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European Urology Today Official newsletter of the European Association of Urology

8-9

Vol. 28 No.3 - June/July 2016

EBU Oral Examination 2016

Spanish record

WHO update

Souvenir photos and list of new FEBUs

Surpassing the 60,000-mark in kidney transplants

New variants in prostate cancer

23

Prof. R. Vela Navarrete

28

Prof. R. Montironi

Urology’s future: A key role for National Societies Coordinated action is crucial to ensure future of European urology By Joel Vega With additional reporting from J. Bloemberg, A. Venhorst and E. Rivera The national societies of urologists across Europe should exert a more concerted effort to promote the interests of urology, anticipate challenges and boldly respond to opportunities to boost European urology and enable it to provide optimal treatment to patients. This was the recurring message and consensus from the EAU leadership and representatives of around 38 national societies during the annual National Societies Meeting held in Noordwijk (NL) last June 10 and 11. The annual gathering traditionally held in the Netherlands aimed to collate and assess various perspectives on how to invigorate European urology and respond to the manifold challenges faced by urologists across the region. “The only way to progress is to work together. We have a shared heritage here in Europe and it is important to foster this legacy and the significance of this heritage with the next generation of urologists,” said EAU Secretary General Prof. Chris Chapple (GB) during the plenary discussion.

“We have the tendency to define ourselves as surgical specialists. In doing so we narrow our range and this tendency eventually limits the scope and potentials,” Wirth said, to which Chapple responded that promoting certain specialties in urology among young doctors is a vital step, particularly when considering non-surgical aspects of urology, to maintain urology’s comprehensive coverage of the field. “Many young urologists want to be robotic specialists. How do we address this attitude or tendency? Reconstructive urology is poorly covered, and the areas of female urology, andrology and the management of infections are not considered popular. But these will remain as major issues. We have to promote these areas,” said Chapple, underscoring the message that young urologists are needed in fields such as functional urology, andrology and female urology. Pivotal role The national societies, according to Chapple, are in the frontline to ensure that urologists in their countries receive the necessary support from their local healthcare systems. While international groups like the EAU gets involved in pan-European initiatives, national urology groups can influence local regulatory bodies.

“We should have a united front to protect our Changes in healthcare and educational systems, as specialty and forming an alliance with all participants well as medical and technological breakthroughs, here is one way of reaching our goals. The EAU have impacted urology as a specialty and have eroded wouldn’t exist without your support,” Chapple said. urology’s influence, and led to an ignorance amongst the public with regard to the role fulfilled by urologists. EAU Treasurer and Communications Director Prof. Manfred Wirth (DE) said the low or less visible profile for urology could be traced to the lack of a clear and defining role, and he noted that differences in practices, regulation and healthcare standards across Europe, combined with the emergence of an ageing European population have only made the challenges tougher to address. “How we define ourselves will eventually define how we work in the future. This requires us to develop innovations. How do we define our specialty? As organ specialists or surgeons? What about areas such as female urology, oncology, etc…?” said Wirth. Both Chapple and Wirth conceded that there is uneven coverage of urology in Europe. In particular in Spain urologists can claim they are the only urologists in Europe who perform kidney transplantation as the norm: certainly in other countries this has been lost from urology.

EAU projects and short-term strategies were presented to meeting participants

Former EAU Adjunct Secretary General for Science, and prior President of the European Board of Urology, Prof. Walter Artibani (IT) also noted that taking the lead role in a multi-disciplinary setting is equally crucial. “Surgery would be gone over time. We have to be the leaders of the multi-disciplinary team. It's not to defend our territory, but to lead the clinical path,” said Artibani as he called for a real change to be spearheaded by both national and pan-European groups. During the forum, representatives responded to the call and confirmed that sustained collaboration is essential. “We have to continue working together

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

CONSENSUS BY THE SEA EAU executives and representatives of 38 National Societies meet in Noordwijk, The Netherlands

with all different specialties, while maintaining our lead role. This means doing quality research,” said Dr. Patrick Coloby (FR). He said if urologists are known for excellent work and breakthrough research, this can only enhance the distinction and influence of urology. Representatives from Scandinavia called for a more collaborative strategy with other medical specialties because they noted that besides insular interests, the common goal is to ensure better healthcare for patients. They suggested that the EAU could form working groups to examine and provide specific recommendations which directly address the issues of overcrowding in some specialties, lack of uniformity in healthcare standards and improved access to specialised training. To address these issues, the EAU noted that its sub-specialty sections exert efforts to respond to challenges encountered by its members, acting as a direct conduit that could anticipate both professional and medical concerns. Twelve EAU Sections work on specific goals with both short and long-term strategies. Affiliated partners also include young residents, urologists and those based in the academe.

With leaders of the national societies and the EAU executives recognising that a concrete and sustained response is needed to address core goals, the meeting concluded with the consensus that stronger collaborative initiatives (for example in education, professional standards regulation and research) are necessary to provide the best benefit to patients and also to invigorate, enhance and further support the development and maintenance of European urology as a specialty.

EAU Secretary General Chris Chapple stresses the role of a stronger partnership

Noordwijk: EAU execs, national leaders touch base Fifty-seven out of the nearly 70 invited representatives attended the meeting and have met with the EAU Executive board members on one-on-one ‘speed’ meetings wherein they could put forward specific proposals, issues and concerns regarding education, training, research and professional networking, amongst other issues. Participants were also briefed of the EAU’s core activities such as the EAU History Office, the services of the European Urological Scholarship Programme (EUSP), Patient Information initiatives, and the EAU’s participation and involvement in European Union (EU) forums. Through the Scientific Congress Office (SCO), the national societies also gave their evaluation of and input for the Scientific Programme and organisation of the Annual EAU Congress.

www.eau17.org

Participants discuss their input and expectations for the Annual EAU Congress to be held in London next year

Cutting-edge Science at Europe’s largest Urology Congress Abstract submission now open! Deadline: 1 November 2016

June/July 2016

European Urology Today

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How to improve patient compliance Recurrent stone formers require consistent support and behavioral changes Assist. Prof. Dirk Kok Dept. of Urology Erasmus MC Rotterdam (NL)

General Best care practice Best care practice During Consultation Common Practice Common Practice

d.kok@ erasmusmc.nl

Common Practice Common Practice

Live-Coaching / E-Health Live-Coaching / E-Health Live-Coaching / E-Health Live-Coaching / E-Health Live-Coaching / E-Health Live-Coaching / E-Health

noor.buchholz@ gmail.com

➢ Provide different forms of information material. ➢ Increase of fluid intake as simple, cheap and omnipresent part of the metaphylaxis ➢ Keep the treatment-protocols as simple as possible ➢ Prescribe and adjust treatment-protocols for long-term application

During Follow-up Common Practice

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

➢ Treatment in specialised stone clinics ➢ Close patient-provider relationship

➢ Adjust follow-up intervals to risk of recurrence ➢ Direct and indirect monitoring of patients ➢ Intense information of patients about individual risk, chances and prevention ➢ Information about possible chances and risks ➢ Children, disabled and elderly patients need support from their family/relatives ➢ Repeated and supporting information ➢ Provide visual information, e.g. target diagrams

Table 1: Specific measures for improvement of compliance of stone formers

The most notable hindrance for a good compliance is the nature of urolithiasis itself of which the consequences in the form of colic pain are absent most of the time. Furthermore, the complexity of the The lifetime risk of urolithiasis is about 5-15% medical regimen, the duration of treatment, previous treatment failures, frequent changes in depending on stone type and the severity of the treatment, and the immediacy of beneficial effects underlying causes. An individualised recurrence risk assessment according to EAU Guidelines determines and side effects. Simple protocols result in high whether a patient is at high or low-risk. This includes compliance. stone analysis, medical history and a basic set of Education, monitoring, therapy adjustments and blood and urine analyses. behavioural modification are basic methods to Preventive treatment includes a general diet and improve compliance. Most patients follow treatment more easily if they completely understand the lifestyle advice and adequate urine dilution. advantages for their personal life. Moreover, the High-risk stone-formers require precise metabolic direct or indirect monitoring in terms of ‘pill evaluation for specific metaphylaxis. About 75% of counting’, a medication diary, drug monitoring, patients could thus avoid a stone recurrence. The other 25% of patients require a specific direct physician-patient dialogue and electronic pharmacological intervention depending on their monitoring systems can also be of great use. ‘Cue dosing’, that is, the combination of drug intake with particular risk level1. events in daily routine, the use of alarm clocks, or reminders from relatives or friends, can contribute to However, patient compliance has a major impact on clinical outcome and cost-effectiveness of prevention. improving compliance. Simplifying the therapy, e.g. by using sustained-release preparations or We performed an extended literature research on combination preparations, can equally improve urolithiasis/ metaphylaxis/ compliance. Out of 258 compliance3. hits, 16 relevant papers were analysed. Co-Authors: Hans Martin Fritsche (DE); Montserrat Arzoz-Fabregas (ES)

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

Effective reduction of stone recurrence can be obtained by preventive treatments, the simplest of which is adequate water intake. In a dedicated stone clinic offering personalised treatment plus long-term coaching good results can be maintained long-term. The clinical success depends greatly on the cooperation of the patient. To achieve compliance to a regular intake of a pharmaceutical agent, that agent should ideally be free of side-effects, easy to administer and, most importantly have a proven record for stopping the formation of stones. Compliance to lifestyle changes is a continuous long-term process. Half of all patients do not regularly take their medication2. The patients with low compliance can be separated into four different types: patients who refuse to follow the treatment from the beginning (no starting motivation), those who stop the treatment without advice (dwindling motivation), patients who simply forget to take their medication, and patients who stop the treatment because of adverse reactions or perceived recovery. Efforts to enhance compliance should focus on:

“Compliance to lifestyle changes is a continuous long-term process. Half of all patients do not regularly take their medication.” For interventions intended to change habits and/or lifestyles, the following barriers are especially significant: lack of information and skills for self-management, difficulty with motivation and self-efficacy, as well as lack of support for behavioural changes. Therefore, patients need to be informed, motivated and trained in the use of cognitive and behavioural self-regulation strategies. The attending physician needs to be a motivator, a person to contact, and a person in whom the patient can confide.

Treatment and metaphylaxis of the recurrent stone former present a particularly pertinent challenge. Patient compliance has an immense influence on the success of metaphylaxis, which is the decisive factor for preventing stone recurrence. References 1. Borghi L, Meschi T, Amato F, Briganti A, Novarini A, Giannini A. Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. J Urol 1996; 155:839-43. 2. Sabate E. WHO Report. Adherence to long term therapies, evidence for action. ISBN 92 4 154599 2; Geneva, Switzerland; 2003. p. 7-9. 3. Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, et al. Interventions to enhance medication adherence. Cochrane Database Syst Rev. 2014;11: CD000011.

Acknowledgement: This article is an abbreviated version of an article with the same title submitted to a special edition of the Egyptian Journal of Urology on conservative stone treatment on behalf of EAU-EULIS.

• enhancing the starting motivation (by providing personalised information and advice); • preventing the drop in motivation (by providing continuous coaching); • providing tools to remember patients of their treatment; • reducing side effects by personalisation; and • providing patients with continuous insight into their actual situation. The WHO describes compliance as a ‘multidimensional phenomenon’, which is determined by the interaction system-related factors, social and economic factors, therapy-related, patient-related, condition-related, and healthcare team factors2. Table 1 summarises the specific measures that a physician can take to improve compliance.

EAU Section of Urolithiasis (EULIS)

European Urology Today

The following recommendations can be made to improve the compliance of patients: The cheapest and most sustaining measure should be used first (information about the cause and origin of the disease, and about the risks of recurrence and chances of metaphylaxis), followed by the most effective and least harmful (drinking habits, amount per day, distribution over the day, correct beverages); followed by more ambitious measures for the patient (eating habits and lifestyle changes), and finally medication, which should be as simple as possible to maintain long-term compliance.

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Renal colic and the inconveniences of treatment are quickly perceived to be insignificant, because the level of suffering of a stone-former is assumed to be low in daily life. Patients must be aware of the high likelihood of recurrence. Furthermore, patients must recognise that the only possibility of avoiding or reducing the probability of recurrence is consistent metaphylaxis.

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Update from the Guidelines Office Meetings, trainings and a testimonial Professor Malcolm Lucas The Guidelines Office Board is sad to say goodbye to Mr. Malcolm Lucas, who was previously an exceptional Chairman of the Urinary Incontinence Panel for 6 years and continued afterwards as a Panel Member. We would like to thank him for his unwavering commitment and hard work for Mr. Malcolm Lucas the Guidelines Office, particularly the Urinary Incontinence Panel, and wish him well for the future. Guidelines Office Chairmen Meeting The Guidelines Panel Chairs met with the Guidelines Office Board last May, in Amsterdam. This highly productive meeting, chaired by Prof. Dr. James N’Dow, served as an opportunity to discuss Guidelines activities for the 2017 versions and proposals planned for the coming two to five years. Presentations were given by Prof. Dr. Alberto Briganti on the work of the impact assessment group (IMAGINE), by Prof. Dr. Axel Bex on the work of the newly established consensusfinding committee (CONFIDENCE) and by Prof. Dr. Anders Bjartell on the development and handling of a Conflict of Interest policy for the GO Panel members. (More detailed information of the work of the IMAGINE and CONFIDENCE groups was given in the previous issue of European Urology Today). As always, the meeting served as an opportunity for the Panel Chairs to ask questions of the Board and discuss plans for their Panels over the upcoming years. The Guidelines Board and Panel Chairs will meet next in October in Lisbon.

Guidelines Panel associates training in May in Amsterdam

members during panel meetings. All senior panel members are very open about their personal experiences, are enthusiastic to teach the associates and actively broaden our knowledge of this very interesting discipline.

I am really looking forward to working with a new group of panel associates on this different topic. Every guidelines panel will have their own view on how to address certain clinical questions. Consequently, it will be interesting to work together with a new panel using a standardised approach to evaluate the available literature for their chosen clinical questions.

Over the past two years the guidelines office has provided us with extensive training on developing I am exceptionally thankful to PICOs and the methodology of systematic reviews. The all the members of the Chair of the Guidelines Office, Prof. James N’Dow, in Neuro-Urology Panel for giving partnership with the Guidelines Methods Committee, me the opportunity to chaired by Prof. Richard Sylvester, have been exceptionally supportive. The organised training contribute to their guidelines. Every Neuro-Urology Panel sessions were very inspiring as you were given the meeting aims to identify fields opportunity to meet associates from different panels of interest for clinicians and to and countries. As a result of this you become aware of provide the best quality of the differences in clinical practice which exist, further Lisette ‘t Hoen emphasising the need for the development of clinical evidence for guideline guidelines based on current evidence and not just production. Furthermore, I would also like to thank the Guidelines Office for providing me with the expert opinion. opportunity to become involved with the EAU My next step as a Guidelines Senior Associate has just Guidelines Associates Programme. So far, it has been a highly educational process and I would strongly begun, with a collaboration with the Male Hypogonadism Guidelines Panel. As a Senior Associate recommend becoming involved in the EAU Guidelines Associates Programme to all residents and young my role is to guide the Male Hypogonadism Panel urologists. associates through the systematic review process.

Urology’s future: A key role for National Societies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 EULIS: How to improve patient compliance. . . 2 Update from the Guidelines Office . . . . . . . . . 3 EAU-RF: European Active Surveillance of RCC study (EASE) . . . . . . . . . . . . . . . . . . . . 4 ESFFU: BoNT-A: Treating urinary incontinence in MS patients. . . . . . . . . . . . . . 6 EBU Oral Examination 2016: Congratulations to 291 new FEBU’s!. . . . . . 8-9 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . 10-13

Guidelines Panel Chairs meet with the Guidelines Board

Cutting-edge Science at Europe’s largest Urology Congress

Associate Training In April, the Guidelines Office and the University of Aberdeen Faculty once again co-ordinated a Guidelines Panel Associates Training session (Step 2), which looked into the systematic review methodology in greater detail. The training involved presentations from the Aberdeen faculty in the morning and more practical sessions in the afternoon where the Associates specifically worked on examples of systematic reviews, involving development of the search strategies, abstract and full text screening, data abstraction, risk of bias assessment, data analysis and interpretation.

Apply now and win!

ESU section: 1st ESU-ESUT Masterclass on Operative Management of BPO. . . . . . . . . . . . . . . . . . . 13 Urolithiasis ESU course in Kosovo. . . . . . . . . 17 Association of Ukrainian Urology holds congress in Kiev. . . . . . . . . . . . . . . . . . . . . . 18 ESU e-courses . . . . . . . . . . . . . . . . . . . . . . . 18 Spain exceeds 60,000 kidney transplants in 2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 History office: On the Foundation of Modern Urology. . . . . . . . . . . . . . . . . . . . . . 24 Obituary: Ernst J. Zingg. . . . . . . . . . . . . . . . . 24 Ten questions with Mohan Saheb Gundeti. . . 25 White nights in Tallinn, Estonia. . . . . . . . . . . 26

Lisette ‘t Hoen – My experiences as an EAU Guidelines Office associate In 2013, I became involved in the Neuro-Urology Guidelines Panel as an associate member. When I started, the transition process to standardised evidence-based guidelines had just begun. Thus, the process of identifying and developing relevant PICOs for systematic reviews was novel for the majority of the Neuro-Urology Panel members.

Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 26

Will you be an EAU Award Winner in London?

The Neuro-Urology Guidelines Panel members decided to enlist associates from their own institutes to carry out the various panel-related systematic reviews. Personally, I became involved in the Neuro-Urology Panel, through Prof. Bertil Blok, co-chair of the panel, and my supervisor at the Erasmus Medical Centre Rotterdam.

EAU Crystal Matula Award 2017 For a young promising urologist under the age of 40 who has the potential to become one of the future leaders in academic European urology. National Societies can nominate a candidate for this award or eligible candidates can apply by contacting their national urological society directly.

The Neuro-Urology Panel actively engages all associate members. Upon joining associates are assigned to a specific clinical question (PICO) and begin working on the related systematic review. The systematic reviews ultimately provide the evidence on which guidelines are based. As associates within the Neuro-Urology Panel we were also involved in updating guideline topics which were distinct from our individual systematic review topics. Personally, I found this highly educational and it has been very rewarding to learn from the senior panel

EAU Hans Marberger Award 2017 For the Best Paper published on Minimally Invasive Surgery in Urology. This paper must have been published or accepted for publication between 1 July 2015 and 30 June 2016.

June/July 2016

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

ESUP: 2016 novelties on prostate cancer from the WHO. . . . . . . . . . . . . . . . . . 28 YUO/YAU section: Comprehensive urology training in Madrid. . . 29 EUSP Clinical Visit. . . . . . . . . . . . . . . . . . . . . 29 International relations office: EAU Training Course Ghana . . . . . . . . . . . . . 31 Russian Society of Urology releases online version of journal. . . . . . . . . . . . . . . . 31 104th Congress of the Japanese Urological Association . . . . . . . . . . . . . . . . . 31 European Tour 2016: Academic Exchange Programme . . . . . . . . . . . . . . . . . . . . . . . . . 31 ERUS: Training in robotics . . . . . . . . . . . . . . 32

Deadline: 1 November 2016 For more information, rules and regulations: www.eau17.org/the-congress/awards

www.eau17.org Guidelines Office

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

Baltic16: Prospects in emerging onco-urological treatments. . . . . . . . . . . . . . 27

#EAU17

EAUN section: Perspective from Malta. . . . . . . . . . . . . . . . . EAUN–sponsored project on continence topics. . . . . . . . . . . . . . . . . . . . . Compassion in urological healthcare . . . . . . Nursing in motion . . . . . . . . . . . . . . . . . . . .

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European Urology Today

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European Active Surveillance of RCC study (EASE) European registry to start in Italy, other countries to follow Prof. Alessandro Volpe Assistant Professor of Urology University of Eastern Piedmont Novara (IT) alessandro.volpe@ med.unipmn.it

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

Christien Caris Clinical Project Manager EAU-RF Arnhem (NL)

The secondary objectives are: • to assess growth rate and progression rate of newly diagnosed, incidental, histologically (biopsy) confirmed, <4 cm RCCs that are followed conservatively with serial imaging; • to assess cancer-specific and progression-free survival of patients who are diagnosed with such tumours and are managed conservatively with active surveillance; • to demonstrate that overall survival in this study population is not significantly different compared to the overall survival of the general population without RCC with similar age and co-morbidities; • to identify clinical and pathological prognostic factors of fast growth rate and progression for small RCCs; • to evaluate the correlation of serum and/or urine molecular and genetic markers with growth rate and progression of small RCCs; and • to evaluate the correlation of molecular and genetic markers on needle biopsies of small RCCs with growth rate and progression. Patient selection criteria A total of 400 patients with small, incidentally detected, histologically confirmed RCCs will be included and data related to the oncological outcomes of an active surveillance approach will be collected.

An investigators meeting took place in Munich, during the Annual EAU Congress

Electronic Case Report Form The web-based database management system Marvin will be used for collection of patient data. The system is intuitive and easy to use. Study status Italy is ready to start and the study has been submitted to the ethical committee in the Netherlands. Other countries will follow shortly. Please join us. New sites are welcome!

c.caris@uroweb.org In collaboration with the EAU Research Foundation, Prof. Alessandro Volpe of the University of Eastern Piedmont in Novara, Italy, has started a registry of patients with small, incidentally detected, histologically confirmed renal cell carcinomas who are under active surveillance. During the annual EAU congress in Munich, a very successful investigators meeting took place and a lot of them showed interest in this registry project called the European Active Surveillance of Renal Cell Carcinoma study (EASE). There were representatives from Italy, France, Norway, Finland, United Kingdom, the Netherlands, Denmark, Sweden and Spain and they are keen to participate in this observational registry. Rationale Active surveillance can be considered a reasonable strategy for elderly patients with small renal tumours or patients with significant co-morbidities who are not good surgical candidates. If measurement of tumour growth rate in an active surveillance protocol is helpful for initial conservative management of patients with incidentally diagnosed small renal tumours, it is necessary to identify reliable genetic or molecular serum, urine or tissue markers that can differentiate small renal tumours with inherent aggressiveness and metastatic potential at diagnosis, thereby enabling the urologist to choose the most suitable conservative or active, individualized management approach for the individual patient. The primary objective of this study is to assess the over-all survival of patients who are diagnosed with incidental, histologically (biopsy) confirmed, <4 cm RCC and are managed conservatively with active surveillance.

If you are interested in participating, please contact the EAU Research Foundation on researchfoundation@uroweb.org.

One of the patient selection criteria is a renal tumour of ≤ 4 cm

Study procedures A percutaneous biopsy of the renal mass will be performed in all cases to histologically confirm the diagnosis of RCC. Biopsies will be carried out under local anaesthesia with ultrasound or CT guidance. At baseline, information is collected on demographics, medical history, tumour-related symptoms, performance status and use of concurrent medications. A physical examination is performed, BMI is calculated and blood and urine are collected. Abdominal imaging will be performed by CT or, in case of contrast allergy or abnormal serum creatinine, by US or MRI. All patients will follow an active surveillance protocol as agreed by the attendees of this investigators meeting. Follow-up visits will be scheduled three and six months after diagnosis, every six months up to three years and yearly thereafter, until 10 years of follow up. A follow-up visit will also be carried out at the time of progression when it occurs. Follow-up visits will include medical history and physical examination, and assessment of concurrent medications, Charlson comorbidity index, ECOG performance status, EORTC QLQ-C30 questionnaire, BMI, blood and urine analysis and serial abdominal imaging. Voided urine and blood samples, as well as tumour tissue, will be collected and stored for future analysis of molecular and genetic markers.

Study team Principal Investigator: Alessandro Volpe, mailaddress: ale.volpe@me.com Assistant Professor of Urology University of Eastern Piedmont Novara, Italy

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 2016! For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website http://www.uroweb.org/education/scholarship/

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European Urology Today

The web-based database management system Marvin will be used for collection of patient data

EAU Research Foundation Wim Witjes, Scientific and Clinical Research Director Christien Caris, Clinical Project Manager Joke van Egmond, Clinical Data Manager

European Urological Scholarship Programme (EUSP)

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June/July 2016


Cutting-edge Science at Europeâ&#x20AC;&#x2122;s largest Urology Congress

#EAU17

32nd Annual EAU Congress Abstract submission deadline: 1 November 2016

www.eau17.org June/July 2016

European Urology Today

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BoNT-A: Treating urinary incontinence in MS patients What are the benefits of choosing 100 U or 200 U? Prof. Emmanuel Chartier-Kastler Dept. of Urology Academic Hospital Pitié-Salpétrière Paris (FR) emmanuel. chartier-kastler@ aphp.fr

Dr. Salima Ismail Dept of Urology Academic Hospital Pitié-Salpétrière Paris (FR)

ismail.salima@ gmail.com Overactive bladder symptoms are the most frequently reported urinary symptoms in multiple sclerosis (MS) patients. Urgency, frequency and urge urinary incontinence have been reported in 38-99%, 26-82% and 27-66% of these patients, respectively1. Anticholinergics remain the first line therapy for these symptoms2–4, despite the limited evidence of their efficacy in MS patients(1). Eventually, anticholinergics may become inefficient or not tolerated, and second-line therapy may be needed4-7. Combination of anticholinergic drugs is one option. Since 2012, intradetrusor injections of Onabotulinum toxin A (BoNT-A) have been accredited in several countries as a treatment for refractory urinary incontinence related to neurogenic detrusor overactivity (NDO)1. An initial dose of 200 U8 to 300 U2,4,5 of BoNT-A is usually administered in NDO cases. In 2005, Schurch et al.9 presented the results of their randomised, placebo-controlled, 24-week study in which 59 patients with urinary incontinence caused by NDO were included. Out of these 59 patients, 53 had a spinal cord injury (SCI) and 6 had MS. All were on clean intermittent catheterisation (CIC) at the beginning of the study and were randomised in three groups: placebo, 200 U and 300 U of intradetrusor BoNT-A injections. Compared to baseline, patients in both treatment groups had a significant decrease in incontinence episodes post treatment (p≤0.05), which was not the case in the placebo group. Catheterisation frequency remained mostly stable in all three groups for the duration of the study. The first large, multicenter, randomised, placebocontrolled, phase 3 study was published by Cruz et al.2, in 2011. A total of 275 patients (154 MS and 121 SCI patients) with urinary incontinence due to NDO were included. Randomisation groups were the following: placebo, 200 U and 300 U of BoNT-A. Mean EDSS scores in these three groups were 5.1 ± 1.3, 4.9 ± 1.5 and 5.1 ± 1.5, respectively. Patients were followed for ≥ 52 weeks. The proportions of patients that were completely dry at six weeks were 7.6% in the placebo group, 38.0% in the 200 U group and 39.6% in the 300 U group. More specifically, among MS patients, 12.0%, 43.4% and 41.2% of patients were completely dry in the placebo, 200 U and 300 U BoTN-A groups, respectively. De novo CIC rates were the following: 12% in the placebo group, 30% in the 200 U group, and 42% in the 300 U group. Decision to begin CIC was based on the investigator’s clinical judgment. A phase 3, 52-week, international, randomised, placebo-controlled trial evaluated the efficacy and tolerability of BoNT-A for urinary incontinence from NDO. In this study, 416 patients (227 with MS and 189 with SCI) were randomised to receive 200 U or 300 U BoNT-A or placebo. For MS patients, mean total EDSS score was 5.1 ± 1.3. At six weeks, the change from baseline in urinary incontinence was of -30%, -67% and -74% in the placebo, 200 U and 300 U of BoNT-A groups respectively. Moreover, 36% of patients were completely dry in the 200 U group compared to 41% in the 300 U group. Among patients who were not on CIC at baseline, CIC had to be initiated in 10% of patients in the placebo group, 35% of patients in the 200 U group and 42% of patients in the 300 U group. EAU Section of Female and Functional Urology

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European Urology Today

Decision to begin CIC was based on each investigator’s assessment7. Ginsberg et al.8 pooled data from the abovementioned last two studies in order to evaluate the efficacy and safety of intradetrusor BoNT-A injections in MS and SCI subpopulations. Among a total of 691 patients, 381 patients had MS and 310 patients had a SCI. At six weeks, among the MS group, dry rates were of 10.7% in the placebo group, 41.5% in the 200 U group and 44.2% in the 300 U group. In SCI patients, dry rates were of 7.3%, 30.9% and 35.9% in the placebo, 200 U and 300 U groups, respectively. Mean delay, upon patient’s request, for retreatment were 295 (200 U group) and 307 days (300 U group) among MS patients, compared to 253 (200 U group) and 211 (300 U group) days among SCI patients. Urinary retention rates in MS patients correlated with the dose of the received treatment as de novo CIC was necessary in 31.4% and 47.1% of patients in the 200 U and 300 U groups, respectively.

