European Urology Today January - March 2019

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European Urology Today Official newsletter of the European Association of Urology


Vol. 31 No.1 - January/February 2019

The MET landmark study

Two new research projects greenlit

Social media in office urology

Medical Expulsive Therapy to promote spontaneous stone passage

EAU RF grant furthers onco-urological research

The figures will make you think again

Prof. G. Zeng


Dr. T. Zuiverloon


Dr. S. Czarniecki

EAU19: Setting the pace for urology in 2019 Final preparations are in full swing for Europe’s biggest urological event By Loek Keizer and Erika De Groot Pioneering research and technologies, worldrenowned experts, a surge in top-quality abstracts and courses, and live surgeries in 4K and 3D; the 34th EAU Annual Congress (EAU19) promises to deliver advancements and essentials in urology and related medical disciplines this March. EAU19’s Scientific Programme is packed with in-depth presentations from key opinion leaders, highlyinteractive discussions, developments in evidencebased medicine, and the latest research outcomes. The Annual Congress is the EAU’s flagship event and the go-to meeting for urological specialists from all over the world. Read on and find out what sets EAU19 apart this year! Record-breaking numbers The number of submitted abstracts for EAU19 and the acceptance rate surpassed those of previous congresses. Approximately 5,500 abstracts were submitted for EAU19 from 80 countries across the world, a sizeable increase compared to EAU18’s 4,676 abstracts and EAU17’s 5,038 submissions.

Watch and learn in HD, 3D and 4K EAU19 will uphold the EAU tradition of offering live surgery sessions, which has attracted thousands to the Annual EAU Congresses for over a decade. The congress will deliver contemporary technologies and updates for diverse procedures. It will showcase the surgical approaches and strategies of highlyexperienced surgeons and how they tackle conventional and complex cases. These live surgeries will be broadcasted in high-definition, in 3D format, and in 4K resolution from the Fundació Puigvert hospital in Barcelona. Sixteen different live procedures will be performed during the session “Technology development never ends!” on 16 March from 10:30 to 18:00, interspersed with pre-recorded cases. The session will commence with updates on the status, recovery and possible complications of patients who were treated during the live surgeries at EAU18 in Copenhagen last year.

The EAU Section of Uro-Technology (ESUT), in cooperation with the EAU Robotic Urology Section (ERUS) and the EAU Section of Urolithiasis (EULIS), will deliver an ambitious programme centred on The acceptance rate of 32.04% for the upcoming novel technology that improves performance of congress also eclipsed the EAU Congress in video-assisted surgery and diagnostics in all fields of Copenhagen (30.78%) and London (24.9%). The top endourology. The session will also focus on imaging five topics with the highest acceptance rates for EAU19 developments, as well as new instruments and include Paediatric Urology; Prostate Cancer (Basic devices that improve ergonomic design during the research: Novel therapies); Infectious Diseases; New laparoscopic and robot-assisted cases. In addition, Experimental Technologies and Techniques; and the latest digital advancements for flexible endoscopy Geriatric Urology. of the upper urinary tract in the diagnosis and treatment of tumours and calculi will be The increase in these numbers also means a surge in demonstrated. the number of quality abstracts, renowned faculty members, and poster sessions which include the For a sneak preview of the live procedures that will be Expert-Guided Poster Tours. formed: these will include 3D laparoscopic partial nephrectomy; en-bloc bipolar bladder tumour Initially introduced at EAU18, 15 Expert-Guided Poster resection; 4K laparoscopic radical prostatectomy; Tours will be an integral part of the EAU19 “Lithovue” single-use ureteroscopic lithropsy; prone programme as well. Similar to the concept of a endoscopic combined intrarenal surgery; percutaneous guided museum tour, members of the Scientific nephrolithotripsy; flexible single-use ureteroscopic Congress Office (SCO) and other internationallylithotripsy; and robot-assisted radical prostatectomy known experts will lead and inform delegates. The with nerve-sparing to name a few. authors will present their abstracts, share updates and best practices; and the SCO will act as moderators The ESUT faculty – surgeons and moderators – will and also share their insights. consist of renowned experts. Prof. Dr. Andreas Johannes

