their own home institute, verified by a letter provided by their Head of Department. Application forms will be available on the EUSP website from October 2017. Click 'CC-ERUS' to find a drop-down list of ERUS Robotic Host Centres. Kidney transplant scholarship A third newly created scholarship opportunity stems from a collaboration between the EAU Section of Transplantation Urology (ESTU) and the University of Miami, Florida Fellowship on Kidney Transplant. ESTU has launched a joint European-U.S. fellowship in renal transplant surgery where a young urologist will be hosted for a minimum period of 18 months, six of which will be spent at a European urologicalnephrological centre of excellence in renal transplant, and 12 months at the Miami Transplant Institute at Jackson Memorial Hospital in Miami, Florida. The ESTU links up senior experts in the field of renal transplantation and young urologists interested in the kidney transplantation, as it believes that renal transplantation cannot be performed optimally without a urologist. In light of this goal, the intention behind these ESTU scholarships is to develop the important role of the urologist in renal transplantation.

The aim of this joint European-U.S. fellowship is to fully integrate a young urologist together with a young nephrologist with surgical and medical participation at a hospital or kidney transplantation unit in both continents with participation at the surgical and medical levels at the hospital and clinics, along with time spent at the Human Leukocyte Antigen Lab and Organ Procurement Organisations. Educational participation will also be required at multidisciplinary meetings such as selection meetings for kidneys, KP and living donors, high-risk committee meetings, and morbidity and mortality reviews, as well as other research opportunities. Some of the European Excellence centres that will be available to receive candidates for the six-month period are: • Hospital Clinic Barcelona, Spain – A. Alcaraz • Fundacio Puigvert Barcelona, Spain – A. Breda • Guy’s Hospital London, United Kingdom J. Olsburgh • Hospital Ramon Y Cajal Madrid, Spain – J. Burgos Revilla • University Hospital Dresden, Germany – M. Wirth • University Hospital Coimbra, Portugal – A. Figueiredo The fellowship selection process will be led by a selection board consisting of urologists and nephrologists from the EUSP, ESTU and the EAU Section Office, as well as representatives from the University of Miami. Scholarship candidate requirements are the following: 1) National Board Certified Urologist or Nephrologist 2) Clinical experience of at least two years in Renal Transplant Programme Centres 3) European Board of Urology (EBU) degree should be required or certified 4) USMLE (United States Medical Licensing Exam) Steps 1 and 2 (at least) 5) Should be required or certified. Ideally also Step 3 6) Academic Commitment to the field under the super-specialisation (minimal impact factor): Curriculum Vitae At the completion of the entire fellowship, an ESTU-EAU Fellowship on Kidney Transplant Certificate will be awarded on behalf of the EAU/EUSP. For further details and all other EUSP scholarships on offer, visit the EUSP website at: www.uroweb.org/education/

Renal stones in practice An advanced course during the 3rd Nephro/Urology meeting in Rome Dr. Pietro Manuel Ferraro Rome (IT)

pietromanuel. ferraro@unicatt.it

Prof. Giovanni Gambaro Member EULIS Board UCSC - Policlinico Universitario Agostino Gemelli Dept. of Nephrology Rome (IT) giovanni.gambaro@ unicatt.it

Renal stones are common and their prevalence is continuously increasing over time. The patient with stones requires a multidisciplinary approach which integrates urological, nephrological as well as nutritional and genetic expertise.

EAU Section of Urolithiasis (EULIS)

August/September 2017

The course “Renal stones in practice: An advanced course” (http://www.fondazione-menarini.it/Home/ Eventi/3rd-International-Meeting-onNEPHROLITHIASIS-RENAL-STONES-IN-PRACTICE-anadvanced-course/Presentazione), held in Rome in June 8 to 10 2017, was organised by Prof. Giovanni Gambaro (Università Cattolica del Sacro Cuore in Rome, Scientific Board of EULIS) and Dr. Emanuele Croppi (Florence) and sponsored by the International Foundation Menarini, Milan, and endorsed by EULIS and ERA EDTA.

During the course, plenary lectures were presented followed by thorough discussions on various aspects of renal physiology and stone formation, as well as the physico-chemistry of the urine and the link between stone composition and clinical characteristics of the The course aimed to improve the multidisciplinary patients with renal stones. Hereditary and care of patients with stones by gathering an international panel of experts in urology, nephrology, metabolic forms of stones chemistry, genetics and nutrition to provide not only and how to diagnose International faculty members them were also cutting-edge information but also practical insights for daily clinical practice. The ultimate goal was to discussed, while issues regarding stone establish in 24 European or Mediterranean hospitals small teams (one nephrologist, one urologist) for the complications such as bone disease and infections global treatment of nephrolithiasis. were examined. The course also highlighted the importance of nutrition as a risk factor for stones and the decision-making process for the best urological intervention. Course participants also worked in small groups to take up real clinical cases under the guidance of expert tutors. Each case was discussed interactively in plenary Participants from Europe and Mediterranean countries with their tutors sessions.

The course will hopefully strengthen the cooperation between urologists and nephrologists for them to optimise the management of stone patients, and thus reduce the costs associated with stone treatment. Furthermore, the meeting will improve awareness on this complex disease and help boost the number of centres involved in the care of patients with stone disease. The European faculty members were also involved in three business meetings under the auspices of the EULIS to create a European network of stone clinicians using a shared platform to investigate and treat patients. European Urology Today


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

paul.meria@ sls.aphp.fr

An Illustrated Guide to Pediatric Urology

Childbirth Trauma Childbirth-related trauma occurs in many women, who can be affected at various degrees. Significant perineal lesions can impact dramatically their quality of life and often require surgical management. Historically, such problems were considered as the “price to pay” for being a mother, but fortunately this concept has evolved and currently a systematic approach of perineal morbidity can be proposed to many women with injuries. Many guidelines were also established by scientific societies and are currently available to practitioners.

Paediatric urology is currently a real specialty, carried out by urologists or paediatric surgeons. In their daily practice, they are involved in the management of congenital or acquired urological diseases in new-borns, infants and children. Editor Ahmed H Al-Salem, an experienced Saudi Arabian paediatric urologist, wrote this exhaustive textbook with the aim of covering all aspects of the specialty.

An important part of the textbook dealt with genital problems such as priapism, benign and malignant testicular diseases. Another part provided an overview of vaginal problems and sexual development disorders. This textbook is easy to read and well-illustrated. Each chapter displays many photographs and hand drawn figures. All paediatricians and urologists involved in paediatric surgery will be satisfied with this excellent work, which can be also recommended for trainees.

This excellent textbook fills a lack and provides the reader with expert knowledge in the fields of UAB and DU, which are sometimes neglected in clinical practice and research. Editors ISBN e-Book Published Publisher Edition Pages Illustrations Binding

He provided the reader with 31 chapters dedicated to various congenital and acquired conditions. Congenital malformations were addressed in the first chapter, which described all abnormalities of the kidney and those of other genito-urinary organs. The following chapters covered all aspects of upper urinary tract problems, including obstructive uropathies, benign and malignant tumours, and cystic diseases. Ureteral diseases and urolithiasis were described in special chapters before addressing infectious diseases and bladder dysfunctions. The succeeding chapters covered all aspects of bladder and urethral diseases, including various malformations such as exstrophy-epispadias complex, urachal remnants, posterior urethral valve, utricular cysts and hypospadias.

In these chapters, the authors first considered pharmacologic management and its limits, and described various invasive treatments such as surgical procedures, including bladder outlet reduction, cystoplasties, and bladder wraps procedures. Electrical bladder stimulation techniques were described, focusing on nerurostimulation and neuromodulation. The indications of each technique were reviewed and the authors concluded the book by examining future issues such as tissue engineering techniques, including stem cell injection therapy.

: C.R. Chapple, A. Wein, N.I. Osman : 978-3-319-43085-0 : available : 2017 : Springer International Publishing : 1st : 89 : 1 in colour : Hardcover

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This original textbook tackled a very important public health problem and the authors must be congratulated for their didactic approach. Their work is exhaustive and well-illustrated, and will be very useful for all practitioners involved in obstetrics, female urology, and pelvic floor rehabilitation. Editor ISBN e-Book Published Publisher Edition Pages Illustrations Binding Price Website

: S.K. Doumouchtsis : 978-1-4471-6710-5 : available : 2017 : Springer-Verlag London : 1st : 329 : 11 b/w, 50 in colour : Hardcover : €165.00 : www.springer.com

: € 187.00 : www.springer.com

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EU-ACME members may generate and print Credit Registry Reports online. Editor Stergios K. Doumouchtsis, with the help of more than 30 worldwide leading experts, focused on various childbirth-related complications and their management. After an overview of female pelvic anatomy and anorectal physiology, the authors considered the epidemiology and the pathophysiology of pelvic floor disorders related to delivery trauma. In the succeeding chapters they addressed the principles of assessment and the management of childbirth injury. Special chapters were dedicated to lower urinary tract and gastrointestinal tract problems. Healing process and obstetric fistula were described separately before a segment that focused on prevention, risk assessment, prediction and prognosis of delivery trauma.

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

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Underactive Bladder

Author ISBN e-Book Published Publisher Edition Pages Illustrations Binding Price Website

: Ahmed H. Al-Salem : 978-3-319-44181-8 : available : 2017 : Springer International Publishing : 1st : 702 : 211 b/w illustrations, 775 illustrations in colour : Hardcover : €284.50 : www.springer.com

Book reviews


European Urology Today

Underactive bladder (UAB) is accepted as a “clinical concept” since detrusor underactivity (DU) is an urodynamic set of findings. Currently, DU is defined as a “contraction of reduced strength or duration resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span.” The consensus group led by Chris Chapple, on behalf of the ICS, considered the symptom complex they called UAB, and its relation with DU which is not synonymous. Editors Chapple, Alan J. Wein and Nadir I. Osman, wrote this book with the help of 15 recognised experts to update the knowledge on UAB and DU. They first addressed current aspects of terminology and definitions before dealing with the pathophysiology of UAB. They focused on epidemiologic data and diagnostic tests before looking into various treatment aspects.

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August/September 2017

Canadian Urological Association (CUA)

EUREP - CUA Exchange Programme Belgian resident gains insights on Canadian urology

The next day, all final-year residents were immersed in the world of urodynamics. Drs. Jerzy Gajewski and Greg Bailly of the Dalhousie University in Halifax, Canada, chaired this four-hour course. In the first part, they taught basic principles such as how to set up and perform modern urodynamic studies, and how to identify patients who need urodynamics. Afterwards, we were taught how to interpret urodynamics and how to recognise artefacts. Finally, vdconinck@ we were all examined with urodynamic trace-based gmail.com tests. I am convinced that this very interesting course will improve the quality in interpreting and reporting In June of 2017, I had the great opportunity to take part urodynamics. in the EUREP – CUA Exchange Programme during the annual meeting of CUA that was organised in Toronto. Comprehensive scientific programme The CUA annual meeting offered a comprehensive Each year, the EAU and the Canadian Urological and well-organised scientific programme. I attended Association (CUA) select an EAU member to take part in state-of-the-art lectures about immuno-oncology, the Canadian Senior Urology Residents (CSUR) Annual infertility, and the contemporary use of meshes in Scientific Retreat, followed by the CUA annual meeting. prolapse and incontinence surgery. I especially liked Selection is based on the results of the E-BLUS (basic the presentation of Timothy D. Averch, urology laparoscopic urological skills) exam, EBU (European professor and director of the UPMC Kidney Stone Board of Urology) exam, PubMed publications and an Center, Pittsburgh, USA, who presented an overview assessment of one’s curriculum vitae. on how quality of medical management of stone disease can be improved. In the end, he stated that CSUR Annual Scientific Retreat based on the AUA guidelines clinicians should offer The CSUR Annual Scientific Retreat and CUA annual thiazide diuretics and/or potassium citrate to patients congress were organised in Toronto from June 23 to 27. with recurrent calcium stones and chronic stone The first day, I was introduced to all Canadian Senior formation but with no other metabolic abnormalities. Urology Residents in a pleasant and casual atmosphere during a unique axe-throwing experience. It was great During the last session, changes in CUA guidelines fun and an ideal way to meet one another. I found out were discussed. My impression was that CUA the medical training is quite different in Canada. guidelines are mainly based on AUA guidelines, Medical degrees are generally received following a which are quite similar to EAU guidelines. The only four-year programme at most universities after having major difference I noticed was that in their guidelines passed the Medical Council of Canada Qualifying they already stated that oncologic outcomes are Examination. Post-graduate training in urology lasts similar for open versus laparoscopic versus robotic five years. After residency, 75% of urologists complete cystectomy. This statement was assessed with a 1a one or more sub-specialty fellowships. level of evidence. Dr. Vincent De Coninck Urology resident OLV hospital Aalst (BE)

Hands-on courses I also attended three hands-on courses. The first course was about flexible ureteroscopy, chaired by Dr. Tom Chi of the University of California in San Francisco. He shared his experience on using single-use digital flexible ureteroscopes. He explained how his patients and practice benefit from this technique, based on a case-cohort study comparing two groups of patients undergoing flexible ureteroscopy. The first group (115 patients) underwent surgery utilising disposable ureteroscopes and the second group (65 patients) was treated with reusable fiber-optic flexible ureteroscopes. He found that single-use digital flexible ureteroscopes can reduce procedure time for over 10 minutes while preserving excellent clinical outcomes. He concluded that these ureteroscopes represent a feasible alternative to reusable ureteroscopes with a low rate of scope failure comparable with reusable ureteroscopes (4.4% versus 7.7% respectively, p = 0.27).

short presentation about optimal techniques to maximise patient outcomes, we received personalised instructions with the new virtual reality simulator for training on photoselective vaporisation of the prostate. Unforgettable experience The evenings were filled with receptions, delicious dinners, animation acts with stilt walkers and concerts. It was a great chance to meet reputed urologists from all over the world in a warm and pleasant atmosphere. I would like to thank the EAU and CUA for giving me the opportunity to take part in this resident exchange project. It was an unforgettable experience to join the congress and to experience the generous hospitality of the Canadians. I am convinced that the knowledge I have acquired and the friends I made will be useful in my future.

