European Urology Today June/July 2017

European Urology Today Official newsletter of the European Association of Urology

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Vol. 29 No.3 - June/July 2017

Urinary bladder cancer in 2017

Speaking the same language in prostate mpMRI

EBU ensures top standards

Pathology sampling and reporting

PI-RADS, PRECISE, MET-RADS-P reporting systems

383 new FEBUs passed exams in Ankara, Warsaw, Budapest, Brussels

Prof. R. Montironi

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12-14

Dr. F. Sanguedolce

The future of urology: Strength in diversity, quality of care Showcasing priorities at the National Societies Meeting in Noordwijk

By Loek Keizer

“Urology doesn’t necessarily have a bad image, but no image at all,” Prof. Maurice Stephan Michel EAU Secretary General Chris Chapple referred to (Heidelberg, DE) said on behalf of the German Society urology being “under attack” at several points during of Urology. “As a society we organised the Urologicalthe Plenary Session that opened the EAU National Testicular Cancer Week to make the link between Societies Meeting on June 9. The future of the field is urology and urological cancers more clear. We had a uncertain and Europe’s national societies have a lot of success with our press releases and received a stake in putting urology on the map as a diverse and lot of coverage for urology in national newspapers. viable medical specialty. A roundtable discussion This is an example of what national societies can do brought together different points of view on which to give urology an identity in people’s minds.” areas urologists should focus on as certain procedures are increasingly being performed by Strength in quality and diversity oncologists or gynaecologists.

EAU Adjunct Secretary General in charge of Science, Prof. Francesco Montorsi (Milan, IT) also reflected on The Noordwijk meeting is an annual gathering that the changing nature of the field of urology, but brings together officials from Europe’s urological emphasised its fundamental strength in versatility societies and the EAU Executive in order to discuss and quality of care. “As urologists, we are responsible issues that affect urology across the continent, for our own future, as long as we provide patients including the role of the EAU and the cooperation with the best possible quality of treatment. In my with the national societies. Representatives from 40 experience, as surgeons are increasingly rated on the national urological societies attended the meeting in internet, people visit urologists because of the quality Noordwijk, The Netherlands on 9-10 June, 2017. of care that they offer.”

The EAU Executive and representatives of the forty national urological societies of Europe

“ESUO is a section that is just beginning, and one of our goals is learning more about office urology throughout Europe. We would love to hear about the situation in your country as we build a network.”

The discussion on the importance of office urology continued on the second day of the Noordwijk meeting, culminating in the ambition of having a day-long programme at the Annual EAU Congress Prof. Helmut Haas (Heppenheim, DE) was invited to introduce the EAU’s newest section: the EAU Section of specifically for “daily practice” urology. Prof. Chapple: “This is a clear unmet need, and it will be very Urologists in Office (ESUO), of which he is the attractive for this group of people who are less chairman. In Germany, a sizeable proportion of urological treatment occurs not by general practitioners interested in the intricacies of robotic salvage procedures.” or clinically, but in specialised urologists’ offices.

about European Union Research Networks that the EAU is also closely involved in. Mr. Jan Nawrocki (Brighton, GB) presented on behalf of the European Board of Urology, and Mr. Kieran O’Flynn (Manchester, GB) on the British experience with (online) auditing and quality improvement of individual surgeons.

The meeting also features one-on-one sessions that allow representatives from each country to speak to members of the EAU Executive individually, giving each society a chance to bring their unique needs to the attention of the EAU. For an impression of the diversity of concerns and requests in these one-onone sessions, please see page 3.

“Furthermore, I believe urology remains a versatile field. We are in less danger of identifying with one organ or procedure than, for instance, cardiac or vascular surgeons. When we work on the scientific programme of our annual congress, it sometimes feels like we’re compiling a meeting of ten different associations!”

Future directions for urology “I think urology is grossly under-recognised by the general public,” opined Prof. Jens Sønksen (Herlev, DK), the newly-appointed Adjunct-Secretary General.

Prof. Chapple agreed: “We need to ‘upgrade’ this recognition, as well as the ownership of urology. It is our opinion that the management of urological conditions should continue to be driven by the urologist.”

An informal survey of the panel members and the audience raised a range of topics where urology might or should be focusing on in the near future.

These included the lead that urologists could be taking as antibiotic resistance increases (due to experience with urinary tract infections), the shifting demographics of urologists as more women enter the ranks of urologists, and increasing emphasis on female and paediatric urology.

“The EAU is working on this by organising Urology Week and Prostate Cancer Awareness Day, and using social media to shape public perception. National societies can do the same for the populations of their countries.” Chapple also pointed to the role of medical schools, stating that they could do more to stimulate their students’ interest in urology as a career choice.

Prof. Chapple summarised much of the discussion on the role of the EAU in his call for the Association to produce a white paper that deals with medical oncology “not just on prostate cancer, but on kidney and bladder as well to prove that urology is pivotal.

The European Commission generally does not involve itself in national medical policy, and there are different Prof. Haas introduces the new EAU Section of Urologists in regulations across Europe, but the Executive feels we Office (ESUO) to the assembled representatives need these documents to engage effectively with the European Union and medical companies.”

Prof. Haas: “These offices fill the gap between the kind Informing and collaborating of treatment that GPs can offer and the more intensive The Noordwijk meeting also serves as a showcase of treatment that requires a hospital stay. In our experience, these offices are popular with patients the EAU’s initiatives and activities, both informing national societies and calling on their participation. because of the long-term care offered by a single This year, invited speakers were Prof. James N’Dow urologist, the ‘familial’ atmosphere, and because the (Aberdeen, GB) on behalf of the EAU Guidelines offices generally require less travel to reach for Office, and Mrs. Michelle Battye (Sheffield, GB) to talk patients, as opposed to (regional) hospitals.”

Prof. Hein Van Poppel (Leuven, BE), EAU Adjunct Secretary General in charge of education added that the attention of medical students and residents must be drawn to urology, emphasising andrology, female urology and paediatric urology as areas that deserve much more interest.

The aforementioned roundtable discussion raised many interesting issues, not the least of which concerned new directions for urology to consider as the field is changing. Prof. Chapple had earlier raised concerns and asked the other EAU Executive members and some audience members to voice their opinions on the matter.

Prof. Manfred Wirth (Dresden, DE), EAU Treasurer, spoke cautiously about urologists identifying too closely with robotic surgery. “We are organ specialists.

If urologists identify themselves as (robotic) surgeons first, they tie their field to technical developments and seriously risk losing their jobs as technology makes surgeons obsolete.”

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

WEEK 2017

A future for regional meetings The meeting continued on Saturday, addressing continued need for educational activities at the national societies’ own meetings and the future of the EAU’s regional meetings in Central and South-eastern Europe.

Prof. Chapple announced a return to the regional approach, albeit with a different scientific concept.

“After speaking to you all, it is clear how much the regional meetings were respected. We looked at the attendance figures and it was clear that we could count on 50-60 senior urologists, but a relatively low number of residents. In the Baltic states, the Baltic Meeting is essentially a rotating national meeting between the three countries, with EAU involvement.

We would like this model for the Central European and South-eastern Meetings as well.”

National societies will take the lead in organising the meeting in turn, with support from the EAU for a joint scientific programme. The regional advisory board will consist of presidents of all the region’s societies, as well as a key opinion leader from each country.

Prof. Sønksen will take the lead on behalf of the EAU.

www.eau18.org

Abstract submission now open! Deadline: 1 November 2017

25-29 SEPTEMBER

June/July 2017

European Urology Today

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USANZ Trainee Week Week-long programme provides incisive updates and cordial links Dr. Peter-Paul Willemse Fellow Oncology and Endo-urology UMCG Groningen Groningen (NL) ppmwillemse@ hotmail.com Each year all residents from Australia and New Zealand gather for a five-day long Trainee Week and every year the Urological Society of Australia and New Zealand (USANZ) invites eight residents from over the world to join this event. The Trainee Week is held in a different Australian section every year and the clinical programme is developed by the convenor in consultation with their local training, accreditation and education committee.

The programme also includes exam practice and interactive clinical sessions. This year USANZ trainee week was held from November 20 to 24, 2016 at the Crowne Plaza Hotel in Coogee, Sydney. Coogee is one of Sydney’s most picturesque beachside suburbs with a beautiful white sandy beach with calm waters for swimming and surfing. The hotel overlooked Coogee Bay and the great Southern Ocean.

Trainee Week started on Sunday with a written and practical examination for the fifth-year urology residents (SET5’s) while the fourth-year residents observed the examinations to prepare themselves for the examination next year. Fifth-year residents also completed a laparoscopic session unther the supervision of Anthony Hutton. The day ended with a welcome barbeque on the terrace overviewing Coogee beach. We met the trainee board and all the residents who made us feel really welcome.

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

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European Urology Today

Monday morning started with a group training session on the iconic Coogee beach at 6 a.m. under the supervision of two professional trainers. After an hour of physical drilling everybody lingered for some healthy Australian breakfast. At 8 a.m. Simon Bariol, the Convenor of the Trainee Week gave us a special warm welcome. Apart from my EAU college Anneleen Verbrugghe, six other trainees, from the Urological Association of Asia (UAA), the Specialist Urology Registrars Group from the UK (SURG) and from the Canadian Urological Association (CUA), were invited.

The next four days featured lectures by renowned urologists from Australia and New Zealand and case discussions prepared by residents. Monday covered topics in uro-radiology, uro-pathology and trauma.

Radiologist Dr. Daniel Moses lectured on MRI prostate. He showed that MRI gives a better soft tissue image and better borderlines than conventional imaging. He also explained diffusion weighted imaging and enhancement scans and clarified the difference in PIRADS grading between the peripheral and central zones. He clearly explained all the PIRADS stages and location of the tumour.

Dr. Nina Wines, dermatologist, started with a quiz on different genital skin diseases and medications. After showing some interesting pictures she emphasized that male patients prefer to apply ointments rather than creams. She also discussed the clinical presentation of intra-epithelial neoplasia and treatment with Imiquimod, 5-fluoracil, photodynamic therapy and laser. Dr. Fiona Maclean, pathologist, showed practical aspects of cancer pathology for urologists. Aside from giving an overview of the changes of pathological renal cell carcinoma which results to a wide pathology classification for this type of carcinoma, she also showed the nuances in a report. Among other things, she explained some terms used in pathology, e.g. why a sarcomaotid CCRCC is merely a ‘bad looking’ renal cancer and not a real sarcoma. She also pointed out the changes in the grading system, i.e., from Fuhrman to the ISUP nucleolar grading.

Session on urological traumas Dr. Anthony Chambers, General Surgeon and Colonel of the Army Reserve, gave an overview of the management of servere trauma, which mainly involves resucitation and damage control. This lecture was followed by interesting case presentations on renal injury, pelvic fracture and concommittant bladder and urethral injury and intraoperative gynaecological ureteric injury. Thereafter, Dr. Paul Sved enlightened us in the simple, but potentially

All residents from Australia and New Zealand and eight invited residents gathered for the lectures by renowned urologists

dangerous world of the optimal TURBT. He discussed techniques, challenges, tips, material use, complications and risk factors. Dr. David Gillatt, chair of the afternoon sessions, gave recommendations on optimal management and follow-up of NIMBC. We had a free Monday evening and some of the registrars invited us to dine in a local restaurant at Bondi Beach. On the advice of the programme committee I walked with two fellow invitees, Dr. Anneleen Verbrugghe and Dr. Sergey Tadtayev, the famous and really beautiful coastal cliff path from Coogee to Bondi Beach.

"In accordance with the EAU guidelines on testicular cancer, he recommended to only perform a chest X-ray in the follow-up of advanced germ cell tumours to prevent accumulative radiation dose due to repetitive chest CT-scans and the concommittent risk for secondary cancers."

Tuesday morning started with a session on male infertility and andrology, chaired by Dr. Shannon Kim. David Templeton, senior staff specialist of RPA sexual health lectured on the basics of sexual health medicine. He underlined the necessity of putting the patient at ease and the use of non-judgmental questions during consultations. He also discussed several infectious and non-infectious causes of genital ulceration calling them the “Derm Down Under”.

Thereafter, Chris McMahon, sexual health physician, enlightened us regarding office management of male sexual dysfunction. He stated that by year 2020 up to 322 million men would suffer from erectile dysfunction. Subsequently, Dr. Kenneth Vaux, from the Royal North Shore Hospital discussed medical and operative management including PDE-5 inhibitors, intracavernosal injections, vacuum devices and penile prosthesis. He explained the “Wilson” rear tip extender stitch and the proximal sock in proximal perforation. Urologist Dr. Gerard Testa from Shire, noted that Peyronie’s disease was first described in 1265 in France. He discussed the two stages of the disease and both the surgical (Nesbitt, Yacchia and Plication) and non-surgical management. For the latter there is scant literature, besides the use of

steroids and collagenases. Dr. Kishani Kannangara, endocrinologist and andrologist, explained “what the testis do for a living” and lectured on risk factors and causes of testosterone deficiency. The current and approved indications for testosterone therapy are not really different than in Europe and these are summarized in the PBS criteria.

Tuesday afternoon was reserved for social activities.

I was invited by Dr. Ross Fowler to a catamaran boat cruise in Sydney Harbour with 20 other fellow residents. The boat cruise was really marvellous.

Everyone enjoyed the nice weather especially after three days of lectures. We had a wonderful party in the waters off Sidney Harbour, and sailed under Sydney Harbour Bridge with a fantastic view of the Opera House and City Center. The cruise also brought us to a quiet beach near Tarongoo Zoo where we had an Australian barbeque in the boat.

Funtional urology session On Wednesday, functional urology topics were covered. The day started with presentations on risk factors and treatment of pelvic organ prolapse. Dr. Vincent Tse discussed ‘Pelvic Politics’ which is about the intercollegial discussions among surgeons, gynaecologists and urologists. Thereafter, SET 5 trainees presented on topics such as the treatment of overactive bladder and stress urinary incontinence in females and in men who underwent radical prostatectomy.

Wednesday afternoon was reserved for the “Masters of the Uroverse”, a section versus section quiz were residents from all seven Australian states and New Zealand competed against each other in a Jeopardy-style quiz on urological subjects. It was real fun to watch and the participating residents impressed with the knowledge they gained after five years of training. That evening we were invited for a chique dinner at the Watsons Bay Hotel, located at the south bank of Sydney Harbour, which overlooks the city center. After the dinner some of the residents showed us Sydney’s nightlife, and I can say that the Aussies really know how to party!

Thursday morning started with lectures on testicular cancer. Dr. Manish Patel discussed the principles of retroperitoneal lymph node dissection and indications like NSGCT growing teratoma syndrome and desperation surgery. Thereafter, Dr. Peter Grimson lectured on the follow-up and treatment of advanced testicular cancer. In accordance with the EAU guidelines on testicular cancer, he recommended to only perform a chest X-ray in the follow-up of advanced germ cell tumours to prevent accumulative radiation dose due to repetitive chest CT-scans and the concommittent risk for secondary cancers.

After lunch the last lectures of this week were on prostate cancer with topics such as active surveillance, the role of PSMA-PET CT-scan and chemo-therapeutic treatment in hormone-sensitive prostate cancer. The prostate cancer session ended the five-day-long Trainee Week with all participants gaining updates and insights on management options.

Boattrip Sydney Harbour

I would like to thank USANZ and the EAU for this opportunity to travel “Down Under” and meet my fellow colleagues from Australia and New Zealand.

June/July 2017

Identifying National Societies’ needs One-on-one meetings with EAU Executive raise wide range of issues The 2017 National Societies Meeting featured one-on-one meetings that allowed representatives of each society present in Noordwijk on 9-10 June to speak to members of the EAU Executive. These frank conversations revealed a lot about the different needs of urologists across the continent.

In spite of the efforts of the EAU to harmonise and improve patient care across the continent, standards of living, politics and economics can create hugely diverging challenges for urologists. In one one-onone meeting, a national society might call on the EAU to consider designing a standard registration system for oncological procedures, while in the next, the realities of a largely cash-based society can make en-bloc membership difficult.

As long as these vast differences exist, the EAU has to remain flexible in order to reach as many urologists as possible, though without compromising the quality of its science and other services.

Stimulating research Several societies mentioned the terms for participation in existing scholarship programmes as difficult for their younger members: specifically the requirement of having written a relevant PubMed-indexed article has been a stumbling block for some. The EAU executive is reviewing this requirement in order to come up with a viable alternative for some countries.

Similarly, the acceptance rate of abstracts at the Annual EAU Congress was a topic that was discussed during several meetings in Noordwijk. The EAU has a strict and anonymous selection process for abstracts in order to guarantee the quality of the science presented at its Annual Congress and other meetings and is extremely hesitant to adjust these procedures.

Profs. Montorsi and Van Poppel discuss the collaboration with the Lithuanian Society of Urologists, represented by Profs. Kincius and Jievaltas

The European School of Urology does offer courses for abstract-writing, which can be useful for young urologists in countries with less experience at successful submissions. The EAU Executive also stressed the role of the individual societies’ senior members in stimulating research and publication from their younger members and residents.

Collaboration on meetings The meetings in Noordwijk also covered cooperation between the EAU and national societies regarding the latter’s meetings. The EAU often offers ESU Courses or hands-on training at these national meetings, as well as high-profile international speakers. The society representatives were invited to submit requests for specific speakers or topics. In some countries, for instance, there was a clear desire to receive education on laparoscopic procedures, while others had clear preferences for invited faculty.

Profs. Chapple and Wirth lead the group discussion in Noordwijk on Saturday

Countries’ national urological societies are also partners in organising the EAU’s Regional Meetings, like the recent Baltic Meeting (see page 18). The attending representatives were also polled on their interest in future participation in the organisation of regional meetings. By joining several countries in organising a single meeting, this creates more attendees and consequently, more EAU/ESU involvement.

European mediator The EAU is in a unique position to shape or at least influence European healthcare policy through its involvement in the European Union. The Noordwijk meeting further illustrated the different ways in which the EAU is working together with other parties to raise politicians’ awareness of urological issues that the continent will be facing as average lifespans increase.

The future of urology: Strength in diversity, quality of care. . . . . . . . . . . . . . . . . 1 USANZ Trainee Week . . . . . . . . . . . . . . . . . . . 2 Identifying National Societies’ needs . . . . . . . 3 Urinary bladder cancer in 2017. . . . . . . . . . . . 4 Speaking the same language in prostate mpMRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Some societies petitioned the EAU Executive to initiate Europe-wide standards for the registration of certain procedures for the sake of insurance companies, as well as for implants, which in some countries have to be registered. EAU (Guidelines) definitions as to what constitutes an implant would be very helpful for these national societies.

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

Many of the talking points from the forty one-on-one meetings were carried over to a group discussion on Saturday the 10th. The EAU Executive praised the societies for their input over the two days, and reiterated Europe’s urologists’ ambition to recruit more young urologists, to advertise the specialty among the general public and in the European political arena.

ESU section: 2nd ESU-ESUT Masterclass on Operative Management of BPO. . . . . . . . . . . . . . . . . . . 15 23rd Congress in Serbia . . . . . . . . . . . . . . . . 17 ESU course in Cyprus . . . . . . . . . . . . . . . . . . 17 BALTIC17: Pursuing challenges and opportunities. . . . . . . . . . . . . . . . . . . . . . . . 18

Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11 EBU ensures top standards for patient care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-14

EULIS: Sofia event examines key updates in stone management. . . . . . . . . . . 23 Obituary: Mostafa Elhilali. . . . . . . . . . . . . . . 23

IF IT DOESN’T CHANGE PRACTICE, IT DOESN’T HAVE IMPACT

Call for proposals biological samples MAGNOLIA study . . . . . . . . . . . . . . . . . . . . . 23 ESFFU: Understanding Bladder Pain Syndrome/Interstitial Cystitis . . . . . . . . . . . . 24 EULIS: Medical expulsive therapy for stones. . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 24 European Tour 2017 - Academic Exchange Programme . . . . . . . . . . . . . . . . . . . . . . . . . 27 Ten Questions: Paul Abrams. . . . . . . . . . . . . 28 EUSP: Rewarding experience at Guy’s & St. Thomas Hospital. . . . . . . . . . . . . . . . . . . 30

Our 2016 Impact Factor

One journal, one community. Our heartfelt thanks to the many authors, reviewers and readers who contribute to the journal’s success. We really are in this together.

Journal Citation Reports® 2017, published by Thomson Reuters

Examining key topics in urothelial carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . 31 105th Meeting of the Japanese Urological Association (JUA) . . . . . . . . . . . . . . . . . . . . . 32 Japanese Tour 2017 - International Academic Exchange Programme. . . . . . . . . . 32

europeanurology.com

June/July 2017

EAUN section: European Specialist Nurses Organisations (ESNO). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Getting the right diagnosis. . . . . . . . . . . . . . 39

European Urology Today

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Urinary bladder cancer in 2017 Pathology sampling and reporting Prof. Rodolfo Montironi Chairman EAU Section of Uropathology (ESUP) Ancona (IT) r.montironi@ univpm.it Co-authors: Antonio Lopez-Beltran (PT), Marina Scarpelli (IT), Silvia Gasparrini (IT), Liang Cheng (USA) The best management for patients with carcinoma of the urinary bladder depends on a close collaboration among urologist and pathologists. The pathologist is involved in making the diagnosis as well as in the evaluation of prognostic and predictive factors in biopsies of the bladder, transurethral resection of the bladder (TURB) and cystectomy specimens.

Adequate clinical information is of paramount important to pathologists for them to choose the best approach in the evaluation of the specimens.

Cystoscopic findings can give useful information on the nature and extent of bladder lesions. Any tumours diagnosed previously have to reported, including the histologic type and grade, and primary location. If prior therapy has been administered (intravesical or systemic chemotherapy, radiation, immunotherapy, etc.), it has to be described.

Handling of specimens The most common bladder specimens are biopsy and TURB. Their histopathological examination provides the basic information needed to decide the patient’s subsequent therapy. Additional information on curative-intent specimens (such as cystectomy) determines the adequacy of applied therapy or further need for surgery or adjuvant radiotherapy or/ and chemotherapy [1-8].

Biopsy Effort should be made to identify the mucosal aspect of biopsy fragments to allow better visualisation of the urothelium of the surface. However, this is not always feasible. As a general rule, for each biopsy at least three levels of sections should be available on a slide. Deeper sections into the block are needed when the surface urothelium is not entirely visible or in case of denuded samples, to exclude the possibility of denuded carcinoma in situ (CIS) [9,10].

sampled entirely in order to find possible residual foci of cancer. For neoplasms invading macroscopically the wall of the bladder, multiple samples, including the area grossly suspicious for deepest penetration, have to be taken and evaluated microscopically to assess pT2a/b vs. pT3a. Grossly visible tumour at resection margins (R2) (the soft tissue margin should be inked) or/and in perivesical fat (pT3b) must be included in the gross description of the pathology report [11].

In case of partial cystectomy, the margins of resection of the bladder wall have to be examined microscopically for tumour involvement. Unless submitted previously for frozen section examination, ureter and urethral margins are sampled as shave sections. This approach allows the pathologist to visualise on the slide the entire mucosal circumference. In those cases of urachal adenocarcinoma in which partial cystectomy with excision of the urachal tract and umbilicus is performed, the soft tissue surrounding the urachus, i.e., the margins of the urachal tract as well as the skin around the umbilical margin, should be sampled and examined histologically [6,11,16].

The alternative to partial sampling with regular histological cassettes is the complete sampling with large format histology (Figure 1). The whole mount technique has the paramount advantage of showing the architecture of the urinary bladder and the precise identification and localisation of tumour neoplasm(s).

In addition, it is much easier to compare the morphological features with those seen in cystoscopy, TUR and biopsies, as well as imaging results. Large format histology has been shown not to be superior to sampling with regular histological cassettes in detecting adverse pathological features [17].

In cystoprostatectomy specimens, sections should include the prostatic urethra to identify tumour invasion from a separate carcinoma of the urethra.

Sections of penetration to prostate from bladder by the tumour have to be taken to document stage pT4 bladder cancer. The prostatic parenchyma has to be examined to assess the presence of concomitant prostate cancer (which is not an uncommon occurrence), and its prognostic features. The whole mount technique can be used to sample the prostate from cystoprostatectomy specimens [18].

Non-invasive urothelial neoplasms Use of the 2016 WHO classification system is the international standard [10,19] (Table 1) (Figures 1 and 2). Other systems, in particular the 1973 WHO classisication, may be used alongside. Grading of Transurethral resection papillary urothelial tumours should also take cancer The routine way to process TURB specimens is to heterogeneity into consideration. It is based on the submit the tissue entirely for histological examination. worst grade.

When dealing with large neoplasms, exceeding 10 cm in diameter, it is suggested to submit one tissue Bladder cancer variants cassette per cm of diameter (up to 10 cassettes).

The 2016 WHO classification system is recommended Additional selective cassettes are processed until the [19] (Table 2) (Figure 3). UC is known to show variants invasion of the muscularis propria (MP) is seen. The and divergent differentiation ranging from 7% to 81% pathologist can choose to submit the remaining of the [20,21]. In an analysis of 165 TURP specimens Billis et TURB sample when invasion of the MP is identified al (8) found squamous and/or glandular following the first selective sampling approach [11]. differentiation in 7% of tumours. In this series, the patients with divergent differentiation presented with The second TURBs used for deep muscularis propria a higher clinical stage at presentation in comparison staging are usually of low volume. This can easily be with conventional UC [22]. In a study of 448 processed entirely. Large bulk completion with TURB consecutive TURBs and 295 subsequent cystectomy for tumours previously resected incompletely, the specimens, Wasco et al [23] found that UC with pathologist can decide to submit less material divergent differentiation was more likely to invade the provided that the initial TURB has already shown the muscularis propria (Detrusor) at TURP and presence of invasion of the MP [12,13]. extravesical fat at cystectomy when compared to pure or conventional UC. Jozwicki et al [24] correlated the Follow-up TURB for a bladder-preservation approach mapping studies of 38 cystectomy specimens with following chemotherapy or/and radiotherapy is survival. They found that the presence of more than processed by adopting the conventional routine way.

80% pure UC within a surgical specimen was a factor of favourable prognosis. In addition, an increasing Cystectomy specimens number of histologic subtypes (increasingly variants As a general rule, samples processed with regular and divergent differentiation) led to a poorer histological cassettes are taken from representative prognosis. UC variants and with divergent areas of the neoplasms, from normal-appearing differentiation have been considered to have a worse urinary bladder, the prostate and seminal vesicles, or prognosis when compared with pure UC; However, other organs, such as the uterus, included in the stage matched cohorts show limited differences. From specimen [14]. Any suspicious-appearing areas of the practical point of view, when multiple histologic mucosal induration and reddening need to be subtypes are present, the pathologist should provide sampled. Adequate mapping of the trigone, anterior, relative percentages for each, e.g., invasive UC (70%) posterior and lateral walls, and dome of the bladder with squamous (20%) and glandular (10%) should be performed, as well as in cystectomy differentiation [25]. specimen with less visible residual tumours in a setting of surgery following neoadjuvant Lymphovascular invasion (LVI) chemotherapy [8,15].

LVI usually appears as a small group of malignant cells in blood or lymphatic vessels, occasionally filling In cystectomy specimens with no residual tumour completely the vascular space (Figure 4). A tumour (i.e., pT0) on initial histological examination, prior infiltrating the lamina propria (pT1) is sometimes resection sites or mucosal ulcerations have to be over-diagnosed as vascular invasion. Strict criteria 4

European Urology Today

must be utilised in establishing a diagnosis of LVI because peri-tumoural stromal retraction is a common feature that can mimic a vascular space. The utilisation of immunohistochemistry for endothelial markers (CD31, CD34, D2-40) for a diagnosis of LVI is used only in selected histologically equivocal cases.

Reproducibility in the detection of LVI can be poor, even when immunohistochemistry is used [26].

It is an important prognostic factor both in TURB and cystectomy specimens [27-34]. In the TURBs it is as predictor of poor outcome, including progression and metastasis in T1 cancer [28,30,34]. This means that LVI predicts tumour behaviour and guides treatment decisions when seen in TURB material [28-30,34].

When LVI is seen in TURB it is present in 65% of the corresponding cystectomies; it is associated with lymph node metastasis in 41% of patients [29]. LVI was also an independent prognostic factor in patients treated with radical cystectomy [32,33]. In a retrospective investigation of 750 bladder cancer patients, LVI was an independent predictor of recurrence and decreased overall and cause-specific survival in lymph node-negative invasive cancer treated with cystectomy [31]. All this means that it is recommended to report LVI in TURBs and cystectomy specimens with invasive cancer.

Staging of urinary bladder tumours A role of a pathologist is to define the depth and extent of invasion into the subepithelial connective tissue (pT1) (Figure 5), muscularis propria (Detrusor) (pT2), or beyond (pT3 or pT4) [35-37]. The depth of invasion is an important prognostic factor in UC (Table 3).

In T1 disease (i.e., invasion into the subepithelial connective tissue), different sub-staging systems have been proposed. Such methods, however, are difficult to use because of lack of orientation of the specimen [19,38]. However, pathologists are encouraged to include in the pathology report the results of some kind of assessment of the extent of lamina propria invasion: above, at, or below muscularis mucosae, maximum diameter of invasive component of the neoplasm, or depth in millimeters.

Designation of a neoplasm as muscle invasive is insufficient and inappropriate. The precise type of muscle invasion, i.e., muscularis mucosae (pT1 tumours) vs. muscularis propria (Detrusor) (pT2 tumours) invasion, have to be clearly indicated [39,40]. A descriptive “urothelial carcinoma with muscle invasion, indeterminate for type of muscle invasion,” could be added to the pathology report in those cases for which the type of muscle infiltrated is not certain whether it is hypertrophic muscularis mucosae or muscularis propria. In such cases, Smoothelin immunohistochemistry is used as an adjunct to morphology to confirm invasion of the muscularis propria in selected cases [41].

In TURB specimens with UC invading into muscularis propria, it is not feasible to sub-stage the depth of detrusor invasion. Adipose tissue can be seen in the subepithelial connective tissue and muscularis propria. For this reason the presence of tumour in the fat is not considered as diagnostic for extravesical spread; this is only feasible in cystectomy specimens [40,42]. The microscopic distinction of invasion of the muscularis propria (pT2b) from microscopic perivesical adipose tissue invasion (pT3a) seldom can be difficult. This is due to the fact that the boundary between the outer margin of the muscularis propria and perivesical fat is not sharp and well-defined [43].

Involvement of the prostate gland may occur in three different ways. UC arises from the prostatic urethra with secondary prostatic stromal invasion (i.e., transurethral mucosal route). Involvement of prostatic stroma may be the direct invasion from a bladder primary UC [44]. UCs from extravesical fat can invade back into the prostate. The latter two ways are considered as direct transmural invasion. AJCC 7th edition defines direct extension of urinary UC into the prostate as T4 disease. Patients with UC infiltrating the prostatic stroma have a significantly worse five-year disease specific survival than those with UC originating in the prostatic urethra. It excludes transurethral mucosal prostatic stroma invasion from the pT4a stage. In the situation in which UC is seen in both sites, separate urinary bladder and prostatic urethral staging are used.

Seminal vesical invasion (SVI) by bladder cancer has adverse effect on prognosis and is comparable to pT4b tumours [45-47]. SVI may occur via bladder transmuralPVST or intraurethral-prostatic routes and both have

similar poor prognosis [47]. In the study by May et al [45] of male pT4 tumours, those without SVI had 5- and 10-year CSS rates of 21% and 17%, respectively, compared to 41% and 32% to those with SVI, respectively. While the 2016 AJCC included SVI as pT4, the actual pT4a/b subcategory is not yet specified [35].