"The initial dosage of intradetrusor BoNT-A injections in MS patients must be chosen according to the desired goal, the severity of disease that patients suffer and CIC use." Although MS patients were included in the above-mentioned studies, it must be noted that the lower urinary tract dysfunction in MS is different from the one in SCI and that therefore, the bladder drainage management are also different. Indeed, in Cruz et al.’s2 study, before receiving intradetrusor BoNT-A injections, only 21.4% of MS patients were on CIC compared to 91.6% of SCI patients. In a study performed by Kalsi et al.6 in 43 MS patients treated with 300 U of intradetrusor BoNT-A, 98% had to perform CIC after treatment compared to 65% before treatment. Therefore in MS patients, one may consider administering a lower initial dose of BoNT-A in order to decrease the possible need to perform CIC5.

U BoNT-A compared to 31.4%8 for 200 U BoNT-A injections. The 100 U BoNT-A dose seems a like a logical choice in patients who are not on CIC as it has an excellent continence rate and it maximises their chances to continue voiding spontaneously. All in all, the adequate dosage of BoNT-A in MS patients should be chosen based on the physicianpatient informative discussion, the EDSS level and on whether or not the patients are already practicing CIC. Without any doubt, MS patients may greatly benefit from BoNT-A injection for urinary incontinence if they fail first-line therapy. References: 1. Phé V, Chartier-Kastler E, Panicker JN. Management of neurogenic bladder in patients with multiple sclerosis. Nat Rev Urol. 2016 May;13(5):275–88. 2. Cruz F, Herschorn S, Aliotta P, Brin M, Thompson C, Lam W, et al. Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: a randomised, double-blind, placebo-controlled trial. Eur Urol. 2011 Oct;60(4):742–50. 3. Cameron AP. Pharmacologic therapy for the neurogenic bladder. Urol Clin North Am. 2010 Nov;37(4):495–506. 4. Karsenty G, Denys P, Amarenco G, De Seze M, Gamé X, Haab F, et al. Botulinum toxin A (Botox) intradetrusor injections in adults with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review. Eur Urol. 2008 Feb;53(2):275–87. 5. Mehnert U, Birzele J, Reuter K, Schurch B. The effect of botulinum toxin type a on overactive bladder symptoms in patients with multiple sclerosis: a pilot study. J Urol. 2010 Sep;184(3):1011–6. 6. Kalsi V, Gonzales G, Popat R, Apostolidis A, Elneil S, Dasgupta P, et al. Botulinum injections for the treatment of bladder symptoms of multiple sclerosis. Ann Neurol. 2007 Nov;62(5):452–7. 7. Ginsberg D, Gousse A, Keppenne V, Sievert K-D, Thompson C, Lam W, et al. Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. J Urol. 2012 Jun;187(6):2131–9. 8. Ginsberg D, Cruz F, Herschorn S, Gousse A, Keppenne V,

Intradetrusor BoNT-A injection studies exclusively on MS patients are scarce. Two studies evaluated the efficacy of 100U BoNT-A in MS patients. Mehnert et al.5 conducted a pilot study in which 12 patients with multiple sclerosis and overactive bladder symptoms such as urgency, frequency and/or urgency incontinence were treated with intradetrusor injections of 100 U BoNT-A. The follow-up time was of 12 weeks and the mean EDSS score was of 5.0 ± 1.5. A continuous drop of the mean number of incontinence episodes was noted, but this difference was not significant. Chartier-Kastler et al. , in a 52-week study, randomised 144 spontaneously voiding MS patients, with urinary incontinence secondary to NDO, to receive BoNT-A or placebo. The mean EDSS score was 4.7 ± 1.4. Results showed that patients treated with 100U of intradetrusor BoNT-A had a significant and clinically meaningful improvement in incontinence, urodynamic parameters and quality of life. In fact, 53% of patients in the treatment group were completely dry at six weeks compared to 10.3% in the placebo group. At the end of the study, CIC rates in the treatment and placebo groups were 15.2% and 2.6%, respectively. Criteria for initiating CIC was when one the following criteria was met: post void residual volume ≥ 350 ml regardless of symptoms or post void residual volume ≥ 200 ml and < 350 mL with associated symptoms.

As for the intradetrusor 100 U BoNT-A injections, the continence rate (53%)10 is close to the 200 U BoNT-A continence rate (41.5%)8 in MS patients. However, the de novo need of CIC rate is only 15.2%10 for 100

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At the light of these studies, the initial dosage of intradetrusor BoNT-A injections in MS patients must be chosen according to the desired goal and to the severity of disease that patients suffer. In the cited studies, the EDSS scores were similar as they ranged from 4.7 ± 1.4 to 5.1 ± 1.52,7,10. There is clearly no advantage administering 300 U of BoNT-A compared to 200 U when only considering urinary continence in spontaneously voiding patients. Indeed, continence rates are similar (36-41.5% for 200 U vs. 39.6-44.2% for 300 U), but the de novo need of CIC increases significantly with dosage (30-35% for 200 U vs. 42-47.1% for 300 U)2,7,8.

Aliotta P, et al. OnabotulinumtoxinA is effective in patients with urinary incontinence due to neurogenic detrusor overactivity [corrected] regardless of concomitant anticholinergic use or neurologic etiology. Adv Ther. 2013 Sep;30(9):819–33. 9. Schurch B, de Sèze M, Denys P, Chartier-Kastler E, Haab F, Everaert K, et al. Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomised, placebo controlled 6-month study. J Urol. 2005 Jul;174(1):196–200. 10. Chartier-Kastler E, Denys P, Keppenne V, Brucker B, Egerdie B, Magyar A, et al. Efficacy and safety of OnabotulinumtoxinA 100U for treatment of urinary incontinence due to neurogenic detrusor overactivity in non-catheterising multiple sclerosis patients. EAU 2016 meeting; Munich, Germany.

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EBU Oral Examination 2016: Congratulations to 291 new FEBU’s! Venues & Candidates

Board of Examiners

• Brussels: 240 candidates • Budapest: 4 candidates • Warsaw: 47 candidates

• Brussels: 70 urologists • Budapest: 4 urologists • Warsaw: 25 urologists

IMPORTANT DATES EBU Online Written Examination: 18 November 2016 EBU In-Service Assessment: 9 & 10 March 2017 EBU Oral Examination: 3 June 2017

Visit www.ebu.com for more information

Average score per country Austria 6 Belgium 8 Croatia 9 Czech Republic 6 Denmark 9 Finland 6 France 8 Germany 8 Greece 7 Hungary 8 Italy 7

The Netherlands 8 Poland 8 Portugal 7 Romania 8 Slovakia 6 Slovenia 7 Spain 7 Sweden 8 Turkey 7 United Kingdom 8 Pass rate: 91%

Examiners & Trustees Brussels I. Adamakis A. Antoniewicz, Chairman EBU Examination Committee J. Bellringer F. Birkhäuser G. Bogaert G. Bonkat M. Çek J. Comet Battle C. Conde Redondo C. Cracco B. Da Costa Parada P. Daly T. De Reijke J. Domínguez Escrig H. Erol A. Figueiredo

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F. Fusco S. Giannakopoulos Á. Gómez-Ferrer Lozano M. Gunst M. Heuser W. Hochreiter J. Hofbauer S. Hruby C. Imbimbo J. Jepsen H.C. Klingler E. Lledo García C. Mamoulakis M. Marszalek L. Martínez Piñeiro S. Mattocks J. Mayor de Castro R. Molina Escudero

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C. Saussine S. Siracusano S. Sözen A. Strauß A. Symes S. Tekgül P. Temido D. Tilki V. Tzortzis E. Van der Horst J. Van Moorselaar K. Van Renterghem F. Villacampa Aubá N. Von Ostau S. Walter P. Whelan A. Wille T. Zellweger

Budapest Z. Bajory T. Flaskó P. Nyirády Warsaw A. Antczak T. Borkowski B. Darewicz T. Demkow P. Dobronski J. Dobruch T. Drewa Z. Jabłonowski A. Kołodziej P. Kryst M. Lipinski M. Matuszewski

J. Matych P. Radziszewski M. Roslan W. Rózanski A. Sikorski M. Słojewski M. Sosnowski T. Szopinski T. Szydełko Z. Wolski S. Wronski R. Zdrojowy H. Zielinski

June/July 2016


Successful candidates EBU Oral Examination 2016 Brussels (urologists) Feras Al Jaafari, United Kingdom Maarten Albersen, Belgium Ignacio Alcojor Ballesteros, Spain Mahmud Saladin Helmut Alloussi, Germany Tarik Almdalal, Sweden Manuel Alvarez Ardura, Spain Osama Andura, Germany Berber Arbeel - Weening, The Netherlands Harm Christiaan Arentsen, The Netherlands Muhammad Zeeshan Aslam, United Kingdom Abdulaziz Bakhsh, Germany

Victor Basset, France Andreas Becker, Germany Roland Becker, Germany Igor Bláha, Spain Martin Wilhelm Heinrich Bögemann, Germany Romain Boissier, France Kliment Bonev, United Kingdom Johannes Bründl, Germany Roberto Carando, Switzerland Marcello Casuscelli, Spain Kostas Chondros, Greece Frederique Cohnen - Van Ravesteyn, The Netherlands Beatriz De La Cruz Martín, Spain

Tiago De Moura Olival De Mendonça, United Kingdom Liesbeth De Wall, The Netherlands Mutlu Deger, Turkey Virginia Del Rosario Rodríguez, Spain Dimitrios Deligiannis, Greece Erwin Denies, Belgium Thomas Deuchert, Germany Tina Dieckmann, Germany Konstantinos Dimitropoulos, Greece Tünkut Doganca, Turkey Tamer Elhusseiny, United Kingdom Barbara Erber, Germany Begoña Etcheverry Giadrosich, Spain Alexandros Fiamegkos, Greece Ioannis Galanos, Greece Héctor Garde García, Spain Johannes Gärtner, Germany Vitalie Gherman, Romania Carmen Gomez Del Cañizo, Spain Pablo Gómez Lechuga, Spain Antonio Guijarro Espadas, Spain Ingrid Guiote Partido, Spain Katrin Harrer, Germany Isabel Maria Heidegger, Belgium Santiago Henao Macaya, Spain Vital Hevia Palacios, Spain Michaela Hilburger, Germany Thomas Horn, Germany Philipp Markus Huber, Switzerland Savu-Nicolas Iordan, United Kingdom Annika Carina Jendryan, Germany Pablo Jimenez Marrero, Spain Isabel María Jiménez-Valladolid De L'HotellerieFallois, Spain Daniel Jonas, Germany Patroklos Ioannis Katafygiotis, Greece Seyed Ehsan Khaljani, Germany Rehan Sohail Khan, United Kingdom Fuat Kizilay, Turkey Henrik Kjölhede, Sweden Christian Kories, Germany Antonios Koudonas, Greece Christina Kountidou, Germany

June/July 2016

Jennifer Kranz, Germany Maartje Kuenen, The Netherlands Peter Kolja Kvist, Denmark Michael Ladurner, Austria Vladimír Lenko, Slovakia Utku Lokman, Turkey Victor Lucian Madan, Romania Mia Gebauer Madsen, Denmark Amr Mahmoud, Germany Luis Guillermo Martinez Bustamante, Slovenia Natália Nikolaevna Mashanova Martins, Portugal Odilo Maurer, Germany

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João Rodrigues De Jesus Ferreira Cabral, Portugal Percy Miguel Rodriguez Castro, Spain Marta Rodriguez Izquierdo Jimenez, Spain Ana Margarida Rolim Meirinha, Portugal Daniel Roberto Salas Chavez, Spain Pol Servián Vives, Spain Sabina Sevcenco, Austria Tobias Simpfendörfer, Germany Georg Stiendl, Austria Elena Stojkova Gafner, Switzerland Natalia Swietek, Austria Hendryk Tech, Germany

Samuel Méndez Ramírez, Spain Dubravko Mišic, Croatia Fabio Monni, Switzerland Nikolaos Mourmouras, Greece Belal Mousa, Sweden Sandra Mühlstädt, Germany Tobias Nordström, Sweden Christian Offermanns, Germany Altan Elvis Omer, Romania Anders Joakim Örtegren, Sweden Zdenek Otava, Czech Republic Puck Oude Elferink, The Netherlands Vlad Pantea, Germany Athanasios or Thomas Pappas, Greece Karen Patberg, Germany Ioannis Perdikis, Greece Emre Can Polat, Turkey Alicia Martin Poulsen, Denmark Ignacio Puche Sanz, Spain Miha Pukl, Slovenia Edgar Gregorio Rodríguez Ramírez, Spain Ramón Rogel Bertó, Spain Luis Miguel Romero Vargas, Spain Dimitrios Rompolis, Greece Roberto Rosini, Italy Erkin Saglam, Turkey Jehad Saidi, Germany Jouren Kristin Schadendorf, Germany Gabriel Schell, Switzerland Eckhard Johannes Schenk, Germany Lydia Schilchegger, Germany Johannes Boris Schmidt, Germany Tammy Smeenk, Belgium Marios Stavropoulos, Greece Isabella Syring, Germany Thomas Tailly, Belgium Antoine Emile Jean Teyrouz, Spain Dan-Petre Tica, France Marloes Tijnagel, The Netherlands Miriam Traumann, Germany Maaike Van de Kamp, The Netherlands Hannes Van Den Bossche, Belgium Saskia Van der Meer, The Netherlands Suresh Venugopal, United Kingdom Ville Virta, Finland Marie-Louise Vrang, Denmark Joachim Christian Weißflog, Germany Aristeidis Zacharis, Greece Christopher Ziesel, Germany

Muhammad Elmussareh, United Kingdom Pieter Jan Elshout, Belgium Ümit Eskidemir, Turkey Otto Ettala, Finland Vanessa Fenner, Switzerland Beat Förster, Switzerland Toni Franz, Germany Verena Freier, Germany Cathaysa Fumero Gorrín, Spain José Horacio García Rubio, Spain Gabriele Gaziev, Italy Nicolas Geurts, Belgium Helena Gimbernat Díaz, Spain Alba Gomáriz Camacho, Spain

Çagrı Tekdös, Turkey Paolo Umari, Italy Carl Van Haute, Belgium Janneke Van Uhm, The Netherlands Jan Vašinka, Czech Republic Thomas Von Rütte, Switzerland Matthias Walter, Switzerland Sam Ward, Belgium Christian Wetterauer, Switzerland Michel Wyndaele, Belgium Aiman Dany-Jan Yassin, Germany Barbara Ysebaert, Belgium Fabio Zattoni, Italy

Enrique Gomez Gomez, Spain Jost Graf Von Hardenberg, Germany Beatrix Grewe, Germany Giovanni Grimaldi, Italy Annaeva Grimm, Germany Srood Hanna, Sweden Michaël Henderickx, Belgium Manuela Hieß, Austria Satoshi Hori, United Kingdom Julian Hoven, Germany David Hradil, Czech Republic Alessandro Izzo, Italy Daniel Juchem, Germany Andrés Koey Kanashiro Azabache, Spain Tuomas Kilpeläinen, Finland Anne-Sophie Knipper, Germany Olivia Köhle, Austria Katharina Kolarik, Austria Marie-Christine Kuhl, Germany Beatriz La Iglesia Lozano, Spain Kay Niklas Liebig, Germany Tilman Lüdert, Germany Brussels (residents)* Philipp Maletzki, Switzerland (status 11-6-2016) Michał Maciej Malkowski, Germany Reinhard Aigner, Austria Altaf Mangera, United Kingdom Ghalib Al Badaai, France Michele Manica, Italy Adam Alleemudder, United Kingdom Rajendar Reddy Marri, United Kingdom Emanuela Altobelli, Italy Hugo Martins Pires Coelho, Portugal Lorenzo Angelini, Italy Laura Mateu Arrom, Spain Nuno José Araújo Abreu Fidalgo de Oliveira, Portugal Grégoire Mayor, Switzerland Ana Arrébola Pajares, Spain Christian Meyer, Germany António Rui Azevedo Freitas, Portugal Leonardo Misuraca, Italy Frederic Baekelandt, Belgium François-Xavier Nouhaud, France Tereza Balajková, Czech Republic Soraia Nunes Viveiros Rodrigues, Portugal Jörg Bauer, Germany Timo Nykopp, Finland Daniel Alexandre Israel Benamran, Switzerland María Yanira Ortega González, Spain Nathalie Biemold, The Netherlands Renan Javier Otta Oshiro, Spain Ahmet Bindayi, Turkey Armando Jorge Pereira Dias, Portugal Stefan Buchner, Austria Ricardo Manuel Pereira E Silva, Portugal Oriol Calaf Perisé, Spain Amelia Pietropaolo, Italy Edgar Miguel Calvo Loureiro Tavares Da Silva, Portugal Praveen Lakshmanan Pillai, United Kingdom Cristina Cámara Moreno, Spain Lucas Regis Plácido, Spain Isaac Leandro Campos Braga, Portugal Ahmed Abu-Bakr Riaz, Pakistan

Warsaw Krzysztof Balawender Piotr Belda Radosław Biernacki Krzysztof Bukowski Justyna Buras - Pitek Marcin Chtiej Magdalena Chudzian Łukasz Dacko Łukasz Dołowy Bartłomiej Dymek Michał Fryczkowski Natalia Gacuta Maciej Głuszko Marcin Gnyp Jacek Jakubowski Zachar Karakoz Wiktor Kepa Jakub Kłacz Michał Kups Wojciech Lewandowski Joanna Lisowska Marcin Łykowski Łukasz Madry Karol Moskal Tomasz Mutrynowski Jacek Ornat Tomasz Pawlin Grzegorz Pedzisz Krzysztof Pekala Wojciech Połom Jan Powroznik Rafał Przybyła Michał Puszynski Przemysław Rzepecki Paweł Samocik Witold Smolenski Tomasz Suchojad Bartosz Sutkowski Michał Swolkien Michał Szlaga Norbert Szydłowski-Pesko Magdalena Walerys Tomasz Wiatr Adam Wojciechowski Łukasz Wójcik Dominik Wojtkowiak Krzysztof Wozniak Paweł Wozniak Aleksandra Zemłai

Budapest Judit Csapó Anikó Hajdu Viktor Varju József Zoltán Kiss

*) Final-year residents have received a provisional diploma which states that the holder will obtain the FEBU diploma, and can use the FEBU title when he/she is certified as a urologist.

European Urology Today

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

The authors searched the Cochrane Kidney and Transplant Specialised Register to 21 September 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Randomised controlled trials (RCTs) of susceptible patients (e.g. past history of UTI) or healthy people in which any strain, formulation, dose or frequency of probiotic was compared to placebo or active comparators were included.

tebj@medisin.uio.no

Risk factors and UTI following radical cystectomy The objective of this study was to evaluate clinicopathologic features associated with the risk of urinary tract infection (UTI) after radical cystectomy (RC), and determine the underlying organisms responsible for these events. The authors reviewed 1,248 patients treated with RC for bladder cancer from 2000-2010 at Mayo Clinic. UTIs diagnosed within 90 days of surgery were recorded. Multivariable logistic regression analysis was performed to evaluate the association of clinicopathologic features with postoperative UTI. UTI was diagnosed in 129 (10.3%) patients within 90 days of RC. Median time to UTI was 22.5 days (IQR 14,42).

All RCTs and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) looking at comparing probiotics to no therapy, placebo, or other prophylactic interventions were included. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes. Nine studies that involved 735 people were included in this review. Four studies compared probiotic with placebo, two compared probiotic with no treatment, two compared probiotics with antibiotics in patients with UTI, and one study compared probiotic with placebo in healthy women.

There was limited information on harm and mortality with probiotics …diabetes, PBT, continent diversion, and no evidence on the impact of and urine leak were associated with probiotics on serious adverse events UTI risk following RC On multivariable analysis, factors associated with a significantly increased UTI risk were diabetes (OR 2.; p < 0.001), receipt of a perioperative blood transfusion (PBT) (OR 1.58; p = 0.03), continent urinary diversion (OR 2.17; p < 0.001), and development of a urine leak (OR 3.42; p < 0.001). Culture-specific infection data were available for 88 of the patients, with a total of 113 UTIs diagnosed among this cohort. Of these, 36.8% of UTIs were polymicrobial. Drug-resistant S. aureus and Enterococcus were isolated in 45.0% and 12.8% of infections, respectively. Fungal elements were present in 27 (23.9%) cultures, and were the sole organism in 15 (13.3%). No significant differences in microbial distribution or timing of infections were detected between patients who underwent conduit versus continent diversion. It is concluded that diabetes, PBT, continent diversion, and urine leak were associated with UTI risk following RC. Multiple organisms, drug-resistance, and fungal elements were commonly identified, supporting the use of initial broad-spectrum coverage, including consideration of anti-fungal therapy, upon diagnosis of UTI after RC.

Source: Risk Factors and Microbial Distribution of Urinary Tract Infections Following Radical Cystectomy.Parker WP, Toussi A, Tollefson MK, Frank I, Thompson RH, Zaid HB, Thapa P, Boorjian SA. Urology. 2016 Apr 25.

Probiotics for preventing urinary tract infections Since probiotic therapy is readily available without a prescription, a review of their efficacy in the prevention of UTI may aid in making decisions about potential prophylactic therapy. The objectives of the present study were to answer the following questions: • Compared to placebo or no therapy, did probiotics (any formulation) provide a therapeutic advantage in terms of morbidity and mortality, when used to prevent UTI in susceptible patient populations? • Compared to other prophylactic interventions, including drug and non-drug measures (e.g. continuous antibiotic prophylaxis, topical oestrogen, cranberry juice), did probiotics (any formulation) provide a therapeutic advantage in terms of morbidity and mortality when used to prevent UTIs in susceptible patient populations? Key articles

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All studies aimed to measure differences in rates of recurrent UTI. Most studies had small sample sizes and reported insufficient methodological detail to enable robust assessment. Overall, there was a high risk of bias in the included studies which lead to inability to draw firm conclusions and suggesting that any reported treatment effects may be misleading or represent overestimates. No significant reduction in the risk of recurrent symptomatic bacterial UTI was found between patients treated with probiotics and placebo (6 studies, 352 participants: RR 0.82, 95% CI 0.60 to 1.12; I2 = 23%) There were wide confidence intervals, and statistical heterogeneity was low. No significant reduction in the risk of recurrent symptomatic bacterial UTI was found between probiotic and antibiotic treated patients (1 study, 223 participants: RR 1.12, 95% CI 0.95 to 1.33). Current evidence cannot rule out a reduction or increase in recurrent UTI in women with recurrent UTI who use prophylactic probiotics. The most commonly reported adverse effects were diarrhea, nausea, vomiting, constipation and vaginal symptoms. Two studies reported study withdrawal due to adverse events and the number of participants who experienced at least one adverse event. One study reported that withdrawal occurred in six probiotic participants (5.2%), 15 antibiotic participants (12.2%), while the second study noted that one placebo group participant discontinued treatment due to an adverse event. There was limited information on harm and mortality with probiotics and no evidence on the impact of probiotics on serious adverse events.

Source: Probiotics for preventing urinary tract infections in adults and children. Erin M Schwenger, Aaron M Tejani, Peter S Loewen First published: 23 December 2015. Editorial Group: Cochrane Kidney and Transplant Group DOI: 10.1002/14651858.CD008772.pub2

A retrospective analysis of inpatients with paired positive urine cultures was performed. The authors focused on ciprofloxacin-resistant (cipro-r) Gramnegative bacteria, extended-spectrum beta-lactam (ESBL)-producing Enterobacteriaceae, carbapenemresistant Enterobacteriaceae (CRE) and carbapenemresistant non-fermenters (CRNF). Comparisons were made between frequency of each resistant phenotype following a previous culture with the same phenotype and overall frequency of that phenotype and odds ratios (OR) were calculated. A regression to assess the effects of other variables on the likelihood of repeated resistant culture was performed. A total of 4,409 patients (52.5% women, median age 70 years) with 19,546 paired positive urine cultures were analyzed.

…knowledge of microbiology results in the six preceding months may assist antibiotic stewardship and improve appropriateness of empirical treatment for UTIs

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com overexpression when comparing pTa-Pt1 tumours with pT2-pT4 tumours. MMP-11, FAP, ADAM12 and MMP-9. These were then evaluated in an independent cohort comprising 635 consecutively treated cases (340 upper tract tumours and 265 bladder cancer). Immunohistochemistry was used to stain for expression of the five proteins and immunostaining was blindly examined by two pathologists and dichotomised into high and low expression by the median score.

The median follow-up was 31.7 months (range 1-175.8) and during the time 60 patient with upper tract tumours and 52 with bladder cancer died of disease and a further 70 patients treated for upper tract cancer developed metastasis along with 76 of The frequency of cipro-r, ESBL, CRE and CRNF the bladder cancer cohort. MMP-11 expression was amongst all cultures were 47.7%, 30.6%, 1.7% and associated with higher pathologic stage (p<0.001) 2.6%, respectively. ORs for repeated resistant phenotype were 1.87, 3.19, 48.25 and 19.02 for cipro-r, amongst the upper tract tumours as well as the presence of lymph node metastasis (p<0.001), ESBL, CRE and CRNF, p < 0.001 for all. At one month, vascular invasion (p<0.001) and perineural invasion the frequency of repeat resistance phenotype was 77.4%, 66.4%, 57.1% and 33.3% for cipro-r, ESBL, CRE (p=0.002). In the bladder cancer groups very similar results were observed with higher MMP-11 and CRNF, respectively. expression associated with higher pathologic stage Increasing time between cultures and the presence of (p<0.001), lymph node metastasis (p=0.012), high grade (p=0.001), vascular invasion (p<0.001), an intervening non-resistant culture significantly perineural invasion (p-0.006) and higher mitotic reduced the chances of repeated resistance. index (p=0.023). In multivariate Cox regression Associations were statistically significant over the analyses, which adjusted for standard duration of follow-up (60 months) for CRE and up to clinicopathologic characteristics, MMP-11 expression six months for all other pathogens. was independently associated with cancer-specific mortality (hazard ratio [HR] in upper tract tumours: The investigators concluded that knowledge of microbiology results in the six preceding months may 3.027, p=0.005; in bladder cancer: 2.631, p=0.010) and with metastasis development (HR in upper tract assist antibiotic stewardship and improve tumours: 2.261, p=0.018; in bladder cancer: 1.801, p= appropriateness of empirical treatment for UTIs. 0.026).

Source: Predicting antibiotic resistance in urinary-tract infection patients with prior urine cultures. Dickstein Y, Geffen Y, Andreassen S, Leibovici L, Paul M. Antimicrob Agents Chemother. 2016 May 23

Predicting poor outcomes in urothelial carcinomas

This study showed tissue expression of MMP-11 was independently associated with metastasis-free survival and disease-specific survival and this correlated with aggressive pathologic features. It might serve as a valuable biomarker especially if it could allow us to identify which high grade superficial tumours would progress to muscle invasive or metastatic tumours.

Source: Matrix metalloproteinase-11 as a marker of metastasis and predictor of poor survival in urothelial carcinomas. Li W-W, Wei Y-C, Huang C-N et al.

Despite radical surgery patients with muscle invasive urothelial carcinoma develop metastatic disease in up to 40% of cases. Tumour invasion and metastasis are J. Sur. Oncol. 2016; 113:700-707. multi-stage processes, including growth, local proteolysis, and migration of tumour cells through the degraded connective tissue. All these steps involve interaction with the extracellular matrix (ECM). Matrix metalloproteinases (MMPs) are zinc-dependent proteolytic enzymes, which break down the ECM and regulate cytokine and growth factor activity. As a consequence they play a critical role in cancer progression. Review of a transcription profiling database suggested matrix metalloproteinase 11 (MMP-11) was highly expressed in advanced-stage urothelial carcinomas, suggesting a role for this protease in cancer progression. This paper analysed MMP-11 expression and its associations with clinicopathologic factors and survival in a wellcharacterised cohort

Patient choices affect by travel Patients’ choice of prostate cancer treatment is influenced by differences in efficacy, toxicity and how the patient views the acceptability of the risks involved. Surgery and radiotherapy are both acceptable treatment options for localised disease. This study evaluated if there was any evidence to suggest this affected the treatment patients elected to undergo.