The next day, I went to a hands-on workshop about minimally invasive percutaneous stone therapy. Dr. Kenneth Pace, associate professor at the University of Toronto, lectured on the indications and limitations of standard, mini, ultra-mini and micro PCNL. He also discussed single-step dilation, low-pressure irrigation and the "vacuum cleaner" effect of irrigation. This allows stone clearance during mini PCNL without additional devices, under the influence of the turbulence produced by the irrigation fluid. He concluded that these minimally invasive PCNL techniques appear to be safe for treatment of small stones and offer a new option in treating nephrolithiasis. The third course I attended was about photoselective vaporisation of the prostate, chaired by Dr. Gerald Brock, Dr. Dean Elterman and Dr. Kevin Zorn. After a

Receiving the CUA-EUREP 2017 Exchange Programme award from Dr. Curtis Nickel, CUA President

A chance to join the ...

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

2018 Canadian Tour The European Association of Urology (EAU) and the Canadian Urological Association (CUA) are pleased to announce the 2018 Canadian tour! The CUA/EAU International Exchange Programme will send Canadian faculty to Europe and European faculty to Canada. The programme aims to promote international exchange of urological medical skills, expertise and knowledge. For 2018 the CUA/EAU International Exchange Programme will provide grants to enable three Junior EAU Members to participate in the Canadian Tour. The tour should take place from 10-26 June 2018 starting with visits to different urological centres in Canada, culminating with participation at the 73rd CUA Annual Meeting in Halifax, NS, from 23-26 June 2018. 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 2.5 to 3 weeks at the earlier mentioned time

August/September 2017

Information and application forms For all further information and programme application forms please visit uroweb.org/canadaexchange or contact the EAU Central Office, T +31 (0)26 389 0680, F +31 (0)26 389 0674, E: a.terberg@uroweb.org. Application deadline: 1 November 2017 EAU Central Office, Attn. Angela Terberg, P.O. Box 30016, 6803 AA Arnhem, The Netherlands

Canadian Urological Association (CUA)

European Urology Today


EBU recertifies Department of Urology in Pilsen (CZ) First EBU-certified training centre Faculty Hospital in the Czech Republic Prof. Milan Hora Faculty Hospital Pilsen Faculty of Medicine in Pilsen, Charles University Pilsen (CZ) horam@fnplzen.cz

Training programme in urology for residents in Czech Republic – Five Years Part


Final Year

Basic part – two years

18 months of urology

Examination – discussion of three cases

Two months internal medicine Two months general surgery Two months anaesthesiology and ICU

Advanced part – three years

30 months of urology including paediatric urology, gynaecological urology, andrology

Examination – practical exam, written test, oral test, one paper

One month of oncology and radiotherapy The Department of Urology is part of the Faculty Two months of general surgery Hospital which has a 1,700-bed capacity. The One month of gynaecology department is also an affiliate of the Charles University, which has one of its Faculties of Medicine in Pilsen. Our urology department received EBU certification for the first time in 2011 under the direction of the author, and Training programme in the Czech Republic comprehensive and expert care to patient suffering its programme has been certified for a second period from urological diseases. The residents rotate through The Czech RTPU takes five years and is described in of five years in October 2016. different sub-units of the department, such as wards, the table above. operating rooms and the out-patient department. The department has a 70-bed capacity including four The programme is prepared according to the Residents are trained in ultrasonography, prostate paediatric beds, and is currently staffed by 21 full-time European Urology Residency Curriculum of the EBU. biopsies, and urodynamics. At the end of their urologists, including 10 residents. In 2016, the training, residents should be able to perform all Every resident has his or her own personal tutor, department carried out a total of 38,810 outpatient common endoscopic procedures (TURB, TURP, written educational programme including a plan of consultations, 3,188 hospital admissions, and rotation on wards and departments, and logbook. The ureteroscopy), nephrostomy and common open performed more than 2,700 surgical procedures. teaching process is regularly evaluated by 13 certified procedures (external genitalia, lumbo- and laparotomy with at least deliberation of kidney, open staff members. The department is the only urology centre for the prostatectomy). Residents are required to assist in all Pilsen region which has a population of 572,000 procedures including laparoscopic operations, open One of the main goals of the residency is to educate inhabitants. We cover the entire spectrum of the residents for them to independently provide radical oncological surgeries such as cystectomy, speciality with emphasis on uro-oncology. Moreover, we are specialised in the diagnosis and treatment of kidney tumours (218 surgeries for kidney tumours in 2016) and laparoscopy (401 in 2016). Sub-speciality areas such as BPH, lower urinary tract dysfunctions (including urodynamics, female urology), urolithiasis, andrology and paediatric urology are led by experienced staff members. Urology is also taught to students of the Faculty of Medicine. All subspecialties that collaborate with urology are present in the hospital, including radiology and pathology. The department’s research activities are focused on kidney tumour (diagnosis, role of laparoscopy, histopathology e.g. papillary RCC, cystic lesions etc.), diagnosis of prostate cancer, biomarkers (mainly in prostate cancer and bladder cancer) and penile cancer.

EBU Certified Centres

percutaneous operations and surgery for stress incontinence. They are trained in the sub-specialties paediatric urology, urodynamics, gynaecological urology, andrology and oncourology. Residents who are into research can start their study in the PhD programme. Residents are also encouraged to participate in the EBU In-Service written assessment every year (the fee is covered by the Czech Urological Society), and the EBU Written Examination is mandatory to certify Czech urologists. We believe the assessment is the best way to validate the residents´ knowledge. Before completing the residency, every resident must submit at least one article to any peer-reviewed medical journal and present at least two papers at national urological conferences, which are prerequisites for the final exam. Passing the European Urology Residents Education Programme (EUREP) in the last two years of the residency is recommended. Other pre-requisites for the final exam are a completed training programme including number of procedures, a practical exam, a special paper about a defined topic (at least 15 pages) and the EBU Written Examination. The final exam is an oral exam performed in the presence of five commissioners with two questions for the candidate (it can be replaced by the EBU Oral Examination, which is recommended), and the presentation of the special paper with discussion. Final certification is issued by the Czech Ministry of Health. We believe that the EBU certification we recently renewed is a mark of excellence.

Staff of the Urology Department of the Faculty Hospital Pilsen

EBU Certification for HELIOS Marien Klinik Department of Urology in Duisburg gains recognition Dr. Frank Van Dorp HELIOS Marien Klinik Urologische Klinik Duisburg Duisberg (DE)

frank.vom-dorp@ helios-kliniken.de Our motivation in applying for the EBU certification was the first step to get an independent opinion regarding our teaching curriculum. Although we already have a curriculum adhering to the requirements of the DGU (German Association of Urology), we sought further input to improve our curriculum, which is also needed since our residents participate in the In-Service Assessment organised by the European Board of Urology (EBU). HELIOS Marien Klinik Duisburg Duisburg is one of the largest cities in the Ruhr area and its industrial history makes it unique. Urological care for nearly 500,000 citizens has a long tradition in Duisburg. With 48 beds, the Department of Urology is part of a maximum care medical centre in Hochfeld and Hamborn, and has been affiliated since 2012 with Helios Kliniken Deutschland. Furthermore, the hospital is affiliated with the Heinrich Heine University in Düsseldorf. Twenty-five clinical departments guarantee high and substantial quality in medical treatment. EBU Certified Centres


European Urology Today

The main focus of the urological department is on urological oncology with a special emphasis on laparoscopic kidney surgery and the diagnosis and treatment of transitional cell carcinoma of the bladder. With regards to prostate and bladder cancer, a specialty is open pelvic surgery in regional anaesthesia. The Department of Urology also offers intensive care for patients suffering from urinary incontinence. The complete spectrum of pharmacological and surgical treatment is offered to our patients, including paediatric urological services in cooperation with the Department of Paediatrics. There are 10 full-time urologists in our department who perform nearly 3,000 operations each year. The department is nationally accredited for the whole five years of clinical training. Three residents are currently in our urological training programme. A rigorous and comprehensive conference schedule, guidance and support in clinical research activities, and supervision of the resident’s level of education, are among the highlights of our residents programme. All residents are required to document their surgical activities, which undergo annual evaluation by the clinical head.

use an efficient approach in managing clinical problems; • Journal club: Key articles from urologic literature are reviewed by the faculty and residents; • Urologic oncology conference: Attended by urology faculty and residents, with members of the Oncology, Radiotherapy, Radiology and Pathology Departments; and • Morbidity and mortality conference: Held weekly with all heads of clinical departments.

Residents are also encouraged to take part in regional, national and international educational courses and meetings. Although the EBU examinations are not mandatory in certifying a German urologist, we believe that the assessment helps validate a resident’s knowledge based on high European standards. We believe the EBU certification is a mark of excellence which reflects our commitment to maintain high quality in our residency training programme.

Residents’ activities Residents may attend different weekly conferences that are held in the Urology Department such as the following: • Case conference: Presentation of patients that are scheduled to undergo surgery in the following week. This conference prepares residents for the oral board examination, provide them with experience in presenting cases in an organised and well-structured manner, and enable them to

The team of the Urology Department in Duisburg

August/September 2017

Stronger arguments than ever for the GPIU! Global Prevalence of Infections in Urology: Long-term, worldwide surveillance study on uro-infections Prof. Florian Wagenlehner UKGM Universitätsklinikum Giessen Klinik und Poliklinik für Urologie Giessen (DE) florian.wagenlehner@ chiru.med.uni-giessen. de

Dr. Zafer Tandogdu Newcastle University Northern Institute For Cancer Research Newcastle Upon Tyne (UK)

zafer.tandogdu@ ncl.ac.uk

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


Co-authors: R. Bartoletti, G. Bonkat, T. Cai, B. Koves, T. Perepanova, A. Pilatz The Global Prevalence of Infections in Urology (GPIU) study is a worldwide-performed point prevalence study intended to create surveillance data on antibiotic resistance, type of urogenital infections, risk factors and data on antibiotic consumption. Apart from the GPIU main study, several side studies are taking place; currently, the side study evaluating prostate biopsy is amongst the most important. The GPIU study has been annually performed since 2003. Due to the tremendous and enthusiastic participation of more than 1000 hospitals/ centres from 70 countries, screening of 27,542 patients took place over the last years, and which yielded important information about infection-related issues of urological patients. The collected information is not available in any other sources. Aims of GPIU The primary aims of the study are to do the following in urology departments throughout the world: (1) Evaluate urology practice in terms of hospital infection control, which includes: a. Control programs 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 ESIU (European Section for Infections in Urology) / European Association of Urology (EAU) recommendations, and (3) Certificate for infection control. Easy web-based participation GPIU is an international internet web-based study. All patient information is reported anonymously to the central study file. The study is fully sponsored by the EAU. EAU EAU Section Section of of Urolithiasis Infections in(EULIS) Urology (ESIU)

August/September 2017

The internet web-page for this year's participation is: http://gpiu.esiu.org/ Impressive enrollment of patients A total of 27,542 patients were so far screened in the GPIU studies between 2005 and 2015. Healthcare-associated infections in urology were seen in around 11%, with one-third being severe infections, such as urosepsis or pyelonephritis. There were also significant differences between regions and types of hospitals1,2. GPIU collates key intelligence information The studies showed that the bacterial spectrum is comprised of pathogens Escherichia coli (31%), followed by species of Pseudomonas (13%), Enterococcus (10%), Klebsiella (10%), Enterobacter (6%) and Proteus (6%). Candida spp. and Pseudomonas spp. occurred significantly and more frequently as causative agents in urosepsis than in other types of infections. 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 resistance rates of most of the uropathogens against the antibiotics tested did not show significant 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 Asia4. GPIU addresses key aspects of EAU guidelines As antibiotic prophylaxis is an important part of antibiotic consumption, data on routine antibiotic prophylaxis have been evaluated showing that antibiotic prophylaxis in urological patients was highest in Latin America (84%), followed by Asia (86%), Africa (85%), and Europe (67%)3,5. The antibiotics most frequently used for prophylaxis were second-generation cephalosporins, ciprofloxacin, cefotaxime, and amoxicillin plus beta-lactamase inhibitor. 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 guidelines6. 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.

"On behalf of the EAU, the ESIU has suggested a new concept of classification of UTI. It is recommended that a case of UTI is described by a severity grade from 1-6 and risk factors are described by phenotyping in the ORENUC system5" GPIU addresses 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 pathogens7. To expand the database and receive more information in this important field, the prostate biopsy side study will also be performed in 2017. GPU challenges 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

Box 1: Benefits for GPIU-Investigators • On-line certificate of infection control • Statistics on-line • Recognition in GPIU publications • Slides with study results Box 2: Study dates for 2017 Please choose one day in one of the following periods in November 2017: 1-3 November 7-9 November 14*-16 November

21-23 November 28-30 November

*The 18th November 2017 is also the Antibiotic Awareness Day of the European Centres for Disease Control - ECDC

Box 3: Practical guide for GPIU investigators: 1. D  ecide on the most desirable study day for your department. 2. Log-on to the GPIU-Internet address and register yourself as investigator and fill in the fields requested to achieve EU-ACME points (http://gpiu.esiu.org/) 3. You may print out pdf´s 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 side 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 side 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 2018. 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.