Tumours involving the bladder diverticulum comprise 0.8-10.8% of bladder tumours [48]. It lacks a consistent MP layer in its wall [41]. Thus, diverticular cancer has no pT2 stage as the tumour directly invades from the subepithelial connective tissue into the perivesical adipose tissue [48-51]. The 2016 AJCC now officially recognises the approach of “skipping” pT2 in diverticular cancer staging [35].

Lymph nodes Pelvic lymph node (LN) dissection is a part of radical cystectomy for carcinoma of the bladder [52]. All LNs should be examined histologically. This is due to the fact that the pN stage as well as prognosis depends on both the number and the location of positive LNs. The minimum number of LNs in cystectomy specimen is not well defined. In an investigation by Fang et al [53], the minimum number of LNs for radical cystectomy with pelvic lymphadenectomy was investigated, requiring submitting more tissue, including fat, if a minimum number of 16 LNs was not collected. In a period of four years, the median number of LNs increased from 15 to 20. This approach resulted in the decrease of mortality risk by 48% [31].

Stephenson et al [54] showed the prognostic significance of measuring the aggregate lymph node metastasis diameter. Fleischmann et al [55] have shown that extracapsular extension in metastatic lymph nodes (Figure 6) is associated with very poor prognosis.

Checklists and Guidelines The literature is not short of satisfactory checklists and guidelines for handling and reporting of bladder cancer specimens [2-4,11,56]. Institutions such as the College of American Pathologists have outlined “essential” elements for reporting specimens resected for invasive bladder cancer [3].

References, Tables and Figures 4 to 6 The references, tables and and Figures 4 to 6 of this article are available from the EUT Editorial Office by sending an e-mail to: EUT@uroweb.org with reference to the article “Urinary bladder cancer in 2017” by Prof. Montironi, June/July issue 2017.

Figure 1: Whole mount section of the bladder with high grade urothelial papillary carcinoma (nuclear details not shown)

Figure 2: Urothelial carcinoma in situ

Figure 3: Urothelial carcinoma with squamous differentiation (Arrow)

June/July 2017

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European Urology Today

5

Speaking the same language in prostate mpMRI Standardising communications of mpMRI information with PI-RADS, PRECISE, MET-RADS-P reporting systems Dr. Francesco Sanguedolce Fundació Puigvert Dept. of Urology Barcelona (ES)

fsangue@ hotmail.com Prof. Anwar Padhani Mount Vernon Hospital The Paul Strickland Scanner Centre Northwood (UK) anwar.padhani@ stricklandscanner. org.uk English has been widely accepted as “lingua franca” in the scientific world for information exchange, the sharing of experience and dissemination of knowledge.

negative predictive value, and tying a clinical management plan for the different PI-RADS scores.

For some of these, improvements in technology are required; however, the PI-RADS community is already working on refinements as evidence accumulates in order to optimise diagnostic accuracy.

much more work to do, this approach is stimulating practitioners across the globe to standardise and optimise current technology and identify more systematically the areas where improvements/ refinements are needed.

As a clinical community of urologists, it is in our interest to engage in these processes for the sake of our patients.

3. Woo S, Suh CH, Kim SY, Cho JY, Kim SH. Diagnostic Performance of Prostate Imaging Reporting and Data System Version 2 for Detection of Prostate Cancer: A Systematic Review and Diagnostic Meta-analysis.

European urology. 2017 Feb 11. PubMed PMID: 28196723.

4. Moore CM, Giganti F, Albertsen P, Allen C, Bangma C, Briganti A, et al. Reporting Magnetic Resonance Imaging in Men on Active Surveillance for Prostate Cancer: The PRECISE Recommendations-A Report of a European School of Oncology Task Force. European urology. 2017 Apr;71(4):648-55. PubMed PMID: 27349615.

5. Padhani AR, Lecouvet FE, Tunariu N, Koh DM, De Keyzer F, Collins DJ, et al. METastasis Reporting and Data System for Prostate Cancer: Practical Guidelines for Acquisition, Interpretation, and Reporting of Whole-body Magnetic Resonance Imaging-based Evaluations of Multiorgan Involvement in Advanced Prostate Cancer. European urology. 2017 Jan;71(1):81-92. PubMed PMID: 27317091.

Pubmed Central PMCID: 5176005.

Another important step forward has been the standardisation of reporting changes of mpMRI findings at the follow-up of prostate cancer patients References 1. Barentsz JO, Richenberg J, Clements R, Choyke P, Verma on Active Surveillance (AS) (Figure 2). The PRECISE S, Villeirs G, et al. ESUR prostate MR guidelines 2012.

(Prostate Cancer Radiological Estimation of Change in European radiology. 2012 Apr;22(4):746-57. PubMed Sequential Evaluation) recommendations (4) have PMID: 22322308. Pubmed Central PMCID: 3297750. been developed in order to: 2. Weinreb J.C. BJO, Choyke P.L., Cornud F., Haider M.A., 1) standardise the mpMRI features -compliant to Macura K., Margolis D., Schnall M.D., Tempany C.M., PI-RADS v2 guidelines- that need to be reported in Thoeny H., Verma S. American College of Radiology. patients recruited into AS protocols, including PI-RADS v2.2015. Available from: http://www.acr.org/ baseline and follow-up studies; Quality-Safety/Resources/PIRADS. 2) grade the likelihood (Likert scale 1 to 5) of significant mpMRI changes during follow-up according to predefined criteria, that may trigger Transition Zone histologic reassessments and subsequent switch T2W DWI DCE to definitive treatment; 1 Any Any 3) define a check-list that needs to be followed when reporting mpMRI findings in a cohort of 2 Any Any patient on AS. 3 ≤4 Any Unlike the PI-RADS system, the PRECISE reporting scheme was developed through a Delphi-like process by a pool of experts in MRI, but validation is still lacking.

4 5

5 Any Any

Any Any Any

In medicine, the need to speak the “same language” is important for a variety of clinical and surgical activities; these include the standardisation of training of clinical and surgical practice, and for reporting Areas in need of further improvement include the Peripheral Zone outcomes. Urology is at the forefront where language refinement of criteria of those changes on mpMRI DWI T2W DCE standardisation is widely pursued and applied. during follow-up that may indicate definitive 1 Any Any treatment, as well as to define whether a 2 Any Any Next-generation imaging technology use in urologic confirmatory biopsy may be avoided when (and 3 Any oncology is quickly evolving particularly for prostate which) significant changes are reported by readers. cancer. Multiparametric MRI (mpMRI) has recently Any + been introduced as a tool capable of characterising Last but not least, the most recent reporting system 4 Any Any morphological and functional characteristics of introduced for prostate cancer MRI has been the 5 Any Any prostatic lesions using different sequences, like the T2 METastasis Reporting and Data System for Prostate weighted (T2W – looking at morphology), diffusion Cancer (METRADS-P): as the same acronym intuitively Figure 1: The PI-RADS v2 scoring system weighted imaging (DWI – looking at cellularity and suggests, it deals with the standardisation of Fig 1. The PI-RADS v2 scoring system gland water content), contrast enhanced (DCE – acquisition, interpretation and reporting of the looking at vascularity) and the magnetic resonance whole-body MRI (WB-MRI) in the assessment of spectroscopic imaging (MRSI – looking at metastatic prostate cancer (5). The need of developing metabolism). mpMRI utility has been shown for the such a reporting system derives from the poor diagnostic process when cancer is suspected and for accuracy of currently used imaging tools employed in local staging, for follow-up in the context of active this set of patients (specifically Computer tomography surveillance and, more recently, in the detection and (CT) scan and Bone Scan (BS)). Many recent studies follow-up of metastatic lesions using the technique of have shown that clinical assessments and PSA may whole body MRI (WB-MRI). not be efficacious enough for assessing the treatment effectiveness of next generation androgen axis The first formal attempt at a reporting and directed systemic therapies (e.g., Abiraterone or communication system for primary cancer detection Enzalutamide); imaging assessments are needed but was introduced in 2012 by the European Society of CT/BS can be limiting in this setting.

Urogenital Radiology (ESUR). The PI-RADS (Prostate Imaging Reporting and Data System) adopted some The recommendations were agreed among a panel of of the principles of a similar successful imaging experts and were made compliant to the Prostate reporting system for breast cancer (BI-RADS). The aim Cancer Clinical Trials Working Group (PCWG) as well was to communicate the likelihood of the prostatic as to the Response Evaluation Criteria in Solid gland in harbouring significant cancer (1).

Tumours (RECIST v1.1) guidelines. MET-RADS allows patients to be categorised into subgroups according to By standardising the reporting of each MRI sequence skeletal, node, visceral and/or soft tissue involvement based on the features displayed, a Likert-like score by metastatic deposits. MET-RADS can be used for from 1 to 5 was introduced according to the established metastatic disease or when just suspected progressive likelihood of significant prostate cancer. (e.g., in M0 Castration Resistant Prostate Cancer).

This allowed for quicker and easier understanding of Parameters taken into account include not just the reports from technically-minded radiologists to assessment of anatomic site(s), number and volume Figure 2: The PRECISE reporting form and scoring system clinical urologists and radiation therapists. of metastasis but also functional activity of lesions.

PI-RADS score 1 2 3 4 4 5

PI-RADS score 1 2 3 4 4 5

(Table from Moore et al. European Urology. 2017 Apr;71(4):648-55. Reproduced with permission from Elsevier and the author)

A refinement of the PIRADS system has been then published in 2015 (PI-RADS version 2 (2)). The main changes included the recommendation to use DWI and T2W as dominant sequences for the peripheral and transition zones respectively. As a consequence, only one score/lesion was provided by the radiologist; the role of contrast enhanced sequences (DCE) was limited to just upgrading certain PIRADS score 3 lesion in the peripheral zone (See Figure 1). Finally, the MRSI was deemed not useful and was removed from the reporting system.

Several groups have analysed the performance of the two PIRADS versions and, recently, results have been pooled in a meta-analysis: in a head-to-head comparison, the sensitivity for prostate cancer detection of PIRADS v2 was significantly higher than PIRADS v1 (0.95 vs. 0.88; p = 0.04), even though no difference was observed in terms of specificity (3).

However, there are still unmet needs with PIRADS v2, like a high inter-observer agreement, a refinement of PIRADS score to better characterise PI-RADS 3 lesions, validation of key characteristics (e.g. size cut-off between PI-RADS 4 & 5 lesions), improving the 6

European Urology Today

A template form has been proposed to report findings in a structured manner which incorporates a Likert-type score (1 to 5) reporting the likelihood of WB-MRI features in keeping with the relevant response assessment category pattern (response – stable – progressive) (See Figure 3). Uniquely scoring also applies to bone lesions (unlike RECIST/ PCWG criteria) whose response to treatment until now has been reported as just “progression” or “noprogression”.

MET-RADS introduction is relatively recent and again inter-observer agreement and validation studies are needed, especially to see whether an earlier and more precise identification and quantification of metastatic disease response may have an impact on treatment choices in these patients and on their survival time.

To conclude, many efforts have been undertaken for standardising the reporting and communication of MRI in different sets of prostate cancer patients to improve accuracy and understanding of findings, between radiologists and different specialists involved in prostate cancer care. Even though there is still

Figure 3: The METRADS-P scoring system and reporting form

(Table from Padhani et al. Eur Urol. 2017 Jan;71(1):81-92)

June/July 2017

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

The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem.

Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 51 A 77-year-old man presented as an emergency with severe right inguinal pain of sudden onset radiating caudally and voiding difficulties. Due to the pain the patient was unable to lie still. The history consisted of 35 pack-years of cigarette smoking and moderate alcohol consumption but was otherwise unremarkable. Current medication included clopidogrel and tamsulosin. Body mass index was 32 and on physical examination a mass was palpable in the middle lower abdomen.

Urinalysis showed micro haematuria but no sign of infection.

Ultrasound showed a fluid-filled non-echogenic structure in the middle lower abdomen and mild

Case study No. 52

dilatation of both renal pelvicalyceal systems, more pronounced on the right side. A plain abdominal x-ray showed calcifications in the lower pelvis (fig 1). A transurethral catheter was inserted but drained only 30 mL of urine and did not alleviate the pain.

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.

Discussion points: 1. What are likely differential diagnoses?

2. What further diagnostic management is helpful?

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).

Case provided by Prof. Malte Böhm and Dr. Hans Peter Stockamp, Dill-Kliniken, Dillenburg, Germany Email: malte.boehm@microdissect.de Readers are encouraged to provide interesting and challenging cases for discussion.

Fig. 1: Plain pelvic x-ray (arrows indicating calcifications)

Calcified pelvic large mass – CT or MRI needed Fig. 1: Locally advanced tumour visible

Comments by Prof. Jacques Irani Paris (FR)

gross haematuria (although under clopidogrel) and/ or burning and/or frequency in the past months.

This 77-year-old gentleman had a sudden inguinal pain radiating caudally which is not typical of a renal colic despite the intensity, the sudden onset and the inability to lie still because of the pain. A stone blocking the uretero-vesical junction could give urinary symptoms but these are, essentially, frequency and not voiding difficulties that this patient complained of.

Urinary infection is unlikely given the symptoms and the negative urinalysis.

A paramount feature is the huge mass palpable in the middle lower abdomen although the patient is overweight. Obviously, the first hypothesis would be acute urinary retention as the mass was fluid-filled on ultrasound with a mild dilatation of both renal pelvicalyceal systems. However, a transurethral catheter was inserted, drained only 30 mL of urine and did not alleviate the pain. We assume that the correct position of the catheter was confirmed.

The diagnosis of bladder distension is also challenged by the results of the plain abdominal X-ray showing calcifications in the lower pelvis. When scrutinized History of the patient is not very useful to solve the attentively, Figure 1 shows that the calcifications delineate a round-shaped mass corresponding very riddle: the 35 years of cigarette smoking would raise the hypothesis of a bladder tumour but there likely to what has been palpated and seen on is not much in favour of this hypothesis - mainly no ultra-sound.

CT scan for suspected vascular aneurysm Comments by Ass. Prof. Malte Rieken and Prof. Shahrokh Shariat Vienna (AT)

Malte Rieken

Shahrokh Shariat

In this case, a 77-year-old patient with severe right colicky pain of sudden onset presents to the ER. The most striking finding in this case appears to be a palpable mass in the middle lower abdomen. On ultrasound this mass is fluid-filled and not echogenic. A bladder in retention can be excluded as the catheter drains only 30 ml.

Based on the bilateral dilatation of the upper urinary tract, which is more pronounced on the

June/July 2017

symptomatic right side, an obstruction by internal or external cause should be taken into consideration. Urolithiasis is more unlikely and does not explain the fluid-filled palpable abdominal mass. As the patient is a heavy smoker and suffers from microhematuria, urothelial cancer might be the reason for his upper tract obstruction. However, this also would not explain the fluid-filled non-echogenic mass in the middle lower abdomen. As this patient has several vascular risk factors such as long-term smoking and obesity and already takes clopidogrel, a compression of the ureter by a dissecting aortic aneurysm extending to the iliac artery might be a differential diagnosis.

Our priority is to alleviate the patient’s suffering through adequate pain management. Once this is achieved, if renal function allows, we would perform a contrast-enhanced abdomino-pelvic CT scan with delayed cuts (CT urography). This should help to clarify the nature of the fluid-filled structure (vascular?) as well as the dilatation of both renal pelvicalyceal systems. Depending on the findings from the CT scan, further investigation of the microhematuria by cystoscopy should be performed.

What diagnosis seems to be the most likely?

Because of the arguments given above, discussion should revolve around the diagnosis of a cystic structure with rim calcification, indenting the bladder but not communicating with it. The exact diagnosis of this mass that is compressing the bladder is not yet clear.

One likely origin would be the intestine: enteric duplication cyst or mesenteric cyst. Another possible diagnosis would be a non-pancreatic pseudocyst or a lymphangioma.

The patient should also be interrogated again as it is expected that he should already have felt discomfort in the lower abdomen and dysuria for some time.

This explains possibly why he was on tamsulosin (although this is quite ordinary at his age).

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

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

How to go further?

A CT scan should bring valuable information.

However, it is likely that a contrast MRI of the pelvis would be a useful adjunct.

Case Study No. 51 continued An emergency CT scan was performed which showed a large aneurysm of the right common iliac artery in the process of rupturing, and a small aneurysm of the left iliac artery. The patient was still haemodynamically stable when he was transferred to the vascular surgery department to undergo immediate surgery. However, he developed multiple complications, underwent surgery several times and eventually died in hospital a month later.

Fig. 2: CT scan shows multiple hepatic metastases

Discussion points: 1. Are there any further investigations needed?

2. How can this patient be treated?

Case provided by Oliver Hakenberg, Department of Urology, Rostock University.

E-mail: oliver.hakenberg@med.uni-rostock.de

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7

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

fsangue@ hotmail.com

New combinations for mHSPC ASCO this year saw the presentation of two complimentary studies, which were simultaneously published in the NEJM. Both reported data in which men commencing androgen deprivation therapy and were then randomised to receive that alone or the addition of abiraterone 1000 mg o.d. plus prednisolone 5 mg o.d. As such, they investigated the hypothesis that more effective inhibition of the androgen-receptor signalling in men initiating systemic therapy leads to improved outcomes.

LATITUDE [1] was a double blind placebo controlled trial in which 1,199 men with high-risk metastatic castration sensitive prostate cancer were randomised in a 1:1 ratio. High-risk was defined as at least two of the three following risk factors: a Gleason score of 8 or more, at least three bone lesions or the presence of measurable visual metastasis. With 30.4 months of follow-up there was a significant improvement in overall survival (HR 0.62; CI 0.51-0.76, p < 0.001) with an even more significant improvement in median time of radiographic progression-free survival (HR 0.47; CI 0.39-0.55, p < 0.001).

Significantly better outcomes were observed in all secondary end-points, including the time until pain progression, next subsequent therapy for prostate cancer, initiation of chemotherapy, and prostate specific antigen progression (p < 0.001 for all comparisons), along with next symptomatic skeletal events (p = 0.009). There was as expected an increased incidence of grade 3 hypertension and hypokalemia in the combination arm. These findings led to trial being unblinded and crossover to allow for patients in the placebo group to receive abiraterone.

STAMPEDE [2] presented the day before incorporated patients from a wider cohort. It enrolls men that were intended for long-term ADT including those with newly diagnosed metastatic prostate cancer or node-positive disease, or high-risk locally advanced (with at least two of following: a tumour stage of T3 or T4, a Gleason score of 8 to 10, and a PSA level ≥ 40 ng/ml) or disease that was previously treated with radical surgery or radiotherapy and is now relapsing with high-risk features (in men no longer receiving therapy, a PSA level > 4 ng/ml with a doubling time of < 6 months, a PSA level > 20 ng/ml, nodal or metastatic relapse). Radiotherapy was mandatory for patients with node-negative, non-metastatic disease and optional for patients with node-positive non-metastatic disease. The reported rate of use of radiotherapy was 39% in the combination group and 40% in the ADT-alone group.

In the absence of comparative data, patient choice and the ability of health care systems to support the use of these drugs will determine the relative use of docetaxel and abiraterone. “ Patients were randomized in a 1:1 ratio but not blinded. In this analysis 1,917 men are included 52% were metastatic, 20% node-positive and 28% node-negative non-metastatic. With 40 months of follow-up overall survival was improved in the combination arm with a HR 0.63 (CI 0.52-0.76, p < 0.001) and in those with metastatic disease this fell to 0.61. This was associated with significant improvements in failure-free survival (HR 0.29; CI 0.25-0.34, p < 0.001) Currently the standard of care for men presenting with metastatic disease is ADT plus docetaxel although in STAMPEDE the reduction in risk of death was just 24% (HR 0.76) and only in the high-volume disease subset of CHAARTED was a similar size risk-reduction to the abiraterone combination observed (HR 0.63). None of the docetaxel Key articles

8

combination trials showed such an improvement in time- to-progression.

These trials raise the question of what should be regarded as the contemporary standard of care.

Abiraterone has a better side effect profile than docetaxel and is an easier treatment to administer logistically. Conversely, the treatment duration is longer, some patients have long-term effects of glucocorticoid use, and cost is a consideration.

In the absence of comparative data, patient choice and the ability of health care systems to support the use of these drugs will determine the relative use of docetaxel and abiraterone. Then of course is the tantalising question of whether the combination of ADT plus docetaxel plus abiraterone would improve outcome even further. Only trials will tell.

Source: Fizazi K, Tran NP, Fein L et al.

Abiraterone plus prednisone in metastatic, castration-sensitive prostate cancer.

NEJM. 2017; http://dx.doi.org/10.1056/ NEJMoa1704174.

James ND, de Bono JS, Spears MR et al.

Abiraterone for prostate cancer not previously treated with hormone therapy.

NEJM. 2017; http://dx.doi.org/10.1056/ NEJMoa1702900.

Dutasteride linked to lower risk of transrectal prostate biopsyassociated UTI The use of dutasteride for two years was associated with a reduced risk of overall and severe TBPA-UTI among men undergoing a two-year repeat prostate biopsy.

The objective of this study was to evaluate whether the use of dutasteride is associated with a lower risk of transrectal prostate biopsy-associated urinary tract infection (TPBA-UTI) among men in the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) study.

A retrospective analysis of 6045 men undergoing two-year repeat prostate biopsy in REDUCE was performed. Participants had been randomised to receive dutasteride 0.5 mg or placebo daily. TPBA-UTI was defined as the presence of urinary symptoms and the prescription of antibiotics by the treating physician within 30 days after biopsy. Severe TPBA-UTI was defined as TPBA-UTI requiring hospitalisation.

Comparison of TPBA-UTI between treatment arms was done using Chi-square test and logistic regression adjusting for participant characteristics.

Appropriate endpoints for evaluating new antibiotic therapies for severe infections

Mr. Philip Cornford Section editor Liverpool (GB)

There is an urgent need for consensus on valid endpoints for clinical trials evaluating antibiotic therapies for severe infections.

In the present era of rising antimicrobial resistance, slowly refilling of antibiotic development pipelines, and an aging population, we need to ensure that randomised clinical trials (RCTs) determine the added benefit of new antibiotic agents effectively and in a valid way, especially for severely ill patients.

Unfortunately, universally accepted endpoints for the evaluation of new drugs in severe infections are lacking.

philip.cornford@ rlbuht.nhs.uk validated questionnaires were used to evaluate urinary and sexual quality of life during follow-up.

Questionnaires used were the Prostate cancer index (PCI) until 2011 and then the Expanded Prostate Cancer Index Composite Short Form (EPIC-26). A method to convert these scores has been developed.

The authors of this paper reviewed and discussed the current practices and challenges regarding endpoints in RCTs in this field and proposed novel approaches.

Out of 15,209 CaPSURE patients, 1,821 have been included undergoing open (n = 1,137) or robot-assisted (n = 755) radical prostatectomy. Both arms were not statistically similar regarding baseline characteristics given that patients undergoing open surgery were more likely to have low-risk prostate cancer (CAPRA score 0-2) compared with patients included in the robot-assisted group (64%, versus 46%, p < 0.01).

Thus, pathologic Gleason score and pT stage were significantly higher in the robot-assisted group limiting comparisons of oncologic outcomes between both groups. Nevertheless, in spite of these discrepancies, the five-year actuarial biochemical-free survival was comparable in both groups (87% and 85%, p = 0.38).

Usual endpoints actually recommended for drug development suffer from important flaws. Mortality requires large sample size and only partly related to the infectious process. Clinical cure rate is highly subjective in critically ill patients where symptoms may be related to other inter-current events.

Currently, composite endpoints, hierarchical nested designs, and competing risks analysis seem to be the most promising new tools for designing and analysing clinical trials in this area, although they require further validation.

Mean scores did not significantly differ between the two groups at baseline and at follow-up time points.

However, the open surgery group reported significantly superior scores in urinary incontinence and urinary bother scores within the first year after surgery compared with the robot-assisted group. No difference in continuous sexual bother scores was reported. Both groups’ patients demonstrated a continuous improvement in quality of life during post-operative follow-up. Functional recovery tended to stabilise at two to three years after surgery.

It is concluded that regulatory authorities, pharmaceutical companies, and clinicians need to agree on the most appropriate clinical endpoints for severe infections to ensure efficient approval of new, effective antibiotic agents.

As the vast majority of previous comparative series were published by high-volume academic centres, the present series adds to the current literature by providing patient-reported outcomes in a community-based setting...

Currently, composite endpoints, hierarchical nested designs, and competing risks analysis seem to be the most promising new tools for designing and analysing clinical trials in this area, although they require further validation

Source: Appropriate endpoints for evaluation of new antibiotic therapies for severe infections: a perspective from COMBACTE’s STAT-Net. Timsit, JF., de Kraker, M.E.A., Sommer, H., et al.

As the vast majority of previous comparative series were published by high-volume academic centres, the present series adds to the current literature by …among men undergoing a twoproviding patient-reported outcomes in a communitybased setting, approaching the real-world year repeat prostate biopsy, the use Open versus robot: populations of non-academic centres where most of dutasteride for two years was The new endless debate patients are treated. In line with recent prospective data, the patterns of change over time were largely associated with a reduced risk of Recent published clinical trials have exacerbated the similar between both surgical groups. And the debate overall and severe TBPA-UTI debate regarding the ideal surgery when performing a still goes on… radical prostatectomy. To date, no high-level of evidence study (Swedish and Australian trials) has Of the subjects included in the study, 3067 (50.7%) Source: Community-based outcomes of open demonstrated a clear superiority of one approach over versus robot-assisted radical prostatectomy; were randomised to the placebo arm and 2978 another in terms of oncologic or functional outcomes. Herlemann et al.

(49.3%) to the dutasteride arm. A total of 51 (0.8%) Eur Urol. 2017; doi:10.1016/j.eururo. 2017.04.027. men had TPBA-UTI, including 38 (1.2%) in the placebo arm and 13 (0.4%) in the dutasteride arm (univariable However, in the recent Australian trial, only one relative risk [RR] = 0.35, p = 0.001; multivariable odds surgeon was involved in each arm and long-term ratio [OR] = 0.34, p = 0.003). The number needed to functional results were not reported. PopulationStress urinary incontinence: treat (NNT) to prevent one TPBA-UTI was 125 subjects. based studies and systematic reviews have suggested Does the type of surgery and/ Of these, 14 (28%) had severe TPBA-UTI, including 12 a lower rate of peri-operative complications (shorter (0.4%) in the placebo arm and only two (0.07%) in the hospital stay, lower risk of transfusions) after or sling really matter? dutasteride arm (univariable RR = 0.17, p = 0.021; robot-assisted prostatectomy compared with open multivariable OR = 0.17, p = 0.031). The NNT to prevent retropubic surgery; however urinary and sexual In the present study, the authors have updated the one severe TPBA-UTI was 309 subjects. functions were often not analysed. literature search and the synthesis of high-level of The authors concluded that among men undergoing a In the present article, the authors used the prospective, evidence trials assessing the efficacy and safety of several surgical procedures for the surgical two-year repeat prostate biopsy, the use of nationwide, mostly community-based prostate cancer dutasteride for two years was associated with a registry CaPSURE to compare both approaches focusing management of stress urinary incontinence. reduced risk of overall and severe TBPA-UTI. on functional outcomes. This database included clinical A total of 4,224 records were retrieved and four (pre-treatment characteristics, pathology, outcomes Source: Dutasteride is associated with data= and patient-reported (demographic, comorbidity, authors reviewed the full texts. Only randomised reduced risk of transrectal prostate biopsyquality of life) variables for over 15,000 patients from controlled trials were included discussing outcomes associated urinary tract infection and related 43 sites. from the use of mid-urethral slings. Second-line hospitalizations; Moreira DM, Andriole GL, treatment trials including only patients who failed Patients undergoing radical prostatectomy for Nickel JC, Roehrborn CG, Castro-Santamaria other surgical treatments were excluded. The quality localised prostate cancer between 2004 and 2016 and of trials was assessed by the Jadad score and the R, Freedland SJ. reporting quality of life outcomes at one or more time review was conducted according to the PRISMA World J Urol. 2017 Apr 10 points were included in the analysis. Self-reported, guidelines.

Intensive Care Med (2017). doi:10.1007/s00134-0174802-4

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Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de The efficacy of procedures were evaluated by both objective (pad tests, urodynamics, stress test) and subjective (satisfaction rates) criteria. The term overall continence rate was considered in case of mixed subjective and objective endpoints used in several papers. Overall, 30 papers reporting outcomes from 28 trials were included. Sensitivity analyses were limited to randomised controlled trials of good methodological quality and to trials with follow-up duration over five years.

Mid-urethral slings demonstrated higher cure rates compared with Burch colposuspension according to any definition of continence (82%, versus 74%, p = 0.0003), and objective continence rates. As compared with pubovaginal slings, midurethral tapes were associated with lower rates of reoperation without statistically significance. Both procedures showed similar effectiveness.

exact diagnosis of febrile UTIs in children. Use of inadequate urine sampling techniques during diagnosis may lead to impaired accuracy in UTI diagnosis. This could lead to the assumption that children, having diagnosed their UTI by the use of possibly inadequate urine sampling techniques should not be evaluated as consequently compared to those, where the diagnosis relied on sterile urine sampling techniques.

When compared to patients only receiving standard of care, these patients were younger, had a lower PSA (mean 15.6), and have more clinical T1-T2 disease.

Only 6% of these patients had a high-volume metastatic disease. Median operation time was 215 minutes (16 robot-assisted radical prostatectomy, one open surgery), with a mean blood loss of 250 ml. No intraoperative complications have been reported.

Patients were discharged at Day 4.

The investigators hypothesised that children with possibly contaminated urine samples during the initial diagnosis may show a lower rate of VUR in subsequent VCUGs because of a wrong diagnosis initially compared to children, where accurate urine sampling techniques were used.

Pathological results showed a high rate of positive surgical margins (82%), of seminal vesicle invasion (70%) and of lymph node involvement (70%). The mean number of nodes invaded was 10 in positive patients. After three months, 70.6% of men reported the absence of local symptoms and of persistent incontinence. To compare, obstructive voiding with the need for medical interventions was reported in more than one-third of control group patients.

…urine-sampling technique during initial UTI diagnosis alone should not be used as predictor for the reliability of UTI diagnosis and should not influence the further management after UTI

Between 2009 and 2014, a total of 555 patients underwent a primary VCUG indicated because of febrile UTIs. Patients with urine collection methods other than bag urine and catheter/suprapubic When comparing retropubic and transobturator tapes, aspiration (SPA) were excluded from this study (mid-stream urine, potty urine, n = 149). 402 patients objective and subjective continence rates were superior in the retropubic TVT group, whereas overall were evaluated (male/female 131/271, mean age 1.91 continence rate was similar with both procedures. The years), VUR rates and grades were compared between patients where urine was sampled by the use of a overall risk of complications was significantly higher urine bag only at the time of diagnosis (n = 296, in the retropubic TVT group. This risk was higher 73.6%) and those where sterile urine sampling regarding bladder or vaginal perforation (4.8%, versus 1.6%), pelvic haematoma (1.7%, versus 0.3%), (catheter, suprapubic puncture) was performed (n = urinary tract infection (10%, versus 7.9%), and voiding 106, 26.3%). Four patients were excluded due to equivocal data on urine sampling.

LUTS (9.2%, versus 5.7%).