Patients were less likely to receive This study showed tissue expression radiation compared with surgery the farther they lived from the treatment of MMP-11 was independently facility. These trends were also associated with metastasis-free Predicting antibiotic resistance survival and disease-specific present when each risk group was in UTI patients with prior urine survival and this correlated with analysed cultures aggressive pathologic features In order to improve antibiotic prescribing, the investigators of this paper sought to establish the probability of a resistant organism in urine culture given a previous resistant culture in a setting endemic for MDRs.

Using the Gene Expression Omnibus plus Array analysis of 93 bladder cancer specimen’s and looking for enhanced gene expression (at least 100x) five genes were identified as showing significant

Using the National Cancer Database 222,804 patients with cT1-T3aN0M0 prostate cancer and treated with radical prostatectomy (surgery) external beam radiation therapy or brachytherapy (radiotherapy) were assessed. Multivariable logistic regression was used to determine whether radical distance to the

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Dr. Francesco Sanguedolce Section editor London (UK)

This study suggested that failure to get a good early PSA response might suggest resistance to the new androgen receptor-pathway inhibitors. The percentage of primary resistance in the pre-docetaxel setting is reported to be < 20% for all three agents. Identification of patients with early resistance to treatment may have an impact on clinical practice. Understanding the mechanism of resistance may aid in the development of new drugs or drug combinations.

fsangue@ hotmail.com

Value of the control group in the PLCO Prostate Cancer Screening Trial Published in 2009, the American PLCO trial did not show any survival difference favouring prostate cancer screening based on PSA testing. The primary outcome was the prostate cancer mortality. Findings from this randomised controlled trial were counterbalanced by those reported in the European ERSPC trial.

treating facility influenced the rate of receipt of radiation therapy rather than surgery (Table 1). Patients were considered to be living in rural counties if the population was less than 2,500.

Sources: Early PSA response is an independent prognostic factor in patients with metastatic castration-resistant prostate cancer treated with next-generation androgen pathway inhibitors. The updated results from ERSPC trial with a follow-up Fuerea A, Baciarello G, Patrikidou A et al.

Table 1: Distance to treatment facility and likelihood of radiation treatment

Eur J Cancer 2016; 61: 44-51.

% of men receiving radiation

AOR (95% CL)

p

Distance

Urban (218,148)

0-5 miles

53.3%

1

5-10 miles

47.0%

0.87 (0.85-0.90)

< 0.001

10-15 miles

43.6%

0.82 (0.80-0.85)

< 0.001

> 15 miles

33.8%

0.53 (0.52-0.55)

< 0.001

Rural (4,656) 0-25 miles

62.3%

1

25-50 miles

55.5%

0.76 (0.61-0.94)

0.013

50-75 miles

38.4%

0.34 (0.27-0.44)

< 0.001

> 75 miles

23.8%

0.20 (0.16-0.26)

< 0.001

AOR = adjusted odds ratio, CI = confidence interval

Patients were less likely to receive radiation compared with surgery the farther they lived from the treatment facility. These trends were also present when each risk group was analysed. This data suggests the burden of significant daily travel makes radiation treatment logistically more difficult and therefore less popular. This is particularly an issue as we consider increasing centralisation of services to improve outcomes.

Sources: Association between travel distance and choice of treatment for prostate cancer: does geography reduce patient choice? Muralidhar V, Rose BS, Chen Y-W, Nezalosky MD, Nguyen PL. International J Rad Oncol Biol Physics 2016 doi: 10.1016/j.ijrobp.2016.05.022

Department of Cancer Medicine, Gustave Roussy, Cancer Campus, Grand Paris, University of Paris-Sud, Villejuif, France DOI: http://dx.doi.org/10.1016/j.ejca.2016.03.070

Local inflammation and Bladder Pain Syndrome The understanding of bladder pain syndrome remains poor with empirical treatment and lack of clear recommendations. Multiple theories have been proposed to explain this syndrome including epithelial disruption, mast cell and vascular abnormalities. The authors of this research article postulated the involvement of a peripheral inflammatory disorder. The first work was conducted in 15 women suffering from bladder pain syndrome and in 15 healthy controls (women undergoing tension-free vaginal tape surgery). Under general anaesthesia, 5-mm biopsies were taken above the trigone. RNA was extracted and then 96 inflammatory mediators were analysed by RT-PCR. A hierarchical clustering was performed based on the gene expression analysis. Fifteen differentially regulated genes were identified suggesting an inflammatory process in the bladder pain syndrome pathology. The five most dysregulated genes were CCL21, IL12A, CXCL1, TNF, and FGF7. Particularly, CCL21 and FGF7 were positively correlated with clinical phenotypes assessed by the ICS/PI questionnaire.

Given these findings, the authors used animal experiments to strengthen their conclusions. The PSA response predicts authors used cystometric analysis and behavioural prognosis in mCRPC assessment after bladder instillations including CCL21 or FGF7. While no significant difference was reported after FGF7 treatment, these preclinical studies in As we have an increasing number of options to manage mCRPC and head-to-head data is unavailable female rats showed that CCL21 increased bladder contractions and pain-related behaviour highlighting the optimal use of new therapies remains to be the role of this gene as pain mediator. clarified. Of particular significance is the understanding and identification of predictive and prognostic factors that would allow for an individual …this interesting study highlighted therapeutic strategy and estimation of expected benefit. The role of PSA response as a surrogate the need for more systematic gene end-point has been debated in mCRPC. This study expression analysis and molecular aims to assess the clinical significance of early PSA response during therapy with enzalutamide, characterisation from human abiraterone acetate and orteronel. Data from patients recruited in clinical trials were retrieved from the Gustave Roussy clinical database including both pre-docetaxel and post-docetaxel patients. PSA values were obtained at baseline and 28 day after treatment initiation. Early PSA response was defined as a decline > 50% from baseline. The effects of clinical characteristics on radiographic progressionfree survival (rPFS) and overall survival (OS) were examined using the Cox model. A PSA decrease of > 30% from baseline at any time was observed in 65 patients (56%), while a PSA decrease >50% was observed in 48 patients (41%). Early PSA response was assessed in 118 patients and was found to be associated with longer rPFS and OS (p < 0.0001 for both). Median rPFS was 13.9 and 5.6 months (hazard ratio [HR]:0.38, p < 0.001) for patients with and without an early PSA response, respectively. Median OS was 32.2 months in patients with an early response and 15.9 months in patients without (HR: 0.4, p < 0.01). It remained prognostic for OS in multivariate analyses (HR: 0.5, p = 0.009) that included validated pre-therapeutic prognostic factors for mCRPC. In order to assess this further, the prognostic values of early PSA response for rPFS and OS were confirmed in an independent cohort of 95 abiraterone acetate-treated non-trial patients. Key articles

June/July 2016

bladder biopsies to improve our understanding of this insufficiently known disease

This article supports the role of upregulation of inflammatory mediator genes in bladder pain syndrome. Nevertheless, one size does not fit all. Indeed, important biologic variability has been suggested in this relatively small cohort of patients. Some cases with bladder pain syndrome exhibited completely distinct transcriptional profiles suggesting that inflammatory upregulation was surely not the only responsible mechanism leading to this pathology. However, this interesting study highlighted the need for more systematic gene expression analysis and molecular characterisation from human bladder biopsies to improve our understanding of this insufficiently known disease.

Source: The expression of inflammatory mediators in bladder pain syndrome. Offiah I, Didangelos A, Dawes J et al. Eur Urol. 2016 Mar 7. pii: S0302-2838(16)00248-7. [Epub ahead of print]

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk Evaluations including urinary (ICIQ, PGI-I, pad use), and sexual (EHS, GAQ) functions, pain and satisfaction (5-point scale).

The mean delay between radical prostatectomy and implantation was three years. The mean operative time of the combined procedures was 133 minutes. No technical difficulty was reported for ProACT devices implantation with regard to the presence of the penile prosthesis. Pain was mainly felt in the penoscrotal area requiring step 3 opioids in all patients. The mean number of pad per day decreased from 2.8 to 0.3. Both urinary and sexual functions were significantly increased at last follow-up (mean The major criticism of the PLCO was related to the rate 23 months). of PSA testing in the control group. This rate was assessed at 50% in the initial report. Nevertheless, Combined implantation of penile this evaluation was inaccurate but used as such in the 2012 USPSTF recommendations against PSA testing. prosthesis and ProACT device These rates of PSA testing were determined by a was feasible with no significant follow-up survey involving only a sub-group of participants. Men were considered as having a PSA surgical limitation. The main test when this test was performed within the past advantage was the reduced year, and only as part of a routine physical examination. Men receiving a PSA test for a specific invasiveness of the ProACT prostate problem, the follow-up of a previous health device… problem, and/or having their last PSA test more than one year ago were not counted as tested. Combined implantation of penile prosthesis and ProACT device was feasible with no significant …definitive conclusions on the surgical limitation. The main advantage was the uselessness of PSA testing related to reduced invasiveness of the ProACT device in moderate post-operative stress urinary incontinence the initial PLCO trial results should compared with the artificial urinary sphincter. Moreover, a synchronous implantation of both devices be taken with extreme caution did not seem to impact the functional outcomes of each device separately. Nevertheless, a longer When re-evaluating these rates of PSA testing in the follow-up is awaited to ensure the absence of control group, more than 80% of the participants deleterious effects of the ProACT device on the penile without baseline contamination reported having at prosthesis. least one PSA test during the trial, in addition to the already known 10% of control men with baseline PSA Source: Combined implantation of a penile prosthesis and adjustable continence therapy contamination. Thus, overall, the control group ProACT in patients with erectile dysfunction and included 90% of men having a PSA test during the study period. More interestingly, the follow-up survey urinary incontinence after radical showed that men in the control group reported more prostatectomy: results of a prospective pilot study. Yiou R and Binhas M. cumulative PSA testing than men in the intervention group. A good Figure is attached in the brief J Sex Med. 2015 Dec;12(12):2481-4. correspondence from the authors illustrating this huge contamination rate. truncated at 13 years showed a significant 21% relative reduction in prostate cancer in intention to screen analyses, and 27% in men who actually attended screening. The rate ratio of prostate cancer mortality was 0,85, 0,78, and 0,79 at 9, 11, and 13 years, respectively. A total of 781 men needed to be invited to screening and 27 to be diagnosed with prostate cancer to avert one death from the disease.

To conclude, definitive conclusions on the uselessness of PSA testing related to the initial PLCO trial results should be taken with extreme caution. The main conclusion of this trial could be that systematic PSA testing in an organised screening program did not seem to have a greater impact on specific mortality than the clinically meaningful use of intermittent PSA testing.

Source: Reevaluating PSA testing rates in the PLCO trial. Shoag JE and Hu JC.

Erectile and ejaculatory function preserved with convective water vapor energy treatment Most surgical treatments for male lower urinary tract symptoms and benign prostatic hyperplasia affect erectile and ejaculatory functions negatively, leading to patient dissatisfaction.

NEJM 2016;374:1795-96.

One-shot treatment of postprostatectomy urinary and erectile dysfunction

The authors sought to determine whether water vapour thermal therapy, when conducted in a randomized controlled trial, would significantly improve lower urinary tract symptoms secondary to benign prostatic hyperplasia and urinary flow rate while preserving erectile and ejaculatory functions.

Combined treatment of urinary incontinence and erectile dysfunction after radical prostatectomy may be indicated in a sub-group of operated patients. No clear consensus exists regarding the association of both surgical therapies.

Men at least 50 years old with International Prostate Symptom Scores of at least 13, a peak flow rate of at least 5 to no higher than 15 mL/s, and prostate volume of 30 to 80 cm(3) were randomized 2:1 between Rezum System thermal therapy and control. Thermal water vapour (103°C) was injected In this prospective trial, Yiou and Binhas assessed the into lateral and median lobes as required for concomitant implantation of the adjustable continence treatment of benign prostatic hyperplasia. The control procedure entailed rigid cystoscopy with therapy ProACT and apenile prosthesis. Overall, six simulated active treatment sounds. Blinded group patients (mean age 66.8) received a synchronous implantation and functional outcomes were recorded (active = 136, control = 61) comparison occurred at prospectively. In addition to these patients, four three months and the active arm was followed to 12 additional patients received the two devices months for International Prostate Symptom Score, asynchronously. All patients had non-severe stress peak flow rate, and sexual function using the urinary incontinence with a pad use < 4 per day, and International Index of Erectile Function and the no previous history of radiotherapy. Procedures were Male Sexual Health Questionnaire for Ejaculatory proposed at least one year after the initial surgery. Function.

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Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

No treatment- or device-related de novo erectile dysfunction occurred after thermal therapy. International Index of Erectile Function and Male Sexual Health Questionnaire for Ejaculatory Function scores were not different from the control group at three months or from baseline at one year. Ejaculatory bother score improved 31% over baseline (p = .0011). Also, 32% of subjects achieved minimal clinically important differences in erectile function scores at three months, and 27% at one year, including those with moderate to severe erectile dysfunction. International Prostate Symptom Score and peak flow rate were significantly superior to controls three months and throughout one year (p < .0001).

…convective water vapor thermal therapy provides sustainable improvements for 12 months to lower urinary tract symptoms and urinary flow while preserving erectile and ejaculatory functions The investigators concluded that convective water vapour thermal therapy provides sustainable improvements for 12 months to lower urinary tract symptoms and urinary flow while preserving erectile and ejaculatory functions.

Source: Erectile and ejaculatory function preserved with convective water vapor energy treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: Randomized controlled study. McVary KT, Gange SN, Gittelman MC, Goldberg KA, Patel K, Shore ND, Levin RM, Rousseau M, Beahrs JR, Kaminetsky J, Cowan BE, Cantrill CH, Mynderse LA, Ulchaker JC, Larson TR, Dixon CM, Roehrborn CG. J Sex Med. 2016 Jun;13(6):924-33. Epub 2016 Apr 27.

Perirenal fat stranding on CT: is there an association with bladder outlet obstruction? The investigators aimed to determine the association between perirenal fat stranding (PFS) on CT and bladder outlet obstruction (BOO). CT scans from 122 patients who had undergone urodynamic study for lower urinary tract symptoms (LUTS) were registered after exclusion of patients with renal or retroperitoneal disease. Images were independently reviewed by two radiologists and compared with those of 244 age- and sex-matched control patients without LUTS. The PFS severity was scored on a four-point scale, and the interobserver agreement was assessed with kappa statistics. The severity score and incidence was compared between the groups, and the association with baseline characteristics was analyzed. For the LUTS group, an association between PFS severity and urodynamic and laboratory data was evaluated.

PFS severity was associated with the degree of BOO and impaired renal function PFS was more frequent and more severe in the LUTS group than in the control group (p < 0.001); its presence was significantly associated with male gender and older age (p < 0.001). PFS was predominantly bilateral in both groups (80.1-93.2%). In the LUTS group, PFS severity scores were significantly correlated with the maximum flow rate, maximum detrusor pressure and estimated glomerular filtration rate (p < 0.001). Inter-observer Key articles

12

agreements were excellent for PFS presence (κ = 0.883) and severity (κ = 0.816). Severe PFS was observed in older, male patients with LUTS. PFS severity was associated with the degree of BOO and impaired renal function. The authors concluded that recognition of PFS on the CT scan may warrant further evaluation of BOO and appropriate management to prevent renal impairment.

Source: Perirenal fat stranding on CT: is there an association with bladder outlet obstruction? Han NY, Sung DJ, Kim MJ, Park BJ, Sim KC, Cho SB. Br J Radiol. 2016 May 16:20160195. [Epub ahead of print]

Stone patients: Is it just a question of stone-free rate or also QoL? The primary outcome when treating urinary stones is the stone-free rate which is regarded as the obvious condition to return patients to normal life. However, many factors may have a significant impact in the journey that patients experience such as the time needed to clear the stones, definition of stone-free, side-effects of treatments, etc.

Another interesting finding was the discrepancy observed between patients and practitioners with respect to acceptability of treatment. In one of the study that was analysed, the former favoured long-term prophylactic medication whilst the majority of the latter declared that patients would prefer experiencing one or two acute stone episodes rather than undertaking long-term drugs. This may be explained by the observed and well-known lack of patients’ adherence to long-term treatments, also considering that most of stone formers are young adults and the life-long treatments are unlikely to be followed for such a long time. Another economic factor lacking in literature is the overall resources impact on the national health systems for the management of stone formers, not just in terms of the treatment of acute episodes but also regarding follow-up management in the long-term to prevent recurrence and deal with mental and physical components of HRQoL. Overall, there is an urgent need to switch stone patients’ management more from the patient point of view rather than from a mere stone-free rate measurement. This implies, first of all, better engagement from practitioners to adequately inform patients, especially with regards the implications of treatment options other than just the effectiveness of stone-free rates.

All of that may have implication in the patients’ quality of life (QoL) and in returning to work, with both social and economic consequences. International guidelines consider several treatment options equivalent from the effectiveness point of view as by the primary outcome (i.e. stone-free rate), but they don’t include the impact of quality-of-life related implications. This is due to the lack of robust evidences in literature investigating this latter factor, which should be consider as important as the stone-free rate.

Finally, a structured PROM tailored to stone patients is the new frontier that urologists with special interest in stone disease need to explore and develop.

A recent systematic review has been conducted in an attempt to summarise the sparse and weak evidence in literature with respect to the health-related quality of life (HRQoL) in stone patients. They retrieved 35 papers analysing the HRQoL in stone patients either undergoing intervention (medical and/or surgery) or without, and the patients’ preference.

Outcomes of microscopic subinguinal varicocelectomy with and without the assistance of Doppler ultrasound

There were six randomised controlled trials (RCT) and 29 observational studies. Due to the heterogeneity of both types of publications, no quantitative analysis was carried out.

Overall, there is an urgent need to switch stone patients’ management more from the patient point of view rather than from a mere stone-free rate measurement The main findings include: 1) Almost all studies reported HRQoL as secondary end-points, being radiological stone-free rate as the preferred one. 2) There is a lack of tailored patient reported outcome measure (PROM) for stone disease. When performed, analysis of HRQoL has been carried out with generic tools with the most popular being the SF-36 and the EQ-5D. 3) Quality of life of stone patients is affected not just during the acute episodes but also during the intervals. This finding suggests that mental and physical conditions are not completely restored to normal even after treatments due to the persisting fear of a recurrence (especially in frequent stone formers, like cystinuric patients) or due to residual stone fragments deemed insignificant by clinicians. 4) HRQoL improves only in the mid-term follow-up, being observed most often at three months after passage or treatment of stones; on the other hand, data are lacking with respect to measurements at long-term, when recurrences may happen. 5) Data are lacking also with respect to the time needed to return to work: obviously this is an important aspect that has not yet been investigated and which has potentially huge economic implications, given the relatively high prevalence of urolithiasis. 6) SWL seems to be the preferred treatment option; however, patients also tend to prefer treatment options already experienced, most probably because they may feel it as a less risky procedure whose consequences have already been known.

Source: How Do Urinary Calculi Influence Health-Related Quality of Life and Patient Treatment Preference: A Systematic Review. Raja A, Hekmati Z, Joshi HB. J Endourol. 2016 May 16. [Epub ahead of print]

The investigators aimed to compare the surgical outcomes and complications between microscopic subinguinal varicocelectomy (MV) and intraoperative vascular Doppler ultrasound-assisted microscopic subinguinal varicocelectomy (IVDU-MV) for infertile patients with varicoceles. One hundred seventy-two infertile patients with varicoceles were randomly divided into IVDU-MV group (n = 85) and MV group (n = 87). Patients' operative and postoperative parameters, semen parameters, and the pregnancy rate was assessed. The mean follow-up period was 21 months (range, 13-34 months). The operative time was significantly shorter in the IVDU-MV group than MV group (41.9 ± 13.6 vs 52.7 ± 14.1 minutes, p < .05). The number of intraoperative arteries spared was significantly greater in the IVDU-MV group than the MV group (1.9 ± 0.8 vs 1.3 ± 0.7, p < .05). In addition, the average number of spermatic veins ligated was significantly greater in the IVDU-MV group (7.8 ± 2.1 vs 7.0 ± 1.9, p < .05). The post-operative hospital stay showed no significant difference.

Compared with MV, IVDU-MV is superior in shortening operative time, increasing the number of spermatic arteries spared, spermatic veins ligated, and sperm motility after surgery Sperm concentration, sperm motility, and the percentage of grade a+b sperm were significantly increased in both groups at three, six, and 12 months after surgery (p < .05), and the sperm motility was higher in IVDU-MV than MV group (43.98 ± 7.64 vs 36.98 ± 5.10, p < .05) in 12 months after surgery. Sperm morphology was comparable between the two groups. The pregnancy rate showed no significant difference (36.8% of the MV vs 34.1% of the IVDU-MV, p > .05).

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

The study demonstrated that both MV and IVDU-MV are effective methods for the improvement of semen parameters in infertile men with varicocele, with a natural conception rate of 35% over a mean follow-up of 21 months. Compared with MV, IVDU-MV is superior in shortening operative time, increasing the number of spermatic arteries spared, spermatic veins ligated, and sperm motility after surgery. IVDU should be routinely used as an effective tool to improve outcomes and safety of varicocelectomy.

Source: Outcomes of microscopic subinguinal varicocelectomy with and without the assistance of Doppler ultrasound: A randomized clinical trial. Guo L, Sun W, Shao G, Song H, Ge N, Zhao S, Liu Y, Zhang X, Xiao Z, Yuan M. Urology. 2015 Nov;86(5):922-8.

Treating local recurrent PCa after radical radiotherapy: An unresolved question While local recurrence of prostate cancer after radical prostatectomy can be “easily” managed with salvage radiotherapy, more complex and still debated is the appropriate treatment option that should be offered to patients affected by local recurrence after prostate cancer radiotherapy and that would benefit from salvage treatment. Salvage radical prostatectomy (SRP) is renowned to be a challenging procedure, being associated with a consistent risk of severe complications including incontinence, rectal injury and anastomotic fistulas. Other minimally-invasive techniques have been proposed as options with an alleged lower risk for complications like cryotherapy and high-intensity focused ultrasound. However, evidence is lacking in literature with respect to safety and effectiveness of these treatment options; as a result, recommendations in the international guidelines are weak on this regard. Few papers have compared SRP with salvage cryotherapy of prostate (SCP) showing better overall survival with SRP but controversial results in terms of cancer-specific survival. Notably, these series included open SRP only(1-2). Recently, a retrospective, single-institution match-paired study compared robotic SRP vs SCP outcomes within a small cohort of patients with clinical local recurrence of prostate cancer after radical radiotherapy(3). Patients undergoing robotic SRP and SCP were six and 17 respectively; presenting prostate cancer clinical features were comparable between the two groups.

In experienced hands, robotic salvage radical prostatectomy can be considered a valid alternative to the open SRP with the potential advantages that robotic surgery can bring… After a mean follow-up time of 7.2 and 14.1 months poorer functional and oncologic outcomes were recorded for SCP: the incidence of biochemical recurrence was 16.7% and 23.5% respectively for robotic SRP and SCP, and same figures were reported for complication rates, even though no significant statistical differences were recorded for these outcomes. Higher severe incontinence rate was observed in the robotic SRP group [5.9% (n = 1) vs 16.7% (n = 1)];

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conversely, urethral strictures (n = 2) and fistula (n = 1) were recorded in the SCP group only. However, given the very small number of events recorded, no statistical analysis could be performed. Regardless the limited number of patients recruited and short follow-up time (especially for the robotic SRP), the authors concluded that trends were in favour of robotic SRP both on oncological and functional outcomes and SPC could be an effective alternative. Even though the quality of the study is weak, it raises an important question: given the increasing number of patients undertaking radiotherapy as radical treatment for prostate cancer a rise in the number of patients requiring salvage therapy after local recurrence may be expected(4). This is contrasted by a significant lack of evidence in literature which needs to be addressed.

women (adjusted incidence rate ratio (IRR): 6.06, 95% CI; 3.18-11.55). Additionally, preeclampsia in kidney-transplanted women was early onset (diagnosed < 34 gestational weeks) in half of the cases. There were also persistent risks of cesarean delivery (adjusted IRR: 4.14, 95% CI; 2.56-6.66), preterm delivery (adjusted IRR: 4.45, 95% CI: 2.13-9.30) and a birth weight below the 10th percentile (22.7 vs. 9.7%) in the kidney-transplanted group. A high proportion (63%) of the kidneytransplanted women with chronic hypertension developed preeclampsia.

Using consistent diagnostic criteria, this study shows high rates of maternal and neonatal complications in pregnancies following kidney transplantation

On multivariate logistic regression analysis, the only variable significantly associated with early recurrence was the pathological stage (OR 3.76, 95% CI 1.17e12.1, p = 0.027). On multivariable survival analysis, RFS and CIS were predictors of CS death (HR 0.86, 95%CI 0.78-0.94, p = 0.001; HR 3.68 95%CI 1.07-12.7, p = 0.039, respectively).

super-obese transplant recipients at one, three, and five years was 88, 82, and 76%, compared to 96, 91, 86% in patients transplanted with BMI < 50. A propensity score adjusted analysis further demonstrates significant worse survival rates in super-obese patients undergoing kidney transplantation.

Accidental spillage of tumour as possible cause of early recurrence was reported in only one case because of the rupture of the endobag when retrieving transvaginally the specimen: this patient developed peritoneal carcinosis and vulvar recurrence after four months.

Thus, the super-obese patients had increased mortality and worse DGF rates as well as significantly worse long-term graft and patient survival compared to underweight, normal weight, and obesity class I, II, and III (BMI 40-50) patients.

Authors speculated about different potential mechanisms by which pneumoperitoneum may increase risk of micro-tumour dissemination and these include:

World J Surg. 2016 Jun 22. [Epub ahead of print] 1) CO2 decrease intraperitoneal immunity and vascular permeability and alter intra-cellular adhesion, thus favouring cellular spillage; 2) Pulsatile insufflation may promote migration of tumour emboli, whose formation can be enhanced by prolonged manipulation of the bladder; 3) Batson plexus, venous vascular route connecting pelvic plexus to vertebral veins, may be responsible for the spread of tumour cells/emboli from the bladder to distant and unusual sites of metastasis.

In experienced hands, robotic salvage radical prostatectomy can be considered a valid alternative to the open SRP with the potential advantages that robotic surgery can bring in terms of better definition of planes and details, enhanced dexterity and minimal invasiveness. In this series, the rate of severe incontinence was lower than other historical reports with open SRP (16.7% vs 56%-68%).

Using consistent diagnostic criteria, this study shows high rates of maternal and neonatal complications in pregnancies following kidney transplantation. In particular, it reveals a high rate of early onset preeclampsia requiring operative pre-term delivery, conferring long-term risks on both the mother and child.

On the other hand, further improvements of cryotherapy (or similar minimally-invasive techniques) may provide safer profile with similar oncological outcome in the near future.

Source: Pregnancy outcomes following maternal kidney transplantation: a national cohort study. Majak GB, Sandven I, Lorentzen B, Vangen S, Reisaeter AV, Henriksen T, Michelsen TM. They argued that the combination of these three

Acta Obstet Gynecol Scand. 2016 Jun 11. doi: 10.1111/ Currently, SRP is the first treatment option to be offered aogs.12937. [Epub ahead of print] to patients with local recurrence after radiotherapy and > 10 years of life expectancy; where expertise is available, robotic approach may be beneficial. Cryotherapy can be considered as an alternative Old dilemma returns: option, even though patients should be counselled Is pneumoperitoneum a risk about the risk of urethral stricture and fistulas and of the potential higher likelihood of cancer recurrence. Sources:

1) Population-based comparative effectiveness of salvage radical prostatectomy vs cryotherapy. Friedlander DF, Gu X, Prasad SM, Lipsitz SR, Nguyen PL, Trinh QD, et al. Urology 2014;83:653-7.

2) Locally recurrent prostate cancer after initial radiation therapy: a comparison of salvage radical prostatectomy versus cryotherapy. Pisters LL, Leibovici D, Blute M, Zincke H, Sebo TJ, Slezak JM, et al. J Urol 2009;182:517-25.

3) Single-institution comparative study on the outcomes of salvage cryotherapy versus salvage robotic prostatectomy for radio-resistant prostate cancer. Vora A, Agarwal V, Singh P, Patel R, Rivas R, Nething J, Muruve N. Prostate Int. 2016 Mar;4(1):7-10. doi: 10.1016/j. prnil.2015.11.002. Epub 2015 Dec 17.