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 (Box 4). On behalf of the EAU, the ESIU has suggested a new concept of classification of UTI. It is recommended that a case of UTI is described by a severity grade form 1-6 and risk factors are described by phenotyping in the ORENUC system5. GPIU draws attention to urosepsis During recent GPIU studies we have seen an increase in the reported percentage of urosepsis8. In 2006, the percentage of HAUTI being urosepsis was 9.3%, in 2007 it was 15.4% and in 2008 it was 21.8%. The ESIU believes this might be due to more blood cultures being taken which is also in accordance with general recommendations. However, in order to avoid a too high registration of urosepsis investigators are encouraged to stick to the definitions of urosepsis presented in the ESIU guidelines. Resistance to antibiotics is continuously increasing, which is the strongest argument ever for taking part in the GPIU-study! With few new antibiotics against gram negative pathogens in the pipeline, it is crucial that we use those we have in a prudent way.

Box 4: Important modifications of the CDC/ NHSN criteria which will be used in the GPIU 2017 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 asymptomatic 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, since the treatment of ASB has to be initiated before any such interventions. Therefore, screening for HAASB should be included into the upcoming GPIU study; however, 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

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. Cek M TZ, Naber K, Tenke P, Wagenlehner F, van Oostrum E, Kristensen B, Bjerklund Johansen TE. Antibiotic Prophylaxis in Urology Departments, 2005-2010. Eur Urol 2012;in press. 7. 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 2012;epub ahead of print. 8. 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.

European Urology Today


Three-dimensional printing technology in urology 3D printing in medicine to expand as research discovers new applications Dr. Aurus Dourado Meneses São Marcos Hospital Teresina (BR)

Other models were developed. Shin et al. reported three-dimensional printed model of prostate anatomy to facilitate nerve-sparing prostatectomy9. Srougi et al. reported the use of three-dimensional printers to estimate the resection limits for partial adrenalectomy10. Ataley used pelvicalyceal system 3D printed models on residents' understanding of pelvicalyceal system anatomy before percutaneous nephrolithotripsy surgery11.

aurusdm@gmail.com Co-authors: J. Gomez Rivas, K. Ahmed, G. Cacciamani, D. Veneziano, Z. Okhunov and S. de Cassio Zequi (YAUWP Group - Uro-Technology & Communication) Three-dimensional (3D) printing is an additive manufacturing process that has been first introduced in 1984 by Charles Hull, with the invention of stereo lithography apparatus (SLA - a photosensitive resin polymerised by an UV light)1. Since the inception of this new concept, technology has significantly evolved allowing the engineers and designers to make 3D models using digital objects.

Education and training The advent of 3D printing to develop training devices and simulation models for surgical training and education proved to be a valuable tool in several medical fields, namely maxillofacial, orthopaedics, vascular, cardiac, neuro, thoracic, and liver surgeries and several others. In urology, simulation-based training is being increasingly used for trainees as a means of overcoming the learning curve associated with new surgical skills and 3D printing presents unique opportunities for the direct ‘‘printing’’ of organ structures.

Blankstein et al. designed flexible ureteroscopy course using ureteroscopy model in which bladder, In the following years, several types of manufacturing single calyceal and double calyceal models were 3D technologies were developed enabling the production printed with a translucent, acrylonitrile butadiene styrene (ABS)-like, plastic material and dyed red to of 3D objects with different printable materials, simulate internal colour and translucency. The mean ranging from different types of polymers, ceramics, post-course task completion times and overall wax, metals to human cells. As one of the fastest performance scores were significantly better than at areas of industry expansion, 3D additive manufacturing is changing techniques in biomedicine. baseline and lead to improved short-term technical skills among junior level urology residents12. Therefore, it is not surprising that in the last 15 years 3D printing had a rapid expansion and impacted different areas of medicine and pharmaceuticals, and Golab reported the use of 3D personalised silicone replica for partial nephrectomy (PN) training. The it has been used to pattern cells; make tissues, authors, prior to each PN, simulated the procedure on organs; construct surgical replicas for planning, laparoscopic trainer with patient-specific silicone counselling and training; build medical devices and model. They concluded that the experience gained prosthetics and in numerous other biomedical during training with silicone models improved the applications. performance on surgery and possibly reduced the need and duration of intraoperative renal ischemia13. In urology, 3D printing has been used for several Ghazi et al. in Rochester developed kidney models for purposes and in this article we present the current training, which simulates kidney anatomy with state of technology as well as its potential impact in tumour and bleeding vessels simulating blood flow translational and clinical medicine. for robotic and laparoscopic partial nephrectomy training. Surgical planning and patient counselling It is important to note that even in the age of Atalay et al. printed five personalised pelvicalyceal advanced imaging technology, the pre-operative system models which were used for patient surgical planning is based on multi-detector information in percutaneous nephrolithotripsy computer tomography (CT) allied with conventional surgery. Patients demonstrated an improvement in techniques of reconstruction such as multi-planar their understanding of basic kidney anatomy by 60%, reconstruction (MPR), maximal intensity projection kidney stone position by 50%, the planned surgical (MIP) and volume rendering or magnetic resonance procedure by 60% and understanding the imaging. complications related to the surgery by 64%11. However, these conventional techniques have some Additionally, Okhunov at the University of California, limitations. For instance, they are unable to present the reconstruction of all structures at the same time in constructed 3D printed models of human kidneys with extensive urolithiasis and used these models to assist the same image (intrarenal arterial branches, in preoperative planning to determine the optimal acquired on the arterial phase and the enhanced collecting system, and obtained at the excretory phase percutaneous nephrostomy tract for percutaneous for example), compelling the surgeon to form mental nephrolithotomy (PCNL). By using fused deposition maps based on two-dimensional (2D) images in gray modelling of white thermoplastics, they were able to print kidney parenchyma and staghorn stone scale. This task is even harder in complex cases, separately with anatomically-correct size and shape, especially for trainees and patient’s comprehension. and by using polyjet printing they were able to construct a rubber-like kidney. Models were used for To address this limitation, several publications using 3D printed physical renal models have been published. residents and fellow’s education resulting in a higher familiarity with the shape and orientation of the stone The real size of the models, coloured structures and the tactile sensation by touching the 3D printed kidney and led toward greater overall confidence in performing PCNL14. allowed more fully understanding of the kidney anatomy, especially the interrelationship among the kidney, tumour, vasculature and collecting system. The Kusaka et al. used individual 3D printed models to plan and guide the surgical procedures for authors noted that trainees, patients and their family members reported an improved comprehension of the laparoscopic donor nephrectomy and recipient transplantation surgery. Replicas obtained using tumour’s anatomy and the proposed surgical plan2-4. Wake et al. reported 30-50% of surgeons changed the transparent materials allowed for the creation of surgical approach after visualisation of 3D models and models with visceral organs, blood vessels, and other details and enabled surgeons and trainees to virtually Maddox reported less blood loss in partial treat various pelvic conditions, simulate the procedure nephrectomies planned with physical models5-6. before they perform the surgery, allowing a shorter But only small series addressed this topic and the real operative time and decrease donor risk15. impact of these models on outcomes need to have a better evaluation with future studies. Our institution is Applications in imaging 3D printed technology has been used successfully to currently constructing 3D-printed models of human design and create patient-specific phantoms of kidneys to plan nephron-sparing surgery and the impact of 3D printing, virtual models, and holograms several organs based on DICOM files from CT and MRI for dosimetry analysis and planning of radioactive is the topic of an ongoing study (Figure 1)7. We also seed implantation. Personalised phantoms were also developed an online platform and apps for used for planning interventional imaging-guided smartphones to evaluate the role of virtual procedures and for training fellows to perform reconstructions (www.docdo.com.br). Marconi et al. laparoscopic ultrasonography16-18. Patient-specific reported no differences in anatomy comprehension 8 phantoms may offer the potential advantage of comparing virtual model and 3D printing . Our initial impression is that virtual models and holograms may increased targeting precision of radiation therapies, have the same impact in surgical planning compared which might well result in improved outcomes and diminished complications. with 3D printed models. 30

European Urology Today

Surgical equipment In the past few years, several studies have evaluated the feasibility and cost effectiveness of creating surgical instruments using this 3D printing. This technology is capable of manufacturing low-cost and customisable surgical devices. Several institutions have successfully printed and tested basic surgical instruments including retractors, needle drivers, forceps, surgical clips and ureteric stents19-20. Initial results are promising; however, vigorous testing will be required to assess the safety, quality, and function compared with those commercially available. Bioprinting and personalised medicine Bioprinting is the application of additive manufacturing process to the biomedical field, defined as the layer by layer deposition of biologically relevant material, cells and supporting components into complex 3D functional living tissues. Considered as the holy grail of 3D printing technology, the vision is to have a future where humans can replace damaged and failing organs by simply 3D bioprinting. But despite being a distant reality it has already been utilised for several purposes such as fabrication and modelling of living tissues and organs for medical applications, for drug screening in the pharmaceutical industry, personalised medicine, regenerative medicine, cell-based biosensors and bionics21-22. Up to the present, 3D bioprinting has been used to generate skin, cartilage, bone, and vascular tissues, successfully transplanted in humans in some reconstructive surgeries23-24. However, bioprinting more complex tissues consisting of multiple cell types present diverse challenges that must be overcome in order for clinical studies to become a reality. In urology, there are some initial attempts of tissue reconstruction focused on urethral and bladder tissue engineering using collagen-based scaffolds seeded with urothelial and muscle cells. Zhang et al. recently published their initial results using an integrated bioprinting system to fabricate cell-laden urethra in vitro using PCL and PLCL polymers with a spiral scaffold design, which demonstrated mechanical properties equivalent to the native urethra in rabbit25. Therefore, 3D printing has the potential to replace traditional tissue engineering. In the near future, 3D bioprinting technology may be useful in designing customisable urethra or bladder shaped scaffolds used in tissue engineering or it may allow physicians to generate entire urethra and bladders for urethral strictures treatment and bladder replacement. Parallel to an explosion of articles on 3D printing in the medical field, a crescent numbers of researchers with new ideas and applications have emerged; printers continue to improve with higher speed, lower costs and more contemporary printing materials. There is no doubt that in the near future, 3D printing will be more present in medicine. Thus, it is essential that urologists stay up to date and follow the progress of 3D printing and its possible applications.

Association of Urological Surgeons, 2015. v. 1. p. 89-89. 4. Komai Y, Sugimoto M, Kobayashi T, Ito M, Sakai Y, Saito N. Patient-based 3d printed organ model provides tangible surgical navigation: a novel aid to clampless partial nephrectomy. Journal of Urology. 2014;191(4):e488-e9. 5. Wake N, Rude T, Kang SK, Stifelman MD, Borin JF, Sodickson DK, Huang WC, Chandarana H. 3D printed renal cancer models derived from MRI data: application in pre-surgical planning. Abdom Radiol (NY). 2017 May;42(5):1501-1509. 6. Maddox MM, Feibus A, Liu J, Wang J, Thomas R, Silberstein JL. D-printed soft-tissue physical models of renal malignancies for individualized surgical simulation: a feasibility study. J Robot Surg. 2017 Jan 20. 7. Meneses AD , Rocha BA, ; Mattos PAL, Nogueira AT, Araujo FMA, Saraiva AA, Zequi SC. SinHapticMed: a new Gesture-controlled tool to assist navigation of kidney anatomy in three-dimension during minimally invasive nephron sparing surgery. In: 33 World Congress Of Endourology & SWL, 2015, London. WCE 2015 Simulate. Collaborate. Educate. London: The British Association of Urological Surgeons, 2015. v. 1. p. 65-65. 8. Marconi S, Pugliese L, Botti M, Peri A, Cavazzi E, Latteri S, Auricchio F, Pietrabissa A. Value of 3D printing for the comprehension of surgical anatomy. Surg Endosc. 2017 Mar 9. 9. Shin T, Ukimura O, Gill IS..Three-dimensional Printed Model of Prostate Anatomy and Targeted Biopsy-proven Index Tumor to Facilitate Nerve-sparing Prostatectomy. Eur Urol. 2016 Feb;69(2):377-9. 10. Srougi V, Rocha BA, Tanno FY, Almeida MQ, Baroni RH, Mendonça BB, Srougi M, Fragoso MC, Chambô JL. The Use of Three-dimensional Printers for Partial Adrenalectomy: Estimating the Resection Limits. Urology. 2016 Apr;90:217-20. 11. Atalay HA1, Canat HL1, Ülker V2, Alkan İ1, Özkuvanci Ü3, Altunrende F1. Impact of personalized three-dimensional -3D printed pelvicalyceal system models on patient information in percutaneous nephrolithotripsy surgery: a pilot study. Int Braz J Urol. 2017 May-Jun;43(3):470-475 12. Blankstein U, Lantz AG, D'A Honey RJ, Pace KT, Ordon M, Lee JY. Simulation-based flexible ureteroscopy training using a novel ureteroscopy part-task trainer. Can Urol Assoc J. 2015 Sep-Oct;9(9-10):331-5. 13. Golab A1, Smektala T2, Kaczmarek K1, Stamirowski R1, Hrab M3, Slojewski M1. Laparoscopic Partial Nephrectomy Supported by Training Involving Personalized Silicone Replica Poured in ThreeDimensional Printed Casting Mold. J Laparoendosc Adv Surg Tech A. 2017 Apr;27(4):420-422. 14. Youssef RF, Spradling K, Yoon R, Dolan B, Chamberlin J, Okhunov Z, Clayman R, Landman J. Applications of three-dimensional printing technology in urological practice. BJU Int. 2015 Nov;116(5):697-702. doi: 10.1111/ bju.13183. Epub 2015 Jun 23. Review. 15. Kusaka M, Sugimoto M, Fukami N, Sasaki H, Takenaka M, Anraku T, Ito T, Kenmochi T, Shiroki R, Hoshinaga K. Initial experience with a tailor-made simulation and navigation program using a 3-D printer model of kidney transplantation surgery. Transplant Proc. 2015 Apr;47(3):596-9. 16. Tran-Gia J, Schlögl S, Lassmann M. Design and Fabrication of Kidney Phantoms for Internal Radiation Dosimetry Using 3D Printing Technology. J Nucl Med. 2016 Dec;57(12):1998-2005. Epub 2016 Jul 21.