….this impressive meta-analysis confirmed the superiority of mid-urethral slings over Burch colposuspension and pubovaginal slings for the surgical treatment of primary female stress urinary incontinence

VUR rate in children after sterile urine sampling using a catheter or SPA accounted to 31.1%. In those where urine samples acquired by the use of urine bags were used, 33.7% showed VUR on subsequent VCUG (p = 0.718). There were no significant differences as to VUR grades or gender, although VUR was much more commonly diagnosed in female patients (37.0% vs.

28.2%, p = 0.227).

Children diagnosed with their UTI by use of bag urine in our experience carried the same risk of showing a However, the risk of vaginal erosion was lower in the VUR in a subsequent VCUG compared to those, where the initial diagnosis relied - beneath clinical criteria retropubic group, compared with the outside-to-in - on urine samples acquired by suprapubic puncture transobturator TVT group. Rates of acute urinary or catheterisation. Consequently urine-sampling retention, reoperation, and storage LUTS were comparable between both groups. Sensitivity analyses technique during initial UTI diagnosis alone should not be used as predictor for the reliability of UTI confirmed these findings; nevertheless when limited to studies with at least five years of follow-up, similar diagnosis and should not influence the further management after UTI. outcomes between TVT groups were observed.

Inside-to-out transobturator seemed to offer advantages in terms of vaginal erosion compared with Source: The method of urine sampling is not a valid predictor for vesicoureteral reflux in the outside-to-in procedure, without any significant children after febrile urinary tract infections. difference for continence cure rates.

Haid B, Roesch J, Strasser C, Oswald J.

J Pediatr Urol. 2017 Mar 16. pii: S1477-5131(17)30105-5.

To summarise, this impressive meta-analysis doi: 10.1016/j.jpurol.2017.01.025. [Epub ahead of print] confirmed the superiority of mid-urethral slings over Burch colposuspension and pubovaginal slings for the surgical treatment of primary female stress urinary incontinence. The comparative studies assessing the Cytoreductive radical best mid-urethral route tended to demonstrate a prostatectomy: Early outcomes slight benefit from retropubic sling in terms of objective cure rates at the cost of higher risks of from a prospective trial intraoperative complications. When choosing the transobturator route, the inside-to-out TVT offered the Retrospective data and basic research studies have lowest risk of vaginal perforation/erosion. suggested that local treatment might be beneficial even in the metastatic setting. Multiple prospective Source: Updated systematic review and trials are ongoing, aiming to assess the efficacy and meta-analysis of the comparative data on safety of radical prostatectomy in metastatic patients. colposuspensions, pubovaginal slings, and

midurethral tapes in the surgical treatment of female stress urinary incontinence.

Fusco et al.

Eur Urol, 2017, doi/10.1016/j.eururo.2017.04.026.

Urine sampling method: Not a valid predictor for VUR in children after febrile UTI The likelihood of detecting vesicoureteral reflux (VUR) after febrile urinary tract infections (UTI) in children, logically, should correlate with the correct diagnosis of the UTI. Beneath the unspecific symptoms of fever urine analysis is the main diagnostic criterion for the Key articles

June/July 2017

In the present article, the authors reported the early results from the LoMP trial which investigated the role of surgery in addition to standard of care (mainly androgen deprivation therapy). This article mainly focused on patient’s characteristics, safety, and local symptoms. Metastatic prostate cancer was defined by at least one metastatic lesion (cM1) on bone scan and computed tomography (enlarged lymph nodes were not sufficient for inclusion). Radical prostatectomy was offered to patients fulfilling three conditions: the absence of symptoms related to metastases, a resectable tumour, and the anaesthesiologist approval for surgery. Patients ineligible or unwilling to undergo were analysed as a control group (n = 29). Overall, seventeen patients were included in the trial and underwent radical prostatectomy (81% rate of acceptance).

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

Median follow-up of 248 assessable patients was 72 months. One hundred eighty-six patients (75.0%) showed a decrease in testosterone. Median time to first decrease was 6.4 months. Median percentage of decrease to the nadir was 30% and 112 (45.2%) developed biochemical hypogonadism (serum testosterone < 8 nmol/L). Of all patients with testosterone decrease, 117 (62.9%) recovered to at At three months after radical prostatectomy, 30% and least 90% of baseline levels. Advanced age, increased 11.8% of patients suffered from grade 1 and 2 body mass index, higher baseline testosterone level, complications, respectively. Mean PSA decrease after and lower nadir level were associated with a lower surgery was 72%, and 23.5% of patients had a chance of testosterone recovery. Subgroup analyses of sustained PSA response without any symptoms and 166 patients treated with intensity-modulated without initiation of androgen deprivation therapy. At radiotherapy confirmed the results recorded for the the time of data analysis, 45% of men in the control entire cohort. In survival analyses, neither group became castration-refractory compared with no testosterone decrease nor recovery was predictive for patient in the operated group. biochemical recurrence.

These preliminary results of this prospective trial confirmed the safety of cytoreductive prostatectomy in the metastatic setting. Interestingly, it appears that surgery have a clear impact on local symptom control and could avoid subsequent local progression needing significant medical interventions. No data on erectile function has been reported, but urinary recovery did not seem very different as compared to results published in high-risk localised disease.

The main limitation of this study was the interpretation of oncologic outcomes. No randomisation was done The main limitation of this study was the interpretation of oncologic outcomes. No randomisation was done.

The proposed control cohort of patients largely differed from the operated cohort (mean PSA 15 versus 156, M1b-c patients 47% versus 86%), and did not allow fair comparisons between both groups in terms of PSA responses, survival, symptoms related to metastases.

The use of time to androgen deprivation therapy (ADT) as study endpoint remains also critical as it appears that these metastatic patients, even locally treated by surgery, should receive early ADT. The delay before ADT in order to study the PSA response to local response leads to important ethical considerations. If proposed, the local treatment of M1 patients should probably be integrated into a larger validated multimodal treatment, defined by the study protocol.

Source: Cytoreductive prostatectomy for metastatic prostate cancer: First lessons learned from the Multicentric Prospective Local Treatment of Metastatic Prostate Cancer (LoMP) Trial. Poelaert et al.

Urology, 2017, doi/10.1016/j.urology.2017.02.051.

…EBRT monotherapy influences testosterone kinetics, and although most patients will recover, approximately 45% will have biochemical hypogonadism Thus, EBRT monotherapy influences testosterone kinetics, and although most patients will recover, approximately 45% will have biochemical hypogonadism.

These findings indicate that up to 75% of patients will have a profound testosterone decrease, with up to a 40% increase in rates of biochemical hypogonadism, although the latter events will leave biochemical recurrence unaffected.

Source: External beam radiotherapy affects serum testosterone in patients with localized prostate cancer. Pompe RS, Karakiewicz PI, Zaffuto E, Smith A, Bandini M, Marchioni M, Tian Z, Leyh-Bannurah SR, Schiffmann J, Delouya G, Lambert C, Bahary JP, Beauchemin MC, Barkati M, Ménard C, Graefen M, Saad F, Tilki D, Taussky D. J Sex Med. 2017 May 22. pii: S1743-6095(17)31140-2. doi: 10.1016/j.jsxm.2017.04.675. [Epub ahead of print]

Does peak urine flow rate predict the development of incident LUTS in men with mild to no current symptoms?

The purpose of the trial was to determine whether decreased peak urine flow is associated with future incident lower urinary tract symptoms (LUTS) in men with mild to no LUTS.

Previous studies have examined testosterone levels after external beam radiation (EBRT) monotherapy, but since 2002 only sparse contemporary data have been reported. The aim of the authors was to examine testosterone kinetics in a large series of contemporary patients after EBRT.

The population consisted of (3,140) men from the REDUCE trial with mild to no LUTS defined as an International Prostate Symptom Score (IPSS) < 8.

REDUCE was a randomised trial of dutasteride vs. placebo for prostate cancer prevention in men with an elevated PSA and a negative biopsy. IPSS measures were obtained every six months throughout the four-year study. The association between peak urine flow rate and progression to incident LUTS, defined as the first of medical treatment, surgery, or sustained, clinically significant LUTS symptoms was tested using multivariable Cox models adjusting for various baseline characteristics and treatment arm.

The study was conducted in 425 patients who underwent definitive EBRT for localised prostate cancer from 2002 through 2014. Patients were enrolled in several phase II and III trials. Exclusion criteria were neoadjuvant or adjuvant androgendeprivation therapy or missing data. Testosterone was recorded at baseline and then according to each study protocol (not mandatory in all protocols). Statistical analyses consisted of means and proportions, Kaplan-Meier plots, and logistic and Cox regression analyses.

On multivariable analysis, as a continuous variable decreased peak urine flow rate was significantly associated with increased risk of incident LUTS (p = 0.002); results were similar in the dutasteride and placebo arms. When peak flow was categorised as ≥ 15 mL/s, 10-14.9 mL/s, and < 10 mL/s, flow rates of 10-14.9 mL/s and < 10 mL/s were associated with a significantly increased risk of developing incident LUTS in univariable analysis (HR = 1.39, p = 0.011 and HR = 1.67, p < 0.001, respectively). Results were similar in multivariable analysis, though the 10-14.9

External beam radiotherapy affects serum testosterone in patients with localised prostate cancer

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9

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

tebj@medisin.uio.no mL/s group was no longer statistically significant (HR 1.26, p = 0.071).

…in men with mild to no LUTS, decreased peak urine flow rate is independently associated with incident LUTS. If confirmed, these men should be followed closer for incident LUTS The investigators concluded that in men with mild to no LUTS, decreased peak urine flow rate is independently associated with incident LUTS. If confirmed, these men should be followed closer for incident LUTS.

Source: Does peak urine flow rate predict the development of incident lower urinary tract symptoms in men with mild to no current symptoms? Results from REDUCE. Simon RM, Howard LE, Moreira DM, Roehrborn C, Vidal A, Castro-Santamaria R, Freedland SJ. J Urol. 2017 Apr 17. pii: S0022-5347(17)51884-4. doi: 10.1016/j.juro.2017.04.075. [Epub ahead of print]

Post-operative JJ stent insertion after upper urinary tract ureteroscopy: the question is still open The EAU guidelines for urolithiasis recommend placement of double-J stent after a complicated ureteroscopy (URS) for either ureteral or renal stones.

Many studies, including systematic reviews and meta-analysis of randomised controlled trials, have shown that the insertion of JJ stent is correlated to a high incidence of stent-related symptoms which may require prolonged analgesia, lengthy recovery before a return to normal activity, admission to hospitals, as well as unplanned medical visits.

The Clinical Research Office of Endourological Society (CROES) URS Global Study set up an international database where several centres across the globe entered their data on patients treated with URS (semi-rigid or flexible) for renal and ureteric stones.

Though limited by some biases (e.g. selection bias, reporting bias, etc.), with more than 10,000 patients recruited over the span of nearly two years it has been a source of several publications and information on the management of upper urinary tract stone with this endoscopic approach.

The latest report has focused on the potential predictors for practitioners to insert a stent after a rigid or flexible URS. Variables in observation were patients’ (age, gender, ASA, BMI, use of anticoagulant, solitary kidney, congenital urinary tract abnormality), stones’ (size, site, impaction of stones, and operatives’ (use of ureteral access sheath, length of procedure, hospital stay, complications, readmission to hospital) related.

At the multivariate analysis different variables were found related to the decision to insert a stent in the subgroups of patients treated for ureteric and renal stones…

Overall, JJ stent was placed postoperatively in 63.2% (n = 5,458) of patients treated for ureteric stones and 79.5% (n = 1,436) for renal stones. There was a huge variability (29 to 96%) of JJ stent insertion prevalence across the countries participating in the study.

At the multivariate analysis different variables were found related to the decision to insert a stent in the Key articles

10

subgroups of patients treated for ureteric and renal stones: in the former one the presence of impacted stones, intraoperative complications, a longer operative time, a higher stone burden and an older age were factors related to the outcome. In the latter subgroup of patients with renal stones, a longer operation time, older age, and preoperative stent placement were identified as significant predictors of double-J stent placement. All these factors can easily be associated with a complicated procedure, hence needing the insertion of a JJ stent.

However, controversial results were also recorded: multivariate analysis found inverse correlation of the need of JJ insertion after URS for ureteric stones in the presence of solitary kidney and stone-free status (OR: 0.62 and 0.44, respectively); similar counter-intuitive findings were reported with respect to a lower likelihood for patients to have a stent inserted if they were undertaking anticoagulant drugs, or had a solitary kidney or even had intraoperative complications (OR: 0.51, 0.49, 0.16, respectively) in the subgroup of patients with renal stones.

The authors could not explain these findings; it would have been interesting to know whether other forms of urinary derivation (e.g. temporary open-end or mono-J stent) were used instead of the JJ stent; however, it is likely that a significant role in these controversial data may result from potential biases previously mentioned (selection and reporting biases).

Finally, a model was built according to which fewer post-operative complications should be expected in patients with double J stent; however, this model did not consider the impact of stent-related symptoms and the effect of quality-of-life issues in patients with indwelling stent.

Source: Risks and benefits of postoperative double-J stent placement after ureteroscopy: Results from the Clinical Research Office of Endourological Society Ureteroscopy Global Study. Muslumanoglu AY, Fuglsig S, Frattini A, Labate G, Nadler RB, Martov A, Wong C, de la Rosette JJMCH. J Endourol. 2017 May;31(5):446-451. doi: 10.1089/ end.2016.0827. Epub 2017 Apr 12.

warmers, authors identified the widely available thermos as well as more sophisticated systems, like the Clearify Visualization; however, no comparative studies could identify a specific recommendation on this regard.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

Some evidence are in support of port-systems (Insuflow, AirSeal) that could keep the pressure stable and insufflate warmed gas, whose benefit could also extend not just to a better visibility but even to lower risk of complications for the patients (like postoperative pain or hypothermia).

g.ploussard@ gmail.com on this regard.

Several surfactant products were identified as a physical barrier to prevent droplets condensation: very cheap and largely used solutions like povidoneiodine or chlorhexidine were included, as well as tailored surfactants like FREDTM or ResoclearTM, with a few comparative but inconclusive head-to-head papers.

…limited data were also found with respect to robotic lens which seem to provide superior vision with respect to conventional laparoscopic lens, even though the reason is not fully known Other more recent devices have been introduced in the market consisting of a sheath where the scope is fit and able to generate a flow from the tip of the lens for the prevention of contamination from vapour or blood, or condensation of water on the lens surface.

In some devices the flow is continuous whilst in others it can be activated by the surgeons when needed. In other words, they work like wipers, preventing the need to extract the scope even in dangerous circumstances such as significant and active bleeding. The main issues are the cost, cumbersomeness of their use and the need for larger camera ports.

Finally, limited data were also found with respect to robotic lens which seem to provide superior vision with respect to conventional laparoscopic lens, even though the reason is not fully known.

Source: Visual occlusion during minimally invasive surgery: A contemporary review of methods to reduce laparoscopic and robotic lens fogging and other sources of optical loss; Manning TG, Perera M, Christidis D, Kinnear N, McGrath S, O'Beirne R, Zotov P, Bolton D, All laparoscopic or robotic surgeons have experienced Lawrentschuk N.

Why the camera is getting fogged? The answer may be in Mars’ atmosphere!

the frustrating experience of laparoscopic lens fogging J Endourol. 2017 Apr;31(4):327-333. doi: 10.1089/ end.2016.0839. Epub 2017 Feb 8.

(LLF) during a procedure which might eventually cause a range of problems, from just a delay of the operating time to even a serious tissue or vascular damage.

There are many tricks and tools introduced in the surgical practice to minimise or prevent this issue albeit with no definitive solutions.

A recent review tried to identify the physical principles that are contributing to this phenomenon: hardly understandable notions like “dew point temperature” or “psychometric charts” were introduced to explain how gas insufflated in the abdomen could condense on the surface of a lens scope. Differential of temperature and humidity between the scope and abdominal cavity may cause the condensation of water droplets larger than 190 nm in size that accumulate until finally hampering the vision.

A further factor complicating the “equation” is the CO2 atmosphere produced with gas insufflation in the abdominal cavity, which may resemble the Martian atmosphere with 95.5% of CO2. This is not the same as the known “air-water” models to predict the phenomenon of condensation and it is further complicated by the continuous changes of intraabdominal pressure, variable composition of intra-abdominal air (especially when introducing or extracting instruments from the ports) and production of gas from combustion of tissues.

As a result, current evidence in literature is quite poor in providing solutions to prevent the phenomenon.

Authors, after a systematic approach to literature, could find few articles ranging from self-made remedies to high technological devices.

Some pre-setting recommendations were provided like pre-warming the scope and using a different port for camera and for gas insufflation. Among scope

Making the tract for a miniPCNL: A randomised trial comparing access through ultrasound, fluoroscopic or combined guidance There are several unresolved questions regarding how to perform a percutaneous nephrolithotomy (PCNL) since many variants of each step have been described and applied in practice, based on surgeon’s preference or local protocols.

Currently, access to the kidney can be performed via ultrasound (USG), fluoroscopic (FG) or combined (CG) guidance. Data from the Clinical Research Office of the Endourological Society (CROES) revealed a predominance of FG technique used by practitioners (86.3%) who participated in the study.

Some authors have highlighted advantages from UG access especially in terms of no exposure of radiation for the patients, a better definition of the surrounding organs and (potentially) the identification of main intra-parenchymal artery that can be avoided. Most of these advantages can also be obtained with a CG approach, even though some exposure of ionisation to patients is required.

The trial was designed for patients selected for prone miniPCNL (≤ 18 Ch tract size) with renal stones ≥ 2 cm. The sample size was calculated as of 141 patients per arm according to local historical data of stonefree rate (SFR) achieved with the different approaches: however, it was not clear which was the null hypothesis, or better, the difference of the chosen primary end-point at which the “no-effect” of the treatment(s) in observation could be rejected.

What is sure is that when ultrasound scan skills are available, it is recommendable to use ultrasound guidance in combination with fluoroscopy to get a percutaneous access to the kidney…

Their primary end-points included the difference in stone-free rate (SFR: fragments < 4 mm) at Day 1 and at three months post-op assessed with non-contrast enhanced CT scan, and blood loss (drop of haemoglobin and transfusion rate) across the three groups of patients. Secondary end-points were the access failure rate, complication rate and operating time.

The S.T.O.N.E. metric score system was used to categorise complexity of renal stones (low: 5-6; intermediate: 7-8; high score: 9-13).

No SFR difference was identified in low and high complex renal stones, while UG showed to be inferior in the case of intermediate (7-8 STONE score) complex renal stone with respect to FG and CG approaches.

The authors justified this finding by commenting that in this subgroup of patients more auxiliary tracts were attempted with FG and CG approaches which eventually led to a higher SFRs in these groups. They highlighted the difficulty in creating multiple accesses with just the aid of UG, due to the acoustic shadows caused by the first tract, and the presence of extravasation or blood around the kidney. This was also the reason why a patient ended up with a temporary colostomy for a bowel perforation while attempting a second tract.

No other significant differences were noticed with respect to the other end-points.

There are some other points of interest in the paper worthy of notice: 1) Body mass index was low or normal across all the access groups: this should have favoured the UG group as it is much more difficult to form a percutaneous tract in overweight or obese patients with this tool only because vision and insertion of needle, guidewire and access sheath may be significantly hampered by fatty tissue.

2) Interestingly, most of the patients had the access formed above the 12th rib and only three thorax injuries were reported (all in the CG group) which reflect the high skills of the surgeons; this may make the results of this trial not generalizable as predominant approach worldwide is subcostal.

What is sure is that when ultrasound scan skills are available, it is recommendable to use ultrasound guidance in combination with fluoroscopy to get a percutaneous access to the kidney, so that a minimum radiation exposure with a safe and precise access to the kidney can be achieved, especially when multiple tracts are needed.

Source: A prospective and randomised trial comparing fluoroscopic, total ultrasonographic, However, it is not clear whether these advantages and combined guidance for renal access in may translate to similar or better surgical outcomes of mini-percutaneous nephrolithotomy. Zhu W, Li UG versus FG or CG techniques.

J, Yuan J, Liu Y, Wan SP, Liu G, Chen W, Wu W, Luo J, Zhong D, Qi D, Lei M, Zhong W, Zhang Z, A high-volume Chinese centre has recently published He Z, Zhao Z, Lu S, Wu Y, Zeng G. results from a randomised controlled trial in order to assess pros and cons of each approach and eventually provide more robust recommendations for guidelines

BJU Int. 2017 Apr;119(4):612-618. doi: 10.1111/bju.13703.

Epub 2016 Nov 28.

EAU EU-ACME Office

European Urology Today

June/July 2017

Severe obesity shown to be definitive risk factor for complications in renal transplantation

kidney transplant recipients. This occurred in temporal association with an improvement in median eGFR at six months and consolidation of discharge immunosuppression in most patients to tacrolimus and mycophenolate derivatives.

Many transplant surgeons have observed that obese patients are prone to develop complications after renal transplantation. Evidence stated in literature regarding the topic require additional information and further clarification.

Source: Graft function and intermediate-term outcomes of kidney transplants improved in the last decade: Analysis of the United States Kidney Transplant Database. Keith DS, Vranic G, Nishio-Lucar A.

potentially decrease the morbidity and patient discomfort associated with frequent biopsies while also improving the detection of otherwise occult foci of higher grade disease.

This paper presents data on men with low risk prostate cancer (PSA < 20 ng/ml, T1c, G3+3) who subsequently underwent a mpMRI using a 3T magnet. Imaging included T1 and T2-weighted imaging, plus dynamic contrast and diffusionweighted imaging. Each lesion identified on MP-MRI as a targetable lesion was assigned a Transplant Direct. 2017,25;3(6):e166. doi:10.1097/ magnetic resonance imaging suspicion score The study evaluated the impact of body mass index TXD.0000000000000654. eCollection 2017 Jun. (MRI-SS) based on the Prostate Imaging Reporting (BMI) and patient functional status on the risk for and Data System (PIRADS v2.0). Patients then surgical complications after kidney transplant. This underwent an MRI/US fusion-guided biopsy and retrospective cohort study of adult kidney transplant Is prostate cancer different in both these cores and the original prostate biopsy recipients grouped patients by baseline Karnofsky Afro-Caribbean men? were centrally reviewed. Clinical and imaging status (low function ≤ 70%) and further stratified by variables, including the prostate-specific antigen morbid obesity (BMI ≥ 35 kg/m2) to assess surgical Prostate cancer incidence among Afro-Caribbean men density (PSAD), number of lesions, total lesion complication risk. in the United States is 60% higher, and mortality is volume, total lesion density, MRI-SS, and duration 736 patients were included with surgical more than double the rate observed in white men. between pre-referral systematic and MRI/US complications occurring in 25%. Logistic regression Data suggests they are less likely to receive primary fusion–guided biopsy sessions, were assessed.

Logistic regression modelling was used to assess analysis with interaction terms demonstrated that surgery, but the extent to which this observation is morbid obesity and low functional status related to demographics, access to care, or personal upgrading on MRI/US fusion–guided biopsy. A preference is unclear. However, even if Afro-Caribbean predictive model for upgrading was calculated with conditionally impact risk with an OR of 2.8 [95% CI (1.1-7.3)]. Within the functional status men undergo radical prostatectomy they have been the significant factors identified. cohort, BMI ≥ 35 kg/m2 was associated with found to harbour more aggressive cancers and are more likely to experience recurrence. This paper increased risk of surgical complication, superficial MRI-targeted biopsy cores have wound infection, and delayed graft function. adapts previously developed natural history models to Afro-Caribbean men to produce estimates of disease Independent predictors for surgical complications been shown to outperform the included diabetes and morbid obesity with low onset, progression, and diagnosis risks that pertain to standard-of-care extended sextant functional status. There was no significant difference this population. They then compared the risks with in graft loss or death across the cohorts. estimates for the general population to determine the biopsy approach… extent to which the increased incidence among Afro-Caribbean men is explained by higher risks of The authors concluded that neither morbid obesity nor poor functional status alone predicted increased disease onset, progression, or diagnosis.

76 patients were analysed with a mean age of 62.5 complications, while the combined presence was years and a median PSA level of 5.1 ng/mL. The associated with a significant increase in risk for They used the responses to the National Health average duration between pre-referral and MRI/US surgical complications after renal transplantation. This Interview Survey (NHIS) in 2000 and 2005 to estimate biopsies was 21 months. Twenty patients (26.32%) study, although retrospective, clearly defines severe the age at first PSA test and longitudinal claims data were upgraded (13 to G3+4, 6 to G4+3 and 1 to from the linked SEER-Medicare database to estimate obesity as a definite risk factor with renal G4+4). No patient with a MRI-SS of 2 experienced transplantation. the distribution of inter-screening intervals. The SEER upgrading on biopsy whilst 61.55% of those with database also revealed prostate cancer incidence, MRI-SS 5 did. The PSAD, duration between grade and stage plus race.

Source: Morbid obesity and functional status pre-referral and MRI/US biopsies, MRI-SS, and MRI as predictors of surgical complication after total lesion density were significantly associated renal transplantation. Veasey TM, Fleming JN, with upgrading. A logistic regression model using This study appears to confirm that Strout SE, Miller R, Pilch NA, Meadows HB, these factors to predict upgrading on confirmatory MRI/US fusion biopsy had an area under the curve Mardis CR, Mardis BA, Shenvi S, McGillicuddy men with Afro-Caribbean heritage J, Chavin KD, Baliga P, Taber DJ. (AUC) of 0.84, whereas the AUC was 0.69 with PSA have both more pre-clinical and Am J Surg. 2017, doi: 10.1016/j.amjsurg.2017.05.009. alone. A nomogram was then generated, and using [Epub ahead of print] a probability cut-off of 22% as an indication of progressive prostate cancer upgrading, it produced sensitivity, specificity, positive predictive, and negative predictive values of The data suggested that Afro-Caribbean men were Large database analysis shows less likely to receive at least one PSA test. Despite this 80%, 81.25%, 57.1%, and 92.86%, respectively. improvement in renal the risk of developing prostate cancer is higher. In the MRI-targeted biopsy cores have been shown to general population, the risk of developing preclinical outperform the standard-of-care extended sextant transplantation outcomes biopsy approach for the detection of higher risk disease is 24% to 29% (range across models). In Afro-Caribbean men, however, these risks rise to 30% features when used as part of cancer detection. In this study MRI-SS was combined with current Previous analyses of the United States transplant to 43% and the risk of clinical diagnosis is 33-70% higher than in the general population with a 44-75% clinical factors in determining suitability for active database regarding long-term outcomes in kidney surveillance. This should allow men on AS with low transplantation have shown minimal improvement in higher risk of metastasis before diagnosis among Afro-Caribbean men. risk features to avoid repeat biopsy. the rate of long-term graft loss. This study sought to analyse intermediate-term outcomes and graft function at six months in kidney transplantation in This study appears to confirm that men with Source: Factors predicting prostate cancer adult living and deceased donor recipients in the last Afro-Caribbean heritage have both more upgrading on magnetic resonance imagingpre-clinical and progressive prostate cancer. They decade. targeted biopsy in an active surveillance are more likely to develop prostate cancer at a population. Lai WS, Gordetsky JB, Thomas JV Survival analysis was performed based on the year of younger age, and they are more likely to progress et al. to a metastatic state and/or higher grade before transplant between six months and three years Cancer 2017; 123:1941-8. clinical diagnosis. As a consequence, post-transplant. The Chronic Kidney Disease consideration should be given to commencing Epidemiology Collaboration estimated glomerular screening earlier and possibly more frequently in filtration rate (eGFR) was determined at six months.

Effect of prior receipt of this group of men.

In the latter half of the last decade, graft survival has improved in adult kidney transplant recipients

Source: Is prostate cancer different in black men? Answers from 3 natural history models. Tsodikov A, Gulati R, de Carvalho TM et al.

Cancer. 2017; 123:2312-9.

The unadjusted graft survival between six months and three years improved significantly in the latter half of the decade in both deceased and living donor kidney recipients. Cox analysis showed a 33% reduction in the rate of graft loss and that the improvement in graft survival was due to similar improvements in both death-censored graft and death with graft function survival. A 10% improvement in median eGFR occurred despite worsening donor demographics over time in both donor types. This improvement in eGFR and graft survival occurred in association with a consolidation of chronic discharge immunosuppression from a variety of combinations to over 85% of recipients receiving tacrolimus and mycophenolate derivative immunosuppression.

The authors concluded that in the latter half of the last decade, graft survival has improved in adult Key articles

June/July 2017

New Nomogram for assessing men undergoing Active Surveillance Long-term studies have supported the use of active surveillance (AS) in the management of men with low-risk prostate cancer however standardised criteria for determining candidacy have not yet been well established and there is no widely accepted protocol for assessing disease progression. Many AS protocols involve performing PSA testing, digital rectal examination, and transrectal ultrasound (TRUS)–guided prostate biopsy on a recurring basis for the assessment of disease progression. The incorporation of mpMRI into AS protocols could

antibiotics on pathogen distribution and resistance profile

Clinicians should critically assess prior antibiotic exposure when selecting empirical therapy for patients with hospital-onset urinary tract infections caused by Gram-negative pathogens.

This retrospective cohort study characterised the impact of prior antibiotic exposure on distribution and non-susceptibility profiles of Gram-negative pathogens causing hospital-onset urinary tract infections (UTI).

Hospital patients with positive urine culture for Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and other Enterobacteriaceae ≥ 3 days after hospital admission were included. Assessment outcomes included the distribution of bacteria in urine cultures, antibiotic susceptibility patterns, and the effect of prior antibiotic exposure, defined as 0, 1, or ≥ 2 prior antibiotics, on the distribution and antibiotic susceptibility profiles of the Gram-negative organisms.

The most commonly isolated pathogens from 5,574 unique UTI episodes (2027 with and 3,547 without prior antibiotic exposure) were E. coli (49.5%), K. pneumoniae (17.1%), and P. aeruginosa (8.2%).

P. aeruginosa was significantly more commonly isolated in patients with ≥2 prior antibiotic exposures (12.6%) compared with no exposure (8.2%; p = 0.036) or one prior exposure (7.9%; p = 0.025).

Two or more prior antibiotic exposures were associated with slightly higher incidences of fluoroquinolone non-susceptibility, multidrug resistance, and extendedspectrum β-lactamase phenotype compared with 0 or one exposure, suggesting an increased risk for resistant Gram-negative pathogens among hospital patients with urinary tract infections occurring ≥ 3 days after admission.

The authors concluded that clinicians should critically assess prior antibiotic exposure when selecting empirical therapy for patients with hospital-onset urinary tract infections caused by Gram-negative pathogens.

Source: Effect of prior receipt of antibiotics on the pathogen distribution and antibiotic resistance profile of key Gram-negative pathogens among patients with hospital-onset urinary tract infections. Bidell MR, Opraseuth MP, Yoon M, Mohr J, Lodise TP. BMC Infect Dis. 2017 Feb 28; 17(1):176 DOI: 10.1186/ s12879-017-2270-7

ABO-incompatible living donor renal transplantation increases costs by 40% Incompatible living donor kidney transplant (ILDKT) has become an established and effective option for end stage renal disease (ESRD) patients with willing but HLA incompatible live donors, reducing mortality and improving quality of life.

Depending upon antibody titer, ILDKT can require highly resource-intensive procedures including intravenous immunoglobulin, plasma exchange and/ or cell depleting antibody treatment as well as protocol biopsies and DSA testing.