For EAU members only: EAU19 abstracts available at as of 15 February

New ESU courses Due to the popular demand for courses by the European School of Urology (ESU), three new courses will be introduced at EAU19. ESU Course 05: Metabolic workup and non-surgical management of urinary stone disease (16 March, 08:30-10:30) will address the common findings on dietary and metabolic workup. The course will highlight treatment options (medical and non-medical) for metabolic abnormalities to prevent stone recurrence. Practical management options, significant literature, and urolithiasis treatment examples in “non-index” patients are the core topics of ESU Course 37: Advanced endourology in the non-standard patients with urolithiasis (17 March, 14:30-17:30). ESU Course 47: Improving your communication and presentation skills (18 March, 08:30-11:30) will offer tips and tricks on how to use, among others, non-verbal communication to convey one’s main messages clearly; and to eventually educate and inspire listeners. Industry sessions EAU19 will also feature 17 Industry Sessions supported by leading organisations and manufacturers in the European healthcare sphere. These sessions will comprise of topics such as real-time solutions and best drugs for overactive bladder; new alternatives to treat urinary tract infections; individualised care; management of non-metastatic castration-resistant prostate cancer and many more. These sessions take place throughout the congress days so keep an eye on the scientific programme for those cutting-edge presentations and demonstrations. Competitions for junior urologists Young urologists will have the opportunity to challenge each other in two competitions at EAU19: The EAU Guidelines Cup and the UROlympics.

A full plenary session at EAU18 in Copenhagen. We expect to welcome even more visitors in Barcelona this year

Gross (DE) and Assoc. Prof. Andreas Skolarikos (GR) are assigned as live surgery coordinators in the eURO Auditorium; and Dr. Alberto Breda (ES) will oversee the activities at Fundació Puigvert hospital. Another live surgery session, “Robotic education, innovation and surgery session”, will cover complex robot-assisted partial nephrectomy (RAPN) and radical robotic-assisted laparoscopic prostatectomy (RARP) with extensive pelvic lymph node. The Specialty Session will take place on 17 March from 14:00 to 17:00. January/February 2019

The EAU Guidelines Cup will determine who among junior EAU members know the EAU Guidelines best. The first and second rounds are held online and consist of multiple-choice questions. The top three participants from the second round will receive a free registration to EAU19. They will compete for the title of the EAU Guidelines Cup Champion during the live finale on YUORDay19 (Saturday, 16 March). The audience can also participate by competing anonymously using voting pads. The third-place winner and the audience member with the highest score will receive a full one-year access to over 60,000 items of quality scientific content via UROsource. The prize for second place is the fourvolume set of Campbell-Walsh Urology (11th edition) with easy online access to 130 video clips included. The EAU Guidelines Cup Champion can choose from a selection of ESU masterclasses to take part in.