References 1. Hull, C.W. UVP Inc. Apparatus for production of three-dimensional objects by stereolithography, US 4575330 A. 2. Silberstein JL, Maddox MM, Dorsey P, Feibus A, Thomas R, Lee BR. Physical models of renal malignancies using standard cross-sectional imaging and 3-dimensional printers: a pilot study. Urology 2014; 84: 268–72. 3. Meneses AD, Mattos PAL ,Silva RD, Rocha BA, Nogueira AT, Stolzenburg JU, Zequi SC. 3D printing: a new tool in preoperative surgical planning of complex minimally invasive nephron sparing surgery. In: 33 World Congress Of Endourology & SWL, 2015, London. WCE 2015 Simulate. Collaborate. Educate. London: The British

References 17-25 are available on request at eut@uroweb.org.

Figure 1: Von-Hippel-Lindau Syndrome. A) Coronal contrast enhanced CT scan B) 3D printed model of the right kidney, posterior view. Blue: tumour; purple: cyst; pink: arteries; violet: collecting system; translucent: kidney surface. Source: www.docdo.com.br

August/September 2017

Simulation in urology Is virtual reality the new frontier? Dr. Francesco Sanguedolce Fundacio Puigvert Autonomous University of Barcelona Barcelona (ES) fsangue@ hotmail.com

Prof. Humberto Villavicencio Head of the Urology Dept. Fundacio Puigvert Autonomous University of Barcelona (ES) hvillavicencio@ fundacio-puigvert.es Traditionally, training in surgery has been for many decades –if not centuries- managed by following the principle of “surgical schools” where the prominent local professor taught his art by directly showing his practice to the most talented fellows. In most cases it was mainly a matter of “stealing the art” with the smartest of the trainees watching or even using only their imagination. However, in the last few decades the approach to surgical training has been a topic of growing importance for several reasons, such as: 1) Increased awareness of patients’ safety and rights which has raised concerns on accepted practices; 2) Quickly evolving technologies which have highlighted the need for proper learning curves to reduce costs; 3) Growing pressure in hospitals obliges surgical departments to maximise use of operating theatres; and

4) Standardisation of health care provision worldwide involves the necessity of standardised training across countries and beyond cultural or political differences. A modular step-wise approach to surgical technique has been widely agreed as the most appropriate method for the learning process; this includes a first cognitive phase where the trainee has to go through theory and evidence regarding the surgical technique in question. A second phase involves exposure to simulation for the trainee to acquire proficiency on targeted surgical abilities and confidence with the new technology. The last phase is when the trainee performs in the operating theatre pre-defined steps of the surgery based on different grades of difficulties to gain progressive proficiency. In this process, one of the most crucial issues is the type of simulation which should be included in the curriculum, considering that the speed of the learning curve significantly depends on it. In the past few years, several simulation models have been proposed. Most of the senior urologists would remember courses on transurethral resection of the prostate with apples used as substitutes for prostates. Many other practitioners have been developing laparoscopic skills in the pelvic trainer boxes by using bench models.

ludic settings (e.g. videogame, cinema, etc.) to training professionals. Paradigmatic is the employment of virtual reality in aviation training. When we travel by airplane our lives are “at the mercy” of skilled pilots who have spent many hours on virtual reality simulators before they pilot a plane. The International Civil Aviation Organisation (ICAO) recommends the VR and AR as The team at Fundació Puigvert responsible for the virtual essential tools for the training programmes of aviation reality simulation lab. From left to right: Dr F. Sanguedolce, pilots. Dr E. Emiliani, Dr H. Villavicencio, Dr J. Gaya Similarly, in urology the use of VR is rapidly expanding. Endourological, laparoscopic and robotic surgeries have been the main fields where VR platforms have been developed. However, introduction of smart or highly technological software is not enough for them to be routinely introduced in the training curricula. As in any simulation model, complex validation studies need to be undertaken to make sure these tools are really well designed to successfully transfer skills with the exercise.

A recent systematic review from A. Aydin et al. assessed evidence in literature regarding simulation and training models in urology. Overall, they found 55 models whose efficacy was mostly classified with a level of evidence 2, with only one –the virtual reality platform for endourology called UroMentor- receiving a level 1 recommendation. Authors also highlighted Some centres could even offer ex-vivo or even in-vivo the lack of standardisation of validation processes animal models; however, in many countries nowadays across the studies as well as the need for a more extensive application of validation studies to identify these practice are deemed not legal due to religious the optimal simulation models and the appropriate or cultural concerns, or because they can potentially training curricula. jeopardise hospital policies on cleanliness and infection control. The importance of standardising training curricula is In other institutions, surgical training on cadavers was reflected by the growing need of urological residents also proposed even though its accessibility is even to receive adequate exposure during training for them more restricted. to safely operate once they are qualified. Two independent surveys conducted among Italian and In the meantime, technology has also benefitted German residents highlighted that only a small surgical training: virtual and augmented realities (VR, number (< 5%) of residents are used to perform major AR) have been introduced in many contexts, from or complex procedures by the end of their residency.

Virtual reality and augmented reality are likely to progressively take a predominant part in the training curricula to fulfil both national health care needs as well as trainees’ expectations. The current major limitation of VR is the cost of the devices and software which mostly are available in a few centres of reference; however, institutions may eventually find profit in the long-term by investing in this technology, thanks to hypothetically shorter learning curves and a higher level of proficiency gained by users. Nevertheless, more efforts are needed to increase accessibility and fidelity of simulation models to help strengthen and standardise training curricula. References are available on request at eut@uroweb.org.

The virtual reality simulation lab at Fundació Puigvert includes endourological, laparoscopic and robotic platforms



EAU 17th Central European Meeting (CEM) in conjunction with the national 63rd annual conference of the Czech Urological Society (CUS) 19-20 October 2017, Plzen, Czech Republic CEM17 to focus on core and current urological issues Current topics in urology including major issues in onco-urology, urolithiasis, reconstructive and female urology, among others, will be examined in the 17th EAU Central European Meeting (CEM17) to be held in Plzeň, Czech Republic, from 19 to 20 October 2017. “We will focus on questions we encounter in everyday clinical practice, mainly key issues in onco- urology, urolithiasis, reconstructive and paediatric urology, female urology and voiding dysfunction,” said Prof. Milan Hora (CZ), conference president and Vice-Chairman of the Czech Urological Society (CUS). “A special session is going to be dedicated to basic research in urology and will be led by urologists skilled in urological research.” The two-day meeting will also be unique in the sense that it will be the first time the 63rd Annual Conference of the US will incorporate the CEM, highlighting the meeting’s aim to offer active links not only among urologists in Central Europe but also with their colleagues from other countries. Together with CUS Chairman Prof. Marko Babjuk (CZ) who chairs CEM17’s Scientific Programme, Hora said live surgeries will be presented to examine modern techniques in the treatment of stone disease. “There will be cases involving techniques such as retrograde intra-renal surgery (RIRS), particularly flexible ureteroscopy, and the combination of RIRS with percutaneous nephrolithotomy (PCNL). Moreover, there will be free hands-on training in laparoscopy including E-BLUS testing,” added Hora.

Babjuk said CEM17 provides a platform for urologists and other related specialists in the region to exchange expertise, insights and best practices. “An annual meeting such as CEM17 is a timely opportunity not only to get the latest updates but is also an initiative to boost and foster good relations with our colleagues whether they are in clinical practice or in research,” said Babjuk. To emphasise the international and multi-disciplinary approach of the organisers, Hora said guest speakers will come from various disciplines. “We look forward to the presentations of special guests such as Dr. O. Hes, (Plzeň, CZ), a pathologist and a member of the WHO group in the 2016 classification of uropathology, and Prof. L. Dušek (CZ), a statistician who will discuss cancer statistics in urology. Both of them will speak during the session “Beyond the Frontiers of Urology,” said Hora.

Organisers of CEM17

Opportunities for young urologists Both Babjuk and Hora underscored that boosting urological practice in Central Europe can only be possible by providing the right opportunities to young urologists in terms of education, training and by stimulating research initiatives. “To improve urology in our region, we need to foster the right environment for young urologists and this is not only for clinical practitioners, but also for researchers. With support from regional leaders and from pan-European organisations such as the EAU, we can achieve more,” said Hora. As in previous CEM events, the session Young Urologist Competition will be held and this year urologists from eight countries will examine a range of topics ranging from prostate and kidney cancer to male incontinence. The competition will involve a 10-member jury who will assess the presentations in terms of content, insights, and presentation style, among others. Outcomes from new and ongoing research will be highlighted in the abstract sessions and the goals are to link-up researchers and draw attention to innovative work. “Young urologists can present their research to an international audience, and they can introduce their work in such a way that links among researchers will be facilitated. By discussing methodology or the results of their studies with other researchers and their colleagues, we will have a more dynamic discussion and, perhaps, open up new opportunities,” said Hora.

For details on registration, venue and other general information, visit the meeting website at: www.cem17.org August/September 2017

European Urology Today


Young Urologists/Residents Corner New YAU working party: Uro-technology & Communication Highly specific expertise needed to support EAU Sections and YAUWP groups Dr. Domenico Veneziano Chairman, YAU Uro-Technology working group Reggio Calabria (IT)


Dr. Juan Gómez Rivas ESRU Chairman-elect Member, YAU Uro-Technology working group La Paz University Hospital Madrid (ES) @JGomezRivas

Uro-Technologies and Communication Group: Zhamshid Okhunov: University of California Irvine, USA; Kamran Ahmed: King’s College and Guy’s Hospital, London, UK; Aurus Dourado Meneses: Camargo Cancer center, Sao Paulo, Brasil; Giovanni Cacciamani: University of Verona, Italy. University of California LA, USA; Hendrik Borgmann: Johannes Gutenberg-Universität Mainz, Mainz, Germany. In the last decade there has been an exponential growth of new technologies in urology. Surgical simulators, sensors, three-dimensional (3D) printers, augmented reality and 3D Virtual Reality have become an essential part of routine urologic surgery skills training. Additionally, the expansion of social media have shifted educational and news resources to online platforms. According to a short survey conducted this year, only 18% of urologists receiving the European Urology journal actually read it. Gomez Rivas et al. in a survey published in European Urology Focus in 2016, found out that urologists preferred news sources are Facebook, followed by YouTube, Twitter and other social media platforms.

Knowledge of these tools is needed in order to “think out of the box” and provide us with an understanding on how they can be applied in our daily clinical/ surgical practice. Focusing on each technology and combining them is not only necessary to achieve our goal but may also facilitate collaboration among experts that could lead to possibly revolutionary findings.

• Giovanni Cacciamani: Urology resident at the University of Verona. Fellow in educational tools and protocol development at the University of Southern California, LA, USA.

monitoring treatment response. In oncology, the need for accurate visualisation of tumours during surgery to ensure successful removal of all of the cancerous tissue with curative attempt, while preserving healthy tissue, has spurred the The first on-line meeting of the group was held last application of image guidance in the operating July in 4 different time zones (California, Sao Paulo, room. London and Central European time). After a • Bio Sensors for stress management in training and productive meeting, a list of potential projects for this surgery. Surgery and stress go hand-in-hand. novel working group included the following: According to a list compiled a few years ago, "YAU Uro-Technology working party surgery was considered the fourth most stressful • Video-tracking for training assessment and job, preceded only by firefighters, big CEOs and has created a Twitter account tele-mentoring and pre-recorded mentoring with taxi drivers. Creating a bio sensor for stress @EAU_YAUroTech to keep in touch 3D or 360° glasses. Tele-mentoring is a form of management might potentially reduce the virtual mentoring that enhances medical consequences of this condition. with everyone in the urological education programmes and provides better • Mobile app development for patient community." opportunities for continuing education and communication. Successful communication professional development for health workers and between patients and their health care provider With these goals in mind, a new working party for GPs in remote areas. is a key factor in providing quality health care. Uro-Technologies and Communication was created • 3d printing for surgical planning, training/surgical Methods other than conventional e-mail are during the last Young Academic Urologists (YAU) instrument prototyping and testing. When being studied and developed to address board meeting. The group will be chaired by Dr. presented with a complex surgery or abnormal communication barriers and personalised Domenico Veneziano (Reggio Calabria, Italy) and was anatomy, surgeons have always sought out information between physicians and patients; tasked to facilitate the approach to the latest means to plan the safest possible surgery. From and technologies with the final goal of supporting the EAU the early days of X-rays to the modern CT and MRI • New presentation formats, software, technologies. Sections and other YAUWP groups with highly specific scanning technology, the desire to provide their Although Microsoft PowerPoint has become expertise. Members have been admitted for their patients with the safest treatment possible has almost synonymous with presentations, it is not focused knowledge in different fields of technology driven the advance of surgical planning the only tool to get slides on-screen. There are and their experience in communication using new techniques. With 3D printing technologies other free tools that help create even more tools (SoMe, TED, new software like Prezi). All becoming more accurate and accessible, medical attention-grabbing slideshows and increase our recommended members are already EAU members professionals are increasingly turning to tools like communication skills. and provided a regular application to join the new 3D printers to acquire surgical reference models. working party. Based on the YAUWP requirements, • Novel broadcasting methodologies for educational The YAU Uro-Technology and Communication Group some of the applicants were accepted as full events and use of social media and their relevance will directly collaborate with the European Society for members, while others were designated as in clinical practice. SoMe and new broadcasting Urologic Technology (ESUT) to provide the board associates. Below is the list of officers: technologies represent a vibrant area of members with innovative ideas that could be opportunities for communicating knowledge in developed in the future. • Juan Gomez Rivas: Hospital Universitario la Paz, health care and their potential applications today Spain. Researcher in the field of Social Media and are unquestionable; however, its development in In line with its scientific goals, YAU Uro-Technology smartglasses technology. the urological community is still in infancy. At and Communication working party has created a • Zhamshid Okhunov: University of California Irvine, present the benefits include communication Twitter account @EAU_YAUroTech to keep in touch USA. Expert in 3D printing applied to surgical between associations, urologists, residents, other with everyone in the urological community. We instruments and simulation tools. health care professionals and patients. SoMe encourage you to follow us on Twitter to stay up to • Kamran Ahmed: King’s College and Guy’s facilitates networking, dissemination of study date with our news and progress. Hospital, London, UK. Expert in educational tools, results as well as extensive monitoring of events, non technical skills and bio-measurements. conferences and meetings. In fulfilment of YAU’s core aims, the new group will • Aurus Dourado Meneses: Camargo Cancer center, • Use of fluorescence for surgical land marking and work and research strong evidence on the latest Sao Paulo, Brasil. Expert in 3D printing for IR thermal imaging for surgery: Today, medical technologies and create a platform to enable a closer surgical planning and developer of a dedicated imaging methods have become indispensable in international cooperation among Europe’s urology translational app for mobiles. oncologic diagnosis, treatment planning, and leaders.