4) Use, complications, and costs of stereotactic body radiotherapy for localized prostate cancer. Halpern JA, Sedrakyan A, Hsu WC, Mao J, Daskivich TJ, Nguyen PL, Golden EB, Kang J, Hu JC. Cancer. 2016 May 25. doi: 10.1002/cncr.30101. [Epub ahead of print]

What are the real risks of pregnancy after renal transplantation? The outcomes of pregnancy in renal transplant recipients have been under controversy. Internal design flaws in previous reports of pregnancies following kidney transplantation have been outlined and a validation has been called upon. The aim of this study was to collect information about obstetrical and neonatal outcomes in all Norwegian pregnancies following maternal kidney transplantation and to compare these data with the general Norwegian population. A retrospective cohort study based on 1,272,000 deliveries in Norway between 1969 and 2013 was done. All data were collected from medical records. From the source population, the authors compared 119 first deliveries in kidney transplanted women to 238 first deliveries in non-transplanted women. An explanatory strategy was used in the analysis.

factor for bladder cancer tumour seeding/spillage during laparoscopic cystectomy?

Trends in centralising in tertiary referral centres major uro-oncological procedures have favoured the spread of minimally-invasive techniques for the treatment of muscle-invasive bladder cancer, with increasing popularity of laparoscopic or robotic-assisted radical cystectomies (LRC or RARC) over classical open approach (ORC). Regardless many recent papers have reported similar post-operative oncological outcomes by comparing LRC/RARC vs ORC, concerns of the potential effect of pneumoperitoneum to increasing tumour seeding have been raised since the very first published series. Similar concerns were highlighted also in reports from other oncological specialties with unusual recurrences observed after laparoscopic surgery for colorectal and ovarian cancers. The EAU Section on Uro-Technology (ESUT), for several years, has set up a European database on LRC only; in 2014 they reported five-year oncological outcomes comparable to historical ORC, with Recurrence-Free (RFS), Cancer Specific (CSS) an Overall Survival (OS) rates of 66%, 75%, 62%, respectively. More recently, however, they noticed an unexpected high rate of early recurrence of urothelial cancer in the most favourable group of patients, i.e. those with pT ≤ 2. Moreover, also entity and sites of recurrences were considered so unusual to prompt further analysis.

…the question why patients develop early recurrence with a significant burden (and likely lethal) of metastatic disease remains unresolved…

The overall cohort consisted of 627 patients undergoing LRC, with almost half with pathological stage ≤pT2 (n = 311); early recurrence was defined as any new lesion developed in the follow-up within two years from the procedure and was observed in 8.7% (n=27) of the subgroup patients. Ten of 27 presented with disseminated metastasis; unusual sites of The risk of preeclampsia was significantly increased in recurrences included scapula, corpora cavernosa and kidney-transplanted compared to non-transplanted axillary lymphnodes.

Source: Kidney Transplant Outcomes in the Super Obese: A National Study From the UNOS Dataset. Kanthawar P, Mei X, Daily MF, Chandarana J, Shah M, Berger J, Castellanos AL, Marti F, Gedaly R.

factors could explain the phenomenon observed in their series. Even though the purpose of the paper was (correctly) to raise a concern rather than to advocate recommendation (or contraindication…), it is a matter of fact that larger and more recent series reported more favourable outcomes; on the other hand, a similar rate of early recurrence in the low-risk group was also observed in a recent series of ORC.

Does a negative CMV status confer a higher risk of posttransplant malignancy? It is unclear what effect, if any, the CMV serology status has on the risk of developing malignancy after kidney transplantation. To assess this risk, a nested case control study was done in which the CMV serology status was compared between patients with a malignancy and 2:1 matched-control patients without a malignancy. In a cohort study the hazard of malignancy was compared between patients that were CMV-negative but had a CMV-positive donor and other patients, using Cox analysis.

Fifty-two of 599 patients transplanted in one centre between 2001 and 2014 developed a malignancy. Nine (17.3%) of the 52 patients that developed cancer were CMV-negative but had a-CMV positive donor compared with 6 (5.8%) of the 104 matched-control patients (Odd Ratio (OR) 3.42, 95% Confidence Indeed, the question why patients develop early recurrence with a significant burden (and likely lethal) Interval (CI) 1.15-10.2, p = 0.021). of metastatic disease remains unresolved and the above-mentioned theories will be difficult to prove.

Source: Critical Analysis of Early Recurrence after Laparoscopic Radical Cystectomy in a Large Cohort by the ESUT. Albisinni S, Fossion L, Oderda M, et al. J Urol. 2016 Jun;195(6):1710-7. doi:10.1016/j. juro.2016.01.008. Epub 2016 Jan 18.

Should severe obesity exclude patients from renal transplantation? The authors evaluated the outcomes of super-obese patients (BMI > 50) undergoing kidney transplantation in the US. For this, a retrospective review of 190 super-obese patients undergoing kidney transplantation from 1988 through 2013 using the UNOS dataset was done. These 190 super-obese patients had a mean age of 45.7 years (21-75 years) and 111 (58.4%) were female. The mean BMI of the group was 56 (range 50.0-74.2). A subgroup analysis demonstrated that patients with BMI > 50 had worse survival compared to any other BMI class. The 30-day perioperative mortality and length of stay was 3.7% and 10.09 days compared to 0.8% and 7.34 days in non-super-obese group. On multivariable analysis, BMI > 50 was an independent predictor of 30-day mortality, with a 4.6-fold increased risk of perioperative death.

…the super-obese patients had increased mortality and worse DGF rates as well as significantly worse long-term graft and patient survival compared to underweight, normal weight, and obesity class I, II, and III (BMI 40-50) patients BMI > 50 increased the risk of delayed graft function and the length of stay by twofold. The multivariable analysis of survival showed a 78% increased risk of death in this group. Overall patient survival for

…CMV-negative patients with a CMV-positive donor are at a higher risk of developing malignancy after kidney transplantation

By univariate Cox model, there was a trend toward increased cancer risk in CMV-negative patients with a positive donor (Hazard Ratio (HR) 1.95, 95% CI 0.95-4.0, p = 0.07), but after adjusting for multiple covariates, CMV-negative status was significantly associated with increased risk of cancer (HR 2.55, 95% CI 1.23-5.26; p = 0.012). The authors concluded that CMV-negative patients with a CMV-positive donor are at a higher risk of developing malignancy after kidney transplantation.

Source: CMV-negative kidney transplant recipients are at an increased risk for malignancy after kidney transplantation. Rozen-Zvi B, Lichtenberg S, Green H, Cohen O, Chagnac A, Mor E, Rahamimov R. Clin Transplant. 2016 Jun 10. doi: 10.1111/ctr.12775. [Epub ahead of print]

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

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Key articles

June/July 2016

European Urology Today

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ADVERTORIAL

Clinical practice: Photodynamic diagnosis of bladder cancer Hexaminolevulinate-guided cystoscopy identifies more lesions and improves outcomes in real life

The 2016 updated European Association of Urology (EAU) Guidelines on NMIBC point out that complete and correct transurethral resection of Ta, T1 bladder tumours (TURB) is essential to achieve a good prognosis.4 However, there is not only a significant risk of leaving residual tumour in the bladder after the initial TURB of Ta, T1 lesions (33–55% after resection of T1 tumours, and 41.4% after resection of TaG3 tumours), but also tumours are often understaged by initial resection.4 “In up to 25% of bladder tumours we initially tend to underestimate the aggressiveness of the tumours,” said Professor Thorsten Bach (Asklepios Hospital Hamburg, Germany). “Correct staging is so important, as it has therapeutic consequences for the patient.”

absolute reduction of <10% in recurrence rates within 12 months in patients with TURB (LE: 1a).4 PDDassisted cystoscopy performed by using blue-violet light following intravesical instillation of HAL significantly improved detection of bladder tumours leading to a reduction of recurrence at 9–12 months:9 The difference in overall recurrence rates was statistically in favour of HAL-guided BLC (34.5% versus 45.4%; p=0.006). The benefit was independent of the level of risk and is evident in patients with Ta, T1, CIS, primary, and recurrent cancer.9 “From the clinical perspective the question arises how effective PDD can be performed in real-life setting”, Bach asserted. Therefore, he welcomed the realworld data from several recent studies conducted in Denmark, Germany, Spain and UK.

A prospective study from the UK evaluated a total of 808 patients undergoing PDD-assisted or goodquality white-light TURB (GQ-WL-TURB) in a real-life controlled setting.6 The study found that the recurrence rates at first follow-up cystoscopy (RRFFC) for HAL PDD-assisted TURB was associated with a significantly lower RRFFC compared with GQ-WLTURB (13.6 versus 30.9%; OR: 2.9; 95% CI: 1.6-5.0; p<0.001).6 In the German non-interventional study, optimised TURB was associated with an additional detection rate of cancer lesions by +6.8%.7 Bach pointed out that HAL-assisted PDD detected additional CIS lesions by +25% (p<0.0001).7 Similarly, Against this background, PDD-assisted tumour a Spanish work group demonstrated a significant visualisation has been shown to be more sensitive improvement of diagnosis obtained with HAL-guided than conventional procedures for detection of blue-light cystoscopy (BLC, sensitivity 93.2%, 95% CI malignant bladder tumours, particularly for 91.0-95.1; p<0.001).8 In the Danish study recurrence carcinoma in situ (CIS).4 Based on the data of a risk was reduced by 41% and median recurrence-free German systematic review and meta-analysis9, the updated EAU Guidelines point out the beneficial effect survival was extended from 13.6 to 36.8 months of Hexaminolevulinate (HAL)-guided PDD on detection when PDD was used and followed by immediate TURB chemoprophylaxis under clinical routine of tumour lesions across all risk groups and the

conditions.1 “The observed reduced recurrence rates and prolonged recurrence-free intervals in real-life setting confirm the benefit of guideline-based PDD-assisted cystoscopy with HAL”, Bach resumed. References 1. Lykke MR et al. Scand J Urol 2015; 49:230-6. 2. Witjes JA et al. Eur Urol 2014; 66:863-71.

going to progress into an invasive BC”, said Professor Shahrokh F. Shariat, Medical University of Vienna. During the pre-selection phase for the topic of the year 2016 voting, the participating Innovators in Bladder Cancer (BC)® urologists and oncologists identified three main Topic of the year 2016 topics: risk management of non-muscle-invasive bladder cancer, new surgical approaches for radical “Risk management of non-muscle-invasive cystectomy and molecular profiling of urothelial bladder cancer” was voted Innovators in BC® topic malignancies. “The reason why risk management of of the year 2016. More than 300 urologists around NMIBC has been elected most relevant BC Europe took part: After a pre-selection phase from management topic of 2016 is that this subject really December the final voting occurred at the 31st touches us the most on a daily level: in terms of the annual congress of the European Association of high proportion of our patients with NMIBC and Urology (EAU), which took place in March in high costs”, Shariat explained. “Improved risk Munich, Germany. The topic will be highlighted management represents a cornerstone for stratified and extensively discussed in medical media and treatment of NMIBC patients.” on the online platform “Innovators in BC®”, which is an international science-based website for urologists, oncologists and uro-oncologists fighting bladder cancer (www.Innovators-in-BC.com). “NMIBC is the disease with the highest lifetime treatment costs per cancer patient. Moreover, this cancer causes a major burden on individuals affecting their quality of life and survival: Approximately one third of NMIBC is eventually

Urology Week is an initiative of the European Association of Urology. It unites urological national societies, urology practitioners, urology nurses and patient groups to spread awareness of urological conditions among the general public. Show your support in five easy steps: 1 Cut out the “I Support Urology Week” sign from this page. 2

Hold the sign then take a selfie with it or ask someone to take a photo of you.

3

You can use the poster in this EUT as a backdrop for a selfie or put it on display e.g. on a wall in your clinic’s waiting room.

I support

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European Urology Today

3. Sievert KD et al. World J Urol 2009; 27:295-300. 4. Babjuk et al. NMIBC Guideline 2016; http://www.europeanurology.com 5. NICE BC Guideline 2015; http://nice.org.uk/guidance/ng2 6. Mariappan P et al. Urology 2015; 86:327-31. 7. Burger M et al. V 39.8, DGU 2015. 8. Palou J et al. BJU Int 2015; 116:37-43. 9. Burger M et al. Eur Urol 2013; 64:846-54.

Shahrokh F. Shariat

HEX-EU-000116

Bladder Cancer (BC) represents the most common malignancy of the urinary tract and shows the highest rate of cancer recurrence.1 High rates of recurrence and disease progression place a substantial burden on patients and healthcare resources, as patients require frequent and long-term follow-up.2,3 International guidelines and expert consensus panels are recommending the use of blue-light cystoscopy (BLC) to increase lesion detection rates of non-muscle-invasive bladder cancer (NMIBC) and improve treatment outcomes.2,4,5 Moreover, recent studies confirm the beneficial effect of Hexaminolevulinate (HAL)-guided cystoscopy also in daily clinical practice.1,6–8

#urologyweek Our mission, your Quality of Life

Step Up, Join the Campaign!

4 Share the photos on Facebook, Twitter and/ or Instagram. Remember to add the hashtag #UrologyWeek in your caption! For more inspiration to show your support for Urology Week, visit www.urologyweek.org

June/July 2016


1st ESU-ESUT Masterclass on Operative Management of BPO Heilbronn hosts a compact, comprehensive course Dr. Jan-Thorsten Klein Universitätsklinikum für Urologie & Kinderurologie Ulm (DE)

jtk171272@gmx.net The 1st ESU-ESUT Masterclass on Operative Management of Benign Prostatic Obstruction (BPO) took place in Heilbronn, Germany on last May 20 and 21 with 40 participants from across Europe. Since the format of this masterclass of modern surgical treatment of benign prostate obstruction focused on the different surgical techniques, eight surgeries were scheduled on Day 1. After a short

multiple-choice test, the surgeons showed how to perform a proper prostate resection, using mono or bipolar energy for the surgery. The surgeries were directly transmitted to the auditorium and therefore the audience was able to interact with the surgeon and ask questions concerning the surgical techniques. The first surgical session was followed by an expert theory session for a full hour including surgical indications (guidelines on BPO), choosing the type of surgery, anatomical aspects, basis of HF-surgery and irrigation solutions during TURP. After the lectures, the second part of the live surgeries was performed. The operative techniques focussed on enucleation techniques either using the Thulium laser or a specially designed enucleation sling. Both surgeries showed exactly how enucleation strategies help in prostate surgery and since it was a live surgery, the session also showed the limits of the techniques and how to overcome a difficult surgical anatomy.

Group picture after a successful masterclass

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European Urology Forum 2017 Challenge the experts 4-7 February 2017, Davos, Switzerland EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

Motivated tutors (Dr. Fiedler) and trainees ready for HOT training at the resection model

One on one tutoring (Prof. Rassler)

Prof. Liatsikos during the discussion on a live surgery

After a second expert theory session focussing on preoperative management, the use of high-power lasers and greenlight lasers as an enucleation tool, the third round of live surgeries demonstrated more enucleation techniques using TURIS and a regular monopolar sling. Finally, the last live session focused on Greenlight laser vaporisation and a Holmium laser enucleation of a big prostate.

Overnight the auditorium was converted into a training facility with 11 workstations equipped with VR-simulators, TUR-simulators and a shielded laser lab. There were also four theoretical workstations where different topics were discussed in a kind of ‘Meet the Trainer’ manner.

After a short introduction the participants were trained in the various surgical approaches in BPO The last lecture showed a glimpse of future surgery using the hands-on models. There was also tho opportunity to discuss the different approaches technologies and the newest surgical techniques for and techniques with the tutors. Every 20 minutes the BPO. Devices like the water beam resection or the participants (in groups of four) rotated to the next indication for Uro-Lift or prostate embolisation were workstation for intensive circuit training in BPO thoroughly discussed. After a busy day of surgeries and theoretical discussions of BPO surgery, the surgery and theory. Every group worked in all surgeons and participants met in the Weinvilla, a local workstations and after 3.5 hours an intense training day ended with the final discussion round. The wine restaurant for dinner. feedback evaluation of the participants was overwhelming good. There will definitely be a 2nd Mentored training Day 2 began with the second multiple choice test to ESU-ESUT Masterclass on Operative management of evaluate the learning effect of the course. After the Benign Prostatic Obstruction. test the clinical results of the patients of Day 1 checked during the morning ward rounds showed the results: List of surgeons and performed surgeries on Day 1: pictures of the colour of the irrigation and the urine bag had been taken and were shown including the follow-up of the patients. There were no revisions. • Bipolar TURIS (Live) One patient had clot retention that required manual A. Martov, Moscow (RU) irrigation for clot removal. Overall it was a superb • Bipolar TUR P (Live) result for all eight surgeries. J. Rassweiler, Heilbronn (DE) • Thulium laser enucleation of the prostate (Live) A. Gross, Hamburg (DE) • Bipolar enucleation of the prostate (Live) T. Herrmann, Hannover (DE) • TURIS enucleation of the prostate (Live) J. Rassler, Leipzig (DE) • Monopolar enucleation (Live) V. Pansadoro, Rome (IT) • Greenlight laser vaporization (Live) A. Bachmann, Basel (CH) • Holmium laser enucleation of the prostate single-lobe technique (Live) J. Rassweiler, Heilbronn (DE) Intense tutoring at the lasermodel

June/July 2016

European Urology Today

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9th ESU Masterclass on Female and functional reconstructive urology In collaboration with the EAU Section of Female and Functional Urology (ESFFU)

17-18 November 2016, Berlin, Germany

Urological procedures involved in female and functional reconstructive are complex and demanding. There is only but a few specialised centres that have developed and accumulated expertise, and validated knowledge in this field. The 9th ESU Masterclass on Female and Functional Reconstructive Urology (esufemale16) aims to update and equip urologists with these specialised skills to meet future challenges. The masterclass will commence from 17-18 of November in Berlin, Germany in collaboration with the EAU Section of Female and Functional Urology (ESFFU). Certified urologists with a serious interest in developing a subspecialty in female and functional reconstructive urology are encouraged to join. This ESU masterclass is a comprehensive programme which will impart extensive knowledge in this subspecialised field to urologists. Among the subjects covered in this compact course are management of functional disorders such as lower urinary tract diseases, the pelvic floor and related organs.

#esufemale16

Sessions preview The two-day masterclass offers different modules with topics varying from male and female incontinence to reconstructive surgeries and more. International experts in neurourology, imaging, female and functional urology will update participants on the best practices and research breakthroughs in this fast-advancing field. The notable modules are as follows: Module 1 – Stress Incontinence Module 2 – Bowel Module 3 – Female Reconstructive Surgery Module 4 – Female Sexual Function Module 5 – Overactive Bladder (OAB) Module 6 – Pelvic Organ Prolapse Module 7 – Male Incontinence Module 8 – Neurogenic Bladder Module 9 – Diversion Surgery for Functional Reasons

Application deadline: 16 September 2016 Apply and participate Space availability for the masterclass is limited. Please note that being an EAU member is mandatory in order to apply. For questions concerning the EAU membership, please contact the membership department at membership@uroweb.org. Kindly fill out the online application form found on the website www.esufemale16.org on or before 16 September 2016. A selection among the applicants will be made by the Course Directors. We will see you in Berlin!

More info: www.esufemale16.org

3rd ESU Masterclass on Lasers in urology

#esulasers16

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

Application deadline: 2 September 2016

3-4 November 2016, Barcelona, Spain This year marks the third collaboration of the European School of Urology (ESU) and the EAU Section of UroTechnology (ESUT) for the upcoming 3rd ESU Masterclass on Lasers (esulasers16). The masterclass will take place from 3-4 of November in Barcelona, Spain wherein the participants will experience a comprehensive overview of laser use in urology, interactive sessions and live surgeries to name a few. The main objective The masterclass aims to provide reliable information on laser technology and its applications in urology. This will cover the management of benign prostatic obstruction, bladder and upper track tumours, urinary track strictures, and stone disease. Participants will master the basic concepts of each laser treatment and will know more on how to screen candidates for each approach. They will also learn to optimise laser efficacy and management of commonly encountered complications. What to expect The two-day masterclass will feature in-depth lectures and interactive sessions, which are platforms conducive to further learning. In addition to best practices and evidence-based

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European Urology Today

medicine, international leaders of the field will present their experiences, which will give additional, unique insights. Live surgery will provide participants with the practical insight of clinical laser practice. It will also enable moderators to point out specific techniques and procedures. The use of contemporary laser systems such as the Holmium laser, the 532-nm lasers, KTP-80W, HPS-120W and XPS-180, Diode laser and the Thulium: Yttrium-Aluminium-Garnet laser will be examined. The different techniques regarding usage will be described in detail. Things to look forward to The interactive feature of the operating rooms during the live surgery sessions will enable participants to observe various operations simultaneously. The first live surgeries will focus on stones with moderators O. Angerri (ES) and E. Liatsikos (GR) and surgery by O. Traxer (FR) and T. Knoll (DE) who will perform RIRS + Holmium Laser for lower pole stone and mini-PCNL + Holmium laser for renal stone, respectively. Live surgeries on UTUC will be moderated by J. Gaya and C.M. Scoffone, Turin (IT) with surgery by A. Breda (ES) for RIRS + Holmium for UTUC, M. Brehmer (DK) for RIRS + Thulium for UTUC, and T. Herrmann (DE) leading a team for en bloc laser resection of bladder TCC/Holmium.

The last live surgeries will concentrate on lasers with moderators T. Herrmann (DE) and J. Ponce de Leon (ES). Four surgeries will be performed with C.M. Scoffone (IT) for Holep, L. Carmignani (IT) for Thulep, E. Liatsikos (GR) for Thuvep, and F. Gomez Sancha (ES) demonstrating techniques in Vaporization 180 W. Interested in participating? There is a limited space for this masterclass, maximum of 40 participants. Please note that all applications must be done online on or before 2 September 2016. Selection of the participants will be made by the Course Directors based on the following criteria: 1) You must be an EAU member. For questions concerning membership, please contact the membership department at membership@uroweb.org. 2) It is a first-come, first-served basis (maximum of 40 participants) Looking forward to your participation in Barcelona!

More information at www.esulasers16.org

June/July 2016


Urolithiasis ESU course in Kosovo Enthusiastic participation of Kosovan urologists Dr. Liridon Selmani University Clinical Centre of Kosova Dept. of Urology Prishtina (KO)

liridonselmani@ gmail.com The European School of Urology (ESU) organised a well-attended course on urolithiasis during the 11th Annual Congress of the Kosovo Urologists Association (KUA), which took place in Kosovo’s capital city Pristina last May 27 to 28. The congress focused on urolithiasis although some sessions in the second day discussed other dilemmas and issues in current urology. “We have organised a comprehensive and quality scientific programme and this included the ESU Course on Urolithiasis, which was one of the highlights in this year’s congress,” the organisers said. More than 120 participants, among them about 60 urologists, 20 residents and 40 nurses/medical students attended the two-day congress. Beside local urologists, urology professionals came

Teaching activities 2016 - 2017 European School of Urology

from neighbouring countries such as Macedonia and Albania.

September

Joining ESU lecturers Dr. Somani and Dr. Ploumidis were speakers from the Turkish Urologists Association, Dr. Tepeler and Dr. Atis. The president of the Jordanian Association of Urology, Dr. Shunaigat, also gave a presentation.

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Local urologists joined the discussions on standard, mini/ultra-mini and micro- percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) and topics such as the alternatives to standard PCNL in patients with comorbidity attracted many participants. Meanwhile, the ESU course offered first-hand experience on complicated cases and an insightful debate on potential treatment options. Other topics discussed during the congress were kidney cancer angiogenesis and laparoscopic techniques and issues in prostate cancer management. It was evident that during the sessions which led to enthusiastic discussions, urologists from Kosovo and the region have benefited from the knowledge exchange. Least but not last, the hosts provided a very well-planned social programme. Based on the responses from participants, the Kosovan congress will be remembered as one of the most successful and well organised medical meetings held in the city in terms of quality presentations, in-depth plenary discussions and participation.

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14th European Urology Residents Education Programme (EUREP), Prague (CZ) ESU-ERUS courses at the 14th Meeting of the EAU Robotic Urology Section (ERUS), Milan (IT) ESU course on General update on oncological urology at the national congress of the Armenian Urological Society, Yerevan (AM) ESU course at the time of the EAU 12th South Eastern European Meeting (SEEM), Sarajevo (BA)

October 4

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

November 3-4

3rd ESU Masterclass on Lasers in urology, in collaboration with the EAU Section of UroTechnology (ESUT), Barcelona (ES) 9th ESU Masterclass on Female and functional reconstructive urology, in collaboration with the EAU Section of Female and Functional Urology (ESFFU), Berlin (DE) ESU courses at the 8th European Multidisciplinary Meeting in Urological Cancers (EMUC), Milan (IT) ESU course at the national congress of the Lithuanian Association of Urology, Vilnius (LT) ESU course on Urooncology at the national congress of the Egyptian Urological Association, Sharm El-Sheikh (EG)

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December 8-9 17

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

February 2017 4-7

European Urology Forum 2017 – Challenge the experts, Davos (CH)

March 2017 24-28

ESU Courses, HOT, Innovation in Education at the time of the 32nd Annual EAU Congress, London (GB)

Contact: esu@uroweb.org

www.esufocaltherapy16.org

1st ESU-ESUT Masterclass on Focal therapy for localised prostate cancer 8-9 December 2016, Paris, France EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

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June/July 2016

European Urology Today

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Association of Ukrainian Urology holds congress in Kiev Comprehensive programme attracts more 500 participants Prof. Aleksandr Shulyak Lviv Regional Clinical Hospital Dept. of Urology Lviv (UA) avshulyak@ yandex.ua The Association of Urologists of Ukraine (AUU) held its congress in Kiev from 21 to 23 April this year with the participation of the European School of Urology (ESU) and the European Association of Urology (EAU).

Prof. Marek Babjuk and Dr. Oscar Rodriguez Faba participated in the ESU programme

Organised by the National Academy of Medical Sciences of Ukraine, the Ministry of Health of Ukraine, the Institute of Urology of NAMS of Ukraine, National Medical Academy of Postgraduate Education P. Shupyk, the EAU and AUU, the meeting covered topics such as the treatment of LUTS, early diagnosis of prostate cancer (PCa), treatment of locally advanced, castrate-resistant and metastatic PCa, disease prevention, sexual rehabilitation of PCa patients, new developments in the diagnosis and treatment of onco-urological diseases, endoscopy and laparoscopy. More than 500 urologists attended the congress. Prof. Sergey Vozianov led the April 21 opening day which included the awarding ceremony for leading scientists of the Institute of Urology of NAMS of Ukraine and the AUU. The rank of "Honorary Member of the Association of Urologists of Ukraine" was awarded to Prof. Kostev Fyodor Ivanovich, chief of Department of Urology and Nephrology of the Odessa National Medical University. The Institute of Urology NAMS of Ukraine, Ukraine’s leading public institution in urology, sexology and andrology, has 524 employees, 14 professors, 20 doctors and 43 candidates of sciences. The institute has 14 scientific departments. The high scientific level of practical research is led by Professors S. Vozianov, A. Romanenko and I. Gorpinchenko, to name a few. Key issues and challenges in urology were grouped into different thematic sections to explore and highlight the latest research, experience of leading experts and relevant issues facing urologists in their daily practice. On the first day, the symposium "Modern looks and features in treatment of lower urinary tract symptoms / benign prostatic hyperplasia and overactive bladder," was held with Professors M. Dreyk, I.M. Antonyan and V.I. Zaytsev sharing best practices.