This study sought to compare the cost and reimbursement within the US American healthcare system, exclusive of organ acquisition payments, for ILDKT recipients (N = 926) with varying antibody titers to matched compatible transplants (N = 2762) performed between 2002 and 2011. Data were assembled from a national cohort study of ILDKT and a unique dataset linking hospital cost accounting data, and Medicare claims.

ILDKT increases the cost of and payments for kidney transplant Overall, ILDKT transplants were 41% more expensive than their compatible counterparts ($151,024 vs. $106,636, p < .0001). The incremental cost varied by antibody titers: positive on Luminex assay but negative flow cytometric crossmatch 20% increase, positive flow cytometric crossmatch but negative cytotoxic crossmatch 26% increase and positive cytotoxic crossmatch 39% increase (p < .0001 for all).

ILDKT was associated with higher Medicare payments ($91,330 vs. $63,782 p < .0001), longer median length of stay (12.9 vs. 7.8 days) and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplant.

This calculation shows the marked increase in costs incurred by ILDKT. While absolute figures will be different in European healthcare systems, relative proportions may be similar.

Source: The incremental cost of incompatible living donor kidney transplant: A national cohort analysis. Axelrod D, Lentine KL, Schnitzler MA, Luo X, Xiao H, Orandi BJ, Massie A, GaronzikWang J, Stegall MD, Jordan SC, Oberholzer J, Dunn TB, Ratner LE, Kapur S, Pelletier RP, Roberts JP, Melcher ML, Singh P, Sudan DL, Posner MP, El-Amm JM, Shapiro R, Cooper M, Lipkowitz GS, Rees MA, Marsh CL, Sankari BR, Gerber DA, Nelson PW, Wellen J, Bozorgzadeh A, Gaber AO, Montgomery RA, Segev DL. Am J Transplant. 2017 Jun 14. doi: 10.1111/ajt.14392.

[Epub ahead of print]

EAU EU-ACME Office

European Urology Today

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EBU ensures top standards for patient care The European Board of Urology (EBU) is an independent, voluntary regulatory body that has set, maintained and raised the standards of urological education, training and ultimately, the practice for over 25 years. At its heart is the collective will and determination of 30-member countries to ensure the highest standards for patient care.

The EBU achieves these objectives through the voluntary work of delegates of national associations, in collaboration with various organisations such as the European Union of Medical Specialists (UEMS) and the European Association of Urology (EAU).

Urologists from all over Europe help contribute to the EBU activities, mainly via examinations. One noteworthy example is the EBU Oral Examination. The resulting Fellowship of the European Board of Urology (FEBU) diploma provides a mark of distinction which indicates that a certified urologist or urologist-in-training has achieved a standard of excellence recognised across Europe. To date, more than 5,000 urologists hold the FEBU title worldwide.

Examinations The EBU provides two main examinations: the

In-Service Assessment (ISA) and the FEBU examination. ISA is an easy-to-access, online exam that can be taken at home or with other examinees.

Three main groups benefit from the ISA. Individual residents can test themselves privately and monitor their learning progress in different areas of urology year after year. Training programme directors can easily organise an annual assessment of their trainees by using the ISA as well. Trained urologists can undertake the assessment as part of their CPD/ CME programmes and provide evidence for appraisal processes. Therefore, the ISA is a formative exam and the FEBU examination is a summative exam.

FEBU examinations The FEBU Diploma is given for the successful completion of the FEBU examination. Residents in their final year in recognised training programmes, and trained licensed urologists in a member country are eligible to take the exam.

The EBU Online Written Examination conducted in November primarily tests urological knowledge.

Those who passed are invited to take the oral exam in June the following year. This exam tests clinical

judgement, reasoning, and knowledge. The successful urologist is then able to use the post-nominals “FEBU” upon completing his/her training.

The EBU Oral Examiniations have been taking place for 24 years. They are of great importance and a source of achievement to participating candidates. So far this year, the exams have been conducted by 130 examiners in 12 languages in venues located in Brussels, Warsaw, Budapest and Ankara. The EBU expresses its appreciation to the examiners who have allotted their time and efforts.

National examinations In some countries, the FEBU examinations are a significant part of the requirements of training programmes. Countries such as Austria, Switzerland and The Netherlands use the written FEBU examinations as part of their official national end of training exams. Poland and Hungary use both the written and oral exams in this way. Poland, in particular, has set the example by adopting, supporting and promoting EBU examinations on national and international levels since 1997. In the last 20 years, 658 Polish urologists have obtained the FEBU title.

This year witnessed the culmination of many years of hard work and dedication to the introduction of the FEBU examination in Turkey. Many Turkish urologists have already taken the exam previously in English. Subsequently, two national associations in Turkey have achieved considerable success by forming a joint national board and adopting the exam, which was conducted for the first time in Ankara.

The work of urologists can be difficult at times. They all face challenges which may differ depending on the country of practice. Nonetheless, urology transcends national borders and collectively aims for quality patient care.

The EBU will continue to harness the good will of member countries and individual urologists to maintain and further develop standards for urological education and training. If you wish to contribute to this mission, please contact the EBU office at ebu@ebu.com for more information.

Mr. Jan Nawrocki EBU President ebu@ebu.com

First EBU Oral Examination in Turkey

Board of examiners, Ankara

Successful candidates EBU Oral Examination 2017 FEBUs Turkey Abdullah Açıkgöz Faraj Afandiyev Kağan Türker Akbaba Mehmet Fatih Akbulut Fırat Akdeniz Nebil Akdoğan Emre Can Akınsal Mesut Altan Hüseyin Aytaç Ateş Cemil Aydın Tuncer Bahçeci Cem Başataç Aykut Başer Göksel Bayar Numan Baydilli İbrahim Buldu Sedat Çakmak Serdar Çelik Hacı İbrahim Çimen Önder Çınar Burak Çıtamak

Eyüp Dil Gökçe Dündar Murat Dursun Hüseyin Eren Anıl Erkan Akif Ersoy Erkmen Yunus Emre Göger Serkan Gönültaş Mehmet Hamza Gültekin Mustafa Kadıhasanoğlu Emre Kandemir Mehmet Karabakan Engin Kaya Onur Kaygısız Muhammet Fatih Kılınç Yalçın Kızılkan Orhan Koca Niyazi Özgür Kurul Mahmut Taha Ölçücü Erkan Ölçücüoğlu Kadir Önem Şakir Ongün

Mazhar Ortaç Latif Mustafa Özbek Serkan Özcan Mehmet Özen Burak Özkan Arif Özkan Ünsal Özkuvancı Fahri Erkan Sadioğlu Ahmet Şahan Mehmet Yılmaz Salman Eyüp Burak Sancak Selçuk Sarıkaya Çağrı Akın Şekerci Volkan Şen Haluk Şen Tarık Emre Şener Zülfü Sertkaya Ali Sezer Timuçin Şipal Emrullah Söğütdelen Serhat Tanık Hüseyin Tarhan

Muhammed Naci Tatar Şevket Tolga Tombul Ramazan Topaktaş Fethi Ahmet Türegün Sıtkı Ün Ahmet Ürkmez Fatih Uruç Emrah Yakut Kadir Yıldırım Yıldıray Yıldız Burak Yılmaz Mehmet Yoldaş Özgür Haki Yüksel

FEBUs Poland Daniel Barycki Tomasz Bek Bartosz Binek Rafał Bogacki Michał Borowik Paweł Buraczyński Magdalena Chudzian

The photos in this article were taken at the examinations in Ankara and Brussels.

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Successful candidates EBU Oral Examination 2017 Marcin Cichocki Wojciech Cieślikowski Stefan Czarniecki Stanisław Czeszak Łukasz Czubatka Piotr Dąbrowski Wojciech Dyś Wojciech Gawlas Grzegorz Kasiczak Marcin Kaźmirski

Matthias Beysens, Belgium Francesco Bianconi, Italy Veronika Birkhäuser, Switzerland Leonardo Bizzotto, Italy Rebeca Blanco Fernández, Spain Jennifer Blarer, Switzerland Pedro Botelho Valente, Portugal Marta Capdevila Gonzalo, Spain Marco Capece, Italy Carlos Carvalho Ferreira, Portugal

Pablo Juárez del Dago Anaya, Spain Loïc José Julita, Switzerland Etienne Xavier Keller, Switzerland Simone Marlies Kierok, Germany Gerald Klinglmair, Austria Birgit Kloss, Austria Lorenz Leitner, Switzerland Paula León Medina, Spain Romain Lorion, France Tim Alexander Ludwig, Germany

Paulo Jorge Sousa Dinis, Portugal Jiří Stejskal, Czech Republic Alexander Stix, Austria Michael Stolzlechner, Austria Michal Šurík, Czech Republic Péter Törzsök, Austria Gabriele Tuderti, Italy Filippo Maria Turri, Italy Sanjeev Vamadevan, Switzerland Ellen Katrien Patrick Vandamme, Belgium

Marek Kowalski Kamil Krawiec Bartosz Krenz Maciej Krzyżanowski Mirosław Łesiów Adam Madej Konrad Majcherczyk Natalia Majchrzak Bartosz Muskała Agnieszka Nieradka Krzysztof Nowakowski Anna Orzechowska Wojciech Panek Maciej Pozowski Rafał Przybyła Paweł Pudełko Marcin Sieczkowski

Jozefina Casuscelli, Germany Stefanie Cermak, Switzerland David Charbit, France Chiara Cini, Italy Andrea Cocci, Italy Simbad Costas Ochoa, Spain Ángel Cuevas Palomino, Spain Sandro Roberto da Silva Gaspar, Portugal Raquel Maria da Silva João, Portugal Ettore Dalmasso, Italy David D'Andrea, Austria Charles Dariane, France Vincent De Coninck, Belgium Nicolò de Luyk, Italy Eva de Vries, The Netherlands Manuel Di Biase, Italy Sofia dos Santos Lopes, Portugal

Doris Mannhard, Switzerland Phillip Marks, Germany Laura Martínez Arcos, Spain Daniele Mattevi, Italy Olivier M'Baya, Switzerland Anat Andrea Melnick Melnick, Spain Matthieu Mengin, France Jörg Minner, Germany Irene Mittino, Italy Mario Alonso Narváez Barros, Spain Helena Madelinde Nugteren, The Netherlands Katharina Ollig, Switzerland Christophe Orye, Belgium Keum Dong Philipp Ott, Germany Vito Palumbo, Italy Jorge Panach Navarrete, Spain Maria Loreto Parra López, Spain

Femke Vandercruysse, Belgium Guillermo Sebastián Vélez Guayasamín, Spain Marjan Waterloos, Belgium Susanne Bernadette Winkelhog, Germany Pirmin Wolfsgruber, Switzerland Thomas Ying, Sweden Zaid Zaid Al-Kailani, Germany Mohamed Zarzour, Germany Michele Zazzara, Italy

Mariusz Śliwiński Wojciech Tur Marcin Wajszczuk Patryk Warsiński Paweł Wisz Wojciech Wyroślak Tomasz Zaorski Łukasz Zapała

María del Pilar Alcoba García, Spain

Eva Katharina Drescher, Switzerland Andrea Jimena Durán Rivera, Spain Christophe Philippe Eidler, Austria Francesco Esperto, Italy Ariadna Fabià Mayans, Spain José Javier Fabuel Alcañiz, Spain Riccardo Fantechi, Italy Caterina Fernández Ramón, Spain Stefanie Fiechter, Switzerland Maria Fiol Riera, Spain Nicola Fossati, Italy Tanja Frank, Germany Alexander Friedl, Austria Giorgio Gandaglia, Italy Carlos Gasanz Serrano, Spain Ricardo Godinho de Andrade, Portugal Petros Gorgoraptis, Greece

Giulio Patruno, Italy Nicola Pavan, Italy Alba Poza Fernández, Spain Dario Pugliese, Italy Patricia Ramirez Rodriguez-Bermejo, Spain Matteo Rani, Italy John-David Rebibo, France Laura Redón Gálvez, Spain Cristina Redondo Redondo, Spain Adrien Rene Marcel Riviere, France Nuno Rodrigues Grilo, Switzerland Moisés Elias Rodríguez Socarrás, Spain Daniele Romagnoli, Italy Giuseppe Romeo, Italy Clemens Rosenbaum, Germany Johan Rubenson, Sweden Simone Sannino, Italy

Carlo Bonarriba Beltrán, Spain Hendrik Borgmann, Germany Laura Buckendahl, Germany Özer Ural Çakıcı , Turkey Carlos Carrillo George, Spain Paula Casasayas Carles, Spain Marcela Čechová, Czech Republic Clara Centeno Álvarez, Spain Paul Chiron, France Cathrin Chmelik, Germany Rui Fernando da Cunha Amorim, Portugal Marc de Jong, The Netherlands Steven Deconinck, Belgium Davide Diazzi, Italy Kingsley Ekwueme, United Kingdom Amrou El Hajjar, Germany Christina Luise Engels, Germany

Mofarej Alhogbani, France Hussam Alkhayyat, Germany Hussain Murtaza Alnajjar, United Kingdom Zaloa Amelibia Alvaro, Spain Enrico Ammirati, Italy Antonino Battaglia, Italy Severin Bauinger, Austria Elodie Beels, Belgium Raúl Benítez Sala, Spain Joost Berkers, Belgium

Michelle Grämiger, Germany Tobias Mattias Gross, Switzerland Astrid Grundner, Austria Ana Guijarro Cascales, Spain Alexander Christoph Haab, Switzerland Johannes Heide, Germany Tomáš Hradec, Czech Republic František Hruška, Czech Republic Miroslav Hruška, Czech Republic Manuela Ingrosso, Italy

Giacomo Saraceni, Italy Jan Šarapatka, Czech Republic Julia Elena Schneider, Switzerland Iván Schwartzmann Jochamowitz, Spain Julia Sequeira García del Moral, Spain Dimitrios Siatos, Greece Luís André Silva Santos de Sepúlveda, Portugal Raquel Sopeña Sutil, Spain Francesco Soria, Italy Maria Teresa Soriano Rodríguez, Spain

Younes Fadil Hechadi, Spain Cristina Falavolti, Italy Dragoş Ioan Feflea, Romania Adrian Johannes Forke, Germany Sebastian Frees, Germany Julius Johann Freiherr von Süßkind-Schwendi, Germany Peter Jan Gawecki, Germany Corinna Gedding, Germany Stefan Gensluckner, Austria

FEBUs Hungary Károly András Kraszkó Balázs Nyíri Balázs Ferenc Szabó Péter Balázs Tóth

FEBUs Brussels (final-year residents*)

FEBUs Brussels (Urologists) Mohamad Said Shaker Abdel Hafiz, Germany Ihab Abutabanjeh, Germany Sadik Avdic, Sweden Marinos Berdempes, Greece Martin Bergman, Sweden Liselotte Boevé, The Netherlands

*Final-year residents have received a provisional diploma which states that the holder will obtain the FEBU diploma, and may use the FEBU title, only after having submitted a copy of the Certificate of Accreditation as a urologist at the EBU office.

June/July 2017

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Successful candidates EBU Oral Examination 2017 Petros Georgouleas, Sweden David Gosálbez García, Spain Niels Graafland, The Netherlands Miguel Ángel Gutiérrez García, Spain Jannika Heinzmann, Germany Khalil Hetou, Canada Ines Katharina Hofmann, Germany Clemens Hüttenbrink, Germany Jacob Ingvar, Sweden Anastasios Ioannidis, Greece Łukasz Stanisław Iwanicki, Germany Lukáš Kamarád, Austria Filippos Kapogiannis, Greece Kimia Kohestani, Sweden Nikolay Pavlov Kolchagov, Germany Anastasios Kolovos, United Kingdom Stavros Kontogiannis, Greece Zisis Kratiras, Greece Thorsten Krystofiak, Germany Arjen Kums, The Netherlands Félix Kwizera Rukundo, Belgium Inés María Laso García, Spain Stefan Latz, Germany Verena Lieb, Germany Mazen Bakr A Lingawi, Germany Erika Llorens de Knecht, Spain Pieter Logghe, Belgium Marios Lonis, Greece Pedro López Cubillana, Spain David López Sánchez, Spain

Paul Ludwig, Germany Ricardo Jorge Macedo Lima Fernandes, Portugal François-Xavier Madec, France David Mak, United Kingdom Natalia Marrero Umpiérrez, Spain Frank Martens, The Netherlands Roman Mayr, Germany Götz Christian Melloh, Germany Jana Mester, Germany Herdis Mechthild Miersch, Germany Eugenio Miglioranza, Italy Johannes Mischinger, Germany Georg Müller, Switzerland Gautier Müllhaupt, Switzerland Tim Nestler, Germany Bernhard Neuwirth, Austria Fabio Victor Nussberger, Switzerland Valerio Olivieri, Italy Andrea Orosa Andrada, Spain Katarína Otavová, Czech Republic Andrej Para, Slovakia Codrut Ştefănel Pavel, France Nuno Miguel Pereira Azevedo, Portugal Francesca Pisano, Italy Ana-Maria Cristina Popa, Germany Marcin Popiołek, Sweden Luigi Quaresima, Italy Jan Philipp Radtke, Germany Mohammad Sajjad Rahnama'i, The Netherlands Sanjay Lachhman Rajpal, United Kingdom

Ralf Regensburg, The Netherlands Lauri Reunanen, Finland Maher Safi, Germany Marianne Schmid, Germany Birte-Swantje Schneevoigt, Germany Bianca Scholtz, Sweden Melanie Schremmer, Germany Matthias Schweizerhof, Germany Arcangelo Sebastianelli, Italy Syed Ali Shahzad, United Kingdom Viktor Skradski, Austria Hassen Chemseddine Smaali, France Hendrik Jinne Stiksma, The Netherlands Gjoko Stojanoski, Germany Filip Šubin, Slovakia

Juan Tabares Jiménez, Spain Tilman Wolfgang Todenhöfer, Germany Sara Vellamo Tornberg, Finland Georgi Stoyanov Tosev, Germany Konstantinos Tryfonos, Cyprus Dimitrios Tsavdaris, Greece Salil Umranikar, United Kingdom Anna Elisabeth Vellekoop, The Netherlands Åsa Warnolf, Sweden Lars Weisbach, Germany Michael Weyand, Germany Rob Wijn, The Netherlands Konrad Wilhelm, Germany Peter-Paul Michiel Willemse, The Netherlands

EBU exams in detail The EBU Examination Committee annually organises 3 assessments: E uropean Board Examinations in Urology The European Board Examinations in Urology are summative assessments and consist of 2 parts: Written and Oral Examination. Participation is subject to eligibility.

1. Online Written Examination (Part I) The purpose is to determine whether the candidate demonstrates the minimum level of knowledge recognised by the EBU Examination Committee. The examination consists of 100 MCQ on the entire range of urological topics including basic science.

2. Oral Examination (Part II) The objective is to test the candidate’s ability to evaluate and manage common cases in every day practice. The candidate will be given 3 clinical cases which represent a wide spectrum of urologic practice.

Eligibility Criteria - Final-year resident: Trained as part of an official 14

European Urology Today

national urology training programme in a UEMS/ EBU member country. The training must be completed before 31 October each year.

- Certified urologist: Fully qualified as a urologist by the recognised national authority.

The FEBU diploma is considered as a mark of excellence, an added qualification and an asset to the individual’s CV and portfolio. The FEBU diploma has no legal value and does not confer the legal right to practice urology.

The period between the EBU Online Written and Oral Examination may not exceed 5 years.

3. In-Service Assessment The EBU In-Service Assessment is a formative assessment; it allows the candidates to evaluate their current knowledge base against the current European standards. This assessment encourages teacher and student reflection and is used to inform the teaching and learning process.

UEMS/EBU Member Countries Austria, Belgium, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom.

Credits (category 3) • In-Service Assessment: Candidate receives 2 credits.

• EBU Online Written Examination: Successful candidate receives 2 credits.

• EBU Oral Examination: Successful candidate receives 50 credits.

A certified urologist who is qualified in a non-UEMS/ EBU member country is eligible to take the EBU Online Written Examination, however not the EBU Oral Examination.

IMPORTANT DATES EBU Online Written Examination: Friday 17 November 2017 EBU In-Service Assessment: Thursday 1 & Friday 2 March 2018 EBU Oral Examination: Saturday 2 June 2018

For more information visit www.ebu.com

June/July 2017

2nd ESU-ESUT Masterclass on Operative Management of BPO A focussed and intensive masterclass Dr. Jan-Thorsten Klein Universitätsklinikum Ulm Dept. of Urology & Pediatric Urology Ulm (DE) jan-thorsten.klein@ uniklinik-ulm.de

The 2nd ESU-ESUT Masterclass on Operative Management of Benign Prostate Obstruction (BPO) took place in Heilbronn, Germany last May 19 and 20 and attracted 40 participants from across Europe.

The format of the one-a-half-day Masterclass course was launched last year and is now an annual event attracting 40 mostly young urologists in the beginning of their surgical careers as well as urologists who are specialising in the endourological treatment of the prostate. Day 1 was focussed on surgical therapy strategies of BPO including live-surgeries via OR transmissions, semi-live cases and dedicated lectures on the theoretical background. A busy schedule for a whole day began with a short welcome by Evangelos Liatsikos, chairman of the ESUT and Jens Rassweiler, chairman of the EAU Section Office.

Thereafter, the first surgeries were transmitted showing bipolar prostate resection techniques.

During the surgeries, the surgeons had the opportunity to show the main aspects of their surgical strategies and answer questions from the audience and the moderators.

After the first surgical session the first part of the expert theory took place, covering the whole range of indications for surgery, such as: guidelines on BPO, how to choose the correct therapy method and understanding the surgical anatomy of the prostate. After the lectures and a short break, Part 2 of the live transmissions started. This session focussed on the monopolar management of BPO and the green light laser vaporisation of the prostate using a high power laser energy. Both surgeries showed exactly how to handle the instruments und devices to achieve excellent surgical results.

The second expert theory session included lectures about irrigation solutions and lubricants in the different endoscopic BPO treatments, the principles of HF-surgery and a further discussion on what instruments to use. In the meantime the patients in the OR were changed and the third live surgery session started. This time enucleation

techniques were highlighted. The techniques of TURis enucleation and bipolar enucleation of the prostate were demonstrated.

Thereafter, as the newly introduced component of surgical education, semi-live cases were presented and discussed with the surgeons.

Among the issues taken up were the crucial steps of laparoscopic adenomectomy and roboticassisted adenomectomy, and green-light enucleation of the prostate were shown.

Discussions with the audience and the moderators showed a growing interest in minimal invasive surgical strategies even in big prostate adenomas.

Prostate enucleation techniques The fourth live session covered prostate enucleation techniques using either holmium- or thulium-lasers. These techniques were previously considered as ‘newcomers’ but are nowadays standard procedure in many centres. The type of technique, whether single-lobe, dual or triple lobe techniques, were intensively discussed.

For the second time, a highly intensive Masterclass workshop on surgical management of BPO ended with fully satisfied participants.

Below is a list of participating surgeons and the surgical procedures in the live surgeries: • Bipolar Resection T. Knoll, Sindelfingen (DE) • Bipolar TURIS A.G. Martov, Moscow (RU) • Thulium laser enucleation of the prostate C. Netsch, Hamburg (DE) • Holmium laser enucleation with high energy S. Piesche, Hof (DE) • TURIS Enucleation of the prostate J. Rassler, Leipzig (DE) • Bipolar enucleation of the prostate T. Herrmann, Hannover (DE) • Monoploar Resection of the prostate V. Pansadoro, Rome (IT) • Greenlight laser vaporisation A. Bachmann, Basel (CH) • TUR-B with PDD system blue J. Rassweiler, Heilbronn (DE)

Session moderators interact with surgeons and the audience

Live surgeries are transmitted to the lecture hall

the hands-on training, the group was divided into sub-groups and rotated through the different work stations. The training facility was equipped with different VR-Trainers and TURSimulators using different models.

The subgroups of trainees rotated every 20 minutes. This included also four Meet-theExpert roundtable work stations, which focussed on resection techniques (shown through videos), catheters, instruments and technical devices and the handling of the instruments. Every group was trained intensively. After 3.5 hours of concentrated training, the event ended with the debriefing and a final discussion round.

"Every group was trained intensively. After 3.5 hours of concentrated training, the event ended with the debriefing and a final discussion round."

The last expert lecture session included future technical developments and gadgets. The BPO will be surgically managed with high-pressure water streams, steam and other technical devices for tissue ablation and/or temporary symptom relief.

At the end of Day 1, the TUR-B resection technique with support of a new PDDSystem was demonstrated. This strengthened once again the rapid evolution of endoscopic armamentarium in endourology.

In the evening, after a full day covering all aspects on surgical management of BPO, the surgeons and participants met for discussion of the eventful day. The participants and the surgeons had a good night. The patients from the live surgery had a good night as well. There were no revisions or major bleedings. The ward round the following day showed no significant problems, which reflected the excellent results.

Day 2 included a full workshop on 7 workstations including different TUR models and a mentored training approach. After a short clinical report on the cases of the previous day, including showing photographs of the patients’ urine bags and a briefing on the organisation of

Lectures provide theorectical background to the surgical cases

Teaching activities 2017 European School of Urology July 9-15

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

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15th European Urology Residents Education Programme (EUREP), Prague (CZ) 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 Urological Section of Serbian Medical Society, Belgrade (RS)

October 12 12 12-13 13 17 19

June/July 2017

23-24

December 2

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 course on Diagnosis and management of complications after radical cystectomy at the national congress of the Czech Urological Society, Pilzen (CZ)

ESU course on The current role of laparoscopy in urology at the national congress of the Scientific Society of Urologists of Uzbekistan, Tashkent (UZ) ESU course Management of surgical complications in urology at the national congress of the Russian Society of Urology, Moscow (RU) ESU courses on Bladder and Kidney cancer at the 9th European Multidisciplinary Meeting in Urological Cancers (EMUC), Barcelona (ES) 4th ESU-ESUT Masterclass on Lasers in urology, Barcelona (ES)

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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

European Urology Today

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Education Online

www.cem17.org

Improve your skills: e-learning at your own convenience

CEM17 EAU 17th Central European Meeting (CEM) in conjunction with the national 63rd annual conference of the Czech ˇ Urological Society (CUS)

New EAU Education Online course:

ˇ Czech Republic 19-20 October 2017, Plzen, An application has been made to the EACCME® for CME accreditation of this event

Urolithiasis Introduction to Upper urinary tract endoscopy for Stones Coming soon!

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.

uroweb.org/education

www.esulasers17.org

www.esufocaltherapy17.org

4th ESU-ESUT Masterclass on Lasers in urology

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

23-24 November 2017, Barcelona, Spain An application has been made to the EACCME® for CME accreditation of this event

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

European Urology Today

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

June/July 2017

23rd Congress in Serbia

ESU course in Cyprus

ESU courses on andrology and penile cancer

Assessing bladder cancer management issues

The sexual dysfunction session was led by Prof.

Salonia (IT) who lectured on EAU Guidelines recommendations on male sexual dysfunction, premature ejaculation and Peyronie’s disease. Prof. S. Minhas (GB) spoke on erectile dysfunction after surgical treatment options including prosthesis. The session also ended with an interactive case discussion.

Dr. Vladan Andrejevic Clinical Center of Serbia Urology Clinic Belgrade (RS)

urologicclinic@ eunet.rs

Around 370 participants including 170 from neighbouring countries attended the 23rd Serbian Urology Congress held from April 21 to 22 in Belgrade, Serbia.

Chaired by Prof. A. Aleksandar Vuksanovic, president of the Serbian Urology Association, the meeting attracted the interest of urologists in the region with lectures given by specialists coming from Serbia.

Participants also enthusiastically attended the course organised by the European School of Urology (ESU).

They also appreciated the quality of the lectures and discussions.

The ESU Course, which took place on the first congress day, covered andrology, male genital problems and penile cancer. In the andrology session, Prof. G. Dohle (NL) discussed the EAU Guidelines recommendations on male infertility, male hypogonadism and its management, and the diagnostic challenges in evaluating male infertility.

The non-muscle invasive bladder cancer (NMIBC) session was held on the second congress day and examined key questions on the topic, with Prof. J. Djozic (RS) discussing “BCG Immune Therapy – when, to whom and how,” which was followed by an open forum on bladder-sparing options. Management of localised (Prof. V. Sekulic, RS) and metastatic prostate cancer (Prof. A. Vuksanovic, RS), new lines of therapy, administration of enzalutamide, cabazitaxel and abiraterone were also discussed. The administration of docetaxel to hormone-sensitive CaP patients was presented. Prof. Z. Dzamic, head of the Urology Department of Clinical Center of Serbia, led a session on metastatic renal cancer, which highlighted the dilemmas and current targeted therapy using VGE and mTOR inhibitors.

The congress gave the participants an overview of treatment options and modalities for the various urological pathologies and how they are managed in our region. The ESU course was excellent and focused with presentations that were well-received by all participants.

Regarding penile cancer, Prof. S. Minhas (UK) spoke on the evaluation and treatment cascade in primary penile cancer, including the prevention and management of post-operative complications and lymphocele. The penile cancer treatment algorithm for advanced disease was also discussed, with the session The participants appreciated the discussions that followed each ending with an interactive case discussion. presentation

Dr. Stavros Charalampous CUA President Institute of Functional & Reconstructive Urology Limassol (CY) st.charalampous@ cyprusurology.com

Dr. J.L. Dominguez-Escrig were all skilled and helpful and gave insightful presentations.

The participants gave positive feedback for all presentations and they appreciated the discussions that followed each presentation and the chance to directly ask the ESU faculty members. Local faculty members, Dr. Ch. Kouriefs and Dr. S. Omorfos also presented interesting cases which led to lively debates. The feedback I got was very positive indicating that the course was relevant and challenging. Overall, completing the course was a learning experience.

The European School of Urology (ESU) organised the course ‘Management of bladder tumours' as an add-on We are grateful to the EAU for this close collaboration and our association is very keen to maintain the course during the 2nd Spring Symposium in Urology partnership. On behalf of the Cyprus Urological held in Limassol, Cyprus.

Association, we extend our thanks for the active support and look forward to further collaborations.

The Organising Committee, together with the ESU faculty put together exciting lectures, updates, practical clinical approaches and interactive case discussions. The course gathered more than 80 physicians mainly from Cyprus and Greece. Following the welcome words by Cyprus Urological Association (CUA) President Dr. Stavros Charalampous, Dr. J.L. Dominguez-Escrig introduced the ESU’s aims and activities.

The six-hour course consisted of two parts: a) Non-muscle invasive bladder cancer and b) Muscle invasive bladder cancer. The invited speakers were Prof. M. Babjuk (CZ), Prof. T. Klatte, (AT) and Dr. J.L. Dominguez-Escrig (ES). The updated guidelines on bladder cancer management and all diagnostic tools and treatments strategies were included in the lectures, which were then followed by an open forum. This provided the opportunity to discuss and explore key issues.

The course was insightful, useful and relevant. The tutors were true professionals with a wealth of knowledge to share. Prof. Babjuk, Prof. Klatte, and

Dr. J.L. Dominguez-Escrig from Spain speaking on bladder cancer management

Dr. Dominguez-Escrig introducing the ESU's aims and objectives

EAU Education Online presents;

EAU Guidelines E-Courses How well do you know EAU Guidelines?

The online e-courses feature questions formulated by experts in the field, reviewed by the EAU Guidelines Office and the Young Urologists Office.