Is there a need for a Residents’ Corner in UROsource? Residents consult UROsource but usage frequency is not optimal Dr. Diederick Duijvesz Urologist Canisius Wilhemina Hospital Nijmegen (NL) d.duijvesz@cwz.nl

@DuijvesD Online platforms for training are becoming increasingly important. These easily accessible and extensive databases contain a lot of (clinical) useful information for daily practice. In the field of urology, UROsource is the largest single platform available. It contains over 50,000 items of scientific content varying from the EAU Guidelines, videos of surgical procedures, webinars, articles from urological conferences, and other interesting information.

the need for a Residents’ Corner. This survey was distributed amongst residents via the National Communication Officer (NCO) representing their country and social media (Facebook and Twitter). From a total of 136 respondents, 42.2% was female and 57.8% was male. The year of residency was equally distributed, with six responses from researchers/not in training and 22 responses from certified urologists. Residents from almost all countries in Europe completed the survey, with a high response rate from Spain, Belgium, Denmark, Slovakia and Germany. Some responses came from the United States, Argentina, Honduras and Kenya which could indicate that the need for a ‘Residents Corner’ should not only be limited to Europe.

Around 56.7% of the respondents have never heard about UROsource nor has ever used it before. From the residents that do use UROsource, 23.4% use it once a month and 9.9% once a week. The most interesting topics that are read or viewed are the EAU Residents also use this database, but are having Guidelines, surgical procedures, E-courses, webinars problems in selecting the right content from all that is and the European Urology. Although a minority of available. In collaboration with UROsource, we started residents used UROsource, only 28.3% of them can a Residents’ Corner in their website. This part of find all the information they need. Searching on the UROsource has been constructed with selected topics website is considered to be easy and the lay-out is that are of interest to residents. Before we could well organised, but the topics are too many. effectively select the right content, we conducted a survey amongst residents for an inventory of their When we asked the residents what they think about a needs. Residents’ Corner, 85.6% replied that it could be very useful and 65.9% would use UROsource more often in Using SurveyMonkey we created a survey containing daily practice. Also, 70.7% think that it would become 18 questions about the current use of UROsource and easier to find content that is of specific interest for 32

European Urology Today

residents when this sub-category is available. Within the Residents’ Corner there is a special need for videos of surgical procedures, E-courses, hands-ontraining, ESU-course books, guidelines and also webinars and live surgery. There is less interest in the European Urology Journal, History of Urology, Patient Information and meeting content.

In conclusion, UROsource is used by residents but the number and the frequency of usage could still be improved. There seems to be a special need for selected item such as surgical videos with detailed anatomy, E-courses, guidelines and hands-on training. These topics will be included in the Residents’ Corner.

Although UROsource contains a vast amount of content, residents want more step-by-step surgery with detailed anatomy (surgical anatomy atlas for urology). Also, basic procedures that are performed in the beginning of their training (e.g. scrotal surgery) would be very helpful. Participants also requested for a selection of existing videos so it will be easier for residents to find the content they are looking for.

Currently, we are going through the database to search for videos that could be of interest for residents. If residents are missing certain videos we would like to encourage them to make these videos themselves. Guidance, tips and tricks will be provided via ESRU (esrusecretary@gmail.com)

www.urosource.com August/September 2017

Young Urologists/Residents Corner Working conditions after urology training Spanish residents remain insecure on employment opportunities Dr. Miguel García Sanz Urology resident University Hospital León Webmaster Léon (ES) @ResidentesAEU

Dr. Moisés Rodríguez Socarrás NCO, Webmaster @ESRUrology Team @ResidentesAEU University Hospital Alvaro Cunqueiro Vigo (ES)

Dr. Juan Gómez Rivas ESRU Chairman Elect Chair of the Spanish Residents and Young Urologist Workgroup YUO-EAU Board Member Madrid (ES) @JGomezRivas To be eligible for a training position in urology in Spain one must pass the Medico Interno Residente (MIR) exam. The exam consists of 235 questions concerning general, medical and surgical knowledge. Based on your score, you may choose a position as resident in any specialty including urology.

Approximately 7,200 students get a position each year, while in the 2016-2017 call, a total of 6,328 MIR posts were requested, of which 93 are in urology.

Contract period

Satisfaction with working conditions

Frequency of contract renewal

Have you considered migrating to another country

The duration of urology training in Spain is five years, after which the new young urologist must face the challenge of looking for a job to continue a professional career in the early years after residency. Currently, there are no unemployed urologists in Spain due to the economic recovery in recent years. Still, employment contracts are in poor and unstable conditions compared with other EU countries. Nationwide job opportunities for new specialists vary considerably depending on the geographical area within Spain, and whether the employer is a public or private company. Additional factors like pensions, work placements and exams for fixed positions within the public health system make placements unpredictable at times. A few years ago, the professional demand led to more contracts and most of them with better conditions than what Spanish residents can find at the end of their specialty. This scenario encourages new specialists to seriously consider the idea of going abroad where working conditions may be better.

contract every one to six months, followed by 18% who ask for renewal between six to 12 months, while only 14% were accorded annual renewal. Regarding salary levels, 47% earn between 2,000 and 3,500 euros monthly.

To determine the current status of offers and working conditions available to new specialists in urology, the Working Group of Residents and Young Urologists of the Spanish Association of Urology (RAEU) carried out a survey of young urologists (who had completed their Other aspects included in the survey were hours worked per week, number of duties as specialists and specialty in the last five years) who were asked about their working conditions following their residency. the types of duties. According to responders, 77% have a work contract for 30 to 50 hours per week, We obtained responders from 14 different states of 43% perform four to six night shifts per month, 80% Spain (autonomous communities); 33% of the of which are "on-call". respondents have obtained a permanent or indefinite contract, 62% work in public hospitals, 11% work These results highlight why 43% of young specialists have seriously considered emigrating for work or exclusively in private centres and 27% reported working in both public and private centres. Contracts fellowships. Despite this, more than half of for young urologists in Spain are often short and are responders or 55% are satisfied with the job opportunities they have found at the end of their renewed with varying frequency. According to our survey, 57% of respondents have to renew their residencies.

What type of hospital do you work in?

In recent years, we have seen conditions of employment with less temporary stability and, on the other hand, a greater number of employable professionals. So, although time will tell, the situation in the near future still lacks the stability we would hope for.

Spanish urology residents compete in annual contest Asturias team wins Urology Cup-ACTAS Dr. Diego Carrion Hospital Universitario La Paz Madrid (ES)

diegocarrionm@ hotmail.com

The 3rd Urology Cup-ACTAS contest took place last June 10 during the National Congress of the Spanish Urological Association in Seville, Spain, with the endorsement of Actas Urologicas Españolas, the official journal of the Spanish Association of Urology (AEU) and the American Confederation of Urology (CAU). The event gathered 27 residents from all over Spain, which were grouped in teams of three based on the hospital or region of residency. The event’s main goal

The winning team from Asturias, Spain. From left: María de los Llanos Pérez Haro, Cristina González Ruiz de León (Hospital Universitario Central de Asturias, Oviedo, Spain), Corina Pérez García (Hospital Universitario de Cabueñes, Gijón, Spain).

Participants during the initial rounds

winners competed in the finals with five more multiple-choice questions. Around 50 people attended the event, which was marked with enthusiastic cheering from the audience. The clinical cases prompted insightful comments and discussions by the panel, participants and the audience.

was to review and resolve clinical situations encountered by residents in their daily practice and to promote knowledge exchange. The contest included a clinical case addressing a relevant topic and prepared by the organisation committee. The contest featured four multiple-choice questions, and 10 questions based on relevant papers published in Actas Urologicas Españolas in the last two years.

The event drew a good attendance

August/September 2017

Initial rounds involved three teams, with each winner advancing to the semi-finals, while second-placed teams competed to select the fourth semi-finalist. The semi-finals involved four teams and the eventual

Participating residents enjoyed the contest and all the teams demonstrated excellent teamwork. People also had the opportunity to meet and congratulate each other during the coffee break. The price for the first place was an iPad for every resident. Members of the scientific committee: Dr. Juan Gómez Rivas, Dr. Luis López-Fando, Dr. José Manuel Cózar, Dr. Jesús María Fernandez

Congratulations to the winners, all of the participants and the organisational committee. We certainly look forward to the next year’s competition! European Urology Today


EAU-AUA Academic Exchange Programme Insights on American urological practice Assoc. Prof. Murat Akand Selcuk University School of Medicine Dept. of Urology Konya (TR) drmuratakand@ yahoo.com

Assoc. Prof. Ege Can Serefoglu ÜroKlinik - Center of Excellence in Urology Istanbul (TR)

the hospitality of the entire department and we had the opportunity of socially meeting each member of the department from the residents to the faculty members. We have also observed several urologic surgeries, including a robotic radical prostatectomy and a robotic cystectomy. We were also invited to take part in staff activities such as their scientific meetings and Mobility & Mortality meetings. It was inspiring to learn that as part of the commitment to provide patients with the best medical care, a new pavilion, one of the largest new healthcare developments in Washington D.C., will be built in the main campus of Georgetown. The visit at Georgetown University Hospital was a wonderful start and set high expectations that were fulfilled throughout the whole tour. The programme was not only an opportunity to take part in surgical procedures and clinical activities, but also a unique way to network with American colleagues and share medical experiences.


Dr. Fabio Zattoni University of Padova – Azienda Hospital Dept. of Urology Padova (IT)

On our way to Baltimore, Maryland, we visited the AUA Headquarters, where we had a tour at the William P. Didusch Center for Urologic History with Mrs. Tupper Stevens as our guide. Afterwards, we had dinner with Drs. Alan Partin, Misop Han, Arthur Burnett and Trinity Bivalacqua. The next morning, we attended the Department of Urology’s Grand Rounds where the residents presented their posters which were prepared for the AUA Congress. After observing

Dr. John Lynch and his team at George Washington University

a robotic radical prostatectomy and a robotic radical cystectomy performed by Drs. Mohammad Allaf and Trinity Bivalacqua, we visited the URobotics Laboratory at the Johns Hopkins Bayview Medical Center. Dr. Dan Stoianovici showed us their inventions, and we heard about their innovations in TRUS-guided prostate biopsy. The next day, we had three meetings with Drs. Patrick Walsh, Misop Han and David McConkey, and heard their experiences and remarkable memories.

finding our way, fortunately the extensive orientation programme proved to be very helpful. The latter phase of the programme was the travel to Boston for the AUA 2017 Congress. Our attendance was remarkable as we had the opportunity to attend sessions with presentations from renowned experts and learned new developments in every area of urology. The AUA staff members were very helpful and efficient in lending assistance. Their sincere approach, warm hospitality and great friendship are impressive.

Cleveland Clinic was also a remarkable place. We attended to a two-day symposium and observed the surgeries of Drs. Manoj Monga and Jihad Kaouk. Dr. Monga personally took care of us and exerted great effort to offer an excellent programme. A vast hospital complex, we had difficulties in getting to the OR and

We would like to thank the EAU, AUA, the department heads, faculty members, residents and secretaries of the three centres, and especially Ms. Angela Terberg and Mrs. Ellen Molino who both helped us during the entire programme.

Meeting with Dr. Patrick Walsh (3rd from left)

With Dr. Eric Klein (3rd from left)

fabiozattoni@ gmail.com The 2017 EAU-AUA Academic Exchange Programme consisted of a two-week educational experience at Georgetown University Hospital, Johns Hopkins and Cleveland Clinic. Our programme started at Georgetown University Urology Department with a warm welcome from Dr. Lynch and his team. We were really impressed with

The fellows with Dr. Alan Partin (2nd from left)

The European Association of Urology (EAU) and the Japanese Urological Association (JUA) offer the chance to join the third 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.

• •

For 2018 the JUA/EAU International Exchange Programme will provide grants to enable two EAU members to travel to Japan. The tour should take place from 8-21 April 2018 starting with visits to urological facilities in Japan, culminating with participation in the 106th JUA Annual Meeting, which will be held in Kyoto.