A plenary session on urolithiasis was led by Professors V.V. Chernenko, V.P. Stus and M.I. Uhal. Among the issues discussed were open urethroplasties in patients with complicated urethral strictures and the complex use of thiazide diuretics in metaphylaxis of calcium oxalate nephrolithiasis. O. Nikitin discussed the etiopathogenetic justification of conservative treatment and prevention of urateoxalate urolithiasis. The Plenary Session on "Inflammatory diseases of kidneys and the urinary tract" was led by Professors S.P. Pasyechnikov, F.I. Kostyev and L. Sarychev, among others. They discussed the peculiarities of the course of acute uncomplicated pyelonephritis in women of reproductive age, depending on the taxonomic dependence of pathogens. Speakers S. Pasyechnikov and S. Nasheda examined the prevention of early postoperative complications in transvesical prostatectomy in patients with benign prostatic hyperplasia with acute urinary retention infected with trichomonas vaginalis. In the session "Sexopathology and Andrology,” Professors I. HorpynchenkoI, E.A. Lytvynets led the discussions which covered topics such as the inflammatory aspects of benign prostatic hyperplasia, the hormonal status of male older age groups, systemic inflammatory response in patients with chronic abacterial prostatitis using standard immunogram and features of LPS-dependent cytokine production in vitro, and new prospects in the diagnosis and treatment of chronic abacterial prostatitis. The scientific symposium "Issues in Pediatric Urology" was headed by Professors V.F. Peterburhskyy and A.I. Nakonechny. They tackled the use of laparoscopic techniques for the diagnosis and treatment of non-palpable testicles in children and the modern methods in the surgical treatment of neuromuscular dysfunction of the bladder in children. The ESU organised a course on the modern treatment of bladder cancer with case discussions led by a panel composed of Professors M. Babjuk, (Czech Republic), O. Rodriguez (Spain), S. Vozianov, E. Stakhovsky and O. Shulyak. Babjuk spoke about educational opportunities offered by the EAU and also discussed the EAU Guidelines recommendations on bladder cancer. Rodriguez analysed in detail the diagnosis and initial treatment steps in non-muscle invasive bladder cancer (NMIBC). Other topics included the treatment of NMIBC with intravesical involvement (prostate, distal ureters) and a lecture by Babjuk on radical cystectomy including tips and tricks and urinary diversion, complications and options for their correction. Case reports were presented Y. Bondarenko and two clinical cases triggered an enthusiastic discussion between the panel members and the audience. An on-line course was jointly organised by the Department of the Regional Urology Institute, Institute of Urology, N. Lopatkin and the Institute of Urology (Kiev). The following websites were part of the collaborative work: http://uroweb.ru, http://uro.tv, http://ukraine.uroweb.ru and http://www.inurol.kiev.ua

TREATMENT OF CIS OF THE PROSTATIC URETHRA, WITH PROSTATIC DUCT INVOLVEMENT (TIS PD)

BCG ? One of Dr. Rodriguez Faba's presentations focused on prostate and urinary tract involvement in urothelial ca.

in Ukraine and the CIS countries (Russia, Belarus, Kazakhstan, Armenia, Uzbekistan and others). The online broadcasts aim to expand and provide easy access to education and we believe it is important to engage the press and draw their attention to urological issues. Prof. K. Sarica (Turkey), chairman of the EAU Section of Urolithiasis (EULIS) lectured on the modern approaches to treatment and prevention of urolithiasis. In the plenary session "Cancer in Urology," the discussion was led by Professors E. Stakhovsky,

V. Hryhorenko and S. Shamraev. Among the topics were the radical surgical treatment of muscle-invasive cancer of the bladder, problems and prospects in the modern treatment of metastatic PCa, the role of 5α-reductase inhibitors in the prevention of PCa and BPH treatment, and complications during endoscopic radical prostatectomy. The audience also receive insights regarding optimising the selection of patients with local PCa for radical prostatectomy. The next AUU Congress will be held from 15 to 17 June 2017 in Kiev.

ESU e-courses Enthusiastic feedback from participants Dr. Joan Palou Chair of ESU Barcelona (ES)

“Excellent course and a very good refresher on our current knowledge about NMIBC. Well done!“ - Christos Moiragias “Thanks for the course! I used the risk calculators and it was very helpful! The learning videos are pretty good!“ – Angel Huaman

jpalou@fundaciopuigvert.es The European School of Urology (ESU) provides the latest information for urologists and residents globally through courses found on EAU Education Online. These high-standard, up-to-date courses are prepared by urologists from all over Europe and are supported by the e-learning specialists of the EAU. All accredited courses comply with the EU-ACME and UEMS/EACCME guidelines for e-learning, and the information provided is in line with the EAU Clinical Guidelines. Below are some of the enthusiastic responses we have recently received:

E-course on Non-Muscle-Invasive Bladder Cancer This course gives clinicians a complete view on The lectures were translated simultaneously for the clinical aspects, diagnosis and treatments of NMIBC. congress participants and the Internet users. Online broadcasts were followed by more than 450 urologists “Excellent course for residents! We look forward to more topics!” - Selim Yazar “This is an excellent course you have established. It provides an expert, up-to-date review. This e-course links urologists with updated, proper management. Can’t wait for another outstanding e-course covering other vital topics!” - Nabeel Joda Kuwaijo Al-Shammary “This course is very nice! My compliments!” – Francesco Mappa

“Excellent course!” - Zahoor Fazili E-course on Overactive bladder: mechanisms and management This course covers effective management of pathophysiological conditions affecting the lower urine tract (overactive bladder and neurogenic detrusor overactivity). “I really appreciate these learning tools. Keep on developing, please!” – Francesco Pellegrinelli “It is an effective learning tool and well structured…” – M Hammad Ather E-course on Risk profile-oriented management of BPE/LUTS (CME awarded) This online course helps urologists to personalize the BPE/LUTS patient care. This course is available in English and Spanish and is awarded 1 European CME credit (ECMEC). “Un curso muy importante ya que mejorar mis competencias en el manejo del paciente con hiperplasia benigna de próstata.” [The course is important in refining major scales in managing patients with benign prostatic hiperplasia (BPH)] – Jorge Rosario Tellez “It was a good presentation!” – Georgios Chytas and Nurlan Rashkan “Very nice activity!” – Muhammad Naeem

More than 500 urologists attended the AUU congress in Kiev

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Bladder Cancer

Right ureter Peritoneum

Left ureter

patients.uroweb.org

Mucosa

Muscle layers

Opening of left ureter

Fat layer Trigone of bladder Urethra

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Spain exceeds 60,000 kidney transplants in 2015 Remarkable milestone in Spanish urology Prof. Remigio Vela Navarrete Hospital Fundación Jiménez Díaz Dept. of Urology Madrid (ES)

rvela@fjd.es Spain’s organ transplant programme surpassed 100,000 solid organ transplants in 2015, 62,500 of which were kidney transplants1. To determine what made Spain’s kidney transplant programme a success, an analysis has been done of the different factors and strategies. One relevant factor is that the whole kidney transplant programme has been in the hands of urologists who, from the beginning of the transplant activities, consider both nephrectomy and renal grafting as mandatory urological commitments. Moreover, their surgical activities have been synergistically improved with the strong collaboration of nephrologists and health administrators represented in Spain by the Organización Nacional de Trasplante (ONT). These factors deserve a further look as discussed in the following: Pioneer work of urologists Spain’s urologists and Spanish urology, in general, considered surgical treatment of uraemia an inevitable commitment. In the 1950s, patients with uraemia or terminal renal failure (as it was called later) looked for therapeutic solutions in the Department of Urology. This led to the first kidney transplant performed by urologists in Spain (19601961) which was seen as a challenge in the case of consanguineous living donors, and before the era of effective immunosuppression. Research programmes on renal transplant immunosuppression also began and flourished in the 1950s, giving surgeons a more solid basis for continuing or starting kidney transplant programmes, with surgical protocols already in place. The first research programme in Spain also began in 1958 and by 1964 more than 250 kidney transplants had been performed, with the continuing research on immune tolerance using different strategies. (Chimeras, 6-Mercaptopurin and other)2,3,4. Finally, in 1965, two hospitals started official programmes of kidney transplants led by urology departments: the Fundación Jiménez Díaz in Madrid and Hospital Clínico in Barcelona.5,6 These institutions exemplify best practices in renal transplants and have set the standards being currently used in 43 authorised kidney transplant hospitals across the country.

Resolving administrative issues The need for a coordinated activity, mainly in the cadaver kidney transplant programme, was evident from the beginning of these activities and administrative issues were effectively addressed in each hospital in various ways. Despite the difficulties, taking as an example the HLA typing laboratory, it was still possible to distribute the best donors to the best recipients, making the interchange of kidneys among hospitals possible. Moreover, to improve donations and facilitate the whole coordination of the cadaver kidney transplant programme, the National Health Service created in 1990 a coordination agency, the Organización Nacional de Trasplantes (ONT). Through different strategies and promotional activities, ONT created specific national and regional coordinators in every hospital involved in the programme. The work of the ONT has been extraordinarily successful. For example, thanks to its promotional activities, donations of organs per million inhabitants reached in 2014 a record 39.7 donations PMH. Due to these promotional activities, the living donor’s kidney transplant choice, previously delayed, recently reached 13% of the whole kidney transplant programme. Generous donations from citizens themselves made possible all the transplant activities. Role of expenses and economy From the beginning, the National Health System in Spain has been very generous in supporting the organ transplant programme. Fortunately, the kidney transplant programme has proven that it can help significantly reduce global expenses in the treatment of terminal renal failure. For example, recent comparative studies have demonstrated that expenses in the first years for haemodialysis or renal grafting are similar. However, in the following years, renal grafting reduces expenses, saving around 20,000 euros per year/per patient. Meanwhile, the less expensive alternative to the treatment of terminal renal failure is in the kidney transplant programme.

“Fortunately, the kidney transplant programme has proven that it can help significantly reduce global expenses in the treatment of terminal renal failure.”

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One can appreciate the huge urological workload behind these 60,500 kidney transplants, including not only the surgical work of nephrectomies and grafting, but all activities related to post-operative control, follow-up and potential complications. The kidney transplant programme has not only given Spanish urology a profile of technical and professional excellence in the Department of Surgery of the university hospitals, but also marked urology’s meaningful contribution to public healthcare. Spanish urology is proud of this remarkable achievement and milestone that provide an example to other urological communities.

3.

4. 5. 6.

7.

1. http:\\www.transplant-observatory.org 2. Parra J., Torres J.A., Alvarez F. Rivas J. Albert C., Oliva H.

“Cumulative production of drug irradiation chimera as a method of inducing tolerance for kidney homotransplantations”. An. N. York. Acad. Sc. 99, 781;1962. Parra, J. Torres J.A., Álvarez F., Vela Navarrete R., Albert C., Oliva H. “Kidney homografts: induction of specific tolerance through the lymphoid tissues”. An. N. York Acad. Sc. 120, 524 1964 Vela Navarrete R. “Mecanismo de rechazo del homoinjerto renal”. Rev. Clin. Esp. 99,14 1965 Gil Vernet, J.M. “Homotrasplantation renal”. Journal d’Urologie 75, 86 1967 Gil Vernet J.M., Caralps A., “Human renal homotransplantation. New surgical technique.” Urol Int 23 (3: 201) 1968. Vela Navarrete R., Alférez C., Hernando L. “Aortoiliac haemodynamic and renal transplantation” Lancet 2, 1420. 1969.

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

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

surgeryinmotion.org/school

Surgery in Motion School is a collaboration of

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References

The surgical treatment of uraemia, regardless of the cause (vascular obstruction, urodynamic obstruction, renal parenchyma atrophy, etc.) includes renal grafting and is a specific urological commitment. Spain’s urologists were proven right when in the 1960’s they began to promote and boost the renal transplant programme. To them, nephrectomy and renal grafting were urological procedures. These surgical procedures could be performed with similar technical perfection by other surgeons, as has happened in other countries, or even better, with reduced morbidity by Role of nephrologists laparoscopic or robotic approaches. But an integrated The common objectives in treating terminal renal programme for the treatment of uraemia is much failure by urologists and nephrologists have been a crucial factor that contributed to the success of Spain’s more than surgical intervention. The efficient continuity of such a programme can only be realised renal transplant programme. Nephrology, as a in the hands of urologists because of their holistic medical speciality, formally began in Spain with the knowledge of renal physiology, pathology, renal arrival of haemodialysis. In 1965, a chronic malfunction, urodynamic, etc. and expertise in haemodialysis plan was approved by the National genitourinary surgical procedures. Health Service. Patients with terminal renal failure sought therapeutic management in the Department of Together with clinical activities, a wide field of Nephrology and not only in the Department of research has been explored such as: tolerance to Urology. Thus, the need for strong communication warm and cold ischemia, methods for renal and synergistic collaboration between nephrologists preservation, renal haemodynamic and renal auto and urologists was evident and since that time this regulation, models for renal hypertrophy, control institutionalised collaboration has been maintained. methods of rejection, both experimental and clinical with biological or 2905 2907 pharmacological 2905 2900 2907 strategies. Renal grafting 2678 2900 to the iliac vessels causes 2551 2498 2678 important circulatory 2552 2328 2400 changes with potential 2551 2200 2211 2229 2498 complication in selected 2225 2132 cases.7 The options of 2032 2157 2552 1996 2125 2328 2400 1938 orthotropic grafting, renal 1857 2023 1924 1900 1800 2200 2211 2229 vein diversion to the 2225 2132 1633 portal system, mini1707 2032 2157 1492 incisional approach for 1996 2125 1938 1371 living donor 1488 1400 1857 2023 1240 1924 1900 nephrectomy, potential 1800 1182 use of implantable 1039 987 1633 dialytic membranes, 1017 1707 900 percutaneous stem cell 1492 grafting, have also been 1371 investigated. 1488 1400 1182

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On the Foundation of Modern Urology A new History Office publication by Sergio Musitelli By Loek Keizer

On the Foundation compiles two treatises (Bellini and Malpighi), one chapter of Borelli's De Motu Animalium and two of Malpighi's letters to his master Borelli. These works were intended for contemporary anatomophysiologists and mention several discoveries.

The EAU History Office is proud to launch a new addition to its Classical Library range of books. Prof. Sergio Musitelli (Milan, IT) completed work on a 200-page volume On The Foundation of Modern Urology, a book that offers a reproduction of original 17th century medical texts, an annotated transcription and a translation into English. The findings of Lorenzo Bellini, Marcello Malpighi and Giovanni Afonso Borelli on the function of various organs, kidneys in particular give insights into the earliest discoveries in the human body. Musitelli’s characterful translation and annotations provide historical context and a modern perspective as one consults the original texts. Prof. Musitelli is one of the historical experts of the EAU’s History Office, which is otherwise largely made up of urologists with an interest in the history of their field. His affiliation with the EAU and its History Office stretches back to 1992. Musitelli acted as historical advisor for the 1st International Congress on the History of Urology in Fiuggi, Italy in 1992. A career in classics Sergio Musitelli was born in Milan in 1928, and he attained his Ancient Arts and Graeco-Roman degree in 1951. He specialised in Classical Philology, in Glottology and Indian Literature and Languages (amongst others in Sanskrit, Pali, Prakrit, Hindi, Sindi, Hindustani), in Egyptology and in Romance Philology. Musitelli lectured on Greek Languages and Literature at the University of Milan for ten years. He collaborated with the famous Historians of Medicine Luigi Belloni and Felice Grondona, who charged him with translating nearly all the Greek and Latin medical texts from Hippocrates to the 19th century. He then devoted himself to the History of EAU History office

It is with sadness that we note the death of Professor Ernst J. Zingg, on 27 February 2016, a pioneer in modern European urology. Ernst Zingg, born 27 July 1931, spent his youth in Zürich, Switzerland and graduated from medical school in 1956. As a resident under pathologist Prof. H.U. Zollinger, Zingg obtained an in-depth education in soft tissue anatomy and the morphology, behaviour, and patterns of metastatic spread of malignant tumours. He was mentored as a surgeon by Professors A. Brunner and A. Senning, two of Switzerland’s best thoracic, visceral and cardiovascular surgeons. Zingg began his urology training programme in Zurich under Prof. G. Mayor, the first urologist to establish an independent urology department in a Swiss university. In 1965, Zingg was appointed senior physician and at age 38 served as division chairman and later as urology department head at the University Hospital of Berne (Inselspital), where he was chairman from 1971 until his retirement in 1994. His profound knowledge of modern urological surgical procedures, his expertise in visceral and thoracic surgery and excellent surgical skills ensured Zingg’s professional success as a urologic surgeon with a reputation that is known beyond Switzerland. Clinical researcher and urologic surgeon Zingg and Mayor co-authored the textbook Urologic Surgery, which later became the standard reference book in the German-speaking part of Europe, was translated into Spanish and English. The book was considered as having contributed to the establishment of urology as an independent branch of surgery, providing modern urology the esteem it deserves in the field of medicine. The treatment of non-invasive and invasive bladder cancer was one of his early fields of interest. He was an early proponent of radical cystectomy and in the late 1960s introduced a method to reduce the mortality of this procedure

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Musitelli reflects on the contents of these works: “These fundamental discoveries, that paved the way for our modern Urology were: Berengarius of Carpi’s discovery of the ‘papillae’; Bellini’s discovery of the so-called ‘ductus belliniani’ (the ‘ducts of Bellini’) and Malpighi’s discovery of both the so-called ‘Malpighian pyramids’ and what we call ‘nephron’.”

Prof. Sergio Musitelli

Ancient Science in general and of Medicine in particular. He was Visiting Professor of Urology, Sexology and Andrology at the University of Pavia from 1992 to 2004, when he retired from teaching. Since retiring, Musitelli still studies and works as a Historian of Science in general and of Urology in particular. He has published about 250 scientific contributions (articles, books, etc.) in both English an Italian and has devised the EAU Classical Library, inaugurating its series with the first volume: Mariano Santo’s Libellus aureus de lapide a vesica per incsionem extrahendo (1998). The Foundation Prof. Musitelli’s latest work is based on 17th century treatises from Italian academics of the age. Malpighi held the chair of Theoretical Medicine first in Pisa, then in Bologna till 1662, when he reached Messina to hold the Primary chair of Medicine. He went back to Bologna in 1666 and in 1691 moved to Rome, where he died in 1692. Borelli, was the chair of Mathematics first in Messina (1635-1646), then in Pisa. Bellini was one of both Borelli’s and Malpighi’s disciples. Bellini held the chair of Anatomy in Pisa.

“Berengario, Bellini, Malpighi and Borelli started our modern knowledge of the anatomy of the urinary apparatus, i.e. our modern understanding of the kidney and our ‘modern Urology’, although none of the writers –despite their unquestionable genius– could give any reasonable contribution to the knowledge of “uropoiesis”, owing to the lack of even the faintest idea of chemistry, which was only started by Lavoisier more than one century later.” Considering the implications of these texts for modern-day urology, Musitelli concludes: “The Foundation tells us that the origins and development of Urology as we know it today was the marvellous consequence of the application of the ‘quantitative’ perception of the phenomena inaugurated by the Galilean scientific revolution”, which started all the branches of our modern Science.”

EAU Members can read it for free!

Clinical researcher, urologic surgeon and pioneer 1931-2016

He organised well-attended urology meetings in the 1970s when they were still novel. He presented live demonstrations of urologic surgery techniques with moderators and participants directly interacting with the surgeons. Hundreds of urologists used to travel from all over Europe to attend the three-day urology meetings he organised in alternating years with the Mainz group.

Musitelli came across the historical sources that were translated and analysed in his Foundation thanks to the long and exceptionally fruitful collaboration with aforementioned medical historians Belloni and Grondona, who instructed him to find, to read, analyse and translate nearly all the medical and surgical works from Hippocrates (V-IV century B.C.) to the 19th century, Malpighi, Bellini, Borelli, Fontana, Galvani, Volta etc. included. Many of these texts can be found in the two big volumes Selected Passages on Urological Surgery, also published in the EAU Classical Library.

The 200-page volume On the Foundation of Modern Urology by Sergio Musitelli is now available on UROsource.com.

Ernst J. Zingg

to 25% (!). In 1968 he wrote the visionary PhD thesis on isotopic autologous and homologous transplantation of the urinary bladder.

On the Foundation of Modern Urology is now available on UROsource.com, free for all EAU members.

according to well-defined protocols and not left to the discretion of the individual resident or staff member. Once a week, he visited with his head nurse and staff members every in-patient. At a time when there was still no ultrasound examination, CT or MRI his experience and clinical skills enabled him to identify post-operative abnormalities at a very early stage to the benefit of the patient. Every letter to referred physicians was only sent out after he had personally reviewed, approved and countersigned it.

He served with diligence on the board of the medical faculty for many years and as a member of the Numerous kidney stone patients were referred to him hospital's board of directors. At the Inselspital he for removal of hyperactive parathyroid adenomas and, worked for a more efficient organisation of the in the era before extracorporeal shockwave lithotripsy, university hospital. While the nursing and teaching complex and recurrent intrarenal stones. He duties had to be centralised to assure application of pioneered radical prostatectomy and cystectomy, the uniform nursing algorithms, for organisational and latter known as one of his specialties. administrative purposes the nursing staff had to be placed under the control of the department's leadership. This clear delineation of responsibilities Leadership Zingg established a well-organised urological and duties is one of the reasons for the continued department. Patient work-up, preoperative and good collaboration between nursing staff and postoperative management were implemented physicians, which the hospital is known for.

Early in his career Zingg recognised the importance of expanding the practice of modern urology throughout Europe and that to ensure the success of this goal was the creation of a strong European Association of Urology (EAU). In 1982 he succeeded Prof. G. Mayor as treasurer of the EAU, a position he held until 1994. The first EAU secretary general he worked with was Prof A. Steg, and during the last two active years with the EAU he served under the leadership of Prof. F. Debruyne. Together with Debruyne he developed new statutes for the EAU and established the legal base of the EAU in Berne. Among many other prizes, Zingg was a recipient of the St. Paul’s Medal of the British Society of Urology, the Maximilian Nitze Medal from the German Society of Urology and an honorary European Association of Urology (EAU) membership. He was also made one of the highly select corresponding members of the American Society of Genitourinary Surgeons, testifying to the international esteem for his professional achievements and qualities as a person. Following his retirement Zingg continued to follow developments in European urology and in his former department in Berne. He was known for his astute opinions and expert knowledge while remaining modest and low-key. Only when asked for his opinion would he offer a succinct comment unburdened by the expectation that his suggestions would be followed. Zingg took full retirement following a diagnosis of irreversible neurologic disease. His wife, Monika, provided him with loving in-home care. His former colleagues and students are grateful for his mentorship and will cherish his memory and legacy. -By Urs Studer, Daniel Ackermann and George Thalmann

June/July 2016


TEN QUESTIONS Interview and Photograpy by Joel Vega

Age: 47 Specialty: Paediatric reconstructive and robotic minimally invasive surgery City: Chicago, USA Recent Awards & Current Post: 2016 Winner, EAU Hans Marberger Award; Professor of Surgery, Pediatrics and Obstetrics/Gynecology, The University of Chicago Medicine; Director, Pediatric Urology; Consulting Editor, British Journal of Urology International

• What is the most rewarding aspect about urology? The most rewarding aspect is how we can bridge science, technology and the innovative applications for the betterment of urological patients’ quality of life and survival. Being a paediatric urologist, the innocent smile I see in the face of a child after I helped solve their problem is gratifying. • If you were not a urologist, what would you be? I always wanted to become a doctor since I was an about 10-year-old kid. My grandfather encouraged me and he said, “You should be a doctor and take care of me.” Maybe if I wasn’t a doctor I would have been an entrepreneur. • With a doctor’s hectic schedule, how do you avoid burnout? This is a profession that demands 100 percent of you. If we do this with passion we are less likely to burn out and more likely to forget the stress. For me regular exercise, listening to music, spending quality time with my family helps a lot to balance the work and personal life. • How would you persuade a young doctor to specialise in urology? Teaching and training is my passion. I tell medical students that urology is a rewarding profession because it has a wonderful combination of outpatient clinical work and a variety of endoscopic, robotic and complex open surgical procedures. • What do you think is the biggest barrier to practising medicine today? We are at the crossroads of rising healthcare costs and rapid technological changes coupled with a patient population that is highly informed. You deal with patients who are highly knowledgeable but the quality of background information they receive may not always be very accurate. • What do you most often wish you could say to patients, but didn’t? This has not been the case in my practice. I always have a transparent discussion of outcomes, complications, and expectations with the family and parents about their child and this is the foundation of building a trustworthy relationship. • What’s the last thing that surprised you? Human endurance and creativity surprises me, and also the fact that our potentials can be infinite. I experience this whenever I see a child’s speedy recovery through complex surgeries and achieving normalcy in life. We have infinite potentials to achieve and create within a finite lifespan. • What’s the last wonderful book you have read? Most of the time I like to read about world leaders and people who have had a very great impact or influence on our world. Medicine is an art with a complex decision process! I’ve recently read “Thinking, Fast and Slow” by Daniel Kahneman, a clinical psychologist who won a Nobel Prize. • What’s your favourite hour in a day and why? I walk to my work in the morning around 6. My early start gives me time to think clearly about what I can do best for my surgical patients, future research projects, teaching and writing to transfer skills to the next generation. In the evening I like to spend time with my family, conversing during dinner about the day’s events. • What is your biggest fear? I’ve no fears so far although my three kids once said, “Dad, being a surgeon you should insure your hands.” I have not insured my hands and have not really thought about it. Maybe not having fear is also my optimism.

Mohan Saheb Gundeti

Patient Information Chinese translation of EAU Patient Information The EAU Patient Information and the Chinese Urological Association (CUA) have successfully completed the initial phase of its collaborative project with the translation of the EAU patient information into Chinese.

Science at your fingertips

Under the supervision of Prof. Zhu Gang, Chief Surgeon and Head of the Department of Urology at Beijing United Family Hospital and Clinics, and his team, the translation project started in January this year, which resulted to the Chinese translation of the patient information on Kidney Cancer. The information is now available for download from the Patient Information website patients.uroweb.org/zh Other translations underway The entire project will proceed with other topics planned for translation. Patient Information on Urinary Incontinence, Kidney Stones and Erectile Dysfunction will soon be available in Chinese, and more will follow.

www.urosource.com • Over 50,000 items of scientific content • Create your personal library with your favourite items • EAU members have advanced access

We are grateful for the CUA’s support in disseminating the EAU Guidelinesbased patient information, enabling us to reach more patients on a global scale. Prof. Zhu Gang: The project has been fully supported by the EAU and CUA. Both Prof. Chapple and Prof. Sun Yinghao have regarded this as another proof of the close relationship between the two organisations. Professors Sun Yinghao, Huang Jian and Xie Liping have led the translation project which also involved Chinese urologists. We hope that by sharing the EAU Patient Information not only urology patients but also the general public in China will gain insights on urological conditions and their treatment.

patients.uroweb.org

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White nights in Tallinn, Estonia Well-attended HOT sessions at the 3rd EAU Baltic Meeting Dr. Jan-Thorsten Klein Universitätsklinikum für Urologie & Kinderurologie Ulm (DE)

full anastomosis in a pig bladder model. After a short introduction demonstrating the different steps of the surgical techniques and video clips of the tasks, the participants were divided into small subgroups of three to four participants per workstation.

Following the workstation assignments and briefing, the tutors explained the exercises as well and customised the models to the needs of the participants. jtk171272@gmx.net If a participant had intermediate experience the exercise was changed from easy to a more demanding During the 3rd EAU Baltic Meeting held last May 27 routine such as left-handed suturing or anastomotic and 28 in Estonia’s seaside capital Tallinn two full-day techniques. Tips & Tricks and pitfalls were directly sessions were dedicated to educational surgical discussed at the workstations, making the course a training coordinated by the joint European School of really interactive teaching session on how to perform Urology (ESU)/EAU Section of Uro-technology (ESUT). standardised laparoscopic suturing techniques. Laparoscopy was the topic on Day 1 while Day 2 focussed on semi-rigid and flexible ureterorenoscopy. With the immense interest in these two surgical procedures both courses were all fully booked. Three workstations were well-equipped with dry-lab training boxes and an experienced tutor supervised each workstation. Various models were adjusted to the needs of the trainees which offered a customised training protocol for each participant. The training models used on Day 1 emphasised the different types of suturing techniques beginning with easy single-stitch sutures using a chicken leg model, left-handed suturing techniques, backhand suturing to the performance of a

Three two-hour sessions were offered and all participants showed remarkable progress in their training performance. Even very experienced open surgeons took part in the laparoscopy training and performed their first laparoscopic knotting with success. After the laparoscopy training, two sessions of E-BLUS were offered which gave the participants the opportunity to join the exclusive club of E-BLUSers who have passed the test criteria. Workstations were exchanged and after the Congress Dinner held at the impressive Seaplane Harbour Museum and a perfect almost white night in Tallinn, Day 2 was ready for ureteroscopy.

An experienced tutor supervised each workstation

Day 2 sessions started once more with an introduction which focussed on the indication, preoperative management, surgical technique and post-operative management of semi-rigid and flexible ureterorenoscopy. The participants then formed subgroups of three to four teams and proceeded directly to the workstations to practice all possible stone manipulating techniques (e.g. laser

disintegration, stone-dusting and stone fragment extraction using Dormia baskets or graspers) under supervision of an expert endourologist. To guarantee that everybody performed ureteroscopic surgery at the models, the teams rotated, which meant that the surgeon was replaced by the assistant, with the surgeon taking the role of the assistant. The two-hour sessions were both fully booked reflecting the enormous interest particularly on flexible ureterorenoscopy techniques. The training sessions gave the participants a great opportunity to orient themselves with techniques in a nearly one-on-one hands-on teaching and coaching. As in previous training courses, the best-performing participants have a chance to participate in an exceptional training boot camp to be held in Cacares (ES) with course fees and expenses fully sponsored by the ESU.