Prostate Cancer Learning Objectives • Review the most updated EAU guidelines on Prostate Cancer

Renal Cell Carcinoma (RCC)

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

• Learn how to make informed decisions in treatment of Prostate Cancer Patients Learning Objectives • Test your knowledge on the latest developments in • Review the most updated EAU guidelines on Renal Prostate Cancer according to the EAU Guidelines Cell Carcinoma (RCC) • Learn how to make informed decisions in treatment Urolithiasis of Renal Cell Carcinoma (RCC) Patients • Test your knowledge on the latest developments in Learning Objectives Renal Cell Carcinoma (RCC) according to the EAU • Review the most updated EAU guidelines on Guidelines Urolithiasis • Learn how to make informed decisions in treatment of Renal Cell Carcinoma (RCC) Patients • Test your knowledge on the latest developments in Renal Cell Carcinoma (RCC) according to the EAU Guidelines

• 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

More info: educationonline@uroweb.org www.surgeryinmotion-school.org

June/July 2017

Surgery in Motion School is a collaboration of

An application has been made to the ACCME® for CME accreditation

uroweb.org/education

European Urology Today

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BALTIC17: Pursuing challenges and opportunities Advances in the Baltics reflect prospects in urology

By Joel Vega For the second time since 2014 Vilnius hosted the annual Baltic Meeting held in conjunction with the EAU (BALTIC17), gathering from May 26 to 27 in the Lithuanian capital nearly 300 urological professionals to closely examine prospects and challenges in European urology.

Bladder cancer and renal biopsy issues Prof. Steven Joniau (BE) examined quality-of-life (QoL) issues for high-risk PCa after surgery and radiotherapy. “There are good overall survival (OS) and cancer-specific survival (CSS) following surgery and radiotherapy (RT) for high-risk PCa,” he said.

He, however, cautioned that administering adjuvant (RT) plus androgen deprivation therapy (ADT) have a major impact on QoL, particularly in elderly patients who complain of extreme fatigue.

“Engaging both young and experienced urologists from the Baltic countries to look into clinical dilemmas and quality practices is the right step to boost our specialty,” remarked Dr. Michiel Sedelaar (NL) who gave the opening remarks on behalf of EAU Secretary General Prof. Chris Chapple (GB) who arrived later in the day.

“The best candidates for surgery are younger and potent men who can be treated with a uni or bilateral nerve-sparing radical prostatectomy and accept a 10 to 20% risk of incontinence and around 50% need of adjuvant salvage treatment,” said Joniau.

Sedelaar said events like BALTIC17 is a timely opportunity for many young urologists to boost their knowledge by linking up with their colleagues and joining the discussions on major treatment dilemmas and challenges.

Dr. Achilles Ploumidis (GR) discussed upper-tract urothelial cancer (UTUC) and said that UTUC and bladder cancer are two distinct diseases. “The role of URS plus biopsy in UTUC is essential in diagnosis, risk stratification and therapy,” he said as he underscored that URS should be offered to all patients with suspected UTUC.

Prof. Goran Ahlgren (SE) delivered the EAU Lecture with his comprehensive report on good PSA screening practice as shown in Swedish trials. Noting that screening practices aim to avoid over-diagnosis and correctly classify tumours, Ahlgren looked into the lessons learned from Swedish studies such as the Stockholm3 trials. He said PSA screening is currently not recommended in Sweden and revisions are still on-going with regards local guidelines.

“The Gothenburg study showed that organised PSA screening increases the incidence of prostate cancer and decreases mortality compared to unorganised random PSA testing,” said Ahlgren, suggesting that there is a benefit in the early screening of men.

“Screening should start at 50 years of age and possibly be extended above 70 years.”

Ahlgren also pointed out that screening with PSA only increases benign biopsies and detection of low-risk cancers. “Looking ahead, can technologies such as mpMRI further reduce unnecessary biopsies with detection of low-risk tumours and the detection of more significant cancers?,” Ahlgren asked.

Prof. Alessandro Volpe (IT) lectured on renal mass biopsy and looked into the reasons why there is limited use of renal tumour biopsy such as safety issues and techniques. According to Volpe, there is a need for a wider use of renal tumour biopsy to reduce unnecessary surgeries and support decision-making in patients with small renal masses (SRMs) who are candidates for non-surgical treatments, and those with metastatic RCC who are not candidates for cytoreductive nephrectomy.

In his concluding remarks, Volpe said renal mass biopsy is a feasible minimally invasive procedure.

“Moreover, clinically significant complications are rare and the diagnostic yield is satisfactory in experienced surgeons,” he noted as he added that diagnostic biopsies have a high accuracy for malignancy and histotype.

Nearly 300 participants and exhibitors gather in Vilnius for the 4th Baltic Meeting

“Correlation with RRP (Radical retropubic prostatectomy) has shown that mpMRI has good sensitivity for detection and localisation of >GI 7 tumours,” said Sedelaar adding that there is “…no recommendation on using mpMRI for screening (negative mpMRI).” mpMRI, however, is recommended in cases prior or before repeat biopsies and during repeat biopsy.

Dr. Alexander Rolevich (BY) gave a comprehensive lecture on fluorescent cystoscopy (FC)-assisted transurethral resection (TUR) and looked into the outcome in non-muscle invasive bladder cancer (NMIBC) patients. “FC-assisted TURBT decreases recurrences and the baseline quality of TURBT is a significant factor,” he said and pointed out that FC-assisted TURBT also reduces progression.

Sedelaar further emphasised that when using mpMRI, a quality set-up of well-trained radiologists and the use of PIRADSv2 are mandatory. “When used properly mpMRI can be added to risk models,

He recommended doctors to perform a high-quality TURBT which is “systematic “and comprehensive.

“Perform a check and cross-check and know your recurrence rate,” he said.

Young Urologists Competition: New perspectives A different view on various urological conditions was presented during the highly-anticipated Young Urologists Competition session. Chaired by Professors Bob Djavan (AT) and Sedelaar, the competition tested the abilities of young promising urologists from four participating countries: host country Lithuania and its neighbours Latvia, Estonia and Belarus.

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European Urology Today

BALTIC 17

26-27 May 2017 Vilnius, Lithuania

scarring,” said Chapple whilst underscoring that surgeons face the twin challenges of restoring both function and cosmesis. In restoring function, the goals include restoring the patient’s ability to void with a straight stream, remove strictures, replace the urethra and correct the chordee.

Best Posters Lithuania, Estonia and Belarus led the Best Poster presentations with their insightful studies in prostate and bladder cancers. Six prizes were given by Berlin Chemie and Karl Storz for Basic and Clinical Research studies, respectively.

Meanwhile, Lithuania and Latvia shared the first prize in the Young Urologists Competition. Below are the complete lists of winners: Meeting Chairman Prof. M. Jievaltas (L), Prof. A. Kotsar (M) and Dr. M. Sedelaar during the opening session

Patasius examined BRCA testing for all prostate cancer patients and posed the query whether it should be included in standard care practices. He, however, noted that this possibility may not be viable due to the multigenic nature of BRCA and its long list of suspected alleles and polygenic combination, among other factors. “Genetic counselling is indicated for young patients (less than 55 years) with diagnosed prostate cancer,” he said in his concluding remarks adding that SNP’s included in genetic risk scores could reduce the number of unnecessary biopsies. His statement prompted comments and questions from both the audience and the jury members.

Freimanis looked into the background and incidence of urosepsis and described the study design of his group. “Urosepsis is a serious and threatening situation with a higher mortality risk in the elderly, and in patients with severe concomitant disease and with more severe clinical state at presentation,” he observed. He said that empirical antibacterial therapy should be “in accordance with the local and regional resistance patterns and most common pathogens.”

“Microbiological cultures are of the highest importance in effective management of septic patients and antibacterial therapy should be individually adjusted as soon as possible,” he concluded.

Okas gave a compact overview of urethral trauma management and discussed incidence, morbidity, anatomy, diagnosis, classification, treatment and evidence. In his take-home messages, he highlighted the role of early endoscopic realignment and said that about 50% of the cases do not need any further treatment, around a third of cases can be managed endoscopically and a fifth would need urethroplasty.

Sedelaar gave an overview lecture on the role of multi-parametric MRI in decision-making for screening and focal therapy of prostate cancer (PCa).

“One could say that the urological community is struggling with the role of mpMRI in prostate cancer diagnostics,” Sedelaar said as he examined the uses of mpMRI and current EAU guideline recommendations.

Laparoscopy training sessions attract enthusiastic participants

Dr. Ausvydas Patasius (LT) examined the modern approach to managing hereditary prostate cancer, while his opponent, Dr. Arvis Freimanis (LV) looked into the characteristics and outcomes of patients with urosepsis in an intensive care unit.

Meanwhile, contestants Dr. Rauno Okas (EE) presented his views on managing urethral trauma, while Dr. Leonid Suslov (BY) discussed the importance and limits of warm ischemia during partial nephrectomy.

Berlin Chemie Best Posters, Basic Research • First Prize: A. Kotsar, et al. (Finland/Estonia), 5alpha-reductase inhibitors use and bladder cancer-specific mortality in a Finnish population-based cohort • Second Prize: L. Suslov, et al. (Belarus), Acute kidney injury after partial nephrectomy for renal masses in the solitary kidney • Third Prize: T. Kloskowski, et al. (Poland), Effect of urine on cell line in-vitro: Implication for urinary tract regeneration Karl Storz Best Posters, Clinical Research • First Prize: M. Kincius et al. (Lithuania), Salvage radiation therapy following radical prostatectomy. First results of a multi-centre Lithuanian study • Second Prize: S. Polyakov and A. Yaumenenka (Belarus), Survival in patients with locally advanced prostate cancer: A populationbased study • Third Prize: P. Veskimae, et al. (Estonia), First results of simultaneous kidney-pancreas transplantation in Estonia Young Urologists Competition Award • First Prize, Co-Winner: A. Patasius (Lithuania) Modern approach to hereditary prostate cancer • First Prize, Co-Winner: A. Freimanis (Latvia) Characteristics and outcomes of patients with urosepsis in an intensive care unit • Second Prize: R. Okas (Estonia) Management of the urethral trauma- to realign or not to realign?

• Third Prize: L. Suslov (Belarus) Importance and limits of warm ischemia during partial nephrectomy

Suslov discussed the limits of warm ischemia. “Warm ischemia affects early and late postoperative renal function,” he said whilst noting that animal experiments may not correlate well with human response to ischemia. He said that in studies, only a solitary kidney is the ideal model for research and that among the problems are the absence of randomised trials, the lack of patients and data of renal volume.

Issues in reconstructive and functional urology Issues and dilemmas in reconstructive and functional urology were highlighted the second and last day of BALTIC17 with a discussion on treatments, future perspectives and updates on current standards.

Chaired by Prof. Andres Kotsar (EE) and Dr. Darius Trumbeckas (LT), topics included techniques in solving failed urethral reconstruction, modern management of Peyronie’s disease (PD), myths and facts of vasectomy, and the renovascular reconstruction of grafts in kidney transplantation.

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“We take note of the enthusiastic involvement of many urologists in the region to organise this meeting, which provides a timely and quality venue where we can critically discuss and share knowledge on many scientific and clinical questions,” said organisers Professors Mindaugas Jievaltas (LT) and Feliksas Jankevicius (LT) as they welcomed participants coming from Latvia, Estonia, Belarus, Netherlands, Sweden, Poland and host country Lithuania, among others.

reducing the number of unnecessary biopsies,” he said. In his concluding messages, Sedelaar said mpMRI is not suited for PCa screening but is very useful in detecting and visualising significant PCa in focal treatment. “mpMRI is useful for guided biopsy, patient selections and guided treatment,” he said whilst noting that not all PCa can be visualised and that subsequent mpMRI-guided focal treatment is not curative..

EAU Secretary General Prof. Chris Chapple delivered an incisive lecture on failed urethral reconstruction which is widely considered as a challenging procedure due to the low number of cases and the post-surgical complications. Chapple discussed the main points including epidemiology, the aims of “The jury will not only decide on the actual content surgery, options in the use of tissue, follow-up but also on the presentations and how the contestants procedures and shared his insights on troubledefended their views. A persuasive and elegant shooting and surgical techniques. presentation is among the qualities that we are looking for,” said Sedelaar during the start of the “Adult stricture patients after previous hypospadias contest. repair have poor quality of tissue with extensive

BALTIC17 grants cash awards and recognition to the six best abstract presentations

“The performance of the Young Urologists Competition contestants and the winning abstracts show the quality of work being done in the region and we are encouraged to see the dynamism of urological advances being made here,” said Dr. Michiel Sedelaar who congratulated the winners together with Professors Mindaugas Jievaltas and Bob Djavan.

Jievaltas thanked the Young Urologists Competition and abstract participants for their contribution. He said the continued collaboration among the Baltic countries will help boost urology in the region, and expressed the hope that similar quality work will be submitted for the 5th Baltic Meeting in Riga, Latvia, 25-26 May 2018!

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European Urology Today

June/July 2017

Step Up!

#urologyweek

Join the Campaign for public awareness of urological conditions

European Prostate Cancer Awareness Day 27 September 2017

urologyweek.org

June/July 2017

European Urology Today

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WEEK 2017 25-29 SEPTEMBER

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.

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June/July 2017

European Urology Today

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Sofia event examines key updates in stone management

saricakemal@ gmail.com

“The meeting was also live streamed on the event website…”

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EAU Section of Urolithiasis (EULIS) joined the 8th Endourology and Minimally Invasive Surgery Meeting held last April 24 and 25 in Sofia, Bulgaria. The event was organised by the Department of Urology and Nephrology at the Military Medical Academy of Sofia and the Bulgarian Association of Endourology and SWL with the strong support and endorsement of EULIS. Prof. Iliya Saltirov, an active associate member of EULIS, was the meeting’s local chairman meeting.

EULIS Board Chairman Prof. Kemal Sarica, and EULIS Board members Prof. Juan Antonio Galan, Prof. Alberto Trinchieri, Prof. Jose Reis-Santos and EULIS associate members Prof. Andeas Skolarikos, Assoc. Prof. Atanasios Papatsoris, Dr. Sami Hayek, Prof. Guohua Zeng, Prof. Ahmet Muslumanoglu and members of EULIS working groups, supported the event by giving state-of-the-art lectures and live surgery demonstrations on urolithiasis.

EAU Section of Urolithiasis (EULIS)

More than 170 participants from Bulgaria and the neighbouring countries attended the event which featured live-surgery demonstrations, state-of-theart lectures and debates that examined both surgical and medical treatment of stone disease. Young urologists were given the opportunity to present their research during the moderated poster and video session and practice their skills on the hand-on-training models under the supervision of experienced tutors.

Prof. Sarica performing a mimi-PNL procedure



Call for proposals biological samples MAGNOLIA study

doses administered at 3-month intervals for a total maximum duration of study treatment administration of 27 months.

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

During the study, we collected FFPE block samples of at least 10mm3 of the primary tumour - or in cases where the tissue block was not possible 20-25 unstained 10 µm slides and 1 unstained 5 µm slide of the primary tumour. Fresh tissue of the resected tumour (and in case of recurrence) was also collected.

Blood samples (serum) at V1 (pre-administration), V3, V5, V7, V8, V10 and concluding visit were collected.

Urine Samples prior to cystectomy (and in case of recurrence) have also been collected.

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

Study Design 84 patients were randomly assigned to 2 treatment schedules in a 2:1 ratio, 2 patients randomized for recMAGE-A3 + AS15 ASCI versus 1 patient randomized for placebo, either directly after recovery from surgery, or after recovery from adjuvant chemotherapy. The treatment scheme consisted of 5 doses administered at 3-week intervals followed by 8

Applications If you have interesting basic research proposals that will utilise these samples please contact: Dr. Raymond Schipper, r.schipper@uroweb.org, for further details of the MAGNOLIA study, access to the sample data base which will inform you of the numbers and types of patients and samples available and an application form. Subsequently, the completed application form will be evaluated by the basic research committee of the EAU Research Foundation chaired by Guido Jenster.

M. Colombel, et al. Perioperative Chemotherapy in Muscle-invasive Bladder Cancer: Overview and the Unmet Clinical Need for Alternative Adjuvant Therapy as Studied in the MAGNOLIA Trial. EurUrol 65, p.509, 2014.

MAGE-A3 + AS15 cancer immunotherapeutic product Screening

Randomisation (2:1)

Concluding visit PLACEBO

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

Study design

Prof. Elhilali will be sadly missed as a great family man, philanthropist, colleague and friend.

The Executive

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



Specialised on endourology, Elhilali was involved in Egypt in developing neuromodulation technology and laser prostatectomy, amongst others. His accomplishments in urology were recognised when he was given the titles “Officer of the Order of Canada” and Ordre National du Quebec. He earned lifetime achievement awards from the AUA, CUA, QUA and SIU, and received the Founder’s Award from the Kidney Foundation of Canada. He was awarded the Gold Medal by the Egyptian Urological Association. To acknowledge his contributions, a Visiting Professorship and Chair were established in his name in 2011 at McGill University.

By Guido Jenster (Board Member EAU RF ), Wim Witjes and Raymond Schipper (EAU RF Central Office)



He served as chairman of the Quebec Urology Association (QUA), the Canadian Urological Association (CUA), the Northeastern Section of the American Urological Association (AUA), and was appointed Secretary General and President of the Société Internationale d’Urologie (SIU).

The European Association of Urology has had excellent ties with Elhilali and recognises his significant contributions in urology.



Prof. Elhilali has devoted his life to urology and has made a huge contribution in many different areas. In 1982, he returned to Montreal as Chief of the Department of Urology at the Royal Victoria Hospital, (then McGill University Centre) and Chief of the McGill Division of Urology. He was also professor of surgery in the Faculty of Medicine at McGill University. He was named Chair of the McGill Department of Surgery and Surgeon-in-Chief at the Royal Victoria and Montreal General Hospitals.

Prof. G. Zeng and Prof. Saltirov performing a Super-mini PNL procedure

The meeting was also live streamed on the event website (http://urolithiasis.endourology.bg), giving the opportunity to all those who could not attend the Prof. Sarica and Prof. Skolarikos chairing a session meeting to follow the plenary discussions.

Dedicated urologist and endourologist 1937 - 2017

Prof. Elhilali was born in Egypt and was awarded in 1959 his medical degree at the University of Cairo. He completed his PhD at McGill University in Canada and was certified as urologist by the Royal College of Physicians and Surgeons of Canada. He was appointed Chair of Urology at the Centre Hospitalier Universitaire de Sherbrooke.

EULIS will continue to organise and endorse stonerelated meetings in Europe for a critical examination of the latest developments in the diagnosis, management and follow-up of urolithiasis patients.

The first day of the scientific programme was dedicated to hot topics such as miniaturisation in percutaneous stone surgery, antibiotic prophylaxis, imaging and radiation protection in endourology.

The meeting’s second day featured presentations and demonstrations on current trends and future directions in ureterorenoscopy and pathogenesis and medical treatment of urolithiasis.

Mostafa Elhilali

With great sadness, the European Association of Urology announces the death of Prof.

Mostafa Elhilali, whilst he was attending the American Association of Genito Urinary Surgeons meeting on Saturday, 29 April.

The 8th edition elicited positive feedback from the participants, confirming the role of this annual meeting as a key educational event in Bulgaria with regards updates on stone disease and treatment.



An annual event, the meeting aims to offer up-to-date insights on modern diagnostic and therapeutic minimally invasive techniques in urology.

This year the scientific programme focused on contemporary aspects of diagnosis, treatment and metaphylaxis of stone disease, with presentations by 32 leading urolithiasis experts from 13 countries.



Prof. Kemal Sarica EULIS Chair Dr. Lutfi Kirdar Training and Research Hospital Dept. of Urology Istanbul (TR)



EULIS joins 8th Endourology & Minimally Invasive Surgery Meeting

End of study

Follow-up phase Visits: every 6 months

Week 120

max Year 5

EAU Research Foundation

June/July 2017

European Urology Today

23

Understanding Bladder Pain Syndrome/Interstitial Cystitis BPS/IC models may help researchers understand sympathetic system overactivity and bladder pain

anacharr@ gmail.com

Curiously, chronic adrenergic stimulation-induced pain was blocked by depleting the bladder from nociceptive fibres with systemic capsaicin pretreatment, indicating a direct effect of the adrenergic agent on nociceptive fibers2. Charrua and co-workers excluded a direct effect of the phenylephrine-induced adrenergic stimulation in the central nervous system because intrathecal application of the adrenergic agent had no effect on the bladder pain, function or morphology2. In a later study by Matos and coworkers, it was demonstrated that a prolonged adrenergic stimulation could increase the activity of nociceptive bladder afferents by activating two important bladder pain pathways, mediated by TRPV1 and urothelial ATP. In fact, the response of TRPV1 to natural stimuli was enhanced by chronic adrenergic stimulation and the release of ATP from human urothelial cells in culture increased several fold when incubated with phenylephrine.

Prof. Francisco Cruz Chair ESFFU Dept. of Urology Hospital de S. João Porto (PT)

cruzfjmr@med.up.pt Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) is a condition characterised by supra-pubic pain or discomfort in the pelvic area related to bladder filling, of at least six months duration, often accompanied by a wide range of lower urinary tract symptoms. Some patients present typical cystoscopic findings, glomerulations and Hunner´s ulcers.

Bladder biopsy may confirm the diagnosis and exclude confusable diseases.

Although the aetiology of BPS/IC is unknown, it is a common belief that it is linked to an increase permeability of the urothelium. The leaky urothelium, whatever the cause, is expected to self-perpetuate bladder inflammation and nociceptive fibres activation by letting urine ions and other contents penetrate the bladder wall. However, the causes that make urothelium permeable are far from being clear1.

A systemic origin to BPS/IC, rather than the hypothesis focused only on a bladder problem, is gaining some attention in the last years. BPS/IC is frequently associated with other painful syndromes like irritable bowel syndrome, fibromyalgia or chronic fatigue. Pain maybe referred to parts of the body distant from the bladder. In fact, pain may be felt in the neck and in the lower limbs rather than the lower abdomen or perineal area. All these data suggest, therefore, a common systemic background. Here we present recent evidence that a dysfunction of the sympathetic system can be that systemic defect that underlies BPS/IC. Several studies have suggested that the sympathetic system is overactive in BPS/IC patients, including the demonstration of an increase in density of the sympathetic innervation in the bladder of BPS/IC patients2. In a very comprehensive study, Charrua and co-workers2 measured the levels of noradrenaline in the urine and blood of patients with BPS/IC. They found in 24 hour urine samples an increase in noradrenaline levels when compared with healthy aged and body mass index subjects, documenting the overactivity of sympathetic nervous system in BPS/IC patients. Likewise, basal blood levels of noradrenaline were also increased when compared with normal subjects.

In addition, the response of the sympathetic system during the TILT test done in BPS/IC patients was exaggerated when compared with that of heathy age and body mass index matched controls. The decrease in urinary noradrenaline excretion following Onabotulinum injection in the bladder, which blocks also the release of neurotransmitters like noradrenaline from sympathetic endings, was significantly correlated with the decrease of bladder pain3.

The adrenoceptor involved in these processes was further investigated and it was found that it was the alpha1A-AR subtype4. Thus, when blocking the alpha1A-AR with silodosin it was possible to prevent in rats under treatment with phenylephrine all the findings described above, including bladder pain, bladder hyperactivity and changes in the urothelial morphology. ATP release from the human urothelium was also reduced by the alpha1A blocker silodosin.

Most animal models used to study BPS/IC suffer from important limitations. The most widely used has been the intravesical application of chemical irritants, including cyclosphosphamide and lipopolysaccharide.

However, these rat models are unsuitable for the study of sympathetic dysfunction despite the fact that chronic bladder inflammation increases the density of sympathetic nerve fibres in the body and dome of muscular and suburothelial layers compared to controls, accompanied by a great increase in urinary levels of noradrenaline2. Another option could be the use of cats that develop a disease similar to BPS/IC, known as feline interstitial cystitis FIC5. FIC cats also present signs of an alteration in the sympathetic outflow, with increase urinary noradrenaline levels6.

However, the use of cats in experiments is more and more limited throughout the world and the laboratories with access to such cats are now very few. Thus, there is an unmet need to develop other animal models, preferably using rodents, which might be useful to study the relationship between the sympathetic dysfunction and bladder pain.

Using WAS model in rats Recently, water avoidance stress model (WAS) has also been described to study bladder pain. Lee and co-workers have demonstrated that rats placed 1 hour/day in a podium surrounded by water exhibited bladder hyperalgesia and a prolonged pain behaviour7. Also, it might be recalled that BPS/IC patients have frequent gastrointestinal symptoms, such as chronic pain or Irritable bowel syndrome.

Interestingly, changes in colon activity were also observed in WAS rats showing that this model can be used to investigate the cross-talk of nociceptive inputs between visceral organs, in particular between the bladder and the colon7.

Matos and co-workers have observed that WAS causes an enormous increase in urinary noradrenaline levels, demonstrating the involvement of the adrenergic system in the WAS model8. However more interesting was the observation that the abdominal pain threshold, markedly decreased in WAS rats, could be normalised by the blockade of Chronic adrenergic stimulation model alpha1A adrenoceptors. The relationship between the To further investigate the link between bladder pain state of bladder hyperalgesia and the activity of and sympathetic system a model of chronic alpha1Aadrenceptoes is well demonstrated in the adrenergic stimulation was developed to check if an graph of Figure 1. While WAS rats had a very low increase in the adrenergic tone could trigger bladder threshold for lower abdominal pain (tested by escape pain and morphological changes in the urinary movements to the application of von Frey filaments of bladder that mimic those of BPS/IC patients. The increased rigidity), WAS rats treated with an model consisted on the administration to normal rats alpha1A-AR, silodosin in doses equivalent to dose of a small dose of phenylephrine subcutaneously used in clinical practice , had no hyperalgesia despite during 10 consecutive days2. Visceral pain behaviour, the fact that they maintained high levels of urinary lower abdominal pain threshold, increased number of noradrenaline (Figure 1;8).

also prevented by alpha 1A adrenoceptor blockade with silodosin. WAS stress may lead to urothelial degeneration promoting dilated tight junctions. These changes were also demonstrated to be a downstream event to sympathetic overactivity as they were not present in animals treated with the alpha1A-AR antagonist silodosin. Thus, rat WAS seems a very promising model to study the influence of the sympathetic system in bladder pain and bladder morphology including the urothelium. In addition, the WAS test also allows investigators to explore in the future the role of alpha1A blockers as a treatment option for BPS/IC.

0.12 70

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EAU Section of Female and Functional Urology

24

European Urology Today

0.06

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*

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WAS

WAS + S

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Female MDM

Figure 1 – Graph of bars showing the threshold of response to Von Frey filaments of animals before being submitted to WAS (Basal), 11 days after beginning WAS (WAS) or 11 days after beginning WAS while submitted to Silodosin administration (WAS+S). (*, P<0.05)

Figure 2: Graph of bars showing the threshold of response Figure 1: Graph of bars showing the threshold of response Figure 2 – Graph of bars showing the threshold of response to Von Frey filaments of female without MDM (female sham) and submitted to MDM (female (***,without P<0.001) MDM (female to Von Frey filaments ofMDM). female to Von Frey filaments of animals before being submitted to sham) and submitted to MDM (female MDM). (***, p < WAS (Basal), 11 days after beginning WAS (WAS) or 11 In conclusion, abnormalities in sympathetic activity have been demonstrated in BPS/IC patients who need further back-translation in order to 0.001) days after beginning WAS while submitted to Silodosin determine how an abnormal, overactive sympathetic system can cause BPS/IC. This requires adequate animal models with proven sympathetic administration (WAS+S). (*, p < 0.05) system overactivity. WAS and MDM are interesting and attempts in that direction may help us understand how abnormalities in autonomic nervous BPS/IC has also been associated with stressful events occurring in childhood, calling for additional models which might give the opportunity to researchers to investigate such link. Charrua and co-workers investigated if the maternal deprivation model (MDM) was appropriate to mimic BPS/IC, that is, if MDM mice develop bladder pain and typical morphological changes in the bladder [9]. MDM was induced in new born mice by separating pups, for one hour every day, from their mother and from littermates between Day 2 and Day 15 after birth. Non-separated female pups were used as controls.

About six months later, when those pups achieved adulthood, mechanical pain threshold was analysed by testing mechanical pain threshold with von Frey filaments in the lower abdomen and investigating bladder voiding reflex using filling cystometry. Interestingly female mice subjected to maternal deprivation after birth had lower threshold for abdominal pain (Figure 2) and higher number of voiding contractions in cystometries. The noradrenaline content of the bladders of MDM mice had much more noradrenaline than those of control mice. As TRPV1 KO mice subjected to MDM did not develop pain of bladder hyperactivity, the relationship between the adrenergic system and TRPV1 seems also to be present in this model. Studies already underway will elucidate weather alpha1A blockade will prevent bladder pain in MDM mice.

References

function may contribute to the pathophysiology of BPS/IC, and eventually to other chronic pelvic pain disorders and open the way to new forms of treatment.

1. Hanno, P., et al., Bladder Pain Syndrome Committee BPS/IC has also been associated with stressful events of the International Consultation on Incontinence. occurring in childhood, calling for additional models [BOLD] References Neurourol Urodyn, 2010. 29(1): p. 191-8. which might give the opportunity to researchers to 2. PainCharrua, A., et ofal., Can the Consultation adrenergic systemNeurourol be Urodyn, 2010. 29(1): p. investigate such link. Charrua and co-workers investigated 1.

Hanno, P., et al., Bladder Syndrome Committee the International on Incontinence.

191-8. implicated in the pathophysiology of bladder pain if the maternal deprivation model (MDM) was appropriate 2.

Charrua, A., et al., Can the adrenergic system be implicated in the pathophysiology of bladder pain syndrome/interstitial cystitis? A clinical and experimental study. Neurourol Urodyn, 2015. 34(5): p. 489-96. syndrome/interstitial cystitis?

A tune clinical and to mimic BPS/IC, that is, if MDM mice develop bladder 3.

Charrua, A., et al., Sympathetic nervous system and chronic bladder pain: a new for an old song. Transl Androl Urol, 2015. 4(5): p. 53442. 9 experimental study. Neurourol Urodyn, 2015. 34(5): pain and typical morphological changes in the bladder .

4.

Matos, R., et al., Bladder pain induced by prolonged peripheral alpha 1A adrenoceptor stimulation involves the enhancement of transient receptor potential vanilloid 1 activity and an increase of urothelial adenosine triphosphate release. Acta Physiol (Oxf), 2016. 218(4): p. 265p. 489-96.

MDM was induced in new born mice by separating pups, 275.

5.

Buffington, C.A., D.J. Chew, and S.P. DiBartola, Interstitial cystitis in cats. Vet Clin North Am Small Anim Pract, 1996. 26(2): p. 317-26.

3.

Charrua, A., et al., Sympathetic nervous system and for one hour every day, from their mother and from 6.

Buffington, C.A. and K. Pacak, Increased plasma norepinephrine concentration in cats with interstitial cystitis. J Urol, 2001. 165(6 Pt 1): p.

2051-4. chronic bladder pain: a new tune for an old song. littermates between Day 2 and Day 15 after birth.7. Lee, U.J., et al., Chronic psychological stress in high-anxiety rats induces sustained bladder hyperalgesia. Physiol Behav, 2015. 139: p. 541-8.

8.

Matos, R., et al., STRESS INDUCED VISCERAL PAIN ISUrol, MEDIATED

BY ALPHA 1A ADRENOCEPTORS. Transl Androl 2015.

4(5): p. 534-42. Journal of Urology, 2017. 197(4): p. E47-E47.

Non-separated female pups were used as controls.

9.