Young urologists can also show off their skills during the ultimate endoscopic test, the UROlympics. The competition will determine which participants are the most dextrous on endoscopic stations. Starting from 16 March, they will have the opportunity to set their score during endoscopic tasks provided. At the end of the day, the fastest contender will be proclaimed the most skilled. The top three qualifiers will compete for first place. Aside from the coveted UROlympics titles, the winners will receive educational funds which can be used for EAU events (e.g. travel, accommodation and registration). A Catalan adventure Enrich your learning experience at EAU19, as well as, get acquainted with Barcelona’s famous and yet-to-be-explored destinations. To date, Barcelona became the first (and only) city to receive the Royal Institute of British Architects’ “Royal Gold Medal” for its architecture. The city boasts of nine UNESCO-protected monuments designed by beloved architects such as Antoni Gaudí and Lluís Domènech i Montaner. Admire the house-turned museum Casa Vicens, Gaudí’s first major architectural project which laid the groundwork for his future remarkable oeuvre and paved the way for Catalan Modernism. Gaudí’s other notable creations include La Sagrada Família with the main design depicting a symbiosis of the Holy Scriptures, liturgy and geometrics inspired by nature with light and colour playing the central role. A visit to Barcelona would never be complete without seeing this iconic architectural wonder. Some predict its completion will be in 2026, the centennial anniversary of Gaudí’s death. See where medicine meets architecture in Montaner’s opus, Sant Pau Recinte Modernista. With a 600-year history, this World Heritage site is the largest Art Nouveau complex in the world with its 27 buildings interconnected by underground tunnels. For sun-lovers, Barcelona’s seascape in spring is still captivating. Enjoy the view of four kilometres of beaches from Sant Sebastià, Barceloneta to Nova Icària or Mar Bella. Perhaps Barcelona as host city of EAU19 is more than an active, well-thought-of choice the second time around, possibly serendipitous. After all, the Catalan expression “Salut i força al canut!” can very well be urological; it translates to “Good health, and strength to your balls!” To know what to look forward to at EAU19, see pages 4-5. Join us in Barcelona and explore the Scientific Programme at European Urology Today


The MET landmark study Medical expulsive therapy to promote spontaneous stone passage Prof. Guohua Zeng Guangzhou Medical University Dept of Urology Guangzhou (CN)


Dr. Wei Zhu Guangzhou Medical University Dept of Urology Guangzhou (CN)

in patients with CT-confirmed urolithiasis5. The investigators randomised 1,137 patients with stones of 10 mm or less to receive either 0.4 mg of tamsulosin, 30 mg of nifedipine or placebo. The results showed no significant difference in the rate of spontaneous passage at 4 weeks, the need for pain medication, the number of days of pain medication, and the visual analogue scale of patients’ pain at 4 weeks between those randomised to the tamsulosin, nifedipine or placebo arms. By all accounts, this was an impressively negative trial.

the stone expulsion was detected by using serial CT imaging while the primary endpoint of the SUSPEND trial was effectiveness in decreasing the need for further treatment rather than CT imaging. Furthermore, the average stone size in the SUSPEND trial was < 5mm, and it was not powered to evaluate the effectiveness for stones > 5mm. The results of the present study showed a lack of therapeutic benefit for ureteral stones ≤ 5 mm, which is in agreement with the SUSPEND trial and the study published in Annals of Emergency Medicine.

In the same year, Annals of Emergency Medicine published a trial similar to the SUSPEND trial6. The trial also examined the effects of MET in patients with CT-confirmed urolithiasis. The investigators randomized 403 patients with stones of 10 mm or less located in the distal ureter to either MET with 0.4 mg of tamsulosin or placebo. Like in the previous study, the investigators found no statistical difference in the number of patients who experienced stone passage at 28 days. Unfortunately, only 78% of those enrolled returned for the required 28-day scan, reducing the study’s statistical power.

In conclusion, the results of the present study need to be placed in the context of the entire body of evidence from other well-designed, placebo-controlled trials. The study also makes an important contribution to the debate as to whether we should place our trust in MET in the treatment of ureteral stones.

Urolithiasis affects 1-15% of the general population with a significant risk of recurrence1. Treatment of symptomatic ureteral stones still represents the most common condition in daily urological practice. Most of the small stones will pass spontaneously. Two main factors, the stone size and location, could influence the stone passage. For stone sized < 5 mm passage ranges from 40-98%, while stones sized > 5 mm have a passage rate ranging between 55% and 50%2. Medical expulsive therapy (MET) is aimed at promoting spontaneous passage of ureteral stones and reducing the stone expulsion time after lithotripsy. MET has been recommended for informed patients if active stone removal is not indicated by the European Association of Urology (EAU) guidelines.