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 10 days to two weeks at the earlier mentioned time

Additionally you can contact the EAU Central Office T: +31 (0)26 389 0680 F: +31 (0)26 389 0674 E: a.terberg@uroweb.org

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


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)

EAU Central Office, Attn. Angela Terberg, P.O. Box 30016, 6803 AA Arnhem, The Netherlands

Application deadline: 1 November 2017

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

European Urology Today

August/September 2017

Urology and Urogynaecology working together for LUTS

Register now!

ELUTS17 in Berlin features contributions from EUGA on pelvic organ prolapse management By Loek Keizer “The ELUTS meeting represents a good opportunity to share competences amongst urogynaecologists and urologists. This is the second time since becoming President of the European Urogynaecological Association (EUGA) that a multidisciplinary LUTS meeting features an EUGA session in its scientific programme,” says Prof. Stefano Salvatore (Milan, IT).

On learning from each other’s specialties, Salvatore looks forward to further cooperation. “A regular, structured exchange of knowledge between urologists and urogynaecologists would certainly be welcome, so we look forward to recurrent iterations of the ELUTS meeting. This could also involve educational courses organised throughout Europe by the EAU/European School of Urology and EUGA together.” ELUTS17 is held together with the 10th ESU-ESFFU Masterclass on Female and Functional Reconstructive Urology over the course of three days. The scientific programme is arranged thematically, with a range of LUTS-related topics being discussed in great detail by international leaders in the field. These sessions are accompanied by specialised, half-hour long state-of-the-art lectures.

Prof. Stefano Salvatore

ELUTS17 is a new event for the EAU, offering delegates a comprehensive two-day scientific programme focused on a wide variety of lower urinary tract symptoms. The meeting also features an ESU-ESFFU Masterclass and contributions to the scientific programme by ESFFU, ESGURS and EUGA. Prof. Salvatore is also head of the Urogynaecology Unit at the San Raffaele Hospital, Vita-Salute University in Milan: “In my unit we provide all the diagnostic procedures for female pelvic floor dysfunctions (ultrasound, urodynamics, cystoscopy) and we do any kind of surgery for incontinence and pelvic organ prolapse using a vaginal or laparoscopic approach.” The European Urogynaecological Association is officially the Urogynaecological Section of the European Board and College of Obstetrics and Gynaecology (EBCOG). Together with the European Association of Gynaecological Oncology, The European Association of Fetal Medicine and The European IVF Society, it represents one of the four subspecialties of OBGYN that have been identified by EBCOG. EUGA was founded by Ulf Ulmsten in 2003 and currently has over 2,700 members. Scientific programme contributions Due to the wide variety of conditions that fall under the more general banner of LUTS, the scientific programme has to involve several subspecialties of urology: female and functional urology (represented by ESFFU), genitourinary reconstructive surgery (ESGURS) and the aforementioned partnering with EUGA. This year, the EUGA contributions to ELUTS17 will be focused on pelvic organ prolapse management, in the different phases of a woman’s life. “After what has happened worldwide with meshes, we will try to cover new perspectives in prolapse management, but also re-evaluate, in a critical way, the traditional surgical approaches.”

“A possible future improvement could be achieved through increased research in regenerative medicine and tissue engineering.” “After the launch of Tension-free Vaginal Tape (TVT) in the middle of the 1990s, and with all the following evolutions, there have not been any notable, game-changing breakthroughs in recent years. Unfortunately, even in the pharmacological field I am not aware of any big upcoming developments. I do think that a possible future improvement could be achieved through increased research in regenerative medicine and tissue engineering.”

August/September 2017

On Friday afternoon, the meeting features two parallel sessions: one by EUGA on POP and mesh use, and one by the ESGURS on Peyronie’s disease. ESGURS will also be contributing a parallel session on Saturday morning, featuring semi-live surgery demonstrations on urethroplasty.

“Surgically, urogynaecologists are more confident with vaginal or laparoscopic approaches whereas urologists are more likely to use robotic surgery.” Urology and urogynaecology Prof. Salvatore anticipates discussion between urologists and urogynaecologists: “As EUGA we hope that our contribution to ELUTS17 could help in covering some arguments related to pelvic floor dysfunctions that are more familiar to gynaecologists. In general we believe that an exchange of knowledge and competences in a multidisciplinary approach could improve the level of discussion.” Regarding the division of labour between gynaecologists and urologists when it comes to LUTS treatment, there is no clear picture. “It is quite difficult to generalise, and I would not draw a clear line between urogynaecologists and urologists in the management of LUTS. I do think that it is a matter of personal competence. Usually urologists are more competent in neurourological problems, whereas urogynaecologists are more competent in pelvic floor dysfunctions secondary to pregnancy and delivery, or in problems related to the genitourinary syndrome of menopause.” “Surgically, urogynaecologists are more confident with vaginal or laparoscopic approaches whereas urologists are more likely to use robotic surgery. But, again, this is not a rule.” Speaking generally on the relationship between urologists and gynaecologists, Prof. Salvatore draws on his personal experience: “I have always worked in Academic Hospitals where the cooperation between urologists and urogynaecologists have been very loyal and productive. This has to be the case for the sake of the patient. It is then a matter of the strategic vision of each specific hospital management to organise and set-up a multidisciplinary unit (e.g. a Pelvic Unit), where urologists, urogynaecologists, proctologists and physiotherapists could work together. This would be the ideal situation.”

ELUTS17 European Lower Urinary Tract Symptoms meeting

12-14 October 2017 Berlin, Germany


Key Topics and Sessions at ELUTS17: • Why do clinical trials not correlate with real life clinical practice? • Female stress urinary incontinence • POP and the use of mesh • My BPH patient needs treatment • Male incontinence after radical prostatectomy • NDO and incontinence

For all relevant information, including the full scientific programme and registration details for ELUTS17 please visit www.eluts17.org

European Urology Today






4th Meeting of the EAU Section of Urolithiasis

24th Meeting of the EAU Section of Urological Research

5-7 October 2017, Vienna, Austria

12-14 October 2017, Paris, France An application has been made to the EACCME® for CME accreditation of this event

ESUI17 6th Meeting of the EAU Section of Urological Imaging 16 November 2017, Barcelona, Spain In conjunction with the 9th European Multidisciplinary Meeting on Urological Cancers

In collaboration with the EAU Section of Uropathology

ESUI17: Improving bladder cancer management Advances in the management of urological cancers particularly the role of imaging in bladder cancer diagnosis and treatment are one of the key topics in the agenda of the 6th EAU Section of Urological Imaging (ESUI17) Meeting on November 16 in Barcelona. “There are key issues that need to be examined and discussed such as the role of MRI in the local staging of bladder cancer. Questions such as how we can optimise new technology or what we need to be aware of in terms of limitations and potentials,” said ESUI Chairman Prof. George Salomon (DE). With “New Technologies and Limited Resources” as the meeting’s main theme, the ESUI will closely look into optimal management strategies in prostate, renal and bladder cancers to provide an update on best practices. Held in conjunction with the 9th European Multidisciplinary congress on Urological Cancers (EMUC), ESUI17 will feature various formats such as point-counterpoint debates, thematic roundtable discussions and Q&A forums. Salomon noted the bladder cancer (BCa) session will feature speakers who will discuss both standard and innovative practices that aim to improve BCa therapy. Prof. Marek Babjuk (CZ) will speak on the standard work-up for microhaematuria, focusing on current recommendations in the EAU guidelines. Speakers will also take up MRI in the local staging of bladder cancer, and present insights on how this technology can help doctors in decision-making and improve their treatment plan. Max Kriegmaier (DE) will discuss multiparametric cystoscopy to underscore the potentials in imaging techniques.

Register now! Late registration fees are applicable from 15 August to 16 November

Joint ESUI-EANM session Aside from the review or assessment of clinical practices, the ESUI programme also features a joint session with the European Association of Nuclear Medicine (EANM) to focus on molecular imaging. The issues of cost-effectiveness and improvement of cancer control using PET/CT will be taken up by Stefano Fanti (IT) who will open the session. Other topics include the use of fluciclovine-PET in managing prostate cancer, the role of PSMA and the androgen receptor in improving treatment monitoring of metastatic PCa, and new PET-tracers for renal cell cancer.

“With our aim to broaden the scope of discussion, we hope to stimulate a critical examination of standard and emerging therapies and practices. By carefully re-considering key issues and challenges, we can prompt all participants to exchange ideas and new approaches,” Salomon said. He also reiterated the ESUI’s goal to nurture innovative research by presenting the Abstract Sessions where the best will be recognised with the Best Abstract Award and a cash prize of €1,000. The six top-ranked posters will be presented during the session followed by short discussions. Following the presentations the jury will decide on the winner. Clinical research fellow Dr. Joana Neves won last year the Best Poster Award for her research “Combining mpMRI sequences for the diagnosis of prostate cancer – the value of adding diffusion and contrast enhancement to T2W on 3Tesla: Outcomes from the PICTURE trial” during the 5th ESUI Meeting held in Milan. For additional details on the Scientific Programme, Registrations and meeting venue, visit the meeting website at www.esui17.org. Online registration can be accessed via the meeting website and late fee registration is applicable from 15 August to 16 November. See you in Barcelona!

Last year’s ESUI16 Meeting Best Poster Winner, Dr. Joana Neves (middle)

For additional information visit the ESUI meeting website at www.esui17.org


European Urology Today

August/September 2017

16-19 November 2017, Barcelona, Spain

9th European Multidisciplinary Meeting on Urological Cancers In conjunction with the • 6th Meeting on the EAU Section on Urological Imaging (ESUI)

Implementing multidisciplinary strategies in genito-urinary cancers

• EAU Prostate Cancer Centre Consensus Meeting (EPCCCM) • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) • European School of Urology (ESU)

Preliminary Scientific Programme EMUC17 is held in conjunction with: Thursday, 16 November 6th Meeting of the EAU Section of Urological Imaging (ESUI) EAU Prostate Cancer Centre Consensus Meeting (EPCCCM) ESU Courses on Kidney and Bladder cancer: A clinical scenario based interactive session with the experts (ESU) EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP)

Friday, 17 November ESU/ERUS HOT Robotic Surgery ESU/ESUT/ESUI HOT MRI Fusion ESU/ESUT/ESUI HOT MRI Reading

Saturday, 18 November ESU/ERUS HOT Robotic Surgery ESU/ESUT/ESUI HOT MRI Fusion ESU/ESUT/ESUI HOT MRI Reading FALCON Delineation Contouring Workshop Uropathology Training Workshop for clinicans

Friday, 17 November 08.15 - 08.20 Welcome and Introduction Medical oncologist - Thomas Powles, London (GB) - ESMO Radiation oncologist - Peter Hoskin, Northwood (GB) - ESTRO Urologist - Hein Van Poppel, Leuven (BE) - EAU 08.20 - 10.05 Detection and treatment of clinically significant prostate cancer Chairs: Radiologist - Raymond Oyen, Leuven (BE) Radiation oncologist - Thomas Wiegel, Ulm (DE) Urologist - Francesco Montorsi, Milan (IT) 08.20 - 09.00 MRI before biopsy for all men? YES Urologist - Hashim Ahmed, London (GB) Radiologist - Harriet Thoeny, Berne (CH) vs NO Radiologist - Olivier Rouvière, Lyon (FR) Urologist - Jochen Walz, Marseille (FR) Last judgement: Urologist - Nicolas Mottet, Saint-Étienne (FR) 09.00 - 09.15 Index lesion in prostate cancer: Myth or reality? Pathologist - Mark Rubin, New York (US) 09.15 - 09.20 Questions and answers 09.20 - 09.50 Will level 1 evidence influence our practice in focal therapy? YES Urologist - Mark Emberton, London (GB) vs NO Radiation oncologist - Alberto Bossi, Villejuif (FR) Last judgement: Urologist - Arnauld Villers, Lille (FR) 09.50 - 10.05 Discussion 10.05 - 10.50 The optimal primary treatment of prostate cancer: A focus on the ProtecT study Chairs: Radiologist - Raymond Oyen, Leuven (BE) Radiation oncologist - Thomas Wiegel, Ulm (DE) Urologist - Francesco Montorsi, Milan (IT) 10.05 - 10.15 ProtecT: What have we learnt? Radiation oncologist - Freddie Hamdy, Oxford (GB) 10.15 - 10.25 Would modern staging change the results? Urologist - Silvan Boxler, Berne (CH) 10.25 - 10.35 The statistician point of view Biostatistician - Mahesh Parmar, London (GB) 10.35 - 10.50 Discussion 10.50 - 11.20 Coffee break and poster viewing