Matos, R., F. Cruz, and A. Charrua, CHILDHOOD STRESSFUL EVENTS INDUCE CHRONIC BLADDER PAIN IN ADULTHOOD THROUGH A TRPV1 DEPENDENT MECHANISM. of Urology, 2017.

197(4): p. E380-E381.

4. Journal Matos, R., et al., Bladder pain induced by prolonged peripheral alpha 1A adrenoceptor stimulation About six months later, when those pups achieved involves the enhancement of transient receptor adulthood, mechanical pain threshold was analysed by potential vanilloid 1 activity and an increase of testing mechanical pain threshold with von Frey filaments urothelial adenosine triphosphate release. Acta in the lower abdomen and investigating bladder voiding Physiol (Oxf), 2016. 218(4): p. 265-275. reflex using filling cystometry. Interestingly female mice 5. Buffington, C.A., D.J. Chew, and S.P. DiBartola, subjected to maternal deprivation after birth had lower Interstitial cystitis in cats. Vet Clin North Am Small threshold for abdominal pain (Figure 2) and higher number Anim Pract, 1996. 26(2): p. 317-26. of voiding contractions in cystometries. The noradrenaline 6. Buffington, C.A. and K. Pacak, Increased plasma content of the bladders of MDM mice had much more norepinephrine concentration in cats with interstitial noradrenaline than those of control mice. As TRPV1 KO cystitis. J Urol, 2001. 165(6 Pt 1): p. 2051-4. mice subjected to MDM did not develop pain of bladder 7. Lee, U.J., et al., Chronic psychological stress in hyperactivity, the relationship between the adrenergic high-anxiety rats induces sustained bladder system and TRPV1 seems also to be present in this model. hyperalgesia. Physiol Behav, 2015. 139: p. 541-8.

Studies already underway will elucidate weather alpha1A 8. Matos, R., et al., Stress induced visceral pain is blockade will prevent bladder pain in MDM mice. mediated by alpha 1A adrenoceptors. Journal of Urology, 2017. 197(4): p. E47-E47.

In conclusion, abnormalities in sympathetic 9. Matos, R., F. Cruz, and A. Charrua, Adulthood activity have been demonstrated in BPS/IC through a TRPV1 dependent mechanism. Journal of patients who need further back-translation in Urology, 2017. 197(4): p. E380-E381. order to determine how an abnormal, overactive

sympathetic system can cause BPS/IC. This requires adequate animal models with proven

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Mast cells accumulation, a hallmark of BPS/IC biopsies in humans, also occurs in WAS rats and is

sympathetic system overactivity. WAS and MDM are interesting and attempts in that direction may help us understand how abnormalities in autonomic nervous function may contribute to the pathophysiology of BPS/IC, and eventually to other chronic pelvic pain disorders and open the way to new forms of treatment.

Filament (g)

urinary spots, increased number of reflex voiding contractions, urothelial atrophy associated with a loss of umbrella cells and an overexpression of apoptotic proteins BAX and Caspase 3 in the urothelium were found in rats submitted to prolonged adrenergic stimulation with subcutaneous injections of phenylephrine2.

Filament (g)

Mrs. Ana Charrua Faculty of Medicine of Porto Institute for Research and Innovation in Health (i3S) Porto (PT)

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June/July 2017

Medical expulsive therapy for stones Potential benefit of alpha-blockers for distal ureteral stones Prof. Thomas Knoll Dept. of Urology SindelfingenBöblingen Medical Center University of Tübingen Sindelfingen (DE) t.knoll@klinikverbundsuedwest.de

Prof. Christian Türk Urologische Praxis und Steinzentrum Vienna (AT)

office@tuerk.at Observational treatment is an option for ureteral stones ≤ 6 mm in patients with controlled symptoms and a high chance of spontaneous passage. A huge number of randomised trials and several meta-analysis1-4 have been published, most of them encouraging the use alpha blockers or calcium channel blockers to facilitate stone expulsion of ureteral calculi.

Eventually, EAU guidelines have recommended alpha-blockers for so-called medical expulsive therapy (MET)5,6. However, some recently published high-quality, placebo-controlled randomised trials raised serious doubt about the effectiveness of alpha-blockers. A debate was started on the benefit of MET for conservative management of ureteral stones. So, where is the evidence for MET and how can such conflicting finding be explained?

EAU Section of Urolithiasis (EULIS)

Various meta analyses support the use of MET for ureteral stone management. Hollingsworth et al3 included 693 patients from nine trials, and found a 65% higher liklihood of stone passage with calcium-channel blockers or alpha-blockers. Seitz et al. evaluated 2,419 patients in a meta-analysis of 47 randomised controlled trials assessing the effect of MET including different medications. They could demonstrate a benefit only for alpha- and calcium channel-blockers in terms of greater stone expulsion rates, faster stone expulsion, and reduced analgesic requirements2.

In another meta-analysis that included 32 RCTs on alpha-blockers, Campschroer et al. described a shorter stone expulsion time with less pain episodes for MET4. Tamsulosin was more efficient than the calcium-channel blocker Nifedipine in a systematic review of Wang et al., most probably presenting a class effect for alpha-blockers7. When comparing different alpha-blockers, Silodosin showed highest efficacy in several studies8. Systematic reviews can only be as good as their data source.

Most of the analysed studies were heterogeneous in primary outcome measurement and difficult to compare. Furthermore, many of them were small single-center RCTs that are known tending to show larger treatment benefits than multicenter trials9,10.

The continued use of poor quality data in each ‘new’ meta-analyses calls into question their validity and reliability. However, MET became a set treatment concept for ureteral stones in the past 15 years.

The discussion started when Pickard et al. published in 2015 a large, multi-center, double blinded, three-way RCT comparing tamsulosin, nifedipine and placebo. The primary endpoint was defined by the necessity of intervention. 1,167 patients in 24 UK centers could be included. To the surprise of most urologists, the authors could not find any difference between tamsulosin, nifedipine or placebo for the need of interventions, stone passage rate or pain11.

A year later, Furyk et al. performed a randomised, double-blinded, placebo-controlled, multicenter trial

WEEK 2017 25-29 SEPTEMBER

European Prostate Cancer Awareness Day 27 September 2017

including 403 patients comparing tamsulosin to placebo for patients with distal ureteral stones < 10mm. Only the subgroup analysis of stones 5-10mm showed an increased passage rate in the tamsulosin group, but in the overall analysis and the subgroup of stones <5mm there was no significant difference12.

These papers were thoroughly analysed by the EAU Guideline Panel for Urolithiasis, since the EAU has implemented the recommendation for MET first in a clinical guideline in 2007, based on a collaborative project with the AUA13. While the AUA published new guidelines on the management of distal ureteral stones in 2016 with continuous recommendation for MET in patients with distal ureteral stones < 10 mm14, the EAU panel decided to downgrade the recommendation from Grade A to Grade C in 2016, considering the conflicting data of the two studies from Pickard and Furyk with the available evidence.

However, after counselling the patient about the conflicting data, MET can still be applied15. The contradictory results of systematic reviews on one hand and large high-quality trials on the other, show the dilemma of generating evidence. Are now all published papers on MET wrong and misleading?

Probably not. The definition and assessment of stone passage remains problematic.

Most trials, as the study of Pickard et al., did not prove stone clearance by CT imaging. Correct determination of stone passage is therefore difficult and inprecise. More importantly, the Pickard study was not powered to assess the efficacy of MET in stones > 5mm in the upper or middle ureter.

Additionally, there were no significant differences in pain scales or use of pain medication. Extensive discussions have led to the recommendation given above, to keep MET as an option for conservative management of ureteral stones.

The current evidence on whether to use MET indicates that a potential benefit of medical expulsive therapy

(alpha-blockers) is more likely for distal ureteral stones > 5mm. For smaller ureteral stones (i.e. the majority of ureteral stones) there is no proven benefit.

It is important to inform patients about the possible yet unproven benefit using alpha blockers as well as their off-label use and possible side effects.

References 1. Cervenakov I, Fillo J, Mardiak J, Kopecny M, Smirala J, Lepies P. Speedy elimination of ureterolithiasis in lower part of ureters with the alpha 1-blocker--Tamsulosin. Int Urol Nephrol. 2002;34(1):25-9.

2. Seitz C, Liatsikos E, Porpiglia F, Tiselius HG, Zwergel U. Medical therapy to facilitate the passage of stones: what is the evidence? European urology. 2009;56(3):455-71.

3. Hollingsworth JM, Rogers MA, Kaufman SR, Bradford TJ, Saint S, Wei JT, et al. Medical therapy to facilitate urinary stone passage: a meta-analysis. Lancet.

2006;368(9542):1171-9.

4. Campschroer T, Zhu Y, Duijvesz D, Grobbee DE, Lock MT. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane database of systematic reviews.

2014(4):CD008509.

5. Turk C, Knoll T, Seitz C, Skolarikos A, Chapple C, McClinton S, et al. Medical Expulsive Therapy for Ureterolithiasis: The EAU Recommendations in 2016. Eur Urol. 2017;71(4):504-7.

6. Turk C, Petrik A, Sarica K, Seitz C, Skolarikos A, Straub M, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. Eur Urol. 2016;69(3):468-74.

7. Wang H, Man LB, Huang GL, Li GZ, Wang JW. Comparative efficacy of tamsulosin versus nifedipine for distal ureteral calculi: a meta-analysis. Drug design, development and therapy. 2016;10:1257-65.

8. Ozsoy M, Liatsikos E, Scheffbuch N, Kallidonis P. Comparison of silodosin to tamsulosin for medical expulsive treatment of ureteral stones: a systematic review and meta-analysis. Urolithiasis. 2016.

The remainder of the references of this article are available from the EUT Editorial Office. Please send an e-mail to: EUT@uroweb.org with reference to the article “Medical expulsive therapy for stones”

by Prof. Knoll, June/July issue 2017.

EUROPEAN PROSTATE CANCER AWARENESS Lowering the risk DAY &themortality rate of most frequent cancer in men

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.

4. Join the Thunderclap campaign in European Prostate September.

Stay tuned for more Cancer Awareness Day info!

27 September 2017 5. Download campaign materials or use the Urology Week poster in this EUT issue.

Let’s do this together!

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

communications@uroweb.org

June/July 2017

SEPTEMBER 27TH 2017 13.30-17.00 HRS Paul Henri Spaak (PHS) building, room P1A002

The meeting will be hosted

by Mr Alojz Peterle and Mrs Marian Harkin of the MEPs against Cancer group (MAC) For programme & free registration see epad.uroweb.org

#urologyweek European Urology Today

25

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

paul.meria@ sls.aphp.fr

Emergency Urology Urologic emergencies represent around 5% to 10% of the activity of the emergency departments. Most practitioners such as emergency physicians, general practitioners and urologists are frequently faced with acute urological problems in their daily practice. This textbook, edited by David Thurtle, Suzanne Biers, Michal Sut, and James Armitage, with the help of about 12 co-authors aimed to present a practical review of most urologic emergencies.

MRI of the Prostate: A Practical Approach Prostate cancer is the most frequent cancer in men and current strategies of diagnosis and treatment are strongly correlated with the results obtained with imaging techniques. Multiparametric MRI of the prostate has dramatically changed our approach of prostate cancer. Currently, MRI is the most accurate exam for prostate cancer’s diagnosis and staging.

Likewise, new therapeutic strategies such as active surveillance are more and more dependent on MRI. In writing this textbook, editor A.B. Rosenkrantz was aided by about 30 worldwide experts in imaging techniques. After an introduction on clinical features and pathological aspects of prostate cancer, the authors focused on MRI protocols. They described all available techniques and focused on T2 weighted techniques and MR spectroscopy. Dynamic contrast MRI was also described before addressing PIRADS assessment.

A general chapter described the assessment of the patient referred for an acute urological problem, including clinical approach and initial investigations in view of making an accurate diagnosis. The following chapter was dedicated to upper urinary tract emergencies and described acute kidney conditions and disorders, including renal colic and infection. Lower urinary tract problems were addressed in a special chapter which focused on acute urinary retention and other conditions such as haematuria and infection. Genito-scrotal emergencies and trauma were described in the succeeding chapters before addressing special problems such as paediatrics, pregnancy or post-operative emergencies.

Various daily procedures such as urethral or suprapubic catheterisation, local anaesthesia and catheter management, were also described. The authors concluded with a technical chapter dedicated to interventional uro-radiology procedures. Two appendices were added and described the protocol of management for suspected urinary sepsis and the ABCDE approach (airway, breath, circulation, disability, exposure).

This original textbook is an excellent tool for all practitioners involved in the management of urologic emergencies. Many tables and figures are included in each chapter.

Recent advances in endourology contributed to dramatically change many therapeutic concepts in the field of BPH and, currently, various options can be proposed as an alternative to the conventional transurethral resection of the prostate (TURP).

P.A. Geavlete and co-workers, all of them members of a well-known Romanian institution, aimed to write a textbook dedicated to endoscopic procedures in BPH and related diseases. The first chapter presented endoscopic aspects of prostate anatomy and described various useful landmarks. TURP was exhaustively described in the following chapter and the authors provided the reader with many tips and tricks, either in usual practice or in the event of complications.

dedicated to the penis included agenesis, micro and macropenis and other problems such as duplication, rotation and webbed penis. Vascular anomalies such as haemangioma and lymphedema were described.

Urethral and meatal problems were also considered before addressing acquired penile diseases related to congenital problems. A special chapter covered the complications of circumcision. The concluding chapter consisted in an atlas of dermatological diseases.

Many photographs illustrate the text and some animations complemented photographs online. This comprehensive and concise textbook is very useful for paediatricians, senior paediatric surgeons and trainees and will be the reference work for all practitioners managing cases of abnormal penis in children, infants or adolescents.

Staging and surgical planning were addressed in a special chapter followed by a section regarding the role of MRI in patients’ follow-up and assessment of recurrence. New approaches were also considered and the authors focused on MRI-guided biopsies and active surveillance strategies. The concluding chapters presented many clinical cases in a teaching atlas.

This outstanding textbook is richly illustrated and covers all topics we must know about MRI in prostate cancer. All practitioners, whatever their specialty, will find in this book information very useful for their daily practice. Undoubtedly, this textbook will be of special interest for all radiologists and urologists involved in prostate cancer management.

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

A.B. Rosenkrantz 978-1-62623-268-6 Available 2017 Thieme Medical Publishers 1st 224 More than 700 Hardcover € 118.30 www.thieme.de

Author: M.A.B. Fahmy ISBN: 978-3-319-43309-7 e-Book: Available Published: 2017 Publisher: Springer International Publishing Edition: 1st Pages: 267 Illustrations: 18 b/w illustrations, 282 illustrations in colour Binding: Hardcover Price: € 95.39 Website: www.springer.com

The succeeding chapters were dedicated to all current alternatives to TURP and the authors described bipolar resection, electro-vaporisation, endoscopic incision, laser techniques, microwave thermotherapy, radiofrequency, balloon dilation and stents placement. Based on the preceding chapters, a synthesis algorithm was proposed for BPH management. Two additional chapters addressed endoscopic management of prostatic abscesses and prostatic stones.

This textbook is very practical and wellillustrated. Urologists will find relevant information and we hope the next edition will be supplemented by videos.

Editor: ISBN: eBook: Published: Publisher: Edition: Pages: Illustrations: Binding: Price: Website:

P.A. Geavlete 978-0-12802-405-8 Available 2016 Elsevier/AP, Academic Press 1st 18 Over 500 Hardcover € 108.00 www.elsevier.com

Endoscopic Diagnosis and Treatment in Prostate Pathology: Handbook of Endourology The management of prostatic diseases remains one of the most important fields of our specialty.

Symptomatic benign prostatic hyperplasia (BPH) usually requires medical treatments, but complications and/or medical treatment failure can lead to interventional therapies.

Congenital Anomalies of the Penis Penis anomalies are present in about 6% of total births worldwide and affect one among 1,500 children. Such anomalies can affect infants, children and adolescents for anatomic and functional reasons.

These conditions are frequently managed by paediatric surgeons.

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

D. Thurtle, S. Biers, M. Sut, J. Armitage 978-1-910079-423 Available March 2017 TFM Publishing Ltd. 1st 195 radiological and clinical images Softcover € 40.00 www.tfmpublishing.com

Book reviews

26

European Urology Today

Author Mohamed Fahmy aimed to assemble an exhaustive collection of congenital diseases of the penis. The basis of this textbook was the extensive experience of the author in the field of neonatology and congenital diseases of the genitalia.

The first part of this exhaustive review focused on embryological and anatomical aspects of the penis.

An important chapter addressed the historical aspects of the penis and the authors focused on various stories involving kings and imperators.

The succeeding parts covered all congenital diseases of prepuce, penis, meatus and urethra. The chapter

NGage®: Reach for the original.

NGage Nitinol Stone Extractor

MEDICAL

© COOK 01/2017 URO-D32084-EN-F

June/July 2017

Canadian Urological Association (CUA)

European Tour 2017 Academic Exchange Programme

Canadian urologists tour European institutions for insights on best practices Prof. Michael Jewett University of Toronto Dept. of Urology Toronto (CA)

m.jewett@utoronto.ca In 2010, the Canadian Urological Association (CUA) Executive under the leadership of Past-President Jerzy Gajewski, along with the European Association of Urology (EAU) developed an exchange programme encouraging worldwide collaboration and exchange of urological skills, expertise and knowledge among young academic urologists.

The curriculum provides a selected group of outstanding and promising junior faculty members with the opportunity to interact with colleagues from Europe and Canada. This scientific exchange, part of the EAU’s International Academic Exchange Program, has proven to be a great success and fosters closer relationships between the CUA and the EAU. In the programme, teams of four Canadian and four European urologists alternately visit each other’s region. Each team is composed of one senior and three junior urologists working or affiliated with the academia. Participants in this programme, designated as ‘fellows’ by the EAU, share a strong interest to interact as a team and learn from each other, as well as their hosts. The exchange has been a unique life experience and participants are in agreement that it adds value to Canadian and European urology. The junior members were eager to bring back new ideas, techniques and paradigms from leading urology organisations and communities in the world.

The programme is hosted by each Association prior to their respective annual meetings over a two-week period. The Canadian fellows, selected by the CUA Office of Education for the fourth exchange, were under 42 years of age, had excellent track records in research and/or education and are active CUA members. This year, the fellows who have trained under the Royal College of Physicians and Surgeons of Canada educational programme leading to qualification by examination with Fellowship in Urology (FRCSC) included Dr. Luke Lavallée from Ottawa, Dr. Daniel Liberman and Dr. Kevin Zorn both from Montreal.

The senior delegate or guide who accompanies the Canadian team must have a minimum of 10 years in practice, be recognised internationally in his/her field, have a demonstrated interest in medical education, and a long-term commitment to the activities of the CUA. This year, Michael Jewett, Professor of Surgery (Urology) at the University of Toronto and Princess Margaret Cancer Centre, University Health Network was appointed as senior delegate.

In March 2017, the Canadian team travelled to Dresden, Leuven and Sheffield and then to London for the 32nd Annual EAU Congress. Before the Exchange, the scholars prepared for the visit with a series of teleconferences during which they reviewed the profiles of the host departments and programmes, local history and other regional events. They also prepared a list of potential deliverables from the visits which aim to further strengthen academic urology in Canada and Europe.

Dresden The whirlwind tour started in Dresden, Germany, and was hosted by Prof. Manfred Wirth who leads an outstanding, highly organised and very academic urological Department at the Carl Gustav Carus Universitatsklinikum. Their clinical work and research is dominantly focused on delivery and care of uro-oncology- from imaging, immunotherapy and chemotherapy, to complex open and robotic surgeries. From the fully functional endourological suite to state-of-the-art daVinci robotic room, all levels of procedures are June/July 2017

possible at the Universitatsklinikum. This institution was the model of high-volume clinical efficiency.

The Canadians were impressed by many aspects of their practice including the standardised universal protocol for anaesthesia delivery for all in the high-volume operating room, which allowed for streamlining of patient flow to optimise continuity of surgical care. The broad oncology research programme led by Dr. Susanne Fuessel PhD is focused on LncRNA biomarkers in prostate cancer diagnosis, as well as collecting PC3 urine biomarkers. They also perform studies of metalfilled carbon-based nanotubes for the safer delivery of chemotherapy as well as strong biomaterials research. Meanwhile, Dr. Michael Frohner leads a strong programme in outcomes research.

There was ultrasonography equipment in all examination rooms which are handy in the use and interpretation for renal, pelvic and scrotal evaluations. This contrasts quite differently with practice in North America as exemplified by the insertion of a percutaneous nephrostomy with the patient in supine position immediately after failed retrograde ureteral stent placement under anesthesia, performed by Dr. med. Stefan Propping, Oberarzt, who was also a very gracious host and guide.

Research team at Dresden with the Canadians

The Canadians participated in the weekly, multi-disciplinary grand rounds led by Prof. Wirth together with the head of Radiology. Access to notes, imaging and laboratories were convenient with the use of electronic medical records.

Additionally, a very memorable highlight of our visit at the Carl Gustav Carus Universitatsklinikum was the unique and extensive historical urology equipment collection of Prof. Wirth. Although not well-known to many urologists, Dresden gave birth to advanced uretero-cystoscopic equipment developed by Dr. Maximilian Nitze. The urology museum showcase also houses the original Stern-MacCarthry-designed electro-resectoscope, the Bottini-Freundenberg prostate incision devices and other turn-of-the-century primitive equipment.

The visit was very humbling and illustrated the pioneering work and evolution to today’s surgical tools. Finally, the CUA team also had the wonderful opportunity to visit and appreciate the restoration of Dresden’s Altstadt (Old City).

Leuven After a short plane and taxi ride, the Canadian delegation arrived at the Universitaire Ziekenhuizen Leuven Department of Urology in Belgium, which is a full complement of sub-specialised urologists led

by Prof. Dirk De Ridder. Students enter the programme after a year-long competitive clinical interview; two residents per year begin residency with a funded three-year PhD programme in basic urological science. Current trainees are involved in

Faculty at Leuven with Canadians

second-generation anti-androgen neoadjuvant clinical trials, new treatment options for Peyronies disease based on measures of myofibroblast formation in surgical specimens, novel “urodynamic” measures including bladder accelerometry measurement using implantable microchips, and studies in underactive bladders with nerve stimulation and genomics (prostate cancer).

There was tremendous teamwork spirit among the participants in the training programme and the Canadians had little choice but join in the fun after hours.

Residency training is similar to Canada in terms of clinical responsibility and operative exposure.

Robotic technology has been widely adopted in Belgium, with over 35 robots available for a population smaller than the population of Ontario in Canada where there are only four robots.

The faculty at Leuven is active in basic and clinical research and has a tradition of innovative research by investigators including EAU Adjunct Secretary General for Education, Prof. Hein Van Poppel. UZ Leuven and its network of over 20 regional hospitals have created a sophisticated electronic medical record platform called Nexuzhealth ecosystem. This system allows all physicians in the network to view all medical records. Highlights include data input pages linked to note creation including synoptic reporting for radical prostatectomy. After every surgical procedure, staff members input research data and the electronic data can be used to complete standardised fields in the operative report to improve capture and reduce redundancy. Mandatory reporting, pathologic and clinical outcomes are summarised regionally for anonymous comparison and are freely available to patients and physicians online.

The analytic tools appear robust and user-friendly.

After a tour of historic Leuven, the fellows presented their research on campus to the regional urology alumni and faculty.

“…a very memorable highlight of our visit at the Carl Gustav Carus Universitatsklinikum was the unique and extensive historical urology equipment collection of Prof. Wirth. The visit was very humbling and illustrated the pioneering work and evolution to today’s surgical tools.”

The Canadians' visit to Sheffield

model as well as the plethora of clinical trials currently underway including the BRAVO trial of early cystectomy versus BCG. Outcomes research and data availability with the British Association of Urological Surgeons was a recurrent theme and mirrored what was seen in Leuven.

A formal academic session of presentations was followed by local hospitality with Prof. Chapple acting almost as a full-time host despite his responsibilities for the EAU Congress in London.

There was time for a tour of the region and a very interesting visit to the local scalpel blade firm, Swann-Morton.

London The Exchange highpoint was the participation at the EAU Congress in London where the fellows attended the Opening Ceremony and the Friendship Dinner, as well as presenting work from Canada. Canada had over 100 urologists who attended the Congress and submitted a large number of abstracts which were accepted for presentation.

Sheffield In Sheffield, UK, EAU Secretary General Chris Chapple hosted the Canadians at the Royal Hallamshire Hospital. They were joined by a delegation from the Wu Jieping Medical Foundation and the Chinese Urological Association.

An opportunity to observe a urethral diverticulectomy by Prof. Chapple in a modified prone position was a unique experience and was followed by an anterior urethroplasty using buccal mucosal graft. In the afternoon, all participants were impressed by the speed and efficiency of Prof. Jim Catto’s 90-minute radical cystectomy emphasising the institution’s commitment to Enhanced Recovery after Cystectomy.

There was ample time to hear about Sheffield’s multifaceted and multidisciplinary research platforms.

In the Functional Urology research programme, trainees are involved in tissue engineering for optimising outcomes for mesh surgery with the local biomaterials group. There are also impressive strides using a PLA scaffold for vascular angiogenesis with estradiol stimulation. They use an ascorbic acidreleasing scaffold and adipose-derived stem cells (ADCS) effect on new vessel formation. Prof. Chapple and colleagues are in the process of developing an electronic bladder diary application for improving patient reporting and reliability.

Prof. Catto has spearheaded important research in oncology. He presented work with the Zebra fish

Michael Jewett, Kevin Zorn, Dan Liberman, and Luke Lavallée (from left) at the InternationalFriendship Dinner

Executive and fellows wearing their Canadian ties and cummerbunds

There is an increasing participation by Canadians in the EAU activities in all levels, partly due to the programme exchange. A highlight was the presentation of the Fellows at the wonderful Friendship Dinner where they wore their Canadian ties and cummerbunds, together with their host EAU executive who had received the same as souvenirs of a very successful 2017 exchange.

European Urology Today

27

TEN QUESTIONS Interview and Photography by Joel Vega

Age: 69 Sub-Specialty: Functional Urology City: Bristol (GB) Current Posts: Willy Gregoir Medal 2017 Awardee; Professor of Urology, University of Bristol; Head of Teaching and Research, Bristol Urological Institute at Southmead Hospital; Chair of the International Consultation on Urological Diseases

• What do you think is the biggest challenge in urology?

The ageing population, the increasing complexity of medicine and increasing costs.

There are also the reasonable expectations of patients and in certain countries the systematic problems in healthcare service. In Britain, for example, social care system does not keep pace with the care that is received in the acute hospitals.

• If you were not a urologist, what would you be?

Maybe an honest politician? I see such a distinction between the way we live as surgeons and nurses where we are expected to be completely honest with our patients. Yet in politics it is perfectly acceptable for politician to tell lies and mislead the population. Doctors and nurses should become politicians to cleanse the political world.

• What is your most important piece of advice for doctors just starting out?

One should be completely honest about the basis of management for the patient. Is your treatment evidence-based? Is it right for the patient? Secondly, it’s important to have more than one string to your bow. I would encourage young urologists to take up other interests in urology such as teaching or research.

• What is the most rewarding aspect of being a doctor?

The interaction with the patients and helping them to overcome their problems.

Urology is also a good mix of surgery, medicine and holistic care which makes it quite special.

• What is your advice to other physicians on how to avoid burnout?

If doctors find themselves under pressure, it’s because they put too much pressure on themselves and they accepted too many responsibilities. One needs to take a reality check and ask yourself if you’re doing too many things. One should prioritise.

• What areas in urology should be given more attention?

Urology in older people and more discussions with the patients on what they really want. Sometimes we still take a paternalistic view that we as surgeons know better, and therefore we tend to tell the patient what they should have done. With the ageing population this needs to change.

• What´s the last wonderful book you have read?

‘Sea of Poppies’ by Amitav Ghosh. It’s about India in the 19th century and it uncovered for me the origins of the British Empire and its exploitation of India to grow poppies and manufacture opium for export to China. That was a fascinating historical novel which is part of a trilogy.

• What do you most often wish you could have said to patients, but did not?

That’s an interesting question because in functional urology, for instance, there is so much that we don’t fully understand. I would like to say to a patient I understand completely the cause of your symptoms and I have medicines that can cure. Sadly, that is hardly the case.

• What’s the last thing that surprised you?

The Brexit vote, which is a vote won by 51.9%. Meaning if 1 in a 100 people would have voted the other way, the result would have been different. Despite this the UK government is forging ahead. And I know no urologist, teacher or lawyer who is in favour of leaving the EU. It’s completely irresponsible to put that vote to the people.

• What’s your favourite hour in a day and why?

The hour when the sun comes up and the last hour before sunset. I love nature and I enjoy being outside. In the morning, the light is wonderful. And at the end of the day the light is beautiful, there are long shadows that cast across the countryside and the colours become quite different.

PAUL ABRAMS

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

28

European Urology Today

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)

June/July 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 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 Locally advanced and high risk 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

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 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: Clinical case discussion 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, Ghent (BE) Case discussion “Residual disease” Urologist - Peter Albers, Düsseldorf (DE) Medical oncologist - Karim Fizazi, Villejuif (FR) Radiation oncologist - Gert De Meerleer, Ghent (BE) 15.15 - 15.30 Best of journal session: Radiotherapy Chairs: Radiation oncologist - Bradley Pieters, Amsterdam (NL) Radiation oncologist - Pirus Ghadjar, Berlin (DE) 15.30 - 16.00 Coffee break and poster viewing 16.00 - 17.45 Educational session on bladder cancer: Clinical case discussion 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) 08.30 - 10.15 Oligometastatic kidney cancer Chairs: Radiation oncologist - Vincent Khoo, London (GB) Urologist - Hein Van Poppel, Leuven (BE) Medical oncologist - TBC 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 - 09.35 Can local ablation delay the use of systemic therapy for oligometastasis Surgery Urologist - Susanne Krege, Essen (DE) 09.35 - 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 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 - Frederice 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 - Pirus Ghadjar, Berlin (DE) 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)

16.35 - 16.50 Best of journals: Surgery Chairs: Urologist - Maurizio Brausi, Modena (IT) Urologist - Jochen Walz, Marseille (FR) 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) Pathologist - Sara Falzarano, Cleveland (US) 17.45 - 18.45 Industry session

Sunday, 19 November 08.30 - 08.45 Announcement 3 best unmoderated posters Chairs: Medical oncologist - Silke Gillessen, St. Gallen (CH) 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) 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 - TBC 09.15 - 09.30 How should we treat our metastatic castrate sensitive patients?

Medical oncologist - TBC 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 - Harriet Thoeny, Berne (CH) Urologist - Igle-Jan de Jong, Groningen (NL) Medical oncologist - Silke Gillessen, St. Gallen (CH) Radiation oncologist - Bradley Pieters, Amsterdam (NL) 12.10 - 12.20 Pathologist - Rodolfo Montironi, Ancona (IT) 12.20 - 12.30 Closing remarks Medical oncologist - Thomas Powles, London (GB) - ESMO Radiation oncologist - Peter Hoskin, Northwood (GB) - ESTRO Urologist - Hein Van Poppel, Leuven (BE) - EAU

16.05 - 16.35 Coffee break and poster viewing

10.50 - 11.20 Coffee break and poster viewing

June/July 2017

European Urology Today 29 www.emuc17.org

Rewarding experience at Guy’s & St. Thomas Hospital EUSP Scholarship for Italian doctor at prestigious London hospital Dr. Nicolò De Luyk Hospital Civile Maggiore Dept. of Urology Verona (IT)

ndeluyk@gmail.com Since the beginning of my residency at the Department of Urology at the University Hospital of Verona, I have been fascinated by minimally invasive surgery. I have been involved in the robotic programme of our department and under the guidance of prof. Walter Artibani I understood the benefits and drawbacks of robotic surgical procedures.