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

paul.meria@ sls.aphp.fr

Practical Urodynamics for the Clinician Urodynamics (UD) involves various tests that help the clinicians examine clinical problems in incontinence and low urinary tract symptoms. Clinically relevant data will be obtained provided that the physician performs the tests and their interpretation in check. Editors A.C. Peterson and M.O. Frazer, with the contribution of 20 experts, have collated information intended for practitioners involved in low urinary tract treatment strategies. After a short overview on basic science the authors described the required equipment and the setup of UD laboratory. They focused on the requirements for basic tests and special needs for advanced tests. The role of dedicated personnel was also addressed. An important chapter focused on clinical work-up preceding UD assessment and prior to addressing non-invasive UD tests. In this chapter the authors Book reviews

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European Urology Today

The first chapters focused on epidemiology and diagnosis of UAB. The authors wrote a special chapter which focused on physiology and animal modeling and described the evaluations of patients, including the role of urodynamics.

A significant part of the work addressed the available treatments and the authors focused on non-surgical therapies such as catheters. Drug therapy was described and the authors examined recent developments and listed various novel drugs. A special chapter dealt with neuromodulation focusing on This textbook provides a practical update on UD. Figures and photographs are useful and appropriate. current techniques of nerve stimulation. Surgical techniques, most of them aiming to reduce bladder This publication is a recommended purchase for urologists and physicians involved in incontinence and outlet resistance, were also examined. low urinary tract symptoms management. The succeeding chapters were dedicated to specific aspects of UAB such as diabetes, the elderly and Authors : A.C. Peterson, M.O. Fraser pediatrics. A guide for patients was also provided. ISBN : 978-3-319-20833-6 This original textbook is an important tool for E-book : available urologists. Moreover, a possible consensus about UAB Publisher : Springer definition and management could emerge from this Publication : 2016 exhaustive work. Edition : First Binding : Softcover Authors : M.B. Chancellor. A.C. Diokno Price : € 85.59 ISBN : 978-3-319-23686-5 Pages : 166 E-book : available Illustrations : 60 (3 colour) Publisher : Springer Website : www.springer.com/shop Publication : 2016 Edition : First Binding : Hardcover The Underactive Bladder Price : € 85.59 : 222 Underactive bladder (UAB) is not clearly defined but is Pages Illustrations : 86 (69 colour) considered as a multifactorial condition which Website : www.springer.com/shop includes various symptoms such as hesitancy, weak urine stream, straining, incomplete voiding and overflow incontinence. UAB is related to impaired detrusor contractility, due to various conditions such Practical Functional Urology as diabetes and peripheral neurologic diseases. Clinical problems related to lower urinary tract UAB is a challenging condition and editors M.B. (LUT) are frequently encountered during daily Chancellor and A.C. Diokono took the excellent practice. The first edition of this new title was initiative of writing this textbook. With the help of a recently published and aimed to provide functional dozen authors they collected updated information urologists with a practical amount of information intended for clinicians. and recommendations. provided detailed uroflowmetry and other noninvasive methods. Invasive tests such as cystomanometry and pressure flow study were described in the succeeding chapters, and also included nomograms and figures. The role of electromyography was addressed in a dedicated chapter and the authors examined other practical aspects of UD such as the assessment of paediatric conditions.

Editors J. Heesakkers, C. Chapple, D. De Ridder and F. Farag received the support of a panel of more than 40 worldwide experts to publish this book which fulfils a need among urologists. Basic principles were covered in the first chapter before the same section addressed a broad overview of all conditions affecting the LUT in men and women. They focused on neuro-urology in an extended chapter, examining various neurological causes of LUT such as multiple sclerosis, Parkinson disease, and others. Overactive bladder was also widely described, pointing out the available treatments and the timeline of prescription. Bladder pain syndromes and interstitial cystitis were examined such as female problems, including incontinence and infection. The evaluation and management of pelvic organ prolapse were exhaustively described in a richly illustrated chapter. Men’s problems were addressed and the authors focused on LUTS, bladder disorders, male stress incontinence and erectile dysfunction. A short chapter was dedicated to reconstructive surgery and an additional chapter provided practical recommendations and described the management of urinary catheters. This well-illustrated textbook offers the reader practical information regarding male and female functional urology and represents a good addition to current literature on the subject. Authors ISBN e-Book Publisher Publication Edition Binding Price Pages Illustrations Website

: J. Heesakkers, C. Chapple, D. De Ridder, F. Farag : 978-3-319-25428-9 : Available : Springer : 2016 : First : Hardcover : € 160.49 : 392 : 144 (23 colour) : www.springer.com/shop June/July 2016


Baltic16: Prospects in emerging onco-urological treatments Tallinn meeting showcases progressive developments in the Baltics By Joel Vega Prospects and pitfalls in emerging drug treatments for onco-urological malignancies were the focus of plenary discussions at the 3rd EAU Baltic Meeting (Baltic16) held in Tallinn, Estonia from May 27 to 28, which attracted more than 300 participants. EAU Secretary General Prof. Chris Chapple (GB) set the tone of the annual meeting as he cited the recent gains made by urologists in the region and acknowledged the role of collaborative work. “The EAU is keen to continue the strong collaboration with the Baltic region and we are encouraged by the excellent work we have seen here,” said Chapple. Local organisers led by Dr. Toomas Tamm (EE) also welcomed veteran and young urologists attending the meeting. Tamm said expert speakers from Finland, Sweden, Lithuania, Latvia and Russia were invited to present both regional and international perspectives. “We learn from the synergies between inter-regional collaborations as we highlight the work of young, promising urologists,” he said whilst noting that more than 100 abstracts were accepted for the poster presentations.

response to therapies, co-morbidities, potential toxicities and patient choice are among the factors doctors should look into before deciding on a course of action. “In the absence of prospective data, the modest potential benefits of a continuing castration outweigh the minimal risk of treatment,” he said. Mulders gave an overview on the current CRPC drug landscape and mentioned the role of chemotherapy (docetaxel/cabazitaxel), immunotherapy Sipuleucel T and hormonal therapies (abiraterone) and Radium 223. With regards progression in mCRPC, he said it is very important to look at the patient’s performance status. “When you treat patients in a sequential way you need to look at three parameters and not only the patient’s PSA. You have to measure also the clinical, biological and radiological aspects,” he said. “More active drugs are available, and there are different modes of action (MoA) with the sequencing of the same MoA unsuccessful,” said Mulders in his concluding remarks. “We need more information from prospective, randomized studies and molecular targeting.”

Young Urologists Competition In the well-attended Young Urologists Competition, the benefits and drawbacks of surgical techniques in prostate and kidney surgeries were examined by In the opening session, bladder cancer treatment such presenters Drs. Arnas Bakavicius (LT), Igors Carevs (LV) as radical cystectomy and the attendant complications and Margus Krabi (EE). Bakavicius, who later won the were tackled in the lecture by Prof. Axel Heidenreich prize for best presentation, examined sentinel lymph (DE). “With the high rate of complications associated node mapping as an option in prostate cancer and with radical cystectomy, it is important that we need discussed complications often encountered in to carefully select patients for this procedure,” said procedures such as limited and extended Heidenreich. To reduce complications, he said doctors lymphadenectomies. must do a comprehensive assessment of patient history, BMI, previous surgeries and mental “Extended pelvic lymphadenectomy (ePLND) should capabilities, among others. be performed for staging and therapeutic intent,” he

Opening session on Day 1 of the Baltic Meeting

common adverse consequences of radical prostatectomy. At 12-month post-prostatectomy, 5 to 10% of men may still experience SUI,” said Kivi. Artificial urinary sphincter (AUS) is accepted as standard for the surgical treatment of persistent SUI, he said, adding that around a third of patients after AUS require surgical repair within 10 years. He mentioned treatment options such as AdVance which reported overall success rates ranging from 54.5% to 90.6% and a cure rate of around 51.4% to 73.7%. Zirel examined the various indications for AUS such as post-prostatectomy incontinence, sphincteric dysfunction and neurogenic bladder. “All patients

underscoring the incidence of infections, cuff erosion, tissue atrophy and mechanical failure. Pilsetniece spoke on how to manage complications resulting from female sling surgery such as urinary retention, intra-operative bladder perforation, urethral injury, bleeding and sling extrusion/erosion. “Injury of the urethra or bladder during vaginal dissection is best avoided by placing a urethral catheter or emptying the bladder,” she said. She also mentioned that avoiding excessive sling tension and using intraoperative cystourethroscopy also help reduce the incidence of injuries. According to Pilsetniece, intraoperative cystourethroscopy is always indicated to rule out urethral or bladder perforation, whether the sling is placed through a retropubic or a transobturator approach. In her take-home message, she said a comprehensive evaluation of the problem is crucial. “Before making a decision, evaluate the problem comprehensively and discuss the risks and benefits with a patient, as well as any possible alternative treatments.”

More than 300 participants gather in Tallinn for the 3rd Baltic Meeting

He also noted the key role of an exhaustive assessment of pre-operative imaging studies since these tools can show potential pitfalls such as the extent of cancer spread and anatomical anomalies or differences. Experience is also important for optimal surgical therapies as Heidenreich pointed out that frequently preforming radical cystectomies are necessary for doctors to achieve excellent outcomes. Prof. Hing Leung (GB) reported on the work of his group in Glasgow regarding clinically relevant models for studies of prostate cancer progression. Among the studies being done are the quantitative tissue proteomics of castrate resistant prostate cancer and the in-vivo forward genetic screen to identify novel genes and events in lethal prostate cancer using animal models. “It is important to have these studies conducted as they help us provide optimal treatment strategies for men with resistant or recurrent disease,” said Leung. He expressed optimism that breakthroughs in basic research may occur in the coming years. “Certainly we need more collaborative work and support of our colleagues from other countries,” Leung said. mCRPC: A new drug landscape Other sessions also examined current drug developments in prostate cancer. In a session titled “Current management for metastatic castration-resistant prostate cancer (mCRPC),” Professors Felix Jankevicius (LT) and Peter Mulders (NL) discussed patient selection, new alternatives and sequencing of drug treatment. They said that although there are new drug options, the different modes of action make the current treatment landscape more complex for physicians to determine the best regimen. Jankevicius looked into the aspects of choosing the right treatment for CRPC patients and said previous June/July 2016

said. He added that due to high false negative results, sentinel nodes (SNs) lymphadenectomy cannot replace ePLND. “Instead of super-extended PLND, ePLND plus dissection region with SNs could be considered,” said Bakavicius. Carevs presented an overview on retropubic and perineal approaches for radical prostatectomy and discussed patient criteria selection, the resurgence of radical perineal prostatectomy (RPP) and its drawbacks. “Perineal prostatectomy is a less invasive complement to retropubic approach if lymph node dissection is not required,” he said, noting that it is equivalent to RPP in terms of cancer control. Krabi tackled contemporary dilemmas in small renal masses (SRMs) and discussed issues such as the role of active surveillance for patients with SRMs. He said there are many unresolved issues with SRMs, and that further studies are needed to shed light on issues such as quality of life and the benefits and disadvantages of surgical approaches, among others.

must have sufficient sophistication and hand functionality to operate the pump,” he said, while

Best posters winners Lithuania and Estonia led the best poster presentations with Dr. Z. Milonas receiving the first prize from Karl Storz for his study on a risk nomogram to predict lymph node invasion in prostate cancer patients. An equivalent prize from Berlin Chemie was awarded to Dr. Ž. Ots for his work on the transition of the non-muscle invasive bladder cancer (NMIBC) grading system in Estonia. Below is the complete list of winners: Karl Storz Best Poster Presentation Awards D. Milonas, Z. Venclovas, P. Aniulis, M. Jievaltas (Kaunas, Lithuania) First Prize: ‘Validation of risk nomogram to predict lymph node invasion in prostate cancer patients undergoing lymph node dissection’

L.N. Suslov, A.I. Rolevich, I.A. Zelenkevich, S.L. Polyakov, S.A. Krasny, O.G. Sukonko (Minsk, Belarus) Third Prize: ‘Long-term functional outcomes of nephron sparring surgery for renal masses in the solitary kidney‘ Berlin Chemie Best Poster Presentation Awards R. Ots, Ž. Riispere, M. Sokirjanski, A. Peetsalu (Tartu, Estonia) First Prize: ‘Transition of NMIBC grading system from 1973 to 2004 WHO classification in Tartu 2010-2013’

Challenges in managing incontinence Managing the complications caused by surgical procedures in patients with incontinence was also examined by experts who warned not only about the severity but also the complexity of complications. Topics discussed by speakers Martin Kivi (EE), Ulo Zirel (EE), Zane Pilsetniece (LV) and Marija Barisiene (LT) included male slings surgery, sphincter prosthesis, complications management after female sling surgery and pelvic floor reconstruction, respectively. Kivi gave an overview of male incontinence and looked into the current treatment options in stress urinary incontinence (SUI) such as compression devices, fixed male slings (FMS) and gave pointers on how to optimize support techniques. “SUI and erectile dysfunction (ED) are the most

Barisiene lectured on pelvic floor reconstruction in women and said pelvic organ prolapse (POP) occurs in more than 50% of women over 50 years and that POP surgery is one of the most common urogynaecologic procedures. “There is an 11% to 19% chance of undergoing a single surgery for POP or urinary incontinence during a lifetime,” she said adding that in pelvic reconstruction carefully considering the stage of the problem, overall health and previous surgeries of the patient, surgical expertise and patient’s expectations, are important aspects.

P. Korrovits, O. Poolamets, R. Mändar, M. Punab (Tartu, Tallinn, Estonia) Second Prize: ‘Diagnostic thresholds for detecting inflammation in prostate-specific material – method standardization and proposed optimal cut-off points’

M. Barisiene, A. Cerniauskiene, A. Matulevicius (Vilnius, Lithuania) Second Prize: ‘Complications and its treatment after midurethral sling implantation using retropubic and transobturator route for the treatment of female stress urinary incontinence’ I. Vaivode, M. Jakubovskis, M. Sperga, J. Auzinš, K. Petersons, S. Donina, D. Baltina, V. Lietuvietis (Riga, Latvia) Third Prize: ‘Are small renal masses always harmless and large ones threatening?’

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2016 novelties on prostate cancer from the WHO New variants and grading in prostate cancer Prof. Rodolfo Montironi Chairman, EAU Section of Uropathology (ESUP) Ancona (IT) r.montironi@ univpm.it Collaborators: Antonio Lopez-Beltran (PT), Marina Scarpelli (IT) and Liang Cheng (USA) The World Health Organization (WHO) has just published the fourth edition of the WHO classification of the Tumours of the Urinary System and Male Genital System1 (Figure 1). The new additions to the 2016 WHO classification of prostate cancer, compared with the 2004 WHO classification, are as follows2: 1. 2. 3. 4. 5.

Intraductal carcinoma of the prostate Microcystic acinar adenocarcinoma Large cell neuroendocrine carcinoma Grading of adenocarcinoma Genetic profile of adenocarcinoma

Table 1: Differential diagnoses with HGPIN and cribriform and solid adenocarcinoma

IDC-P is considered to represent a late event in prostate cancer evolution, with intraductal spread of aggressive prostatic carcinoma and cancerisation of pre-existing ducts and acini by high-grade PCa. A minority of cases, however, may be precursors to PCa1-4. Reporting of isolated IDC-P in needle biopsy should include a comment saying that IDC-P is associated with high-grade and high-volume PCa and that therapy may be indicated. Repeat biopsy may also be recommended. IDC-P is not assigned a Gleason score1-4. New variants of acinar adenocarcinoma The variants that look deceptively benign are1-3. • Atrophic • Pseudohyperplastic • Foamy gland, and • Microcystic adenocarcinomas (2016 novelty) Microcystic adenocarcinoma is characterised by deceptively benign-looking at low-magnifications and cystic dilatation and rounded expansion of glands of usual adenocarcinoma with a flat luminal cell lining layer (Figure 5). It can be associated with atrophic and pseudohyperplastic patterns. It may be confused with benign cystic atrophy, especially in prostate biopsies (Figure 6)1-3. In difficult cases, immunohistochemistry can be useful. In particular, microcystic adenocarcinoma is positive for racemase and negative for basal cell marker immunostains, whereas cystic atrophy is negative for the former and positive for the latter. Prognosis is identical to that of usual acinar adenocarcinoma. There are variants of acinar adenocarcinoma with worse prognosis compared with usual acinar adenocarcinoma1-3, such as: • Signet ring–like • Sarcomatoid, and • Pleomorphic giant cell adenocarcinoma (2016 novelty)

Intraductal carcinoma of the prostate (IDC-P) IDC-P is intraductal or/and intra-acinar neoplastic proliferation that has some of the features of High Grade Prostatic Intraepithelial Neoplasia (HGPIN), but with much greater architectural and/or cell atypia, usually associated with high-grade, high-stage prostate carcinoma (PCa). It is characterised by malignant epithelial cells filling large ducts and acini, with preservation of basal cell layer1,3. It can show two patterns: 1. Solid or dense cribriform (Figure 2) 2. Loose cribriform or micropapillary with marked nuclear atypia or comedonecrosis, i.e., necrosis in the centre of the ducts and acini filled with malignant cells. The main differential diagnoses are with HGPIN (Figure 3), and cribriform (Figure 4) and solid adenocarcinoma4 (Table 1). Concerning the distinction from HGPIN, one of the main features that can be easily appreciated at low microscopic magnification is that the ductal-lobular structure is expanded and the gland size increased, whereas in HGPIN the former is preserved and the latter normal. There is a morphologic continuum of IDC-P with HGPIN and distinguishing IDC-P from HGPIN can seldom be difficult. In such situations, immunohistochemistry for PTEN and ERG can be used.

Pleomorphic giant cell adenocarcinoma is exceptionally rare with fewer than 10 reported cases. The largest series is six cases6. Admixed Gleason score 9 usual adenocarcinoma is seen in all cases. A history of hormonal or radiation therapy is common. It is associated with an aggressive clinical course. The differential diagnosis is with bladder carcinoma, pleomorphic giant cell variant (Figure 7). Pleomorphic giant cell adenocarcinoma retains prostate marker expression, such as PSMA, Prostein and NKX3.1. Pleomorphic giant cell bladder carcinoma is positive for GATA3 and/or Uroplakins7. The list of post-therapy variants of PCa includes: sarcomatoid carcinoma (carcinosarcoma), adenosquamous and squamous cell carcinoma, pleomorphic giant cell adenocarcinoma and neuroendocrine tumours. The classification of the neuroendocrine tumours includes1,3: • Adenocarcinoma with neuroendocrine differentiation • Well-differentiated neuroendocrine tumour • Small cell neuroendocrine carcinoma • Large cell neuroendocrine carcinoma (LCNEC) (2016 novelty).

LCNEC of the prostate is exceptionally rare, particularly its pure form8. It is also seen in Morais et al5 found that cytoplasmic PTEN loss and association with small cell carcinoma and ERG expression occur in most of the IDC-P as well as adenocarcinoma. Cases of usual high-grade prostate in intraductal proliferations with cribriform features, adenocarcinoma with expression of NE markers have whereas cytoplasmic PTEN loss and or ERG expression incorrectly been reported previously as LCNEC. It is were never seen in HGPIN. The other differential composed of solid large nests with peripheral diagnosis is with PCa with cribriform and solid palisading and often geographic necrosis (Figure 8). architecture, in particular when PCa cell nests with It shows large cells, low N/C ratio, coarse chromatin, these two architectural patterns shows well defined prominent nucleoli, high mitotic activity, with IHC margins. The evaluation of the presence of the basal evidence of neuroendocrine differentiation. The cells is of paramount importance. largest series is seven cases9. Outcome is poor, even after chemotherapy with seven months survival. In IDC-P is rare in isolated form in needle biopsy tissue, six out of seven cases there was a history of prior being detected in 0.1–0.3% of needle core cases. It is hormonal therapy for PCa. uncommon in the presence of invasive PCa in needle core tissue, being diagnosed in 2.8% of such cases. In Grading of adenocarcinoma the radical prostatectomy (RP) specimens, the The Gleason grading system is one of the most incidence is dependent on the grade and stage of the important prognostic factors10. In November 2014, PCa and can range from 20% to 40% of cases. IDC-P is the ISUP organised in Chicago a consensus conference associated with an average Gleason score of 8 and pT3 on the grading of prostatic adenocarcinoma11. PCa in the RPs. Following a needle biopsy diagnosis of The objectives were: isolated IDC-P, the intraductal carcinoma in the whole prostate gland is found in pure form, i.e., without • The lack of consensus of certain grading issues, associated invasive adenocarcinoma, in ~10% of RPs1-4. many of which not resolved in the 2005 meeting • A realisation that some grading issues were not covered in 2005 EAU Section of Uropathology • Changes in PCa practice have led some clinicians 28

European Urology Today

to challenge the existing grading system, necessitating a response by the pathology community. An example of this is: “Scores 2-5 are currently no longer assigned and certain patterns that Gleason defined as a score of 6 are now graded as 7, thus leading to contemporary Gleason score 6 cancers having a better prognosis than historic score 6 cancers”11. The two main topics of the conference were: 1. 2014 ISUP modified Gleason system 2. Prognostic grade grouping (five-tiered grading prognostic system). The 2014 ISUP modified Gleason system, when compared with the 2005 ISUP modified Gleason system, includes11: • Cribriform glands should be considered as a Gleason pattern 4, regardless of their histology (Figure 4) • Glands with glomeruloid features should be assigned a pattern 4 (Figure 9) • ICP not associated with invasive PAC is not graded • Grading of PAC with mucinous features should be based on its underlying architectural pattern rather than considering all of them as pattern 4. The Gleason pattern 4 morphologic spectrum evaluation should be based on10,11: • Gleason pattern 4 spectrum: cribriform, glomeruloid, fused, and poorly-formed glands • For a diagnosis of Gleason pattern 4, it needs to be seen at 10X lens magnification • Occasional fused glands or poorly-formed between well-formed glands is insufficient for a diagnosis of pattern 4 • In cases with borderline morphology between Gleason pattern 3 and pattern 4, the lower grade should be favoured. Concerning the Prognostic grade grouping, this was linked to the problem of too many scores with similar prognosis, in particular with: • 25 potential scores • 6 is the lowest grade reported although the scale goes from 2-10 • “Patients are told they have a Gleason score of 6 out of 10 and logically but incorrectly think that they have a tumour in the middle of the grade spectrum, contributing to the fear of cancer”11 • Gleason 7 is not homogeneous: 4+3=7 has a much worse prognosis than 3+4=7 • Gleason 8-10 is often considered as one group, i.e., high-grade cancer • Various combinations have been used in the literature including some of the highest impact studies11. There was consensus in the conference to adopt a five-tiered grading prognostic system12. This was presented by Dr. JI Epstein, based on a 2013 Pierorazio et al’s publication13 and supported from the 3 prognostic point of a study on a large number of cases. The histological definition11 of the grading system was: • Grade Group 1 (Gleason score ≤6): Only individual discrete well-formed glands • Grade Group 2 (Gleason score 3+4=7): Predominantly well-formed glands with lesser component of poorly formed/fused/cribriform 33 glands • Grade Group 3 (Gleason score 4+3=7): Predominantly poorly formed/fused/cribriform glands with lesser component of well-formed glands (the component of <5% well-formed glands is not factored into the grade) 5 5 • Grade Group 4 (Gleason score 4+4=8; 3+5=8; 5+3=8) o Only poorly-formed/fused/cribriform glands or o Predominantly well-formed glands and lesser component lacking glands (Poorly- formed/ fused/cribriform glands can be a more minor 77 component) or o Predominantly lacking glands and lesser component of well-formed glands (Poorlyformed/fused/cribriform glands can be a more minor component) • Grade Group 5 (Gleason scores 9-10). Lacks gland formation (or with necrosis) with or without poorly-formed/fused/cribriform glands (the component of <5% well-formed glands is not factored into the grade). Studies supporting the prognostic significance have been published. The studies have as endpoint either biochemical recurrence-free progression or prostate cancer death.

• A contemporary prostate cancer grading system: a validated alternative to the Gleason score14 • The prognostic significance of the 2014 ISUP grading system for prostate cancer15 • Validation of ISUP grading for prostatic adenocarcinoma in thin core biopsies using TROG 03.04 'RADAR' trial clinical data16 • Evaluation of the 2015 Gleason grade groups in a nationwide population-based cohort17 • Validation of a contemporary prostate cancer grading system using prostate cancer death as outcome18. The editors of the major uro-oncology journals are recommending investigators to use the new system19. The WHO blue book published at the beginning of 2016 adopted the five-tiered grading prognostic system (Grade Groups 1-5). For the time being the Gleason score and the new system should be used. It is suggested that has to be done for the individual cancer positive cores as well as for overall score. An example of the application of the new system is as follows: “Right Apex: Acinar adenocarcinoma of the prostate, Gleason score 3+4=7 (Grade Group 2) with 30% pattern 4 involving 70% of 1 core”. Genetic profile of adenocarcinoma The 2016 WHO book also deals with somatic genetic abnormalities in PCa and a model for molecular classification of PCa is included. The discovery of these genetic abnormalities has led to greater understanding of the molecular pathogenesis of PCa and has demonstrated potentially therapeutically actionable molecular defects1,3. The references of this article are available from the EUT Editorial Office by sending an e-mail to: EUT@uroweb.org with reference to the article “2016 novelties on prostate cancer from the WHO” by Prof. Montironi, June/July issue 2016.

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Figure 1: Front cover of the WHO book

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Figure 2: Intraductal10 carcinoma of the prostate Figure 3: High grade PIN Figure 4: Prostatic adenocarcinoma with cribriform architecture Figure 5: Microcystic adenocarcinoma Figure 6: Cystic atrophy of the prostate Figure 7: Pleomorphic carcinoma of the bladder Figure 8: Large cell neuroendocrine carcinoma Figure 9: Prostatic adenocarcinoma with glomeruloid features

June/July 2016


Young Urologists/Residents Corner Comprehensive urology training in Madrid South American doctors assess clinical training experience Dr. Guillermo Luis Siffredi Senior Resident Buenos Aires (AR)

guillermo.siffredi@ gmail.com

Dr. Guilherme Valente Hospital Mater Dei Dept. of Urology Belo Horizonte (BR)

guilhermessvalente@ hotmail.com Efficiency and a methodical training characterised the three-month experience we have had at the La Paz University Hospital (Hospital Universitario La Paz or HULP) in Madrid, Spain, thanks to the Teaching Committee which guided us in every phase of the programme. Right on the first day we were warmly welcomed by members of the Urology Department. We began our morning routine with a clinical session at 8:30 with the resident-on-call reporting the patient's clinical condition to the senior doctors and Head of Service. Clinical decisions were then discussed and surgeries scheduled. The HULP has an exclusive surgical floor with three operating rooms. Every day at least 10 surgeries of

different complexities are scheduled. The procedures include at least one or two laparoscopic surgery (most of them oncological), laparoscopic radical prostatectomy and laparoscopic nephrectomy (radical and partial). Renal stone diseases were also common cases, with flexible or rigid ureteroscopy or percutaneous nephrolithotomy held weekly. Laser is used depending on the doctor’s treatment plan. Prostate enlargement is treated with holmium laser enucleation or bipolar resectoscope. Urethroplasties (end-to-end anastomosis or with mucosa graft) are also performed. Transurethral resection of the bladder is also among the procedures.

Since La Paz Hospital is a teaching hospital all surgeries require the active participation of a resident. The attending physician leads the surgical team, while a first assistant supervises the performance of a resident. The activities in the operating rooms, although overlapping, are organised throughout the week, making it easier for us to plan which surgeries to attend. At times we have to add to our schedule a surgery session on kidney transplantation, since HULP is a referral center for renal transplants. Six kidney transplants are performed at least every month at La Paz. The deputy transplant doctor-on- call performs surgery with assistance from the residents.

Other laparoscopic surgeries were laparoscopic closure of vesico-vaginal fistula, laparoscopic bladder diverticulectomy, laparoscopic radical cystoprostatectomy with ileal conduit. Exceptionally memorable was a laparoscopic ureteral reimplantation surgery performed in a kidney transplant patient. The Urology Department’s comprehensive laparoscopic services, combined with the recent acquisition of a Holmium laser, has resulted in fewer cases of open surgery being performed, cases which were limited to specific indications. Thus, we experienced a wide range and quantity of laparoscopic surgeries.