European Urology Today Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Dr. F. Sanguedolce, Barcelona (ES) Dr. Z. Zotter, Budapest (HU) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL) EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680 F +31 (0)26 389 0674 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.

STONE study More recently, JAMA Internal Medicine reported a References double-blind STONE (Study of Tamsulosin for 1. Zeng G, Mai Z, Xia S, Wang Z, Zhang K, Wang L, et al. Urolithiasis in the Emergency Department) trial in Prevalence of kidney stones in China: an ultrasonography which investigators randomly assigned 512 emergency based cross-sectional study. BJU Int 2017. doi:10.1111/ department patients to 0.4 mg daily tamsulosin or bju.13828. placebo for 28 days7. The investigators failed to 2. Amer T, Osman B, Johnstone A, Mariappan M, Gupta A, observe significant between-group differences with Brattis N, et al. Medical expulsive therapy for ureteric stones: Analysing the evidence from systematic reviews respect to time to stone passage, return to work time, analgesic use, hospitalisation, need for surgery, or and meta-analysis of powered double-blinded randomised controlled trials. Arab J Urol 2017;15:83–93. repeat visit to the emergency department.

Several drug classes are used for MET, including α-blockers, calcium channel blocks, nonsteroidal anti-inflammatory drugs, phosphodiesterase type 5 inhibitors, and corticosteroids. The most widely studied agents are α-blockers. The urinary smooth muscles contain α-adrenergic receptors that facilitate contraction, leading to renal colic and ureteric spasms when stones are present. α-blockers could inhibit basal smooth muscle tone, peristaltic frequency and amplitude, while maintaining tonic propulsive contractions, leading to an increase in the intra-ureteral urine flow and stone expulsion rate as the intra-ureteral pressure decreases. A plethora of research in this field supports the clinical use of MET for ureteral stones management with increasing stone passage, shortening time to passage and alleviating pain3. α-blocker tamsulosin seems to be more effective compared to calcium channel blocker nifedipine, and the relatively new α-blocker silodocin showed superiority to the widely used tamsulosin4.

Finally, the last bit of evidence comes from a study presented at the 33rd Annual Congress of the EAU and is not yet available in manuscript. The study collected data from 4,181 patients admitted with acute ureteric colic. The results showed that in patients with acute ureteric colic who are suitable for initial conservative management, MET use has no benefit in spontaneous stone passage, regardless of stone size or stone position and should not be routinely prescribed. Any benefit from tamsulosin for urolithiasis is small and fleeting.

Benefits for larger stones In contrast to the above findings, however, a multicentre randomised controlled trial conducted from China revealed that tamsulosin use benefits distal ureteral stones in facilitating stone passage and relieving renal colic8. Subgroup analyses find that In 2016, the American Urological Association (AUA) published new guidelines on the treatment of ureteral tamsulosin provides a superior expulsion rate for stones > 5mm, but no effect for stones ≤ 5 mm as stones. Based on the results of a high-quality compared to placebo. The rates of adverse events, meta-analysis focusing on distal ureteral stones including retrograde ejaculation, dizziness, < 10 mm, the AUA panel showed higher stone-free and headache, were similar between the groups. rates for patients treated with α-blockers compared No serious adverse event was found. with placebo treatment. The AUA panel, therefore, recommended MET treatment with α-blockers for patients with uncomplicated ureteral stones < 10 mm. However, the AUA panel did not endorse calcium channel blockers as MET due to insufficient data. Usefulness MET However, despite the multitude of published studies, the debate remains about the usefulness of MET for conservative management of ureteral stones, as most of the research is riddled with bias and confounding factors. Some recently published large placebocontrolled randomised trials have raised serious doubt about the effectiveness of α-blockers. SUSPEND trial A large, well-designed, multicentre study, also called SUSPEND trial – published in The Lancet - examined both α-blocker and calcium channel blocker therapy