Eventually I developed a strong interest for robotic nephron-sparing surgery. I took a dedicated course on robotic training but I wanted to further develop my skills and knowledge. I also wanted to explore the application of the new 3D print technology in pre-operative surgical planning for complex renal masses. I found that the EUSP Clinical Visit would be a unique opportunity to visit a centre of excellence in robotic surgery in another European country and a chance to start my research.

From January 9 to April 7 this year I had the wonderful opportunity for a scholarship at the Department of Urology at Guy’s and St Thomas’ Hospital in London, where application of robotic technology in urology was first pioneered. I sent my project proposal to Prof. Prokar Dasgupta and Mr. Ben Challacombe and was delighted to receive good feedback. Prof. Dasgupta is the first modern robotic urological surgeon in the UK and chairs the Robotic Surgery and Urological Innovation at King’s College London and King’s Health Partners.

Mr. Challacombe is the highest volume surgeon for robotic partial nephrectomy in the UK and also specialises in robotic radical prostatectomy, nephrectomy, pyeloplasty, adrenalectomy and Holmium laser prostatectomy (HoLEP).

Guy's Hospital, located in central London, was founded in 1721 and expanded during the centuries.

It is now a large teaching hospital and together with St Thomas' and King's College Hospital is the location of King's College London School of Medicine, Europe’s biggest healthcare training facility. The department’s typical annual workload includes 20,000 outpatient visits, 4, 000 day case procedures, and 1,700 inpatient admissions with a further 700 stone unit admissions. The Urology Service at Guy’s Hospital is composed of six teams that cover every aspect of urology.

Guy’s Hospital

Scholarship experience On my first day I was introduced to all the members of the staff and I was greatly pleased by the warm welcome. During my stay I worked closely with the eight consultants and two fellows in the prostate and renal team.

skills using different robotic simulators, laparoscopic training modules, the Green Light simulator and ureteroscopy simulators for kidney stones. I also started my project on the application of the new 3D print technology in preoperative surgical planning for complex renal masses.

My routine schedule was as follows: on Mondays OR with Prof. Dasgupta; on Tuesdays a Prostate MDM (multidisciplinary meeting), patient’s discussion, and duties at the prostate and outpatient clinics (general urology); on Wednesdays, OR work (Mr. Challacombe/Mr Brown/Mr. Popert), Renal MDM (multidisciplinary meeting), patient’s discussion and duties at Renal Clinic; on Thursdays OR work (with Miss.

Fernando/Mr. Cathcart), duties at the simulation center; and on Fridays are weekly audit meetings and OR work (with Mr. Challacombe/Mr. Catterwell). The multi-disciplinary oncological meetings discussed very challenging cases and reached a decision on the best treatment for the patient.

Exceeding expectations My personal experience as an EAU scholar at Guy’s Hospital exceeded my expectations. It has been a unique opportunity to familiarize with different surgical procedures and expand my clinical knowledge. Working in a new and different organization has been challenging and rewarding.

I sincerely thank all the staff of the Department of Urology at Guy’s for their great hospitality and for all they have taught me. I can only recommend Guy’s Hospital to all the residents who want to learn new surgical techniques and improve themselves. The knowledge I have acquired will definitely be useful in my professional life and career.

European Urological Scholarship Programme (EUSP)

Together with Prof. Prokar Dasgupta and part of the team at the Simulation Center

During the Friday morning meetings I attended some very interesting lectures given by the most prominent urology experts. Prof. Sherif Mourad, the general secretary of the International Continence Society, gave a lecture on the treatment of vescico vaginal fistulas, Prof. Fiona Burkhard explained the steps of radical cystectomy and the fast-track recovery, Dr. W. Marston Linehan, chief of the Urologic Oncology Branch at National Institutes of Health, gave an exciting speech on genetic conditions with predisposition to renal cancer and, finally, Prof. James Catto, editor-in-chief of European Urology, gave a stimulating talk on bladder cancer.

As my primary area of interest was robotic partial nephrectomy, I spent a lot of time under the guidance of Mr. Ben Challacombe. He explained the step-by-step technique of various robotic procedures and HoLEPs and showed me the benefits of the Firefly Fluorescence Imaging System during partial nephrectomies. He also gave many intraoperative tips and tricks in both standard and challenging cases. I also had the honour of working with Prof. Dasgupta who was very interactive during every surgical procedure. He explained the ways how to achieve great results and avoid complications in robotics. He also taught me the best ways to deal with complications following standard urological procedures.

Guy’s Hospital also hosted the live cases during the EAU17 annual meeting and Mr. Challacombe had been coordinating all the procedures. Being there with him gave me an insight of all the work “behind the scenes.” Besides the OR work, I practised my

Patients are referred from all over the UK and are assessed at the Urology Centre. I was impressed by the organization of this “one-stop clinic” where patients can have a consultation with a urologist, oncologist, radiotherapist and a range of investigations all in a single visit. The Department has two wards providing 50 in-patient beds. There are five theaters two of which are dedicated to robotic procedures. One operating room is equipped with the da Vinci Si® System while the other with the da Vinci Xi®. Both theaters have two surgical consoles, which is particularly useful for training purposes. The Department of Urology hosts a leading 12-month surgical fellowship programme in robotics for two fellows supervised by Mr. Ben Challacombe.

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European Urology Today

Training using the Simbionix simulator

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 September 2017!

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

Sign up for the EAU – Society of Urologic Oncology Exchange Programme!

A two-week scholarship in the USA or Canada for European Onco-Urologists The European Association of Urology (EAU) and the Society of Urologic Oncology (SUO) are pleased to announce a new scholar exchange. Each medical association may send one of its members for a two-week scholarship at a department of choice before or after the respective association’s Annual Meeting.

The Scholarship In 2017, the visit will take place for two weeks before or after the 18th Annual Meeting of the SUO, held in Washington DC on 29 Nov - 1 Dec, 2017. The applicant will then attend the congress and preferably have submitted an abstract to the congress to encourage scientific exchange. The applicant will file a 2-page report to the EAU within one month of returning. All meeting registration fees will be waived and travel and accommodation will be covered by the EAU and SUO. The Society of Urologic Oncology The SUO was founded in 1984, with a mission to enable qualified members primarily interested in the care of patients with malignant GU diseases to meet for the purpose of discussion, development and implementation of ideas to improve care. It stimulates research and teaching in urologic oncology, disseminates the principles of urologic oncology to medical profession at large and brings urologists into a society whose work is principally in malignant disease.

Information and application forms For all further information and programme application forms please visit www.uroweb.org, and select 'Our Partners' at the bottom of the page, and then ‘EAU-SUO Scholar Exchange Programme’ or contact Ms. Angela Terberg at the EAU Central Office: T +31 (0)26 389 0680 F +31 (0)26 389 0674 E a.terberg@uroweb.org We look forward to receiving your application before 1 October 2017.

Training with the Green Light simulator

June/July 2017

Examining key topics in urothelial carcinoma Risk assessment remains a key challenge in managing UTUC

By Joel Vega Risk assessment and evaluation of disease extent remain crucial elements in the optimal treatment and management of upper tract urothelial carcinoma, according to experts who emphasise the need for doctors to conduct a better assessment of disease characteristics.

“Treatment outcomes strongly depend on several pre-treatment factors at presentation as well on the choice of the right treatment for the right patient,” said Dr. Sara M Falzarano, Genitourinary Pathology Fellow at the Robert J. Tomsich Pathology & Laboratory Medicine Institute at the Cleveland Clinic (USA)*.

“In upper tract urothelial carcinoma (UTUC), risk assessment is extremely important and includes evaluation of risk factors,” said Falzarano, one of the discussants and resource speakers at the 9th European Multidisciplinary congress on Urological Cancers (EMUC17) to be held in Barcelona from November 16 to 19.

A multidisciplinary congress, EMUC provides a platform for onco-urological experts and is now on its ninth edition of gathering leading opinion leaders, researchers and cancer specialists to critically examine treatment strategies for urological malignancies. The event is annually organised by three of Europe’s leading and specialised medical associations- the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).

Upper urinary tract (ureter and renal pelvis) disease represents about 5% of urothelial carcinoma at initial diagnosis, the remaining predominantly occurring in the lower urinary tract (bladder and urethra). * Falzarano will take on the role of Assistant Professor of Pathology at the University of Florida in October this year.

“Compared with bladder urothelial carcinoma, patients with UTUC generally are reported to harbour higher grade and stage disease at presentation, with a worse overall prognosis. Since many patients are asymptomatic, early diagnosis can be challenging. Delays from presentation to treatment may represent a concrete issue,” explained Falzarano.

A combination of imaging modalities and pathologic confirmation is required to diagnose UTUC, and the data obtained are essential for risk assessment to identify the best treatment option. The current gold standard surgical management of invasive high-grade UTUC is radical nephroureterectomy (RNU), although kidney-sparing approaches might be indicated in non-invasive low-risk disease, distal ureteric tumours amenable for segmental ureteric resection, and other special circumstances such as solitary (anatomically or functionally) upper urinary tract (due to prior nephrectomy for contralateral urothelial carcinoma, or other reasons).

Challenges in diagnostic staging Regarding disease progression and survival, the strongest prognostic indicator in UTUC is the level of tumour spread at presentation.

“The communication between members of the team is essential in achieving the best outcome.

Discussion and presentation of the different aspects (clinical evaluation, imaging, pathology, etc.) of cases at multidisciplinary tumour boards with integration of professional expertise is a great example of an increasingly implemented strategy to improve multidisciplinary approach,” said Falzarano. She added that appropriate use of electronic medical records and granting the availability of essential patient information in a timely manner to all professionals involved in patient management is another crucial aspect for MDTs.

and practices to achieve a better picture of the state-of-the-art in the different management areas of a certain disease,” she said. A wider exchange of novel and potential breakthroughs and discoveries in the field can help foster in-depth knowledge, helping doctors provide high-quality care, she added.

The EMUC, as an annual international platform for knowledge exchange and discussion of best practices fulfils a meaningful role among urological cancer experts, according to Falzarano.

The EMUC’s main Scientific Programme will be preceded on 16 November with the EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP), the 6th Meeting of the EAU Section of Urological Imaging (ESUI17) and European School of Urology (ESU) Courses. Besides the ESU course and Hands-on Training sessions, ESTRO is organising a delineation contouring workshop with the topic “Target volume contouring in bladder cancer.” A Uropathology Training Workshop will also be held for participants to gain practical insights on uropathology procedures.

“Consultative meetings create the invaluable educational opportunity by bringing together the expertise of professionals from different countries

For other details on EMUC17’s Scientific Programme, registration and CME accreditation, visit the meeting website at: www.emuc17.org

“However, accurate pre-operative pathologic staging of UTUC is challenging due to limitations of the biopsy specimen and the fact that it often does not allow for accurate assessment of the depth of invasion of the tumour into the upper urinary tract wall,” noted Falzarano.

After risk assessment, Falzarano pointed out that a consequent choice of the most appropriate therapeutic modality (open/laparoscopic surgery, radical/segmental resection, endoscopic management, neoadjuvant and adjuvant chemotherapy, etc.) has an essential role in achieving optimal treatment outcomes.

These challenges in the diagnosis and management of UTUC cases, she said, underscore the importance of Pathologist Dr. Sara Falzarano will be one of the speakers at EMUC17 who will discuss upper tract urothelial carcinoma an efficient multidisciplinary team (MDT) approach.

An Exciting New Development in eLearning!

You can now access all the educational activities available on SIU Academy from your iPhone/iPad and Android devices wherever you are!

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MAKE LISBATOIONN

YOUR DESTIN N, FOR EDUCATIO

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d in a relaxed an g. in tt se ly friend

Congress of the Société Internationale d’Urologie Centro de Congressos de Lisboa

www.siu-urology.org

OCTOBER 19–22, 2017

Featuring the SIU-ICUD Joint Consultation on Bladder Cancer, the 3rd SIU Nurses’ Educational Symposium, and the SIU Live Surgery GU-RECON Workshop

#SIU2U

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105th Meeting of the Japanese Urological Association (JUA) Dynamic, in-depth discussions marked international sessions Dr. Masato Fujisawa JUA President Kobe (JP)

masato@ med.kobe-u.ac.jp The 105th Annual Meeting of the Japanese Urological Association (JUA) took place from April 21 to 24, 2017, in Kagoshima. Hosted by Masayuki Nakagawa, professor and chairman of the Department of Urology, Graduate School of Medical Dental Sciences at Kagoshima University, the meeting had the theme “The Emerging Role of Urology – Medical Care Delivered with Skill, Knowledge and Humanity.”

Around 6,313 people from Japan and overseas countries attended the annual meeting. With the Hotel Shiroyama as main venue of the meeting, the participants enjoyed a grand, spring-time view of the volcano Sakurajima and Kagoshima Bay. JUA Honorary Membership Meanwhile, JUA is pleased to announce that Prof.

Manfred Wirth, EAU Treasurer & Executive Member

Volcano Sakurajima and Kagoshima Bay viewed from the Hotel Shiroyama

meeting organisers aimed to organise an international conference with participants from around the world, and this year the number of participants from overseas was about 190, the highest in recent years. The meeting ended on a successful note, and on behalf of the JUA, I thank every guest speaker and participant for their contributions.

Communication, became an honorary JUA member.

His long-time contribution to the development of the EAU and JUA’s ties is widely recognised and appreciated by every member of JUA. Prof. Wirth received the award during a ceremony held a day before the Annual Meeting, EAU delegates JUA invited Prof. Chris Chapple, EAU Secretary General, and Prof. Wirth as faculty members. Wirth gave the EAU Lecture titled “What is the role of radical prostatectomy in locally advanced and oligometastatic prostate cancer?” while Prof. Chapple discussed “Reconstructive surgery - some of the important therapeutic challenges”. Both lectures were very Dr. Wirth with Dr. Fujisawa, JUA President interesting and provided the latest updates to the audience.

“Underactive bladder – an update” by Prof. Chapple, Wirth delivered another lecture during the Update “Urine markers of interstitial cystitis / bladder pain Symposium discussing the topic “Current status and syndrome” by Dr. Akira Furuta, “What is new in the issues affecting the active surveillance of prostate diagnosis of PCA?” by Prof. Wirth, and “Immunecancer”. His lecture “Active surveillance in prostate checkpoint therapy with I-O drug for renal cell cancer-which patients are suitable?” was also highly carcinoma (RCC) ten years after induction of targeted drugs, again going into new era” by Dr. Yoshihiko appreciated by the audience.

Tomita. A panel discussion followed, which was JUA would also like to thank the two doctors for their moderated by Prof. Wirth and Tomita. With Drs. contribution to the EAU/JUA Joint Symposium, one of Tomoya Fukawa, Takashi Kobayashi, Ryuichi Mizuno the meeting highlights. Profs. Chapple and Shin and Masaki Shiota as panellists, the session led to a dynamic and in-depth discussion of current issues.

Egawa served as symposium chairs. Four lectures were delivered by the distinguished doctors: Welcoming JUA-EAU Academic Exchange Fellows The JUA-EAU Academic Exchange Programme started in 2015. This year, JUA welcomed Drs. Derya Tilki and Stavros Tyritzis from the EAU. After having observations under the direction of Prof. Egawa at Jikei University, Prof. Ryoichi Shiroki at Fujita Health University and Prof. Fujisawa at Kobe University, they attended the 105th JUA Annual Meeting where a special meeting was held for the fellows and where they received their certificates.

Main Entrance

Besides the lectures and symposiums by distinguished doctors from overseas, there were several oral and poster presentations in English. The

Kyoto to host 106th JUA Annual Meeting Globalisation is one of the main goals of the JUA Annual Meetings. This policy continues and further globalisation is expected in the future. Next year, the 106th JUA Annual Meeting will be held in conjunction with the 16th Congress of Urological Association of Asia (UAA) in Kyoto, from April 18 to 22, 2018. Prof.

Osamu Ogawa, professor and chairman of Department of Urology, Graduate School of Medicine, Kyoto University will host the 106th conference. Since it is combined with the UAA programme, half of the sessions will be held in English and translations will be provided during the Plenary Session. We believe European doctors who will attend will fully benefit from their participation. We look forward to the involvement of many EAU members in the 106th JUA Annual Meeting.

See you all in Kyoto!

Prof. Chapple delivers the EAU Lecture

Japanese Tour 2017 International Academic Exchange Programme Inspiring tour sheds insights on urological practice in Japan Ass. Prof. Derya Tilki University Hospital Hamburg-Eppendorf Martini-Klinik Prostate Cancer Center Hamburg (DE) dtilki@me.com

Dr. Stavros Tyritzis Athens Medical Center Dept. of Urology Marousi (GR) Assist. Prof.

Karolinska Institute, Stockholm (SE) styritzis@gmail.com We had the great honour and opportunity to participate in the EAU-JUA International Academic Exchange Program from April 9 to 23 this year in Japan. The tour included visits to three hospitals in Tokyo, Nagoya and Kobe and ended with the annual meeting of the Japanese Urological Association (JUA) in Kagoshima.

Our tour started with a visit to the Jikei University Hospital where the Urology Department is chaired

by Prof. Shin Egawa. In his office, Prof. Egawa briefed us on Japanese traditions which helped our understanding of the Japanese culture. In Japan there are approximately 250 surgical robots, although the Jikei University Hospital is one of the few urological centres without a robot. Jikei University is widely known for its solid expertise in conventional laparoscopy. We observed a laparoscopic radical prostatectomy and a laparoscopic cystectomy during our stay at the Jikei Centre. Moreover, the staff members of Jikei University is active in scientific work, and its basic and translational research focus include the use of stem cells for stress urinary incontinence and biomarker discovery for interstitial cystitis. Our hosts took us for dinner to the famous “Gonbachi” restaurant, known to have inspired the Quentin Tarantino film “Kill Bill.“

"From the first day on until the very last day, we received exceptional hospitality from our Japanese colleagues."

Next, we travelled to Fujita Health Centre in Nagoya, considered as Japan’s biggest hospital with approximately 1,400 beds. The Department of Urology is chaired by Prof. Ryoichi Shiroki. Our visit From the first day on until the very last day, we begun with a welcome dinner with Nagoya-style received exceptional hospitality from our Japanese fried chicken. The first day programme at the Fujita colleagues. They had organized the entire tour in detail Health Centre included two robotic partial and for this we are grateful to our hosts who made this nephrectomies and two robotic radical experience memorable. We would also like to thank prostatectomies, which are the only two robotthe EAU and the JUA for the opportunity to be part of assisted procedures that are completely covered by this wonderful academic exchange programme. the Japanese health insurance system. The Fujita 32

European Urology Today

Health Centre owns two dual-console robots, a Si and an Xi. The high number of robots in the country illustrates the problem of a non-centralised system, where it can be difficult to achieve high-volume robotic experience in one centre. In Nagoya we visited the daVinci training centre, one of three in the country, where Japanese surgeons obtain

certification to perform robotic procedures. The department runs a very interesting project with 3D printed surgical models mimicking real renal tissue, led by Prof. Kusaka. The models are used for the simulation and navigation of kidney transplants and robotic partial nephrectomy.

Kobe was our third stop of this exciting journey.

Kobe, a major harbour city, made headline news for its unbelievable recovery following the 1995 Hinsai earthquake. Kobe University Hospital has a 940-bed capacity. The Urology Department, directed by Prof. Fujisawa, has 55 beds and three surgical wards. The hospital is equipped with a da-Vinci S system. One operating room is equipped with a MRI system, where guided biopsies and neurosurgeries are performed. The Urology Department’s research unit focuses on oncology, andrology and regenerative medicine. We visited the new International Clinical Cancer Research Centre, which offers, aside from state-of-the-art Back row, from left: Dr. Egawa, Dr. Nakagawa, Dr. Tomita, surgical treatment, research and the development Dr. Shiroki. Front row, from left: Prof. Wirth, Dr. Tilki, Dr. Tyritzis, of next-generation medical care and new medical devices. One highlight of our Kobe visit was to taste Dr. Fujisawa the world famous Kobe beef.

Our participation in the Annual JUA Meeting in Kagoshima (known for its hot springs and with the meeting venue‘s stunning view of the Sakurajima volcano) concluded the tour. The meeting’s programme included very interesting lectures by world-renowned urologists. We also had the chance to meet old and new friends.

Fujita department (Prof. Shiroki, and staff members)

We had a wonderful time in Japan and we hope the JUA-EAU collaboration will continue in the same way the inspiring sight of cherry blossoms returns each year, and which represents one of Japan‘s most iconic symbols.

June/July 2017

www.esut-iea18.org

www.esou18.org

ESUT-IEA18

ESOU18

6th Meeting of the EAU Section of Uro-Technology in conjunction with the Italian Endourological Association

15th Meeting of the EAU Section of Oncological Urology 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

ESAU17 10th Meeting of the EAU Section of Andrological Urology 24-25 November 2017, Malmö, Sweden “Andrology as an integrated and important part of urology” 10th Andrology Section Meeting covers wide range of male topics

Prof. Jens Sønksen (Herlev, DK)

“All urologists meet patients with andrological problems, and it is obvious that andrological diseases may be symptoms of other, more general pathological conditions. Therefore, it is crucial for all urologists to have a basic knowledge of andrology,” recommends Prof. Jens Sønksen (Herlev, DK).

The 10th Meeting of the EAU Section of Andrological Urology (ESAU) is designed to appeal to all practicing urologists, offering an in-depth look at some topics that are not always covered at other scientific meetings throughout the year.

ESAU17 will take place in Malmö, Sweden on 24-25 November, 2017.

Prof. Sønksen became EAU Adjunct Secretary General – Clinical Practice at EAU17 in London and is also co-organising ESAU17 together with ESAU Chairman Prof. Nikolaos Sofikitis (Ioannina, GR) and Prof. Aleksander Giwercman (Malmö, SE).

Key Topics ESAU17 will cover the physical and psychological complaints of the man during his passage through each of the different chronological phases of his lifespan, including male endocrinology, assisted reproductive technology, sexual health and penile surgery.

“We will cover all aspects of andrology including infertility, hypogonadism, erectile dysfunction and ejaculatory problems,” Sønksen summarises. “There will be much focus on most recent developments and on the link between basic science and clinics.”

Reflecting on the relationship between urology and andrology, Sønksen points out that andrology is an integrated and important part of urology. “All urologists are at times confronted with andrological conditions and it is important for them to recognise that some of these may be symptoms of wider problems.

Thankfully, we can see an steadily increasing number of attendants at the EAU’s andrological meetings.”

The meeting is set to host some of the internationally leading experts in andrology and also from adjacent fields, who are interested in this rapidly growing area of medicine. Key speakers slated to appear include Mr. David John Ralph, and Profs. Carlo Bettocchi, Ateş Kadıoğlu, Kopa Zsolt, Thorsten Diemer, Ferdinando Fusco, and Gert Dohle.

Sønksen: “This level of expertise, together with the opportunity to participate in stimulating discussions and meeting colleagues and friends, means that ESAU17 will offer the complete package for those who want an update on andrology.”

ReproUnion Many experts affiliated with the world-renowned cross-border collaboration ReproUnion will also be speaking. ReproUnion

Early registration deadline: 24 August 2017 Abstract submission deadline: 1 September 2017 is a network of 13 clinical and research units in Copenhagen and its surrounding area, and the Skåne County in Southern Sweden, of which Malmö is the capital.

Sønksen: “A strong collaboration between ReproUnion and the EAU and its Andrology Section has developed in the past year and a half. The two organizations are co-sponsoring scholarships for young researchers and some of the first recipients of these scholarships will be presented at ESAU17. Furthermore, a part of the scientific program of ESAU17 is sponsored by ReproUnion.”

The conference centre (Malmö Börshus) where the meeting will take place is located in the centre of Malmö, Sweden’s third biggest city and metropole in the dynamic Øresund European region. Thanks to the iconic bridge connecting Copenhagen and Malmö, it takes only 20 minutes by train to reach Copenhagen airport and 30 minutes to reach the Copenhagen city centre from Malmö.

www.esau17.org June/July 2017

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ESUR17 24th Meeting of the EAU Section of Urological Research 12-14 October 2017, Paris, France Register before 8 August 2017 and benefit from the early fee!

In collaboration with the EAU Section of Uropathology

ESUR17: Urological research at its prime

www.esur17.org

The cosmopolitan city of Paris will host the ESUR17 in October, in collaboration with the EAU Section of Uropathology (ESUP). This distinguished meeting aims to enhance the clinicians’ knowledge of research strategies, and to broaden the researchers’ familiarity with urological challenges.

The best platform for research “ESUR17 will offer the quintessential setting for clinician-researcher collaboration, and the platform to present the kind of translational research that I do. This meeting is ideal for synergy and for building relationships,” said Dr. David Liu (US) of the Broad Institute.

Prof. Georges Netto (US) of the University of Alabama at Birmingham said “There are over 60 clinical trials ongoing for bladder cancer alone (e.g. monotherapy or in combination with chemoRx/Targeted Rx/ImmunoRx of immune checkpoint inhibitors).

ESUR7 is the optimal venue to discuss these with the global leaders in the field.”

Expectations and some notable lectures “I’m eager to learn, brainstorm and share my research at ESUR17,” said Netto. “My lecture ‘Immune scoring system in modern pathology: A new grading system?’ will address the development of a novel paradigm in predictive biomarkers for immune checkpoint inhibitors. A mechanism-driven approach to predicting response to these promising novel therapeutics is needed. An ‘immune-score’ approach, which encompasses evaluation of immune checkpoint markers (PDL-1), tumour Infiltrating Lymphocyte (TIL) density and innate tumoural genetic alterations, is emerging and will be outlined.”

Robotic Live Surgery

Also presenting at ESUR17, Liu said “I anticipate excellent questions and look forward to potential collaborations and new ideas arising from these interactions. It will be my inaugural presentation at an ESUR meeting. I’m very excited!”

According to Liu, although targeted therapies and immunotherapy have revolutionised the treatment of cancer, chemotherapy continues to be a mainstay of treatment in many cancers. In recent years, detection of deficiencies in DNA repair pathways are found to be predictive of response to multiple therapies, including chemotherapy. “In my lecture ‘Defects in DNA repair genes: Role in chemotherapy response in urological cancers’, I will review some of these findings in urological cancers, their underlying biological mechanisms and preview new approaches to predicting response to chemotherapies.”

“There are multiple areas of research where breakthroughs would be incredible,” said Liu. “These include advances in cell-free DNA

ERUS17 14th Meeting of the EAU Robotic Urology Section 26-27 September 2017, Bruges, Belgium

“Live surgery continues to be a viable educational tool” ERUS17 is the go-to scientific meeting for urologists who are interested to learn more about robotic surgery. It is completely dedicated to the latest developments in robotic urology, has special programmes for beginners and young urologists, and most importantly, it has two days of live surgery and case discussions. We spoke to Prof. Nicolaas Lumen (Ghent, BE) about the current state of robotic urology and the educational value of live surgery. Prof. Lumen is co-chairing Live Surgery Session V on Wednesday, September 27th.

Live Surgery Live surgery attracts big crowds at all of the EAU’s meetings that offer it, evidence of its continued popularity and educational value. Prof Lumen highlights some advantages: “One major advantage of live surgery is that you can learn from troubleshooting during difficulties in robotic operations. You can sometimes see how an experienced surgeon handles an unexpected problem during a robotic procedure.

This, as opposed to edited movies which usually show standard procedures without any difficulties.”

“Single-cell technology may unlock the existence of pre-existing resistant subclones. This may help clinicians customise combination therapies, and clearly define the tumour microenvironment to predict the response to treatments such as immunotherapies. We need to develop a framework to characterise the dependencies and vulnerabilities of individual tumours based on an integrated model utilizing data from the tumour’s DNA, RNA, epigenome, and microenvironment,” Liu concluded.

Breakthroughs in the future Netto and Liu are enthusiastic about the future of urological research. “I think one of the major breakthroughs will be trials that take precision medicine into the next phase where immunogenomics converge,” said Netto.

Experts of today vs. rising stars of tomorrow

Prof. Lumen: “The ERUS meeting gives urologists the unique opportunity to come (and stay!) in contact with colleagues and to share their experiences. For state-of-the-art robotic procedures, it is important to compare your technique with the technique of expert high-volume surgeons. Some technical details or refinements might have serious impact on the outcome of your own surgery.”

“Furthermore, the meeting gives you the opportunity to see what is new in robotic surgery. Not just new technological developments, but also new indications in the field of robotic surgery that might become standard in the next years.”

(cfDNA): the ability to genomically characterise an individual’s disease at multiple time points in a fast, economical, and noninvasive manner. These will allow us to examine tumour evolution under therapy. We can gain insight into what genomic alterations may predict response to therapy, and in the most relevant disease model possible – in the patients themselves.”

“Live discussion, through a moderator adds an interactive dimension that goes well beyond what a surgeon might find in surgical videos on the internet. Showing the entire procedure, even in the background when another case is being discussed allows the audience to focus on some technical details that might not even be emphasised during broadcasting, but of great importance for some attending surgeons.”

Patient safety is the first priority during events that feature live surgery. Consequently, the EAU has established firm guidelines that its events must adhere to in order to be endorsed by the EAU Live Surgery Committee. Lumen: “In order not to jeopardise the patient’s welfare, a correct indication for the (live) surgery is of utmost importance.”

“It is also important that the guest surgeon is able to operate as he or she would at home. The quality control of the EAU-endorsed live surgery label is very important to obtain this. Of every procedure, complications, functional and oncologic outcomes are measured, evaluated and communicated with the EAU.”

Prof. Georges Netto (US)

Dr. David Liu (US)

Additional events on 24 & 25 September: • EAU Young Academic Urologists (YAU) Meeting • Junior ERUS-YAU Meeting • ERUS-EAUN Robotic Urology Nursing Meeting • European School of Urology (ESU) Courses • Technology forum on new robotic technologies Additional events on 26 & 27 September: • ESU/ERUS Hands-on Training in Robotic Surgery

At all times, a patient advocate is on hand to ensure that the patient receives the best possible care and interrupt the broadcast if necessary. Lumen: “Thanks to all these precautions for the patient’s welfare, I think it is ethically acceptable to continue with live surgery as educational tool.”

Hot Topics “As a delegate at ERUS17, I will certainly be following the debate “Pathology reports in radical prostatectomy”, featuring Profs Compérat, Wiklund and Cooperberg,” Lumen explains. “Important decisions, like the need for adjuvant radiotherapy, are made based on the pathology report. These decisions have a major influence on the patient’s quality of life. We are more and more aware that not every extracapsular extension and/or minimal positive margin after radical prostatectomy is an imperative indication for adjuvant radiotherapy.”

“Furthermore, I am very happy to see a talk on the prospective Belgian registry. This is an example of how to obtain data in a prospective fashion in order to evaluate a robotic procedure. It was the base for reimbursement of the robotic material during radical prostatectomy in Belgium.”

Register now!

Late fee deadline: 15 September 2017

www.erus17.org 34

European Urology Today

June/July 2017

PCa17: Interactive update First in a unique EAU series on onco-urology

PCa17 EAU Update on Prostate Cancer

15-16 September 2017 Vienna, Austria

www.pca17.org

New EAU onco-urology series

It’s not often that a mid-year specialised meeting is organised to deliver an interactive, practical and educational programme specifically focused on prostate cancer. This is exactly the goal behind PCa17, an expert-led update meeting that will take place in Vienna, Austria, from 15 to 16 September.