The HULP has a busy academic activity and there are courses for various sub-specialties. Twice a week, discussion forums are regularly scheduled, providing the opportunity for various specialists to explain or discuss certain issues. The presentation of themes are organised to match or respond to the needs of the residents, and the sessions aim to motivate residents to hold critical discussions. One can participate in any of the courses developed by the Urology Department. For instance, we participated in a theoretical and practical course in flexible ureterorenoscopy.

In another part of the hospital, ambulatory surgeries are performed. With the hectic daily routine, residents should efficiently schedule their activities to ensure that services are done and patient needs well taken care of. Furthermore, uretrocisfibroscopies, hydrocelectomies, phimosis surgery, penis biopsy and replacement of ureteral catheters are also among the procedures performed. Surgical interventions do not only take place at the HULP, but are also offered at the Carlos Tercero Hospital where vasectomies and phimosis surgeries are done.

We also appreciate the opportunities we had in actual surgeries and the chance to share insights and experience with physicians from other institutions and countries. We assisted in procedures such as renal transplantation, artificial sphincter placement, flexible ureteroscopy, radical cystoprostatectomy, among many others. Our training period aimed to observe and experience the systematic work of a urology department, learn from their work protocol and get involved with their routine to understand how various surgical procedures are successfully implemented. On top of these opportunities, we were fortunate to learn from their best practices, since laparoscopic surgeries are the main expertise of HULP, one of Spain’s pioneers in laparoscopic surgery. Our professional expectations have not only been met, but we were also inspired, and this would not have been possible without the collaborative support of people who worked as one team.

We had the full support and guidance particularly from senior doctors Mario Álvarez, board member of the Endourology & Lithiasis Group of the EAU’s Young Academic Urologists (YAU), and also a member of a subcommittee of the EAU Section of Oncological Urology (ESOU), and Juan Gómez Rivas, Chairman of the Residents and Young Urologist Spanish workgroup and also an executive committee member of the ESRU and YUO. They both extended their help and guided us in laparoscopic surgical techniques, shared protocols, literature, videos, and also gave tips on pelvic trainer practice which is a part of EAU’s E-BLUS programme.

EUSP Clinical Visit London observation fellowship yields insights in andrology Dr. Selçuk Sarikaya ESRU Chairman, YUO Board Member Keçioren Research and Training Hospital Dept. of Urology Ankara (TR) drselcuksarikaya@ hotmail.com I have the opportunity to receive a three-month clinical visit grant from the European Urological Scholarship Programme (EUSP) to observe and work at the Department of Andrology of the University College London Hospitals (UCLH) in London, the United Kingdom. From March 1 to May 31 this year, I was based in London, one of the world’s financial and cultural capitals. The UCLH is one of the best and the biggest university hospitals in London and was officially opened in October 2005 by Her Majesty the Queen. Services offered at University College Hospital include emergency services, hyper-acute stroke unit, cancer care, critical care, endocrinology, general surgery, ophthalmology, dermatology, general medicine, general neurology, rheumatology, orthopaedics, paediatric and adolescents and urology.

Figure 1: UCL-Westmoreland Street Hospital

June/July 2016

The St. Peter's Andrology Unit is the biggest tertiary referral team within UCLH and has earned both national and international acclaim. Andrology operations are mainly performed in UCL-Westmoreland Street hospital (formerly the heart hospital).

cancer. One of the most exciting operations I observed at the UCLH was the phalloplasty operation which requires a high level of expertise and excellent surgical skills. All team members were actively involved in every phase of the operation.

Dr. David Ralph is consultant urologist at St. Peter’s Hospitals, his practice is entirely confined to andrology. He has a Master’s degree on Peyronie’s disease and is the president of the European Society for Sexual Medicine and past president of the British Society for Sexual Medicine and Andrology Section of the British Association of Urological Surgeons. He runs a large multidisciplinary erectile dysfunction service and is director of the Erectile Dysfunction Clinical Trials Unit. He also leads a European training fellowship for penile prosthesis implantation as well as research fellowships focusing on the molecular biology of erectile dysfunction, Peyronie’s disease and priapism. He is actively involved in post-graduate training, organising live surgery courses and gives lectures at the European School of Urology and the American Association of Urology.

During my clinical visit, I also had chance to attend the 3rd Men’s Health Masterclass held from April 21 to 22. The conference did not only offer a very comprehensive scientific programme but was also well organised. I had a very productive meeting since there were many live surgeries and lectures by senior mentors, including step-by-step surgical procedures for penile prosthesis implantation, penile plication, Lue procedure, sliding technique, etc.

Scholarship activities On the first day, Dr. Ralph introduced me to his colleagues, his fellows and the staff members of the hospital who were all kind and helpful. During my visit, I was very fortunate to attend most of the surgical operations and out-patient clinics as an observer since in the UK one cannot assist or be involved in active patient treatment and surgical operations without being registered with the GMC. Nevertheless, observing the andrology operations was very important and educational, and among the highlights of my experience was observing the technical and mechanical aspects and tricks for prosthesis cases. Almost all andrological and reconstructive operations are performed at the UCLH Andrology Department and all the consultants are talented and experienced. Beside andrologic and reconstructive operations, the team provides treatment for patients with penile

On Thursday afternoons every week, there were meetings to examine the weekly surgical programme and the cases for the week. These meetings helped me understand the concept of surgical operations and I had a chance to read about the surgical operations before the actual procedure. Moreover, before each surgery, Mr. Ralph provided detailed information about the surgery and the patient. Surgical curriculum The University College London – Westmoreland Hospital, which has 12 operating rooms and four catheterization laboratories, is known for its high standards in every field. Andrology operations were

Figure 2: 3rd Men’s Health Masterclass

Figure 3: University College London Hospitals

mostly performed in three or four of the available theatres every day. The operations I observed during the clinical visit are the following: • 3 Phalloplasty operations; • 20 Urethroplasty operation; • 60 Penile Prosthesis implantations; • 10 Testicular Prosthesis implantations; • 2 Total Penectomy / Penile Cancer; • 40 Circumcision procedures; • 20 TESE / Micro-TESE; • 20 Varicoselectomy / Micro Varicoselectomies; • 5 Penile lengthening operations; • 5 Epididimo-vasostomy/Vaso-vasostomies; and • 50 other specified penile or scrotal plastic / reconstructive operations. A great experience As an EAU Scholar, the clinical visit at the University College London Hospital, offered a great experience and boosted my knowledge on andrology and sexual medicine. I strongly recommend to urology residents and young specialists who are interested in andrology and sexual medicine to consider the UCLH’s Department of Andrology for a clinical visit and long-term fellowships. My special thanks to Mr. David Ralph, Mr.Giulio Garaffa, Mr.Nim Christopher, Mr.Asif Muneer and Mr.Chris Poullis for their excellent mentorship. I would also like to thank all the hospital staff, nurses, andrology fellows, especially Drs. Ayo Kalejaiye, Saskia Morgenstern, Marco Capece and Marco Falcone. Finally, I thank the EUSP for providing this priceless opportunity and Ms. Angela Terberg for her assistance. European Urology Today

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June/July 2016


EAU Training Course Basic Urology Workshop in Accra, Ghana Prof. Dr. David Castro Díaz Canarias University Hospital Dept. of Urology Santa Cruz de Tenerife (ES) davidmanuel castrodiaz@gmail.com Ghana’s capital city Accra hosted from 18 to 22 April 2016 an EAU training course on Basic Urology as part of the EAU’s philanthropic African Outreach Programme.

Learning basic surgical procedures EAU International Relations Office

Dr. Victor Ramos (FEBU) and Dr David Hernández (FEBU), staff urologists at the University Hospital of the Canary Islands (Spain), shared their knowledge on basic urology and endourology with local urologists from Accra and neighbouring towns. The course was held at the 37th Military Hospital in Accra under the coordination of Dr. Sunny Mante, Head of the Department of Urology, and Dr Ben Adusei (staff urologist) with the technical support of Karl Storz. This one-week programme allowed local urologists to improve their knowledge and skills on basic urology and introduced them to more advanced endo-urologic procedures.

Participants and course tutors in Accra

We thank Karl Storz for providing the needed Drs. Mante and Adusei were actively involved in the materials as well as technical and human assistance course and welcomed urologists from around the that made this training course a success. Both the country. Participants from the capital and nearby cities had the opportunity to observe and learn endoscopic surgical techniques including transurethral resection of the prostate (bipolar), rigid ureteroscopy, retrograde intrarenal surgery, laser lithotripsy, renal and abdominal laparoscopy. Under supervision and expert guidance, local surgeons performed three to five daily surgical procedures to acquire new knowledge and hone their skills. Facilities at the 37th Military Hospital in Accra are very good and the surgical staff members are fully qualified, friendly and efficiently collaborated to organise the workshop.

local staff and visitors were also very satisfied with the outcome and benefits from this practical training programme.

Step-by-step guidance and practical pointers from the course tutors

Russian Society of Urology releases online version of journal “Urologiia” now available in English Prof. I. Korneyev Chair Membership Department EAU St. Petersburg (RU)

iakorneyev@ yandex.ru “Urologiia,” the official peer-reviewed journal of the Russian Society of Urology (RSU) has recently released its online English version, with selected articles accessible via this link: http://www. urologyjournal.ru/ru/page/journal-english.html. EAU International Relations Office

The journal’s first issue was published in March 1923 with the initiative and support of Prof. Fedorov, the chairman of RSU. It has become a forum for urologists and other professionals, providing updates of current trends in care for patients with urological disease in Russia.

cooperation through clinical and research projects, joint activities at annual congresses and have invited faculty members to provide training courses to Russian and other urologists from mainland Europe. Part of this collaborative work is the release of an English version of Urologiia.

The journal presents original articles, editorials and reviews on a wide range of urological issues including onco-urology, female urology, functional urology and urodynamics, reconstructive urology, laparoscopic, robotic and endoscopic surgery, female urology, paediatric urology and andrology. Published six times per year, the journal is occasionally supplemented by thematic issues to serve its readership of more than 4,200 Russian urologists.

The EAU’s opinion leaders Professors Chris Chapple, Manfred Wirth and Kurt Naber have accepted the invitation to join the journal’s Editorial Board and will publish articles in the coming issues.

Following a meeting between the RSU and the EAU leadership in 2013 during the Annual EAU Congress in Milan, the two organisations are now pursuing closer

RSU Chairman Prof Y. Alyayev and RSU Executive director Prof. M. Gazimiev believe the Urologiia’s English version would strengthen the journal’s reach and international readership. The mutual exchange of experience and educational resources is part of the collaborative initiative which aims for a unified approach to the diagnosis and treatment of patients with urological diseases.

Urologiia, the official peer-reviewed RSU journal

104th Congress of the Japanese Urological Association EAU gives expert lectures in Sendai, Japan The EAU joined the 104th Annual Meeting of the Japanese Urological Association (JUA) held in Sendai last April 23 to 25 with Prof. Francesco Montorsi representing the association. Aside from Montorsi’s lectures in prostate cancer management, the JUA also honoured EAU Secretary General Prof. Chris Chapple with a Honorary Membership Award. Below are some photos taken during the annual congress.

More than 5,000 urologists joined the JUA Congress EAU International Relations Office

June/July 2016

Honorary Award EAU Secretary General Prof. Chris Chapple conveys his thanks to the Japanese Urological Association for receiving the JUA Honorary Membership via a video message.

State-of-the-art lecture on prostate cancer management Prof. Montorsi gives a state-of-the-art lecture on optimising sexual function outcome after RP, an EAU lecture on the role of robotic radical prostatectomy in managing high-risk PCa, a talk on how to get a paper accepted in European Urology, and a lecture regarding treatment challenges in very high-risk PCa. European Urology Today

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EAU Best Papers published in Urological Literature Awards

Apply now!

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

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

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

Apply now!

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

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

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June/July 2016


#SEEM16

SEEM16

Early fee registration deadline: 1 August 2016

EAU 12th South Eastern European Meeting 23-24 September 2016, Sarajevo, Bosnia and Herzegovina SEEM16: Challenges in training and education

Prof. Mustafa Hiroš SEEM16 Chair and Course Director

Evolving treatment strategies trigger prospects and challenges Recent developments in treatment, gains in research and technologies have triggered prospects and challenges in managing urological cancers and diseases, topics which will be examined and explored in the upcoming EAU 12th South Eastern European Meeting (SEEM16) to be held in Bosnia and Herzegovina’s capital city of Sarajevo. SEEM will return for the second time to Sarajevo on September 23 and 24 to host the meeting which attracts not only local urological professionals but also their colleagues from neighbouring countries such as Slovenia, Croatia, Kosovo, Macedonia and even as far as Greece and Turkey. “SEEM 2016 will present and tackle topics such as urologic oncology, castration-resistance prostate cancer (PCa) particularly the treatment of high-grade PCa. The latter topic is relevant since there are many gains, changes and developments in this area in the last two years,” said Prof. Mustafa Hiroš, SEEM16 chairman and course director. Hiroš said the meeting is a wonderful opportunity to put to the table specific themes, issues and dilemmas that concern urologists in the region. “One great quality of regional meetings is that local organisers have the opportunity to shape the programme and the possibility to focus on the themes that are relevant to local practice and demands, while at the same time getting the perspectives and insights of international experts and lecturers,” he added.

The two-day event will feature state-of-the-art lectures, panel debates, Country Competitions, abstract poster sessions, plenary sessions and interactive case discussions, among other activities, aside from a social programme that aims to improve professional ties among urological professionals. The European School of Urology (ESU) will also organise hands-on training sessions in laparoscopy and ureteroscopy. “Urologists from Bosnia and Herzegovina would be trained on new procedures and get updates in female urology and male sling procedures,” according to Hiroš as he noted the need for updates due to the emergence of new data and treatment alternatives and the necessity of instructing doctors on how to manage complications. Known as the meeting which annually attracts enthusiastic participation from young doctors and urological researchers in the region, Hiroš underscored that SEEM has earned the reputation as a reliable platform for urologists to present their work. The knowledge exchange and dynamic atmosphere between veteran practitioners and their younger

colleagues are well appreciated by all participants, said Hiroš. “Certainly, we are aware of the important role of effectively linking up with our colleagues and receive critical evaluation of new work from our peers. This process can only make our standards better, helping us refine and optimize our treatment management strategies,” he said. Sarajevo hosted the 3rd SEEM in 2007 which attracted not only urologists from across the region and elsewhere, but also reflected the dynamic gains and developments in both research and clinical work. “We are grateful for the consistent support and collaboration we receive from the EAU and its affiliate organisations and partners such as the ESU. Without their support these meetings will be difficult to organise and without such professional gatherings we remain uninformed of key developments and will miss the benefits of mutual exchange,” noted Hiroš. Young urologists are encouraged to participate in the HoT courses and poster presentations to refine their skills and draw attention to their work and receive critical assessment. Selected abstracts will be presented in several sessions and the top six research studies will be awarded cash prizes. Moreover, the winning poster presentations will be highlighted in future EAU meetings such as the Annual EAU Congress.

For more details visit the meeting website at www.seem16.org

Early fee registration deadline: 15 August 2016

CEM16

#CEM16

EAU 16th Central European Meeting 7-8 October 2016, Vienna, Austria

CEM16: Consolidating gains in urology

Dr. Michael Rauchenwald Chair CEM16

Longest regional meeting assesses gains and prospects For the first time, the Central European Meeting, known as the EAU’s longest running regional meeting, will be held in Vienna, Austria, from October 7 to 8, to gather both veteran and young promising urologists to assess current gains in urology and future prospects. Now on its 16th year, the CEM is not only the flagship meeting of the EAU’s Regional Office but has earned the reputation as a dynamic platform for knowledge exchange and critical discussion. Moreover, CEM highlights new research from young urological talents across Europe. “We are proud to host the annual CEM in Vienna, an event which brings together urology experts not only from the central region but from across Europe,” said Dr. Michael Rauchenwald, chairman of the 16th EAU CEM. “Vienna has not only been at the forefront of progressive developments in medicine, our pioneers have also made significant contributions to the milestones that have shaped modern urology.” The Scientific Programme will cover the breadth of urology such as uro-oncology, andrology, functional and female urology, infections, urolithiasis, and techniques in reconstructive and minimally invasive urology, among other topics. Current dilemmas and controversies encountered by urologists in the clinical setting, laboratories and in research will also be taken up.

The meeting is also a venue for talented urology researchers to present their findings from new and on-going research enabling them to elicit critical assessment and feedback. “What makes the CEM and other regional meetings a success is the emphasis on critical discussion. By looking into best practices and insights coming from experts and specialists, we get new perspectives which helps refine our own clinical practice and management strategies,” said Rauchenwald. Besides the panel debates, Country Competitions, plenary sessions and interactive case discussions, abstract poster sessions will be presented with moderation from renowned specialists. Abstract presenters have the chance to discuss with experts on a one-to-one basis the implications of their studies, while at the same time creating professional links with other clinicians and researchers. As in previous meetings, the meeting will offer courses and laparoscopy training organised by the European School of Urology (ESU) where young urologists can further refine their

skills and learn new techniques. Course mentors will be present to provide handy tips and tricks and respond to queries from participants regarding complications, practical problem-solving methods and training opportunities. The six best abstract presentations will also be recognized with both financial and critical rewards, providing a boost to young researchers and their colleagues. “CEM aims to act as a facilitator of knowledge exchange while serving the interests of urological professionals. It is a necessary bridge that opens ups and guides urologists to opportunities in European urology,” the organisers said. With the direct feedback from the international faculty and the collegial assessment of the latest clinical and research studies presented during the sessions, Rauchenwald said the meeting will certainly provide a boost to Central Europe’s urological community. “Although there is a diversity in clinical practice, we stand to benefit as a community if we translate our findings into practical clinical use, and that would be possible if we have a meeting such as CEM which gathers urologists with various perspectives, background and training,” noted Rauchenwald.

For details on registration, venue and other general information, visit the meeting website at: www.cem16.org June/July 2016

European Urology Today

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Robotic Live Surgery

#ERUS16

ERUS16

13th Meeting of the EAU Robotic Urology Section 14-16 September 2016, Milan, Italy Registration is open until 31 August

‘The most comprehensive urological meeting on robotic surgery’ The 13th edition of the ERUS meeting will take place from 14-16 September 2016 at the MiCo Milano Congressi in Milan. ERUS16 caters for every urologist who is interested in the latest technical developments and the continuous progress of urological science and practice. The meeting’s aim is to educate the urological community on robotic surgical techniques with the ultimate goal of improving the level of patient care. Below you will find some highlights from the extensive scientific programme. Visit the meeting website for the full programme and see you in Milan! Six live robotic surgery sessions Two procedures take place simultaneously in each hour-long session. Live surgeries will be performed by expert surgeons coming from all around the world at the Department of the Urology San Raffaele Hospital in Milan, Italy. Surgery will naturally follow the EAU’s guidelines for Live Surgery, always putting the patient first. Topics include: • Both radical and nerve-sparing radical prostatectomy • Radical prostatectomy and extended lymphadenectomy for HRPCa • Transperitoneal pyeloplasty • Partial nephrectomy • Radical nephroureterectomy with bladder-cuff • Radical cystectomy: Ileal conduit and removal of the bladder plus lymphadenectomy • Retroperitoneal lymph node dissection • Retroperitoneal tumour nephrectomy

More info: www.erus16.org

ESGURS16

Three semi-live sessions A first for ERUS meetings: these 15-minutes lectures will include videos of procedures performed by experienced surgeons in a step-by-step fashion. This approach will allow participants to carefully analyse all the principal parts and to discuss the tips and tricks of an entire surgical procedure. Topics include: • Robot-assisted surgery for RCC with caval thrombus in left and right kidney • Retzius sparing Robotic Radical Prostatectomy (RPP) • RARC - constructing an ileal conduit and neobladder • One stage pelvic and retroperitoneal primary or salvage lymph node dissection for prostate cancer • Uretero-vesical reimplantation • Evolution of radical prostatectomy: optimizing outcomes • Inguinal lymphadenectomy in penile cancer • A first at ERUS16: lectures on non-urological robotic procedures! State-of-the-Art Lectures The world’s leading opinion makers on robotic surgery, addressing the hottest contemporary topics. Topics include: • The role of MRI before diagnosis and for surgical planning • The practical role of genetic markers in the management of prostate cancer patients

Events

• The role of 3-D imaging reconstructions and intraoperative ultrasound in surgical planning in RAPN • The role of ERAS concepts in RARC patient • Contemporary role of salvage lymphadenectomy in the management of PCa • Robot-assisted renal transplantation • Postoperative radiotherapy after RARP: Who and when 7th Junior ERUS – Young Academic Urologists A special half-day programme for young urologists with special attention to their unique needs. Topics include: • Best 2016 papers • Video presentations • Live Surgery Education and Training ESU courses and Hands-on training: learn from the best. • Advanced video-based course on robot-assisted radical prostatectomy • Advanced video-based course on robotic renal surgery • Video-based course on robot assisted radical cystectomy (RARC) and intracorporeal diversion • Video-based course on robotic reconstructive surgery • Extensive hands-on training at every level

Download the EAU Events app in your store for all information on this meeting

#ESGURS16

8th Meeting of the EAU Section of Genito-Urinary Reconstructive Surgeons In conjunction with the Spanish Genito-Urinary Reconstructive Surgery Group (CRU-AEU)

7-8 October 2016, Madrid, Spain “The 8th ESGURS Meeting (ESGURS16) is continuing its core goal to further develop reconstructive surgery. Leading surgeons in the field will present their new achievements and experiences will be shared through live interaction,” says ESGURS Chairman Dr. Rados Djinovic. As patients demand improved solutions and better quality of life, the increase of current knowledge becomes a higher priority. “It is essential to organise a meeting where experts can participate and contribute to the solving of functional issues. We aim to expand our knowledge so we can help patients further,” says Dr. Javier Romero-Otero of the ESGURS local organising committee. New developments With such a high concentration of the world’s best genitourinary reconstructive surgeons, ESGURS16 offers a platform for discussion and debate. Dr. Romero-Otero says, “Most of the experts will share their experiences from a practical point of view. The meeting will have pragmatic sessions that cover a majority of the problems we find in our daily practice. It is a good platform for urologists involved in functional and reconstructive urology to share their knowledge and brainstorm.”

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European Urology Today

www.esgurs16.org Dr. Djinovic says, “Developments in prosthetic surgery in both primary and re-do cases, urethral surgery, and new modalities in the therapy of Peyronie’s disease will be broadly discussed at the meeting.” Challenges and resolutions The meeting will also focus on addressing current challenges. Dr. Djinovic gives an example: “There are some fields which are still missing good and reliable treatment results for conditions such as Peyronie’s disease, incontinence surgery, and some congenital and rare diseases (e.g. bladder dysfunctions, hypospadias or bladder exstrophy). We will need more intensive collaboration with other specialities as well, like paediatric urology or plastic surgery, to improve care. Also, we need better results with more difficult conditions such as total penile reconstruction in traumatized or transgender patients.” “If I could name one of the major challenges, it would be young male patients with congenital urological problems who will grow up and will increasingly need solutions for their urinary and sexual functions. We are building a neophallus with radial forearm graft with dorsal graft; perhaps penile transplant will be their solution. We are working to improve their quality of life. We are living in an exciting time,” shares Dr. Romero-Otero.

Expected breakthroughs in the field Progress in medical innovations soared in recent years. Dr. Romero-Otero foresees vast improvement in tissue engineering. “Imagine a new era where grafts supply, rejection issues and ischemia will not be problems any longer.” Dr. Djinovic predicts penile transplant may also find its place for transgender patients as some centres already started with penile transplant for patients after traumatic penile loss. He adds that urethral transplant may be an option for patients with severe long urethral strictures. Future applications Reconstructive surgery may have been a field for selected surgeons but demand is rising. Dr. Romero-Otero says, “Our daily practice will start involving more reconstructive surgery. It is time to increase our level of knowledge in this area.” The ESGURS16 meeting will be held in conjunction with the Spanish Genito-Urinary Reconstructive Surgery Group (CRUAEU) meeting, which will take place on 6 October. Late fee registration deadline: 30 September 2016 Abstract submission deadline: 15 July 2016

June/July 2016


#ESUR16

ESUR16

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

“Stimulating the discussion between researchers and clinicians” For three days in October, Parma will be the centre of research in urology as the EAU Section of Urological Research (ESUR) holds its annual meeting there. Its broad scientific programme examines the latest developments, while also taking into account clinical applicability.

urology on one hand and to get support from clinicians for research projects on the other hand.” “And finally, we want to present ‘hot’ fields in experimental research in general, not necessarily focused on urology. We do this in order to show techniques and a general understanding in molecular and cellular biology, both of which are important for urological research. Examples are tumour metabolism, virus-based therapy and non-coding RNAs.”

Abstract submission and registration have opened for the 23rd ESUR meeting, which will take place at the Grand Hotel De La Ville in Parma on 20-22 October. Prof. Saverio Bettuzzi (Parma, IT) is the Meeting Chair. Research is a huge driving force for innovation in urological care, making ESUR16 a not-to-be-missed meeting for urologists, who are looking to get informed on upcoming innovations in their field. We spoke to ESUR Chair Prof. Kerstin Junker (Homburg, DE) on what attendees can expect in Parma.

Urologists who are not directly involved in research can also expect to gain a lot from attending ESUR16: “We are presenting current topics in state-of-the-art lectures, giving an overview not only for active researchers but also for urologists interested in those fields.”

Designing the scientific programme When devising the scientific programme for ESUR16, the organising committee had several considerations and aims. Prof. Junker explains:

Hot topics In striking a balance between research-oriented topics and clinicallyapplicable developments, there are several hot topics which span both considerations. The committee included topics which will become important for practice very soon like checkpoint inhibitors, the role of HPV for penile cancer, metformin and tumour prevention, relevance of tumour heterogeneity for diagnostics and therapy decision in kidney and prostate cancer. Junker: “Tumour heterogeneity is a very important topic, because it is a really critical point in development of tissue-based biomarkers.”

“First, we wanted to make the programme attractive for experimental and clinical researchers working in the field of urology, but also for young urologists who are interested in research but did not start their own research. Second, we want the programme to reflect several important research fields in urology, especially within urological oncology. Here, it is important to find a balance between the different tumour entities.”

Other topics include checkpoint inhibitors: “This is a clinically-relevant new field in metastatic disease, specifically the underlying mechanism, and exploring which biomarkers are best for therapy response prediction, beside checkpoints themselves.” Viruses will also be

“Third, we aim to stimulate the discussion between researchers and clinicians, for example concerning tumour heterogeneity. This is important in order to focus research on clinically important fields in

ESUI16

covered, including their role in tumour development and progression (e.g. HPV in penile cancer) and as therapeutic agents (oncolytic viruses). According to Prof. Junker, research has shown and continues to show promise in several cases: “molecular understanding of tumour biology led to a differentiation in several tumour subtypes with different prognosis and new therapeutic strategies. In muscle-invasive bladder cancer, we should consider basal and luminal subtypes similar to breast cancer. In clear cell and papillary renal cell carcinomas, we can identify aggressive subtypes based on molecular signatures in the near future and the understanding of kidney cancer as a metabolic disease can result in new really targeted therapies. Speakers will be joining ESUR16 from across Europe, and beyond. “It is important to get the best speakers in a specific field, irrespective of where they’re based. Furthermore, the ESUR meeting should bring together researchers from Europe and from other regions.”

More info: www.esur16.org

Abstract submission deadline: 5 July Early fee registration deadline: 15 August

#ESUI16

5th Meeting of the EAU Section of Urological Imaging

Imaging and shifting paradigms in urology

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

24 November 2016, Milan, Italy

Jochen Walz (FR) ESUI Chairman

Urological imaging: Changing paradigms and challenges Milan Meeting to tackle emerging prospects Emerging prospects and the ensuing challenges in urological imaging will be the main focus of the 5th EAU Section of Urological Imaging Meeting (ESUI16) to be held in Milan on 24 November. With “Imaging and shifting paradigms in urology” as overarching theme, the annual ESUI meeting precedes the 8th European Multidisciplinary Meeting on Urological Cancers (EMUC) and aims to provide a timely update on new developments in the field of urological imaging. The day-long Scientific Programme is a compact but comprehensive look into the various aspects of new imaging techniques with six sessions that present Point-Counterpoint discussions, How-I-Do-It Video Sessions, the best of the submitted posters, state-of-the-art lectures and a special joint session with the European Association of Nuclear Medicine (EANM) on molecular imaging.