European Urology Today

doi:10.1016/j.aju.2017.03.005. 3. Hollingsworth JM, Canales BK, Rogers MAM, Sukumar S, Yan P, Kuntz GM, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ 2016;355:i6112. doi:10.1136/bmj.i6112. 4. Hsu Y-P, Hsu C-W, Bai C-H, Cheng S-W, Chen K-C, Chen C. Silodosin versus tamsulosin for medical expulsive treatment of ureteral stones: A systematic review and meta-analysis. PLoS ONE 2018;13. doi:10.1371/journal. pone.0203035. 5. Pickard R, Starr K, MacLennan G, Lam T, Thomas R, Burr J, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. The Lancet 2015;386:341–9. doi:10.1016/S01406736(15)60933-3. 6. Furyk JS, Chu K, Banks C, Greenslade J, Keijzers G, Thom O, et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Ann Emerg Med 2016;67:86–95.e2. doi:10.1016/j.annemergmed.2015.06.001. 7. Meltzer AC, Burrows PK, Wolfson AB, Hollander JE, Kurz M, Kirkali Z, et al. Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial. JAMA Intern Med 2018;178:1051–7. doi:10.1001/ jamainternmed.2018.2259. 8. Ye Z, Zeng G, Yang H, Tang K, Zhang X, Li H, et al. Efficacy and Safety of Tamsulosin in Medical Expulsive Therapy for Distal Ureteral Stones with Renal Colic: A Multicenter, Randomized, Double-blind, Placebocontrolled Trial. Eur Urol 2017. doi:10.1016/j. eururo.2017.10.033.

Rectification Urology Week 2018 article, page 6, Vol. 31 No.5 - October/December 2018

The results of the study have been published in European Urology in 2017. The study is the largest to date and has randomised 3,450 patients. Of equal importance are the methodological safeguards against bias that the investigators put in place, including concealed random allocation stratified by stone size, low rates of attrition, blinding of patients and outcome assessors, and an intention-to-treat analysis. Study design The design and results of the present study are different from the SUSPEND trial. In the present study,


Conclusion In summary, the variety in the design of various trials may explain the discrepancies found. The pooled results from meta-analysis still suggest that α-blockers may facilitate the passage of larger ureteral stones. On the one hand, given the low-risk profile of these drugs, urologists may still consider MET in selected stone patients. On the other hand, urologists have to balance this judgment with the knowledge that several well-designed trials have shown no benefit, and that meta-analysis may be exaggerating the treatment effect.

In the abovementioned article, in the events map entitled "Thank you for supporting UROLOGY WEEK 2018", a screenshot of the tweet by Fundació Puigvert was incorrectly labelled to have originated from Catalunya which should have been Spain. We express our sincerest apologies for the error, any confusion and/or inconvenience this may have caused. M. Wirth Editor-in-Chief

January/February 2019

Update from the Guidelines Office Two 3-hour interactive Guidelines Controversies sessions in Barcelona EAU19 Barcelona March will see the publication of the full text and pocket versions of the 2019 European Association of Urology Guidelines. As always, the Guidelines will be available to collect - free for EAU full members - from the EAU Booth at EAU19, Barcelona.

European Association of Urology

Guidelines 2019 edition

EAU Guidelines Cup live finale at YUORDay18

EAU19: Setting the pace for urology in 2019 . . 1 • EAU Guidelines Poster Walk – Monday, 18 March at 11.30 hrs. Take a guided tour through the 20 best poster abstracts from the EAU Guidelines Panels and Committees. Poster viewing will take place from 11.00 hrs. with an expert guided tour from 11.30 to 13.30 hrs.