PCa17 marks the first of a series that is unique in the EAU’s programme on onco-urology with its emphasis on in-depth and critical discussions. To achieve this, the EAU has gathered experts from across Europe to share their knowledge on a comprehensive list of core issues in prostate cancer management.

Meeting organisers and course directors Prof.

Manfred Wirth, Prof. Jens Rassweiler and Dr. Joan Palou have emphasized the need for a learning event such as PCa17, which required the combined synergies of the EAU Section Offices and the European School of Urology (ESU), plus the expertise of affiliated EAU partners.

“With a dedicated meeting we can provide a practical and thorough assessment of to-the-point and incisive recommendations on systemic treatments, castration-resistant disease, drug selection or sequencing and complications management,” said Wirth, who will chair the discussion on systemic treatments and will speak on PCa biomarkers and genomics, both key issues in current management strategies.

“PCa17 will provide a new didactic concept and participants will be fully updated on all aspects of diagnosis and treatment of prostate cancer. They will be able to follow and understand the actual EAU Guidelines on prostate cancer, and at the same time be informed on upcoming developments which challenge the guidelines,” added Prof. Jens Rassweiler, chairman of the EAU Section Office.

On the first day morning session, and after a one-hour update on PCa guidelines, participants will sit in four discussion rounds, each running for around 45 minutes, that will dissect pertinent issues ranging from patient selection for biopsy, active surveillance, use of imaging and patient follow-up, among other topics.

Resource speakers Prof. Axel Merseburger (DE) and Dr. Monique Roobol (NL) are participating as faculty lecturers and both described PCa17 as an ideal update event with extended, interactive discussions.

Participants will be able to examine, point-by-point, current dilemmas, look into examples of best practices and reflect on how the insights they gain during the discussions can be used in actual clinical practices and decision-making.

Identifying problem areas Merseburger said doctors often faced questions that can complicate therapeutic strategies. “The most important is to define the disease whether it is low or high-volume (metastatic disease) and the aspects which are patient-focused,” said Merseburger (DE), as he referred to systemic treatment, particularly for patients with hormone-naïve metastatic disease.

During the meeting, Merseburger will take up hormone-naive metastatic disease and discuss treatment options.

Sharing Merseburger’s view that individual patient’s characteristics are pivotal factors in any treatment decision, Roobol said PCa management is complicated by the variability in tumour characteristics and individual patient profiles.

“There are two crucial aspects at the time of diagnosis in prostate cancer. The first is the

• • • •

1

European June/July 2017 Urology Today

Dr. Monique Roobol (NL)

Prof. Axel Merseburger (DE)

(expected) characteristics of the tumour, and the second is the characteristics of its host,” said Roobol.

Both Roobol and Merseburger have led multicentre studies on major issues in prostate cancer, and they noted that therapeutic approaches can benefit from recent advances in imaging and genetic studies. “Staging and grading the tumour is becoming more and more accurate with the availability of magnetic resonance imaging (MRI) and more detailed pathology review including, for example, cribriform growth patterns,” explained Roobol.

New research shows that cribriform growth in some PCa forms such as those in Gleason grade 4 is a strong prognostic marker for distant metastasis and disease-specific death in patients with Gleason score 7 prostate cancer, following radical prostatectomy. Another challenge that Roobol underlined is the assessment of a patient’s life expectancy. “Assessing life expectancy remains a challenge but is crucial in determining who should be screened and what treatment should be applied after diagnosis,” she said.

To guide and stimulate participants and steer the discussion into practical insights, each breakout session (which totals to 16 sessions over two days) will be preceded by a comprehensive update on core topics such as diagnosis and staging, local and systemic treatments, patient-centred strategies, and future perspectives in disease management. New research outcomes and experience from expert centres will also be used as discussion points, adding depth to the exchange of scientific perspectives.

Testing knowledge The ESU is also introducing pre- and post-testing procedures for PCa17. To quantify the knowledge attained during the meeting, participants will receive a questionnaire before and after PCa17, which will cover the contents taken up during the meeting. To keep track of answers, a personal voting system will be used, with each participant receiving a voting pad that is linked to their name upon registration. This makes it easier to track personal development during the event and can be linked to their pre- and post-testing results.

The meeting’s Scientific Programme content will not only define the breakout case discussions but will highlight dilemmas often encountered in clinical practice. “The emphasis is not only on new approaches and technologies, but more importantly how real-life case scenarios require approaches that may even show the limits of these new technologies,” said Wirth.

To know more about the aims of PCa17 and details on the Scientific Programme, speakers, registration and other information, visit the meeting website at www.pca17.org.

First, single-topic update on onco-urology series In-depth and interactive break-out sessions Pre- & post-educational assessments Expert mentorship and CME accreditation

March/MayUrology 2017 European Today

35

EULIS17

#EULIS17

4th Meeting of the EAU Section of Urolithiasis 5-7 October 2017, Vienna, Austria Prof. Dr. Christian Seitz

Register now for the early fee!

Deadline: 28 August 2017

EULIS17: Discover the latest advancements for urolithiasis One of the main highlights that make the 4th bi-annual meeting of the EAU Section of Urolithiasis (EULIS17) a must-attend event is its live surgeries. “The use of modern instruments and disposables will be illustrated, in combination with new and significant research developments. The upcoming EULIS17 is a culmination of the latest and best advancements for urolithiasis,” said Prof. Dr. Christian Seitz (AT) of the Medical University of Vienna.

The live surgeries at EULIS17 will be broadcasted from two locations: Pforzheim, Germany and Vienna, Austria. These surgeries will include minimally-invasive stone surgeries such as retrograde intrarenal surgery, percutaneous surgery from standard to mini and super mini Percutaneous Nephrolithotomy (PNL), and integrated approaches.

These and more will be demonstrated by world-class experts in the field.

Exploring the EULIS17 programme “Although the live surgeries will be a significant focal point of the EULIS17’s scientific programme, there are other outstanding features of the meeting that the participants will appreciate as well.

www.eulis17.org

“We build on the present and look forward to the future. We foresee advancements in stone treatment to treat adult and paediatric patients, and we put high importance on interdisciplinarity which will bring relevant collaborations among urologists, researchers and nephrologists. In fact, we have already started; there will be the EULIS ERA/EDTA lecture scheduled for Saturday, 7 October entitled ‘Metabolic diagnosis and medical prevention of Ca nephrolithiasis’.

This lecture will focus on nephrolithiasis and polycystic kidney disease,” said Seitz.

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

Emerging concepts The meeting will also showcase emerging concepts of ureteral stone management, miniaturization of percutaneous scopes used in clinical practice, new digital flexible ureteroscopes, and newly-designed disposable ‘single-use’ flexible ureteroscopes. Seitz encourages participants to “come to Vienna this October to deliberate and brainstorm with internationally-renowned experts, as the meeting will cover all aspects of stone disease.”

As EULIS17 is about the exchange of know-how and the enhancement of surgical skills, the meeting will also offer residents the exclusive opportunity to participate in the EST-1 curriculum outside the European Urology Residents Education Programme (EUREP).

“And last but not least, the charming city of Vienna will provide the picturesque backdrop conducive for learning. What more can you ask for?” concluded Seitz.

Handy and essential info For an overview of EULIS17’s Scientific Programme, please visit the website for more information about the meeting.

Optimise the EULIS17 experience via the handy “EAU Events” app. No lugging around printed materials. Simply download this eco-friendly alternative. Easily browse through the scientific programme, and filter the search by day, session type, and speaker. Create a customised EULIS 17 schedule via the personal planner feature. The app is downloadable via the App Store (iOS) or from the Play Store (Android). The app can be used offline but please note that some features will only be updated when there is internet access such as news, tweets, etc.

Barcelona hosts ESUI17 in November!

With the renewed interest on urological imaging as shown during the recent Annual EAU Congress in London, the 6th EAU Section of Urological Imaging (ESUI17) Meeting on November 16 in Barcelona promises another opportunity for in-depth discussions on a wide range of key imaging issues.

ESUI17’s overarching theme is “New Technologies and Limited Resources,” a pertinent topic in today’s healthcare systems where health professionals often face dilemmas when delivering optimal diagnostic and treatment strategies at a high cost. A timely and comprehensive follow-up to the 2016 edition, ESUI17 will also be held in conjunction with the 9th European Multidisciplinary congress on Urological Cancers (EMUC).

For a preview of what’s in store in Barcelona, we have invited expert speakers to lead the point-counterpoint discussion session on prostate cancer diagnosis. Among the topics are “Let’s break the bank with the costs: MRI before primary biopsy,” which will feature a passionate debate between Nicolas Mottet and Hashim Ahmed- certainly a controversial topic to tackle right in the first round! Our critical engagement, however, do not stop on technological issues as we aim to examine equally relevant issues such as biomarkers, its development and impact on individualized medicine.

The full-day programme is not limited to prostate cancer alone but will also focus on innovations in the diagnosis of renal cell cancer, such as the role of 3D modeling of the vascular anatomy for partial nephrectomy, and an update on contrast-enhanced ultrasound for renal masses, among other topics. And while we gain a deeper understanding of the possible imaging modalities, Pilar Laguna will discuss focal therapy for small renal masses vis-à-vis partial nephrectomy.

Register now for the early fee!

Deadline: 14 August 2017

Advances in imaging technologies Technology and their impact on urological practice will be the focus of the session on positron emission tomography (PET) and computed tomography (CT). PET/CT and upcoming PET tracers for different tumor entities will be examined by opinion leaders and speakers in a session organized in conjunction with the European Association of Nuclear Medicine (EANM).

Again, ESUI17 aims for a higher level by prioritizing in the programme current and controversial issues in urothelial cancer. And in today’s technology-driven world, the dominant opinion seems to be “Let’s have multiparametric everywhere!” But we pause, take stock and carefully reconsider questions such as “What with multiparametric cystoscopy,” and “Does imaging change immunotherapy in bladder cancer?” These and other relevant topics will be on board during the plenary session to prompt all participants to share knowledge and best practices.

The day-long ESUI17 returns to prostate cancer issues during the concluding session with topics such as transrectal ultrasonography (TRUS) and high-resolution ultrasound, to name a few. In other words, the interest for technological gains conveys the overriding concern--Let’s improve the performance of our prostate cancer diagnostics!

Last but not least, we encourage participants to submit an abstract of their latest research for the poster session, where the best will be recognized with the Best Abstract Award.

Deadline is 1 July 2017 (23.59 CET). The poster session will also take place on the same day, and the award winner will receive 1,000 euros, thanks to the generous sponsorship of Exact Imaging.

Be a part of ESUI17 and contribute to the goals of boosting urological imaging. Join us in Barcelona!

George Salomon Chairman, EAU Section of Urological Imaging (ESUI)

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

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European Urology Today

June/July 2017

Management of LUTS "a key area within urology"

Register for the 10th ESU-ESFFU Masterclass by 1 August!

EAU Secretary General on the importance of maintaining this expertise

By Loek Keizer This October, Berlin will be hosting ELUTS17, the first in what is set to become Europe’s annual LUTS event. The EAU is organising the meeting for the first time, working together with Prof. Chris Chapple two of its Sections, the European School of Urology and the European Urogynaecological Association, EUGA. “At the moment, functional urology lags behind other topics within our field, topics like uro-oncology. The purpose of our meeting is two-fold: firstly to draw urologists’ attention to functional urology, particularly as LUTS are extremely common in the ageing European population.”

We spoke to Prof. Chris Chapple (Sheffield, GB), EAU Secretary General and coorganiser of ELUTS17 on the importance of this subspecialty, the cooperation with EUGA and the highlights from the scientific programme.

Collaborative meeting The scientific programme of ELUTS17 is co-organised with the EAU Sections of Genitourinary Reconsctructive Surgeons and Female and Functional Urology, ESGURS and ESFFU, each providing speakers and expertise from their ranks.

ELUTS17 also has a substantial involvement from the European School of Urology, which is organising its 10th Masterclass on Female and Functional Urology (together with ESFFU) to coincide with ELUTS17. The Masterclass will be held on 12-13 October, with the regular ELUTS17 scientific programme taking place on 13-14 October.

Registration for the masterclass is free, but does involve a selection process by the organisers.

Another party that the EAU is working with for ELUTS17 is the European Urogynaecological Association. Prof.

Chapple: “This marks the first meeting in collaboration with the EUGA. There is no doubt that functional urology is an important component of clinical practice and this emphasises the recognition that the EAU gives to this important area of urology.”

“Our collaboration also reflects the close working practice that we have as clinicians interested in the management of both female and male patients with functional urological disorders. The EAU welcomes the EUGA group and hopes that to build on activities of this nature in the future.”

"This collaborative meeting reflects the close working practice that urologists and urogynaecologists have as clinicians."

“This is the first year that this area in urology, in particular with an emphasis on the important issue of lower urinary tract symptoms, is the subject of a large meeting of the European Association of Urology. We are offering a very comprehensive programme incorporating interactive teaching and a multidisciplinary group of speakers.

June/July 2017

We anticipate that this will herald an annual meeting in this field, and at this meeting we will be covering all of the topical areas in the field of functional and reconstructive urological practice in both male and female patients.”

Important topics The scientific programme features state-of-theart lectures, discussions and updates from some of the most experienced LUTS-urologists.

Chapple: “The speakers at the meeting will review the latest developments, diagnosis and management of lower urinary tract symptoms.

There will be a comprehensive overview of the latest developments in the area of minimally invasive treatments for lower urinary tract symptoms, with particular reference to some of the confounding conditions such as underactive bladder, painful bladder syndrome and difficult and troublesome symptoms such as nocturia, urgency and stress incontinence.”

“Whilst there will be considerable focus on management of these conditions in the female patient, there will also be comprehensive overviews of the management of lower urinary tract symptoms in the male patient, both with overactive bladder symptom complex and with other conditions such as urethral stricture disease and erectile dysfunction.”

“Attendees at the meeting will find that this will provide a concise, interactive and up-to-date review of the latest developments in the field of lower urinary tract symptoms and genitourinary dysfunction.”

“The management of lower urinary tract symptoms within urology is often neglected and many consider it to be rather unappealing as a subject area."

LUTS within Urology Prof. Chapple also reflected on the way lower urinary tract symptoms are regarded in the wider urological community. “The management of lower urinary tract symptoms within urology is often neglected and many consider it to be rather unappealing as a subject area."

"It's apparent that the converse is true as there is an increasing prevalence of lower urinary tract symptoms with increasing age, making this a very important and relevant area of urology for the population at large, particularly with the ageing population.”

“Consequently LUTS is an important area of contemporary clinical practice. The associated symptoms, particularly relating to continence, are a significant cause of morbidity, especially in the female population. Storage symptoms in the ageing male are the commonest reason why patients attend a urological clinic, even in situations where the predominant problem is thought to be bladder outlet obstruction due to benign prostatic enlargement.”

“Clearly as a speciality within urology, it is important for urologists to maintain their expertise in many of the areas in urology which are not considered as interesting or appealing as some of the newer forms of endourology. The management of LUTS is a key area within urology in both management of male and female patients. It is important that urologists' expertise in this area is maintained and kept up to date.”

ELUTS17 European Lower Urinary Tract Symptoms meeting

12-14 October 2017 Berlin, Germany

www.eluts17.org

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 and the 10th ESU-ESFFU Masterclass, please visit www.eluts17.org

European Urology Today

37

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38

European Urology Today

16-268105

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Call for papers

June/July 2017

European Specialist Nurses Organisations (ESNO) Advancing the role of specialised nurses in Europe Mrs. Jeannette Verkerk-Geelhoed EAUN Board Member Groene Hart Ziekenhuis Gouda (NL)

j.verkerk@eaun.org The European Specialist Nurses Organisations (ESNO) (www.esno.org ) is founded in 2006 and aims to highlight the role played by specialist nurses in Europe.

Nurses are the largest group of professionals (three million) in European healthcare, and it is expected that in the future the role of nurses will further expand, including that of specialist nurses or nurse specialist.

Thus, nursing societies such as the EAUN are eligible for ESNO membership to support the goals and long-term strategy of ESNO. In 2017, 19 specialised nursing organisations became ESNO members, further expanding ESNO’s influence.

to link-up with politicians. Moreover, ESNO also works with physicians, pharmacists and patient organisations to gain more influence at the EU and European Parliament.

Training framework ESNO aims to set up a common training framework as referred in the Directive of Recognition of Qualifications (http://eur-lex.europa.eu, search for CELEX 32013l0055).

In this directive, the European Union has invited the Nurse Specialist to bring more recognition and unity in the nursing profession. In recent WHO publications, this subject is recognised with reference to ESNO as the key non-government organisation (NGO).

With this framework, ESNO intends to standardise education in Europe for specialised nurses and nurse specialists. ESNO also wants to contribute to nursing guidelines on nursing diagnosis, interventions and outcomes. ESNO works with the European Federation of Nursing (EFN) and the International Council of Nursing (ICN).

"For ESNO, lobby initiatives and public relations in the European Union (EU) are important, striving for a better position for specialised nurses in Europe."

ESNO’s long-term strategy will undergo updates this year and its main goals include the following: (1) A stronger professional organisation; (2) Stronger position in healthcare or in the interdisciplinary team and (3) Greater involvement in decision-making at local and EU policy level. A dominant concern is to achieve wider The level of education of specialist nurses in Europe recognition of specialist nurses in the next five years varies. The Netherlands, United Kingdom and the across Europe.

Scandinavian countries, for example, already have a developed and differentiated educational level of For ESNO, lobby initiatives and public relations in the nursing from MBO level to master’s level (university).

European Union (EU) are important, striving for a better Nurses Specialists on master’s level work at a complex position for specialised nurses in Europe. Ber Oomen nursing level and take over medical tasks from (NL) represents ESNO and its members in the EU, where physicians. In the southern and eastern European he spends time at the European Parliament in Brussels countries, these different levels of education are less developed. The European Qualification Framework (EQF) describes at a European level the eight common European Association of Urology Nurses European reference levels in terms of learning

outcomes, knowledge, skills and competences. These can be used by National Qualification Frameworks (NQF) and relate to the EQF. With this framework, levels of education among European countries can be compared.

The European Commission’s Directorate-General GROW and Directorate-General Health and Food Safety (SANTE) requested ESNO to map the Specialist Nurses health workforce. They started with diabetes in cooperation with the Foundation of European Nurses in Diabetes (FEND), and collaborated with scientists of the University of Leuven (BE). The first step is a literature review classified by age, with the whole process involving five steps.

ESNO projects ESNO also develops E-books which describe the common content of the nursing profession of a specific area. The E-book “Respiratory Nursing at a Glance” has been completed. The E-book on mental health is due for completion this year, while the E-book on oncology is scheduled for next year. ESNO encourages its member organisations to participate in the programme and develop an E-book about their own nursing profession. The project is a good opportunity for these groups to present the scientific core of their nursing specialties, an effective way to highlight their tasks to the general public.

ESNO also aims to establish a European Accrediting Nursing (EAN) programme since specialist nurses need a uniform European accrediting body to be accredited and recognised across Europe. To reach these goals, ESNO collaborates with National Regulatory Bodies.

Nowadays, there are big differences in legal procedures among countries, with some still lacking a specialised register for accrediting nurse specialists or specialist nurses.

Membership benefit The EAUN can benefit from its ESNO membership by being an active member. On the European level, ESNO is very active to achieve a uniform educational level for

specialist nurses and nurse specialists in Europe. The EAUN can support this by attending the meetings ESNO organises where it can present the EAUN’s core mission. The EAUN can also support the Education Committee that ESNO has established this spring to develop a frame work for the recognition of a professional level of specialised nursing. ESNO has invited educators from societies to join the committee to work on common training references that provide a common training framework.

ESNO Summit in Brussels The ESNO will hold its second summit in autumn this year in Brussels (30 November - 1 December), with the summit theme ‘Shifting from Hospital to Primary Care: The role of the specialist nurse’. Topics include: Setting the scene; Experiences with care transition; The patient perspective; Future challenges.

More information at www.esno.org/esno-summit ESNO is organising an abstract or poster session during the summit, and the EAUN has submitted a poster for presentation.

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

Getting the right diagnosis Diagnostic Error in Medicine Conference examines insights in healthcare practices Sue Osborne Urology Nurse Auckland (NZ)

sue.osborne@ waitematadhb.govt.nz Getting the right diagnosis is a key aspect of healthcare. As a registered nurse I have contributed to the formulation of patient diagnoses throughout my career. When I became a urology nurse practitioner in 2010, my scope of practice permitted me to autonomously and collaboratively provide patient-centred healthcare including the diagnosis and management of health conditions.

The Institute of Medicine’s 2015 report ‘Improving Diagnosis in Healthcare’ (1), states that “It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences”. This is a worrying statistic and thought-provoking for all of us involved in the formulation of diagnosis. With this is mind, I was keen to attend the 1st Australasian Diagnostic Error in Medicine Conference, held in Melbourne, Australia, from 23 to 25 May 2017.

A variety of disciplines (including nursing, medicine, pathology, radiology, education and research) were represented by the 220 participants who came from Japan, Singapore, United Sates, Australia and New Zealand. The presenters included world and local leaders in medical diagnosis, and patient advocates all sharing ideas and initiatives aimed at reducing diagnostic error. Right at the beginning I saw the positive energy of the participants, and in this column I European Association of Urology Nurses

June/July 2017

would like to share some of the highlights of conference programme.

can begin to breakdown the embedded culture of our workplaces and empower patients, through our interactions, to speak up and effectively share their The conference theme was ‘Towards safer diagnosis- a information and concerns. It was a thought-provoking team effort’. Day 1 started with a workshop entitled: dialogue that reminded us of our responsibility to “They got it wrong”: How patients and health create environments in which patients and their professionals can make a difference through collaboration families can better understand the diagnostic process to obtain a positive outcome. This interactive session was and feel more comfortable participating in the process. co-hosted by a patient advocate and an emergency department physician. It started with a powerful video Day 2 saw the start of the main conference programmeentitled "‘Jess’ Story” (2), a factual account of a young plenary sessions, case reviews, panel discussions, woman who visited specialists for over four years with interactive workshops, oral abstracts and posters. The a set of symptoms that no specialist was able to link timetable included many thought-provoking sessions with a specific diagnosis. each aimed at improving our understanding of how diagnostic errors occur. Patient and family factors were After a long period, Jess’ grandmother raised the discussed including the difficulties related to possibility of Jess suffering from a rare inherited cardiac presentation with non-specific symptoms, challenges condition called Long QT syndrome, which she had with health literacy, communication and cultural seen on the internet. Jess’ neurologist stated that he did considerations. Clinician factors were explored; the not believe this to be the case but reluctantly agreed to risks associated with inadequate collaboration and refer her to a cardiologist at the family’s request. He communication with colleagues, the impact of varying informed his colleague that he did not believe Jess had levels of health professional knowledge and experience the condition, but the cardiologist went ahead and particularly after long hours, stress, fatigue and ordered a variety of diagnostic tests. The test results personal issues. appear to have then been interpreted both incompletely, and with a closed mind, as the System factors were also found to be critical; time cardiologist also concluded that the young woman did pressure and interruptions that may result in a not have Long QT Syndrome. He in fact informed Jess shortened physical exam and a missed key finding, and her family that he had been unable to make a competing priorities that could lead a clinician to a diagnosis. Jess died less than one year later, aged 17 diagnosis without adequate consideration of years of age, of Long QT Syndrome. differentials, inadequate processes for ensuring follow-up of test results, especially after a patient has The workshop attendees were told that Jess’ devastated left the healthcare setting. Heads nodded around the mother channelled her grief into trying to understand auditorium- these were factors we all recognised from what contributed to Jess’ missed diagnosis and our daily practice. Collectively, they were labelled becoming a patient safety advocate. She strongly ‘contextual factors’, a term that became very familiar believes that better communication between patients over the two-day programme. and health professionals can significantly improve the rate of diagnostic error and this premise was explored One particularly interesting interactive symposium during the workshop through a series of doctor / patient was entitled ‘Cognitive Biases: How Doctors think and vignettes performed by three professional actors. de-biasing techniques’. A detailed case study of an emergency department presentation was used to The provocative scenarios stimulated discussion among identify and explore cognitive biases that impact on the attendees about ways in which health professionals diagnostic error rates. These biases were many and

varied but included premature closure (having one’s mind set on a diagnosis and not taking the time to explore differential diagnoses), confirmation bias (looking for evidence to support a preconceived opinion, rather than for information to prove oneself wrong), availability bias (formulating a diagnosis based on the fact that it comes to mind readily because it is common, easily remembered or recently encountered), anchoring bias (locking onto a diagnosis too early and failing to adjust to new information) and affective bias (the tendency to convince oneself that what you want to be true is true- most common if health professionals find themselves disliking a patient so they might write off a symptom as something minor rather than fully investigating it).

I observed the session participants to be particularly alert and focussed as these biases were discussed.

Many could recall examples of witnessing such biases in action. The symposium leaders urged us to get to know our personal biases and our workplace environments as honestly as we could, in order to begin the process of finding ways to mitigate the effects of these biases on diagnostic reasoning. It was powerful stuff.

As the conveners wound up the conference they reiterated the expert committee’s conclusion that improving the diagnostic process is not only possible, but also represents a moral, professional and public health imperative. I certainly left the conference determined to look for ways to enhance work systems to support the diagnostic process in my work place. I imagine all other delegates were similarly motivated by the content of this really interesting inaugural conference.

References (1) Improving Diagnosis in Healthcare (2015). Committee on Diagnostic Error in Healthcare. Editors: Erin P. Balogh, Bryan T. Miller and John R. Ball. The National Academies Press.

(2) Do No Harm: Jess’ Story. https://m.youtube.com (2012)

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ERUS17

Robotic Urology Nursing

ERUS-EAUN Robotic Urology Nursing Meeting 25-27 September 2017, Bruges, Belgium

Join this unique meeting for OR nurses in robotics Increase your knowledge of procedures, competences and teamwork in the OR There is no harmonised training for nurses and RNFAs at this moment and this meeting aims to fill this gap with a high quality nurses programme. The 2017 edition of the ERUS-EAUN Robotic Urology Nursing Meeting in Bruges is a unique meeting for nurses and RNFAs working in robotic urology. By collaborating with EAU and ERUS we are able to provide an educational programme based on best practice and high standards.

The aim of the ERUS-EAUN Robotic Urology Nursing Meeting is to become the educational platform for OR nurses and RNFAs working with robot-assisted urology surgery. The programme will include the latest research in our field of expertise and also anticipate what the future will bring. The meeting will offer theoretical in-depth knowledge and optional hands-on training for nurses working in robot-assisted urology surgery (for hands-on training separate registration applies).

The first day will be completely dedicated to the operating room nurse / assistant role in theory and practice. This will include state-of-the art lectures on safe positioning, avoiding complications, radical prostatectomy, kidney and bladder cancer, amongst others. Team training, troubleshooting, ethics

and educational video presentations are some of the other important topics that will be discussed with the audience by highly skilled and experienced speakers. This day will deepen the knowledge of the patient's pathway from diagnosis to surgery and increase awareness of the importance of having the right competences in the operating room.

On days 2 and 3, the nurse delegates will attend the lectures and live surgery sessions of the regular ERUS programme, to return home completely updated on the latest developments in the field.

The hands-on course at ORSI (HOT 1) includes: Theory regarding the impact of robotic surgery in a perspective of minimal invasive surgery, including the pros and cons and cost effectiveness of robotic surgery.

• What different robotic instruments are there and which ones are suitable for urology surgery • Handle the Endo GIATM stapler and different cartridges, vessel staplers and sealers and different clip appliers.

• Training on the Si and da Vinci Xi systems: port placement, different clutches, docking and positioning the arms, adjusting the ports, etc.

The hands-on course at the congress venue (HOT 2) includes: • Console training, enabling a greater understanding of the roles in the team, the advantages of 3D vision and high definition, etc.

• Team training and assisting laparoscopically: test your skills, examine the role of the RNFA and practise collaborating with a person in the console • Communication training in high risk settings such as the operating room Registration for the HOT sessions is on a first-come, first-served basis. Few places are still available.

Register before 15 September 2017 and benefit from a discounted fee!

Register now at www.erus17.org

More information: www.erus17.org/special-meetings/erus-eaun

EAUN18: Prime platform for urology nursing research As author Ralph Marston once said, “What you do today can improve all your tomorrows.” It is crucial that nurses share what they know and have the platform to do so. “Nurses are always interested in finding ways to provide optimum care for their patients. The sooner they present their research to a wider audience, the more they help raise the level of patient care,” said Ms. Franziska Geese (MScN, RN) of the University Hospital of Bern.

selected, your video will be presented to an international audience at EAUN18 and your registration fee will be waived!

“Difficult Case” Session Ever encountered a challenging case? Or puzzled by an unusual one? Share them! The cases do not have to be solved as these will be discussed during EAUN18 to generate fresh perspectives and innovative approaches. If your case is selected, you and 4 other winners will be given free registration to EAU18!

Ideal platform Geese said, “The programme of the upcoming 19th International Meeting of the European Association of Urology Nurses (EAUN18) is designed to upskill nurses Top 5 tips for joining these competitions by offering them the opportunity to present their research, and by providing them the latest trends and technologies in urology nursing.”

Tip #1 Take a chance “Already decided to submit your work?

There are four ways nurses can present their research Congratulations! Getting over this first step takes at EAUN18; via the Poster Presentations, Nursing courage. Feelings of insecurity often hinder nurses Research Project Competition, Video Presentations by from sharing their work, but to begin despite those Nurses, and “Difficult Case” Session. feelings is one huge step forward. Go for it!”

Nursing Research Project Competition Do you have ideas on improving urological care, or solutions for issues encountered in daily clinical practice? Submit your research project plan and win €2,500!

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

Poster presentations Submit your abstract on urology nursing, continence nursing or any related field that has relevant applications for clinical practice. Be one of those to bring home the third, second or first prize for the Best EAUN Poster Presentation!

Video Presentations by Nurses Do you prefer expressing your ideas in a visual way?

Create a video presentation (plus an abstract) and if

in conjunction with

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European Urology Today

Tip #2 Read EAUN’s guide “How to write an abstract” “Let this help you with the outline of your research. It gives you accurate and practical advice on how to write your abstract.”

through your presentation. Everyone whom I spoke with and used this service swears by it!

Tip #5 If your abstract is not accepted, keep going “Keep submitting because it raises your chances of being approved. Attend the meeting to enhance what you know and to expand your network.”

An example to inspire you One of the most popular submissions during the EAUN Meeting in Aarhus, Denmark this year was the poster presentation “Can self-installation improve QoL in patients with painful bladder syndrome?” by Continence Advisor Ms. Annette HJuler of the Regionshospitalet Randers. This poster was an excellent example of how nurses can collect daily sample data and transform it into research.

Gather your data and document it well. You have the capability, the experience and the knowledge to do so. Submitting your research can help gain new evidence to improve patient care and can inspire others to expand the research as well.

So hesitate no longer, and prepare an abstract, video, research plan or case to present at EAUN18 in Copenhagen!

Tip #3 Ask for help when needed “If you have colleagues who have written abstracts before, feel free to ask them. In addition, the EAUN has research mentors who can help you if you have questions with regard to developing your research project plan.

Tip #4 Take part in the presentation skill lab “If your work is accepted, take part in the presentation skill lab in Copenhagen to practise your presentation skills. A coach will guide you

Submission deadline: 1 December 2017

www.eaun18.org June/July 2017