August/September 2017

11.20 - 12.35 Immunotherapy in urological cancers Chairs: Medical oncologist - Gerhardt Attard, Surrey (GB) Urologist - Alexander Govorov, Moscow (RU) Pathologist - Rodolfo Montironi, Ancona (IT) 11.20 - 11.35 Biological basics of immune therapy Immunologist - Elfriede Nossner, Munich (DE) 11.35 - 11.50 Prostate cancer Medical oncologist - Charles Drake, Baltimore (US) 11.50 - 12.05 Bladder cancer Medical oncologist - Andrea Necchi, Milan (IT) 12.05 - 12.20 Kidney cancer Medical oncologist - Thomas Powles, London (GB) 12.20 - 12.35 Discussion 12.35 - 12.45 Summary of the EAU Prostate Cancer Centre Consensus Meeting (EPCCCM) Urologist - Manfred Wirth, Dresden (DE) 12.45 - 14.00 Lunch break and poster viewing 13.00 - 14.00 Industry session 14.00 - 15.15 Educational session on testis cancer Chairs: Clinical oncologist - Jan Oldenburg, Oslo (NO) Radiation oncologist - Peter Hoskin, Northwood (GB) Urologist - Fred Witjes, Nijmegen (NL) Pathologist - Michelangelo Fiorentino, Bologna (IT) 14.00 - 14.15 Management of stage 1 Urologist - Peter Albers, Düsseldorf (DE) 14.15 - 14.30 Management of metastatic disease Medical oncologist - Karim Fizazi, Villejuif (FR) 14.30 - 15.15 Case discussion “Stage I seminoma” Case presentation Urologist - Peter Albers, Düsseldorf (DE) Medonc view Medical oncologist - Karim Fizazi, Villejuif (FR) Radonc view Radiation oncologist - Gert De Meerleer, Leuven (BE) Case discussion “Residual disease” Urologist - Peter Albers, Düsseldorf (DE) Medical oncologist - Karim Fizazi, Villejuif (FR) Radiation oncologist - Gert De Meerleer, Leuven (BE) 15.15 - 15.30 Best of journals session: Radiotherapy Chairs: Radiation oncologist - Bradley Pieters, Amsterdam (NL) Radiation oncologist - Ananya Choudhury, Machester (UK) 15.30 - 16.00 Coffee break and poster viewing 16.00 - 17.45 Educational session on bladder cancer Chairs: Radiotherapist - Anne Kiltie, Oxford (GB) Urologist - George Thalmann, Berne (CH) Pathologist - Antonio Lopez-Beltran, Lisbon (PT) Medical oncologist - Maria De Santis, Coventry (GB) 16.00 - 16.20 Bladder preservation: How and for whom? Radiation oncologist - Nicholas James, Birmingham (GB) 16.20 - 16.35 Lymph node dissection: How high is enough? Urologist - Stephen Boorjian, Rochester (US) 16.35 - 16.50 Molecular sub-types and implications for prognosis and therapy Urologist - Roland Seiler, Berne (CH) 16.50 - 17.45 Case discussion Radiation oncologist - Nicholas James, Birmingham (GB) Urologist - Stephen Boorjian, Rochester (US) Urologist - Roland Seiler, Berne (CH) 17.45 - 18.45 Industry session

Saturday, 18 November 08.15 - 08.30 Announcement 3 best unmoderated posters Chairs: Clinical oncologist - Jan Oldenburg, Oslo (NO) Urologist - Michiel Sedelaar, Nijmegen (NL)

16.50 - 17.45 Educational session: Challenging cases in the management of Upper urinary tract TCC Chairs: Urologist - Evanguelos Xylinas, Paris (FR) Urologist - Joan Palou, Barcelona (ES) Clinical case discussion (including perioperative chemo, imaging, pathologist, biopsy) Clinical oncologist - Ananya Choudhury, Machester (UK) Urologist - Morgan Roupret, Paris (FR) Radiologist - Raymond Oyen, Leuven (BE) Pathologist - Sara Falzarano, Cleveland (US)

08.30 - 10.15 Oligometastatic kidney cancer Chairs: Radiation oncologist - Vincent Khoo, London (GB) Urologist - Hein Van Poppel, Leuven (BE) Medical oncologist - Thomas Powles, London (GB) Pathologist - Ferran Algaba, Barcelona (ES) 08.30 - 08.45 The optimal timing of cytoreductive nephrectomy Urologist - Axel Bex, Amsterdam (NL) 08.45 - 09.00 Expanding knowledge of adjuvant therapy Urologist - Karim Bensalah, Rennes (FR) 09.00 - 09.15 Potential biomarkers for decision making Urological researcher - Kerstin Junker, Homburg (DE) 09.15 - 09.25 Can local ablation delay the use of systemic therapy for oligometastasis Radiation therapy Radiation oncologist - Piet Ost, Ghent (BE) 09.25 - 10.15 Case discussion Urologist - Umberto Capitanio, Milan (IT) 10.15 - 10.45 Coffee break and poster viewing 10.45 - 11.25 Oral presentations of the 6 best abstracts Chairs: Medical oncologist - Susanne Osanto, Leiden (NL) Urologist - Hein Van Poppel, Leuven (BE) Radiation therapist - Barbara Jereczek-Fossa, Milan (IT) 11.25 - 11.45 Highlights of Advanced Prostate Cancer Concensus Conference (APCCC2017) Medical oncologist - Silke Gillessen, St. Gallen (CH) 11.45 - 12.15 Is there a shift for selection criteria and definition of reclassification for prostate cancer on active surveillance? Introduction: Pathologist - Rodolfo Montironi, Ancona (IT) Pathologist - Jonathan I. Epstein, Baltimore (US) 12.15 - 12.45 Stand-alone session on recent updates/ novelties 12.45 - 14.00 Lunch break and poster viewing 13.00 - 14.00 Industry session 14.00 - 16.05 Management of loco/regional recurrences (prostate/penile cancer) Chairs: Medical oncologist - Silke Gillessen, St. Gallen (CH) Urologist - Georg Salomon, Hamburg (DE) Radiation therapist - Cesare Cozzarini, Milan (IT) 14.00 - 14.15 MRI/whole body MRI Radiologist - Frédéric Lecouvet, Brussels (BE) 14.15 - 14.35 Use of PET/CT Nuclear medicine - Stefano Fanti, Bologna (IT) 14.35 - 14.45 Salvage surgery after radiotherapy Urologist - Steven Joniau, Leuven (BE) 14.45 - 15.00 Salvage treatment after radical prostatectomy Radiation oncologist - Alberto Bossi, Villejuif (FR) 15.00 - 15.15 Management of local recurrences in penile cancer Urologist - Chris Protzel, Rostock (DE) 15.15 - 16.05 Case discussion Urologist - Gianluca Giannarini, Udine (IT) 16.05 - 16.35 Coffee break and poster viewing

17.45 - 18.45 Industry session

Sunday, 19 November 08.30 - 08.45 Announcement 3 best unmoderated posters Chairs: Clinical oncologist - Jan Oldenburg, Oslo (NO) Urologist - Igle-Jan de Jong, Groningen (NL) 08.45 - 09.00 Best of journals: Medical oncology Chairs: Medical oncologist - Cora Sternberg, Rome (IT) Medical oncologist - Andrea Necchi, Milan (IT) 09.00 - 09.15 Drug repurposing opportunities in urooncology Chairs: Medical oncologist - Cora Sternberg, Rome (IT) Urologist - Hein Van Poppel, Leuven (BE) Speaker: Director Anticancer fund - Gauthier Bouche, Strombeek-Bever (BE) 09.15 - 11.00 Evolving concepts in metastatic prostate cancer Chairs: Medical oncologist - Cora Sternberg, Rome (IT) Urologist - Jeffrey Karnes, New York (US) Radiation therapist - David Dearnaley, Sutton (GB) 09.15 - 09.30 How should we treat our metastatic castrate sensitive patients? Radiation oncologist - Nicholas James, Birmingham (GB) 09.30 - 09.45 Monitoring patients with metastatic disease Radiologist - Anwar Padhani, Northwood (GB) 09.45 - 10.00 Treatment of the primary in metastatic patients Urologist - Markus Graefen, Hamburg (DE) 10.00 - 10.15 Molecular radiotherapy Radiologist - Uwe Haberkorn, Heidelberg (DE) 10.15 - 11.00 Case discussion Urologist - Simon Brewster, Oxford (GB) 11.00 - 11.30 European Commission lecture Director General for Health and Food Safety Xavier Prats Monné, Barcelona (ES) 11.30 - 12.20 11.30 - 11.40 11.40 - 11.50 11.50 - 12.00 12.00 - 12.10

Take home messages Radiologist - Raymond Oyen, Leuven (BE) Urologist - Igle-Jan de Jong, Groningen (NL) Clinical oncologist - Jan Oldenburg, Oslo (NO) Radiation oncologist - Bradley Pieters, Amsterdam (NL) 12.10 - 12.20 Pathologist - Rodolfo Montironi, Ancona (IT) 12.20 - 12.30 Closing remarks Clinical oncologist - Jan Oldenburg, Oslo (NO) ESMO Radiation oncologist - Peter Hoskin, Northwood (GB) - ESTRO Urologist - Hein Van Poppel, Leuven (BE) - EAU

16.35 - 16.50 Best of journals: Surgery Chairs: Urologist - Maurizio Brausi, Modena (IT) Urologist - Jochen Walz, Marseille (FR)

European Urology Today 37 www.emuc17.org

ESAU17 10th Meeting of the EAU Section of Andrological Urology 24-25 November 2017, Malmö, Sweden “Male fertility problems as a sign of more general disease” For two days in November, Malmö will be welcoming experts on andrology from all over the world for the 10th Meeting of the EAU Section of Andrological Urology. This meeting is the first of its kind in several years, organised due to an increasing interest in andrology among urologists. Prof. Aleksander Giwercman (Malmö, SE)

We spoke to local organiser Prof. Aleksander Giwercman (Malmö, SE), who is also a member of the ESAU board. “We’ve seen an increase in the number of attendees at the ESAU meetings that are held at the Annual EAU Congress every year. We thought the time was ripe for a dedicated meeting so that we could spend two whole days discussing andrology-related urological topics.” Giwercman is Professor in Reproductive Medicine at Lund University, with special focus on male reproductive function. He is also senior consultant in andrology at the Reproductive Medicine Centre, Skane University Hospital in Malmö. Prof. Giwercman mostly treats male patients with fertility problems and/or sex hormone deficiency. He also deals with young men coming in for fertility preservation before potentially sterilising medical treatment, for instance as a result of cancer. Male fertility “One of the main topics to be discussed in Malmö will be the urgent need for changing the routines for the management of the male in infertile couples,” Prof. Giwercman explains. “We need to change our routines since male fertility problems should be

considered as sign of a general disease which needs additional attention on top of helping the couples with becoming parents.” “However, there will also be other important sessions, like those on testicular cancer, the management of erectile dysfunction and ejaculatory problems as well as the issue of testosterone replacement therapy.” Recently, a lot of public interest was raised with a report on falling sperm count in recent decades. “That paper on declining sperm count certainly received a lot of public attention but, in fact, does not contain any new information. It is not necessarily going to be a ‘key topic’ but will surely be discussed.” The relationship between andrology and urology is one that Giwercman is clear on: “I think that the andrological topics will more and more get a prominent role on the urological agenda. Andrology is an important part of urology and the growing understanding of the close association between andrological and other urological problems will bring more attention to this medical field.” “We’ve balanced the scientific programme of ESAU17 to suit ‘new beginners’, younger urologists who are starting to specialise in andrological topics, but also to appeal to experts in the area. Basic aspects of andrology will be mixed with more recent and cutting-edge developments in the field.” Regional collaboration ESAU17 can rely on the cooperation of Lund University and the wider ReproUnion cross-border collaboration. Giwercman:

Register now on www.esau17.org “The medical faculty of Lund University is highly involved in organising the meeting. The wider region is also where ReproUnion operates, a collaboration between Danish and Swedish regions that researches reproductive medicine.” ReproUnion is a cross-border collaboration between 13 clinical and research units within the Capital and Zealand Regions of Denmark and the Skane Region in Southern Sweden, dealing with reproductive medicine. “One of the important accomplishments of ReproUnion is the close collaboration with EAU/ESAU on establishing joint postdoc research training programmes aiming to promote research in the field of andrology. Many of the speakers at ESAU17 are affiliated with ReproUnion and will no doubt share the latest results and future plans of the project.” “The end of November is close to Christmas, and visiting Nordic cities at that time of the year is a very special experience. The meeting will be held in the very centre of Malmö in walking distance to the city’s main attractions and its railway station. A trip to Copenhagen Airport only takes 20 minutes and Copenhagen itself is only half an hour away.”






15th Meeting of the EAU Section of Oncological Urology

6th Meeting of the EAU Section of Uro-Technology in conjunction with the Meeting of the Italian Endourology Association (IEA)

19-21 January 2018 Amsterdam, The Netherlands An application has been made to the EACCME® for CME accreditation of this event

24-26 May 2018, Modena, Italy An application has been made to the EACCME® for CME accreditation of this event


European Urology Today

August/September 2017

Updates from the Danish Post-EAUN Meeting Key urological nursing issues examined in “Rethink with Aarhus 2017" meeting Bente Thoft Jensen, Ph.D-MPH Aarhus University Hospital Dept. of Urology Aarhus (DK)

benjense@rm.dk Since 2010 the Aarhus University Hospital (Denmark) has been hosting an annual scientific meeting with focus on research and development in urological nursing in cooperation with the EAUN. The initiative originated in the spring of 2010 during the memorable volcanic explosion of Iceland’s Eyjafjallajøkull Volcano, which then made intercontinental travel a major challenge. At that time it was nearly impossible to fly to the Annual EAU-EAUN Congress in Barcelona due to the fact that air-traffic was totally grounded during that week in April 2010. As chair of the EAUN back in 2010, it was almost unbearable to realise that so many of our colleagues across Europe were unable to make it to Barcelona. The board was very proud of the scientific programme and was looking forward to welcome the highest number of attendees ever recorded by the EAUN at that time. The rest of the story is well-known: improvisation, flexibility and a very good sense of humour were keys in the success of the annual meeting in 2010. As in previous years, the enthusiastic Danish nurses submitted a big number of abstracts and signed-up for lectures and workshops, but, sadly, only a few had the opportunity to present their work.

turned to reality and since then the Department of Urology in Aarhus has been hosting this meeting. Today, this one-day educational meeting has turned into an international event where we invite Danish and international speakers to present key take-home messages from the EAUN and focus on national research, cooperation and development in urological nursing practice. A similar post-EAUN meeting is also a highly recognised annual event in the Netherlands. Meeting highlights The 8th Danish meeting this year was held last May 4 and gathered around 65 nurses. Below are some of the highlights: Mr. Ronny Pieters (BE) from Ghent University Hospital made an excellent opening with the presentation: “Self- catheterisation, the golden standard?” In my view, the audience was convinced that so far CIC IS the golden standard, although we are all still waiting for the breakthrough which may guarantee the absence of side-effects. Mrs. Nihal Mohamed from Mount Sinai in New York discussed the under-reported psychosocial needs in cancer care and the unmet needs in patients undergoing radical cystectomy. What do we actually miss? In particular, we need more pre-information and preparation regarding sexual health, change in bodily functions and psychosocial issues, all of which are often major concerns in the community. Mr L. Drudge-Coates of the King’s College Hospital in London took us on “a guided tour in his racing car”

Co-organisers Erica Grainger and Rikke Knudsen (President FSUIS)

Bente Thoft Jensen and Lawrence Drudge-Coates, both former EAUN Chairs

and brought us the latest updates on how to support the patient with advanced prostate cancer, directions for future care and educational needs.