MRI-based diagnostic pathways, the economic costs will be considered. Another issue to be discussed is multiparametric ultrasound and its impact on current urological practice, particularly on the question on why this technique has not yet triggered wider adaption. Prostate biopsy, sepsis, and new ultrasound-based technologies will also be examined in the same session. Molecular imaging in urology tops the agenda of the joint ESUI-EANM session. Topics up for discussion are the clinical consequences of new imaging technologies for the prostate and bladder, Prostate-specific membrane antigen (PSMA) for initial staging, PSMA radio-guided surgery for recurrent prostate cancer and a look into the new positron emission tomography (PET) tracers.

“Not only do we aim to actively exchange views with other experts and specialists to improve collaboration in multidisciplinary strategies, but we also need to anticipate the challenges brought about by new research, technology and clinical practices,” said ESUI chairman Dr. Jochen Walz.

The How-I-Do-It Video Session will demonstrate practical insights and a peek into the best practices of specialist surgeons with the session showing techniques in MRI/US fusion biopsy such as cognitive approaches, image, mechanical and electromagnetic-based navigation, multiparametric and high frequency ultrasound and artificial neural network analysis (ANNA)/computerised transrectal ultrasound (C-TRUS).

Changing paradigms Changing paradigms in prostate cancer diagnosis will open the meeting with a point-counterpoint discussion on the role of Magnetic Resonance Imaging (MRI) before primary biopsy. Besides the possible benefit of

Imaging for the diagnosis and treatment of urothelial cancer will be taken up with discussions and lectures on Uro-CT and the need for standardisation, a comparative look into Narrow Band Imaging (NBI) and the Storz professional image enhancer system (SPIES) in bladder cancer,

For additional information visit the ESUI meeting website at www.esui16.org June/July 2016

optical coherence tomography (OCT) and confocal microscopy and the use of panoramic cystoscopy in urothelial cancer. Prostate cancer and the latest developments in treatment will round-up the meeting with discussions in prostate cancer imaging focusing on the pros and cons of MRI and active surveillance, image-guided focal therapy as an alternative to whole gland treatment, treatment planning and follow-up in focal therapy and the benefits vis-à-vis the economic burdens of MRI before radical prostatectomy, among other topics. Besides highlighting the challenges in urological imaging, the ESUI meeting also provides a platform for outstanding research and new talents in urological imaging with the annual selection of the best poster presentations. Participants will present their findings with the audience providing critical commentary during the Q&A after each presentation. A prize for best poster will be awarded. Do not miss the submission deadline on 1 July. A Hands-on-Training (HoT) course on MRI/Ultrasound fusion biopsy will be organised for ESUI and EMUC participants on 25 and 26 November with each session lasting for 120 minutes. The course will provide a practical understanding of the different navigation systems and the use of various types of fusion technologies in clinical practice. “We are not only looking into the best practices and opinions of experts from across Europe and outside the region, but we also aim to look into how new knowledge or experience can inform and shape current standards and our own practices. Anticipating these challenges and how we respond and direct our management strategies are important,” said Walz.

Early fee registration deadline: 22 August 2016

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Send your nominations today!

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

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

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

Apply now!

LABORIE

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

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

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

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European Urology Today

June/July 2016


24-27 November 2016, Milan, Italy

Consolidating multidisciplinary strategies 8th European Multidisciplinary Meeting on Urological Cancers In conjunction with the • European School of Urology (ESU) • 5th Meeting of the EAU Section of Urological Imaging (ESUI) • 2016 EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) • EAU Young Academic Urologists Meeting (YAU)

EMUC16: Emerging diagnostics and treatment approaches Impact of new technologies on cancer management New drugs and emerging technologies have entered mainstream management strategies for urological cancers prompting experts to closely look into the role of imaging, drug combinations and genetic research and how these gains may be employed to optimize current standard practices. At the 8th European Multidisciplinary Meeting on Urological Cancers (EMUC16) to be held in Milan (IT) from 24 to 27 November, the focus will not only be on controversial diagnostic

issues and treatment strategies but also how these developments impact clinical practices, disease progression and the patient’s quality of life. Besides discussions on malignancies such as kidney and bladder cancers, new imaging technologies on recurrent prostate cancer (PCa) will be among the topics up for discussion during the fourday event. The role of positron emission tomography (PET) and computed tomography (CT), for instance, will be the focus in one of the first-day sessions where experts will attempt to identify the benefits of employing precision imaging techniques. “A key point is that PET/CT can play a major role in the imaging of prostate cancer patients, especially using the new available tracers. Some indications are already known and scientific literature is rapidly growing (such as PSMA PET/CT in biochemical recurrent prostate cancer),” said Stefano Fanti, associate professor of nuclear medicine at the University of Bologna. Fanti, who also chairs the European Association of Nuclear Medicine’s (EANM) Oncology Commitment, said there are other indications that are new and emerging, among them the use of PET/CT to evaluate response to therapy in recurrent PCa. New gains in technology and drug developments are eagerly welcomed and awaited but these are paired with challenges and dilemmas particularly with regards drug sequencing and data interpretation. “With respect to biochemical recurrence, it is important to properly restage patients, before the occurrence of a widespread diffusion of the relapse,” Fanti pointed out. “For example in a patient treated with radical prostatectomy and biochemical recurrence, before planning salvage EBRT (external beam radiation therapy), the possibility of any disease outside the prostatic bed should be excluded and this could be properly done with PET/CT,” he added. A more inclusive meeting In the last seven EMUC editions, organisers European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU) aimed to present a scientific programme which not only addressed core topics and emerging trends but also attempts to trigger critical evaluation of widely accepted multidisciplinary

#emuc16

approaches. With a gathering of oncologists, urologists, pathologists, radiation oncologists, nuclear medicine physicians, genetic researchers and related healthcare professionals, EMUC examines best practices and evaluates forward-thinking approaches. This year´s EMUC edition will open on 24 November with the Symposium on Genitourinary Pathology and Molecular Diagnostics which will present updates in guidelines and protocols on urological cancers. Seven sessions during the event will cover the whole range of treatment and diagnostic dilemmas, prospects and developments with plenary meetings, debates, lectures and case discussions. Fanti said there is still room to further expand multidisciplinary meetings and make it more inclusive. He noted the real challenge is not so much on the composition of multidisciplinary teams but more on material capabilities and technical expertise. “Imaging experts are not always part of the multidisciplinary team, but the most relevant problem is that most institutions lack specific expertise and facilities for innovative PC imaging. Few centres have available new tracers for PET/CT and multiparametric MRI that are complementary techniques,” he said. Asked what he expects in terms of treatment breakthroughs in the coming years for prostate cancer, Fanti said there is already a build-up or steady progress in the field. “There has been dramatic progress in both the treatment and imaging of prostate cancer. Availability of new therapies (especially treatment of CRPC) and imaging methods (new PET tracers) have made possible a major change in patient’s management,” Fanti said. “Imaging can be the driver to allow the clinicians (either urooncologist or radiation oncologist) to decide on the best treatment option for each patient. The time for personalized therapy has also come for prostate cancer. ”

Early fee registration deadline: 22 August 2016

Download the EMUC16/ESUI16 app in your store for all information on these meetings

www.emuc16.org

www.esou17.org

www.eulis17.org

ESOU17

EULIS17

14th Meeting of the EAU Section of Oncological Urology

4th Meeting of the EAU Section of Urolithiasis

20-22 January 2017, Barcelona, Spain

5-7 October 2017, Vienna, Austria EAU Events are accredited by the EBU in compliance with the UEMS/EACCME regulations

June/July 2016

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

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Perspective from Malta Assessing the EAUN Meeting in Munich Helen Attard Bason Health Department Mater Dei Hospital, Urology Ward B'kara (MT)

habason@ maltanet.net First of all I would like to thank the European Association of Urology Nurses (EAUN) for providing me the opportunity to attend the EAUN Conference in Munich through a grant. It was an extraordinary, inspiring event and my first conference since I have become an EAUN member three years ago. Becoming an EAUN member helped me engage in urology practice and international conferences such those organised by the EAUN facilitate the exchange of knowledge and clinical expertise. The EAUN meeting was professionally organised, informative and interesting and gave me the opportunity to broaden my knowledge particularly in uro- oncology, my area of interest. As a charge nurse working at a urology ward in Malta for the last five years, I coordinate the intravesical therapy for bladder cancer patients and the administration of zoledronic acid treatment for patients with prostate cancer and bone metastasis. The conference was an inspiring experience and boosted my motivation to work in the field of uro-oncology. Take home messages The meeting also gave the opportunity to evaluate current nursing practices, assess the standards we have and how we can achieve a more evidence-based practice. I also reflected on my leadership skills after I European Association of Urology Nurses

12-14 March 2016, Munich, Germany

posters illustrating a research conducted by nurses from Israel titled ‘Choice and insertion of the urinary catheter comparison of urologic vs. internal medicine department nurses’ (Balin & Yakir) inspired me because as an infection control nurse, our team in Again, to quote Drudge-Coates during his talk in the Malta is planning to carry out a similar study. The opening plenary session: “Urology nurses’ practice Israeli study made me realise that despite the needs a change as society is changing and we need to difficulty of carry out such a research due to the lack of time, our experience in Malta share something in keep up with changing demands of society. If you ‘Urology Nurses are like icebergs, don’t change, you die.” It is our goal in Malta that we common with the findings of the Israel study and this will move towards a more specialised role in urology inspires me to proceed with our own study. you only see a fifth of what they by means of education, research and evidence-based do." To conclude, my thanks to all the organisers for such a practice. dynamic meeting which do not only inspire but also gave a very welcome to all and for providing the In Malta, urology nursing is still not acknowledged as On a positive note, after having attended the chance to meet other nurses who share the same a speciality and while I was reflecting on our practices EAUN-ESU course on instillations in NMIBC on goals. My gratitude also to Ms. Hanneke Lurvink for it is evident that we do give the physical care that the Saturday 12, I am proud to say that in my clinic we patient requires while in hospital but unfortunately comply with the guidelines on Intravesical Instillation her hard work as EAUN Coordinator and for helping me with the arrangements and approval of the grant. (EAUN, 2015). There are some changes that are we do not provide the necessary support to patients who were diagnosed with a cancer (renal, bladder, required such as the use of luer lock connected to the I do hope I can join the next EAUN conference in London 2017. I am also looking forward to my EAUN penile or prostate) or after they underwent a major catheter during instillation and to flush the catheter with saline to avoid any spillages after instillation. fellowship this September at the Antoni Van operation such as cystectomy and were discharged from hospital. This might be due to work overload Additionally, I will initiate staff education to reinforce Leeuwenhoek Netherlands Cancer Institute. such guidelines which are related to health and and shortage of staff. This was shown by L. Drudge safety, and using the resources available on the Let me share one of the inspiring slides from the Coates (Saturday, 12th) when he said that ‘Urology conference during the session ‘The pivotal role of the Nurses are like iceberg, you only see a fifth of what website of the conference. they do.’ His statement described our work in the nurse in managing mCRPC: collaborating to improve patient care’, which I am sure will help me work urology wards in Malta. We are competent in dealing Research as a pillar towards improving both the clinical care and Research is one of the pillars of the EAUN strategies with all sorts of complexities, ranging from difficult educational development for both staff and patients. and the professionally created posters presented catheterisation to the instillation of intravesical therapy. Yet I believe that we regard the patient as during the conference confirmed this. One of the someone which requires “repairing” and less as a person who needs the full support of our health care If you want to change your role system. I believe that an important element is missing: that besides the individualised care given to • You need further education the patient, we also have the crucial role to act as a • You need support of your colleagues, doctors, link between the patient and the doctor. management and other health professionals. • You have to be self-confident and believe in Throughout the conference the role of the nurse as a yourself direct link to patients within a multi-disciplinary team • You have to act professionally has been stressed. The urology nurse can have a • You have to network pivotal and active role in the care pathway of the • You have to work hard for your role patients from active surveillance to nurse-led clinics. Mr. Drudge-Coates speaking at the Plenary Session In these settings, the patient can have direct contact met nurses from other countries who have specific roles such as nurse clinician, advanced practice nurse or a chairperson of a multidisciplinary team. They all make a difference in the care of the urological cancer patients by providing information and support during the decision-making process and after hospital discharge.

with the nurse to discuss concerns related to his illness, enabling cancer patients to make informed decisions with regards the treatment pathway and ensure their compliance.

Win a grant for your Nursing Research Project Corinne Tillier, CNS, MANP EAUN Board Member – Science Amsterdam (NL)

urology nursing care. The winner of the EAUN Research Project Competition will receive a grant of € 2,500. Research project plans can only be submitted by e-mail before 1 September 2016.

Fellowship Programme European Association of Urology Nurses

For interested nurses, you can access and view previously submitted plans at the EAUN website. For more information please contact the EAUN (eaun@uroweb.org).

c.tillier@uroweb.org For detailed information please visit the Useful Resources section at www.eaun.uroweb.org Do you have a good idea for a research project to improve nursing care? Join the EAUN Research Project Competition and contribute to international efforts to boost urological nursing.

Wellspect supports this EAUN Nursing Research Competition with an educational grant.

The EAUN recognises the importance of achieving evidence-based health care. With urology nurses expected to play a key role in high-quality health services, it is crucial for nurses to explore patients’ perspectives and the impact of nursing interventions through innovative research projects. With the research competition, the EAUN provides the opportunity for nurses to improve the quality of European Association of Urology Nurses

Application open for EAUN17 Travel Grant The Annual EAUN Travel Grant allows nurses based in Europe to participate in the EAUN Meeting by providing €500 towards the cost of towards travel, registration and accomodation (provided the receipts have been submitted). Candidates will be required to be working in urology and be current members of the EAUN. Non-members can apply for the grant providing they have submitted a paid membership application. Submission deadline: 1 November 2016 For detailed information please visit www.eaun17.org This grant was made possible through an unrestricted educational grant from ASTELLAS.

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European Urology Today

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 31 August 2016 • Only EAUN members can apply • Host hospitals in Belgium, Denmark, the Netherlands, Sweden, Switzerland and the United Kingdom • A great way of widening your horizon For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

European Association of Urology Nurses

June/July 2016


EAUN–sponsored project on continence topics Dutch studies on self-catheterisation offer insights on patient experience Hanny CobussenBoekhorst, dr. MANP Radboudumc Dept. of Urology Nijmegen (NL) hanny.cobussenboekhorst@ radboudumc.nl Co-authors of the project: Edith van Wijlick, Joke Beekman In 2012 we presented a study project at the EAUN congress titled ‘Which factors make clean intermittent (self) catheterisation successful?’ which won us the research grant for the Best Nursing Research Project! For the quantitative study, a prospective multicentre study was conducted in a university hospital, a general hospital and a rehabilitation centre in Nijmegen, The Netherlands, from March 2012 to March 2013 with a one year follow-up. Patients with a variety of diagnoses referred to the outpatient clinic, who were ≥18 years, performed catheterisation at least once a day for three months or longer were included. During the study period, 302 patients were referred for intermittent catheterisation. Of these, 129 were included. Of the 129 (72 male) patients, mean age 62 (22–86) years, seven died and 63 stopped, 32/63 (50%) due to recovered bladder function. Fifty-nine (47%) continued to perform catheterisation after one year. Forty-seven (86%) patients reported catheterisation had become part of their life or had a positive effect on their life. Related to the hypothesis that specific causes can influence the adherence negatively, we only found a European Association of Urology Nurses

weak correlation between increasing age and cessation of catheterisation. However, we feel this correlation is not strong enough and we think that the possibility of offering intermittent catheterisation as an option for older patients should be discussed. The hypothesis that if catheterisation was beneficial for the patient, it would influence adherence to the regime positively was not confirmed. Surprisingly we found that of the patients that discontinued intermittent catheterisation in 50% of respondents, this was due to a recovery of bladder function, and as far as we know this has never been reported before. Further prospective studies on the long-term adherence of intermittent catheterisation in larger groups are needed. Definition of intermittent catheterisation, patient’s education, catheter use, frequency and follow-up care must be better documented to compare results. The project group advised next to the quantitative study also to perform a qualitative study. We then conducted an additional qualitative study using semi structured in-depth interviews about the experiences of 11 patients from the quantitative study. The aim of this study was to get insight in underlying barriers and facilitators for patients dealing with intermittent catheterisation in everyday life. Patients were asked about the initial use of intermittent catheterisation, its use in everyday life, the perceived progress after receiving instruction and guidance, the cause of the bladder problem and the motivation to start intermittent catheterisation.

Patients referred for CI(S)C April 2012-2013 n = 302

Inclusion

At 1 week

n = 112

At 3 months n = 86

At 1 year

Exclusion n = 173

n= 129

n = 49

Stopped: • Physical • Medical • Psychological • BF* recovered

3 5 2 7

Stopped: • Physical • Medical • Psychological • BF* recovered • Not beneficial • Not effective • Reasons unknow • Deceased

1 3 1 13 2 2 1 3

Stopped: • Physical 0 • Medical 3 • Psychological 0 • BF* recovered 12 • Not beneficial 3 • Not effective 2 • Reasons unknown 1 • Deceased 4 • Other reasons 2

Eleven interviews were performed (six males/five • Hanny Cobussen-Boekhorst, Joke Beekman, Edith females). All patients described the instruction and van Wijlick, Judith Schaafstra, Dirk van Kuppevelt follow-up care as positive. Among the barriers were and John Heesakkers. the preparation before the handling, which is more Which factors make clean intermittent (self) difficult than the catheterisation itself, and the fact that catheterisation successful?Journal of Clinical patients felt constrained by the need to plan convenient Nursing, 2016 doi: 10.1111/jocn.13187 times to catheterise themselves. Both studies were recently published in the Journal of Clinical Nursing, • Hanny Cobussen-Boekhorst, Erna Hermeling, and the publication details are as follows: John Heesakkers and Betsie van Gaal.

Patient refused Language barrier Dilatation < 3 months < 1 / day No time CN*/ forgot Other

22 7 55 32 26 17 14

Fig. 1: Study overview * Abbreviations: CN = Continence Nurse; BF = Bladder Function

Patients’ experience with intermittent catheterisation in everyday life. Journal of Clinical Nursing, 2016 doi: 10.1111/jocn.13146 To conclude, these study projects were a great experience, involved a lot of work but gave us the opportunity to work multicentre with very motivated continence nurses. Moreover, this was made possible by the EAUN!

Compassion in urological healthcare Reflecting on the role of compassionate care in holistic healing Sue Osborne Urology Nurse Auckland (NZ)

sue.osborne@ waitematadhb.govt.nz My workplace has four core values that guide our healthcare practices and one of these values is compassion. This overarching philosophy of ‘delivering care with compassion’ drives us to do everything we can to relieve the suffering of those in our care. I recently watched a short video prepared by our District Health Board as part of a Patient Experience Week. Titled ‘In My Shoes,’ the video invokes the feeling of compassion which comes in the moment we allow ourselves to see the world through another person’s eyes. The video provides a glimpse into many of the typical experiences individuals have when entering a hospital environment. Interestingly, it captures not only ‘moments’ of patients and families, but also those of healthcare professionals. The video subtitles give perspective to the images shown, but the only voices you hear are at the end of the 2.5-minute video. At that point individual patients ask “if you could sit in this chair,” “if you could lie in this bed,” “if you could stand in my shoes,” “if you could feel what I feel,” would you do anything different? They asked these questions of healthcare professionals from whom they received care. The commentary was a powerful reminder that by putting ourselves in the shoes of others we are best able to treat them with compassion and empathy. European Association of Urology Nurses

June/July 2016

For me this video was a sensitive prompt. As a urology nurse I deliver care to adults suffering from a wide range of urological diagnoses. Some diagnoses result in physical symptoms that significantly impact quality of life, while others may be outwardly invisible with seemingly minimal physical impacts. All of the conditions, however, have the ability to affect an individual’s confidence, well-being and relationships with their friends and families. In a time-pressured workplace environment it is possible to lose sight of this perspective, and the video reminded me that when I allow myself to acknowledge a patient’s ‘lived experience’ of their diagnosis, I deliver the most compassionate and holistic care.

Within days of watching the ‘In My Shoes” I attended a lecture by Prof. Ron Paterson, New Zealand’s Health and Disability Commissioner from 2000 to 2010. He spoke on “Compassion in Healthcare” and addressed the growing concern regarding the ‘absence’ of compassion in modern healthcare. He urged everyone in the healthcare sector to reflect on their practice and made constructive suggestions on how to affect positive change. One of the ideas that resounded most with me was the importance of access to education that focussed on teaching (or reminding) us not only of the ‘nature of suffering’ but of the value that patients place on ‘empathy, kindness and compassion.’ Another was the value of healthcare practitioners modelling the delivery of compassionate care to our colleagues. Essayist Anatole Broyard reminded us of the importance of compassion in his writings. When facing metastatic prostate cancer he wrote: “Just as he orders blood tests and bone scans of my body I’d like my doctor to scan me, to grope for my spirit as well as my prostate. Without some recognition I am nothing but my illness.” Centuries earlier Jewish philosopher and physician Maimonides reflected on the need for compassion when he prayed “May I never forget that the patient is a fellow creature in pain. May I never consider him merely a vessel of disease.” I find both quotes very powerful. As nursing practice advances, we are often giving diagnoses, ordering investigations and educating patients on treatment choices. We may be delivering this care on a daily basis and eventually develop a ‘thick skin’ that enable us to do our routine tasks. We may cultivate a measure of objectivity

and distance in our practice to avoid burnout. I believe, however, that the moments we let it show that we care, do not have to be exhausting exchanges filled with strong emotions towards patients or their situations. Sensitivity to an individual’s or their family’s needs, and a caring manner may be all that is needed to convey compassion. This should be achievable if our healthcare leaders create an ‘environment of caring’ for us to practice in. We need to practice in wellresourced environments where we feel trusted and valued. We also need the support of working within respectful and knowledgeable teams to invigorate us. Such supports will enable us to focus on what matters most to the patients we work with in the outpatient clinics, wards and operating theatres. I consider access to thought-provoking presentations such as the lecture delivered by Prof. Paterson and the ‘In My Shoes’ video’ as reflective of the goal to support healthcare workers to deliver compassionate care. Each reminds us that it is often the smallest things we do for patients that make the biggest difference. I believe that all nurses have compassion and I hope that as you read this column it will be a gentle prompt for you to also reflect on the question: ‘If you could stand in your patient’s shoes just for a moment, would you do anything any different?’ References Broyard, A. (1992). Intoxicated by my illness and other writings on Life and Death. Clarkson Potters, New York. Paterson, R (2011). Can we mandate Compassion? Hastings Center Report 41(2) p.20-23. Maslen, H. (2013). Is compassion a necessary component of healthcare? Practical Ethics, University of Oxford. http:// blog.practicalethics.ox.ac.uk/2013/09/is-compassion-anecessary-component-of-healthcare/ accessed 26/4/2016. Smajdor, A. (2013). Compassion is not the answer to the failings of the NHS. The Guardian. http://www. theguardian.com/healthcare-network/2013/sep/19/ compassion-failings-nhs . Accessed 26/4/2016.

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Nursing in Motion A video session with a difference Simon Borg EAUN Board Member Mater Dei Hospital Inpatients Theatre Msida (MT)

s.borg@eaun.org

example of how this issue can be addressed. This well prepared video was presented by D. Kisslig (Berne) and underscored the projected demand for nursing services in Switzerland which is expected to increase by up to 13% by year 2020. The video covered various nursing perspectives and emphasised the high level of competence and job satisfaction. In its concluding minutes, questions were asked on what recruitment impact data such as this video had since its launch.

The second presentation titled “Robotic surgery and Nurse, a good mix,” inevitably covered a topic that Some good things need to be re-invented for it to seems to always find its way into any conversation on remain current, dynamic and relevant. urology– DaVinci robot. However, instead of looking at the clinician’s perspective and work, we were This year’s EAUN 2016 Munich video session was offered an insight on the role of nursing which is indeed a video session with a difference. In the past, rarely examined. DaVinci surgery is an exercise in we provided a small window for nurses to look onto a combined competencies and nursing is part of this urologist’s work not normally accessible to many. This emerging specialised service. The video was well time round, we opened a door for nurses to share presented by C. Tillier (Amsterdam), a fellow EAUN their experience and particular competencies gained board member who, incidentally, is not a DaVinci with other fellow nurses. team member. In her own words, she explained that putting this video together exposed her to a Since this was the first video session organised at a specialised nursing perspective and a role that she relatively short notice, the EAUN Board accepted some was not fully aware of. During the open forum, it concessions in the submission process. Presenters turned out that some in the audience also shared her were allowed to present and narrate more than one observation. video submission. Furthermore, up to two video submissions with the same subject matter would be The video showed very clearly the high level of accepted provided they gave a different perspective to competence and responsibility showed by the DaVinci the topic. Lastly, besides videos one could also submit nursing team members during a very complex a collection of photos put together to present a surgery. The video also reflects on the point that particular experience. Due to time constraints, we nursing is a profession that is able to embrace new chose the following four presentations. technology-driven care and assert its role in new developments. During the discussion, however, many We kicked off the session with a nursing recruitment expressed their concern that this development may video put together by the Department of Urology at bring nursing into other areas traditionally held by the University Hospital Berne in Switzerland. Since other healthcare professionals. This notion was nursing recruitment is a world-wide issue, we saw quickly dismissed by Tillier when she pointed out that it fit to start with this presentation to provide an robotic surgery was science fiction just over a decade ago and basically new opportunities of practice are made accessible for nurses which form an integral European Association of Urology Nurses part of such combined team approaches.

25-27 March 2017, London

The presentation went through the team’s experience in a country that does not have the same high level of facilities and amenities that are common in Europe. During the Q&A, Keil was asked if she had any data to show regarding the impact or improvements brought about by this knowledge-sharing project. She mentioned that a follow-up visit is being planned to identify if any benefits were gained. The EAUN certainly looks forward to its annual meeting in London next year for another dynamic video session. As the saying goes- “Trouble shared is trouble halved, joy shared is joy doubled.” What an excellent opportunity it will be to share the joys and challenges experienced by our urological nursing colleagues.

Call for videos

Nursing practices made visual

Submit your own video The EAUN17 meeting in London also features a video session “Nursing in motion’.

The best videos will be granted a free registration for the 18th International EAUN Meeting in London, 25-27 March 2017

The third submission, also with DaVinci as topic, was also well narrated by B. Keil (Heilbronn) and briefly looked into the history of robotics, describing the various components that make up this system and the nursing role. She also highlighted the issue of competence acquisition that nurses must achieve within such a specialised surgical team. To the trained eye, this video managed to show that although it is the same hardware and techniques employed worldwide, the role of nursing is slightly different from place to place. This testifies that this surgical specialisation is yet to reach a level of harmonised nursing training and that up to now the service provider still determines the parameters of nursing practice and training pathways. It may well be the case that this issue should be addressed on an EU level rather than left to individual institutions. An enthusiastic debate also followed regarding the benefits of robotic surgery and the discrepancies of patient discharge timeframes reported by hospitals. The last presentation, also by B. Keil, addressed a noble aspect of the nursing profession, regarding knowledge-sharing opportunities particularly with nurses who may not have benefitted from advanced facilities. Keil discussed her experience as part of an International Laparoscopic Course team member who travelled to Khartoum, Sudan in 2015.

Instructions for video submission can be found on the meeting website, www.eaun17.org. It starts with submitting an abstract on the content of your video (preferably together with an upload of the (preliminary) video) before the deadline of 1 December 2016. Should the video take more time to prepare, then it can be submitted later in time if agreed with the EAUN Office. For all questions concerning video submission please send an e-mail to eaun@uroweb.org.

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

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

www.eaun.uroweb.org

Call for Papers The International Journal of Urological Nursing - The Official Journal of the BAUN

Abstract and Video Submission Difficult Case Submission

The International Journal of Urological Nursing is clinically focused and evidence-based and welcomes contributions in the following clinical and nonclinical areas: • General urology • Clinical audit • Continence care • Clinical governance • Oncology • Nurse-led services • Andrology • Reflective analysis • Stoma care • Education • Paediatric urology • Management • Men’s health • Research

Research Project Plan Submission

Deadline: 1 December 2016

There are many benefits to publishing in IJUN, including:

in conjunction with

www.eaun17.org 40

European Urology Today

• Broad readership of papers—all published papers will be available in print and online to institutional subscribers and all members of the British Association of Urological Nurses • Fast and convenient online submission— articles can be submitted online at http://mc.manuscriptcentral.com/ijun

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

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

June/July 2016


European Urology Today (EUT) June/July 2016