The programme also included the presentation of the latest EAUN guideline and upcoming ESUN-courses and local Danish research projects. These were presented by:

Mrs. N. Love of the Memorial Sloan Kettering Cancer Center in New York lectured on testis cancer and the challenges especially with very young disabled men. She examined questions such as: Is sperm-banking relevant or ethically correct if the patient cannot cope? And in cases when care-givers do not allow such an action, what’s the role of the nurse? These are not easy questions and approaches may differ across borders in Europe due to ethical dilemmas. Mrs. Therese Juul of the Aarhus University Hospital presented the framework for an alternative organisation of follow-up treatment and care in a survivorship clinic for patients treated with any type of cancer.

On my way back to Aarhus (DK) via Amsterdam (a 24-hour ride in a bus kindly provided by the Dutch urologists) I had plenty of time to reflect about the Barcelona meeting. How could we present the “gold nuggets” from the Barcelona programme to our colleagues back home, and moreover, encourage them to present their own work on a national platform? The idea of a national post-EAUN meeting European Association of Urology Nurses

• Brigitta Willumsen, Holstebro (AUH), RN-Ph.D.stud; A new approach to home-based exercise for prostate cancer patients receiving androgen deprivation therapy • Susanne Vahr, Copenhagen University Hospital, RN-Phd. –Stud: Complications in radical cystectomy pathways- whats`s evident? • Annette Hjuler, Aarhus University Hospital, RN-Continence Adviser: Can self-installation improve QoL in Patients with painful bladder syndrome? Finally, "Rethink with Aarhus 2017" would like to thank the co-organisers: Susanne Vahr of the EAUN Board, Rikke Knudsen of the Danish Urological Nurses and Erica Grainger of the Department of Urology, Aarhus University Hospital. The meeting was free and this was made possible due to the continued and enthusiastic support of the following companies: IPSEN, Wellspect HealthCare, BL Medical, IBSA, Janssen, Navamedic and Ferring Pharmaceuticals.

Nora Love (US) lectures on a new role in urology nursing

Ronny Pieters (BE) opens with a presentation on IC

The next meeting will be on June 14, 2018 at the Aarhus university Hospital, Auditorium B, 08.30 AM. The Call for Abstracts will be announced in October.

Scandinavian biennial conference on urology Nurses’ programme delivers thought-provoking insights Rikke Nygaard Knudsen President of The Danish National Society (FSUIS) Århus University Hospital Århus (DE) rikkkn@rm.dk The Scandinavian Association of Urology (NUF) organises a biennial conference for urological doctors and nurses from the Nordic countries. This year the 31st Biennial Conference 2017 was held in Odense, the birthplace of famous fairy tale and Danish author Hans Christian Andersen. The three-day conference gathered participants from Norway, Sweden, Iceland, Finland, USA and the United Kingdom. The conference organisers prepared separate scientific programmes for doctors and nurses, an exhibit and a social programme which included a visit to the Town Hall and a Congress Dinner at the beautiful harbour of Odense.

A session on bladder cancer included a lecture on history titled "Black magic to evidence treatment and care," followed by a presentation of "A Cystectomy Pathway in Denmark anno 2017." This session provided a good and professional discussion on how we can implement research and evidence in our treatment and care. An example from Aarhus University Hospital showed how results from a PhD study is implemented in the pre-operative preparation for patients undergoing cystectomy. Matilda Fagerberg, a nurse from Sweden, performs cystoscopies without assistance from a doctor. In a symposium called "Cystoscopy as a multidisciplinary procedure," she presented the "Swedish Set-up." In Sweden they have a certified cystoscopy education for nurses, and urologists are very "open minded" with regards the role of specialised nurses. From the doctor’s point of view, there are a lot of benefits if nurses perform cystoscopies as a standard procedure. A very interesting symposium, the session showed how the role of urological nurse has changed over the years, and how our specialty is still evolving in many ways.

August/September 2017

Finland, Sweden and Denmark represented at NUF in Odense

The programme also included a poster session (with both poster and oral presentations), a session on "New Technologies," and a discussion about the impact of technology as viewed by patients and nurses. The session "Urological emergencies with focus on nurse’s responsibilities" triggered a discussion regarding the importance of observations by nurses, and the challenges in treating urological emergency cases.

presentations, dedicated speakers and enthusiastic participants.

Theologian Niels Christian Hvidt ended the nurses programme with a themed session "Does Faith Move Mountains? And do Mountains move faith? Current research looks into the links of existential meaning, faith and health in different clinical settings. Moreover, the session examined how attention to these topics has increased. The lecture underscored the importance of reminding ourselves that human beings also have a great need for faith and belief during times of crisis.

The nurses’ scientific programme started with the session "Men, cancer and their partners". Speaker Helle Ploug Hansen is a well-known nursing professor in Denmark. The session tackled topics such as challenges in everyday life among men with cancer and, in particular, how men and their partners differ in the way they respond to the challenges following a cancer diagnosis. European Association of Urology Nurses

Erica Grainger chairing of the session "Urological emergencies"

Rikke Knudsen and Maysa Steitiyeh during “A cystectomy pathway in Denmark anno 2017”

In all, the nursing programme of the biennial congress was an inspiring, thought-provoking meeting with a high level of knowledge,

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

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

www.eaun.uroweb.org European Urology Today


EAUN shares ERAS expertise after radical cystectomy Abu Dhabi nursing workshop to highlight best practices As part of the European Association of Urology Nurses’ (EAUN) goal to share expertise and boost knowledge exchange, a day-long workshop on Enhanced Recovery Protocols (ERAS) following radical cystectomy will be held on November 10 in Abu Dhabi, United Arab Emirates (UAE). The Enhanced Recovery Protocols (ERAS) After Radical Cystectomy Workshop will take place during the fourday 6th Emirates International Urological Conference which gathers opinion leaders, experts, specialists and related healthcare professionals in the UAE to discuss key issues, research developments and best practices in urology. “The workshop aims to provide the participants not only with the main rationale of ERAS but also the core principles for activating the patient. We will also present the EAUN recommendations for urostomy and neobladder management. Moreover, there will be a discussion regarding surgical wound care and the nursing interventions to identify practical insights,” said EAUN Chair Elect Susanne Vahr (DK). Vahr, together with EAUN Scientific Committee member Bente Thoft Jensen (DK) and former EAUN Board member Willem De Blok (NL) will serve as resource speakers and workshop facilitators. During the first segment, the programme will cover key and practical issues such as ERAS principles, pre-operative nursing interventions (education of the patient, nutritional status, smoking cessation and physical exercise), and post-operative nursing interventions (wound care and care of stents, drainage tubes and the indwelling catheter).

With De Blok as lead presenter, two practical sessions will instruct participants on how to teach urostomy patients to regain independence, and another on the proper use of neo-bladder intermittent catheterisation. Thoft Jensen and Vahr will serve as co-facilitators. “These two sessions are important for participants to gain practical insights, identify potential problems and improve their communication skills with regards guiding and informing cystectomy patients. In our experience urology nurses have a need to learn these basic skills and make them part of their nursing care,” the organisers said. The afternoon programme will begin with Thoft Jensen presenting the session on “How to activate the patient to meet discharge criteria regarding nutrition and physical exercise.” Practical recommendations based on best practices will inform participants of helpful tips which contribute to a more optimal nursing approach. After the lectures and practical sessions, participants will be tested by doing a group work based on a patient case. The test work will not only function as a selfassessment of what participants have actually picked up but also identify potential problem areas in clinical routine. Reduced workshop fee rates are available to participants who are also attending the main Emirates International Urological Conference.

Workshop Programme 08.30-08.40 08.40-09.00

09.00-09.30 09.30-10.00


10.30-10.45 10.45-11.30


12.30-14.00 14.00-14.30


15.30-16.00 16.00-16.30

Introduction to the European Association of Urology Nurses Susanne Susanne Vahr (DK) Vahr Anatomy and physiology: 1. Principals of NMIBC and MIBC pathology 2. Radical cystectomy Mohsen M. El-Mekresh (UAE) Principals of Enhanced Recovery Protocols (ERAS) Mohsen M. Susanne Vahr (DK) El-Mekresh Preoperative nursing interventions: education of the patient, nutritional status, smoking cessation and physical exercise. Bente Thoft Jensen (DK) Postoperative nursing interventions: wound care and care of stents, drainage tubes and the indwelling catheter. Bente Willem De Blok (NL) Thoft Jensen Break Practical session: How to teach urostomy patients to regain independence Willem De Blok (NL) & Bente Thoft Jensen (DK) Willem Practical session: How to teach patients with a De Blok neo-bladder intermittent catheterisation. Willem De Blok (NL) & Susanne Vahr (DK) Lunch How to activate the patient to meet discharge criteria regarding nutrition and physical exercise. Bente Thoft Jensen (DK) Test: Group work based on a patient case: Identifying nursing diagnosis and nursing interventions in radical cystectomy using the principals of ERAS Susanne Vahr (DK), Willem De Blok (NL), Bente Thoft Jensen (DK) Summary of test and questions. Break

Full details and registration: www.eusc2017.com/workshops

EAUN18 takes inspiration from Danish tradition Scientific Programme to offer key updates on nursing management Copenhagen will host the 19th International EAUN meeting (EAUN18) from 17-19 March 2018, and as part of the EAUN’s objective to provide top quality meeting updates, the members of the Scientific Congress Office have prepared an exciting, surprising and highly educational programme. “As in London, the congress in Copenhagen will contain some surprises. In EAUN17 we had the excellent “Westminster House of Commons” Session which attracted a large audience. That session was created to honour a tradition of the host country (United Kingdom). In a similar way we will honour Denmark and its traditions in a different and remarkable session,” said Corinne Tillier, Chair of the EAUN Scientific Congress Office. EAUN18 will have two plenary sessions. According to Tillier, the first plenary session will have as overarching theme the EAUN’s goal to provide skills training and knowledge exchange to prepare next-generation urology nurses. This is an important priority for the EAUN as the session will directly address core educational needs.

Abstract and Video Submission Difficult Case Submission Research Project Plan Submission Deadline: 1 December 2017

The second plenary session, on the other hand, will be an in-depth examination of the issue of urinary sepsis. Expert lectures and practical nursing insights will be offered to the participants for them to have a comprehensive and updated knowledge on various nursing strategies and approaches in managing urinary sepsis. Wide range of topics “In this congress we will also discuss various themes such as complementary or alternative medicine in

in conjunction with


European Urology Today

urology, pelvic rehabilitation, Disorder of Sex Development (DSD), bone health in prostate cancer, end-of-life care in urology, conservative bladder care management and many other interesting topics,” added Tillier. The topics were carefully selected in response to the current challenges and pressing issues often encountered by nurses in daily clinical practice. For the first time, the SIG Bladder Cancer Group (Special Interest Group) and the SIG Continence Group have designed a specific thematic session, and members of these working groups will also chair and lead the session. The session of the Bladder Cancer SIG Group will focus on BCG (Bacillus CalmetteGuerin), while the Continence SIG session will take up painful and underactive bladder. Prizes To build on the success of previous EAUN congresses, Tillier said regular features such as the Poster Sessions will be part of the programme with recognition and cash prizes for the top three best posters (€500, 300 and 200). The Nursing Research Competition, which aims to support and encourage innovative work, will offer a €2,500 prize. Also to be featured next year are the well-attended Video and Difficult Cases sessions. “We look forward to meet our colleagues from across Europe and beyond to exchange experiences and share our expertise in all fields of urology,” Tillier said. Submission open Submission is now open for poster abstracts, video abstracts, nursing research plans and difficult cases. Participants who are invited to present in the Video

Stefano Terzoni, Chair EAUN

Corinne Tillier, Chair SCO

and Difficult Cases sessions will receive a complimentary registration, as part of the EAUN’s efforts to promote promising work. Submission is not only open for nurses and members since all abstracts dealing with a topic that is relevant for urology nursing are welcome. The criteria and rules for all submissions can be found at our congress website at www.eaun18.org. Deadline is 1 December 2017. Organisers said they will offer some travel grants to EAUN18 for members. The application date will be announced by email and on the congress website, so watch out for future updates! The congress in London saw a significant increase in participation and submissions, and we hope to receive a record number of submissions and number of participants for EAUN18. See you in Copenhagen! Visit the website for more information!

Submission deadline: 1 December 2017

www.eaun18.org August/September 2017

Profile for European Association of Urology (EAU)

European Urology Today August/September 2017  

European Urology Today (EUT) August/September 2017. EUT is the official newsletter of the EAU.

European Urology Today August/September 2017  

European Urology Today (EUT) August/September 2017. EUT is the official newsletter of the EAU.

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