The Guidelines Office is pleased to announce that it will once again facilitate multiple interactive activities during EAU19, these include: • Two interactive workshop sessions on Guidelines Controversies – Saturday, 16 March, 11.00-14.00 and 14.15-17.15 hrs. These sessions will see pro and con presentations on areas within the EAU Guidelines which have highly conflicting evidence. Each set of presentations will be followed by a methodological comment/elaboration, and audience voting. Topics to be discussed include: • Non-muscle-invasive Bladder Cancer - “Should a TUR be done in all bladder tumours? ” • Urolithiasis – “PCNL: Does the instrument size matter?” • Upper tract urothelial carcinoma – “Is there a role for systemic neoadjuvant chemotherapy in high-risk tumour?” • Prostate Cancer- “No biopsy in case of a normal MRI” • Male Sexual Health – “Focal therapy vs. Robotic surgery for prostate cancer: Reported sexual function outcomes are misleading and require standardisation in guidelines” • Renal Cell Carcinoma – “Should we be doing cytoreductive nephrectomies in M1 patients requiring targeted therapy?”

• EAU Guidelines Cup (brought to you by ESRU) live finale on YUORDay19 - Saturday 16 March at 15.30 hrs. The EAU Guidelines Cup was held for the first time at last year’s Annual Congress and will be held again this year. The competition aims to determine who among the EAU members knows the EAU Guidelines the best! The Cup will consist of three rounds. The first and second rounds will take place online based on multiple-choice questions. The top three participants from the second round will compete during the live finale on YUORDay19. Last year’s winner in Copenhagen was Dr. Dimitrios Deligiannis of Greece – can you beat him? In addition to this exciting programme of events, the Guidelines Office will also have a presence at the EAU19 exhibition. We would encourage everybody to please stop by the EAU Publications booth and meet our dedicated Guidelines Office staff, who will be more than happy to answer any questions you may have regarding the many activities of the Guidelines Office. Systematic Review Training Workshop The Radisson Blu Hotel in Amsterdam was the venue for a well-attended Guidelines Office Systematic

The MET landmark study . . . . . . . . . . . . . . . . 2 Update from the Guidelines Office . . . . . . . . . 3 EAU19: New ESU courses: Just what the doctor ordered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Glove up and get in the UROlympics arena!. . 5 Fraud alert: Book and register only via the official EAU19 website. . . . . . . . . . . . . . . . 5 EAU RF initiates PHOENIX. . . . . . . . . . . . . . . . 6 Systematic Review Training Workshop in Amsterdam

BCa19: Turin welcomes second EAU Update on Bladder Cancer. . . . . . . . . . . . . . . 6

Review Workshop at the end of November 2018. The intensive two-day event saw established Guidelines Panel members, experienced associates and newer recruits participate in a packed programme of events, which featured presentations from the faculty in the morning and practical sessions in the afternoon.

Clinical Challenge. . . . . . . . . . . . . . . . . . . . . . 7

The training covered topics such as the development of a search strategy, abstract and full text screening, data abstraction, and data analysis and interpretation. The Guidelines Office Chairman, Prof. J. N’Dow, opened the event as usual and particularly welcomed the new recruits to the Guidelines team. The training workshop was coordinated by the Guidelines Office Methods Committee. Post-course feedback showed a high level of satisfaction among all those that attended. Particularly well-received were the practical sessions which allowed attendees to apply the lessons learned in the presentations.

• Two European School of Urology courses: • What’s new in the 2018 EAU Non-oncology Guidelines (Incontinence, Bladder/Paediatric Stones, Male LUTS) – Saturday, 16 March 11.00-15.00 hrs.

EAU Guidelines Poster Walk in Copenhagen, March 2018

Auspicious experience in Tunisia for EAU. . . 14 Antibiotic prophylaxis: To be or not to be? . . 15 EAU RF section: SATURN registry enrols 200th patient. . . . . . 16 NIMBUS, a pivotal trial for BCG therapy . . . . 16 Two new research projects greenlit thanks to EAU RF grant. . . . . . . . . . . . . . . . . 17

Social media in office urology this will make you think. . . . . . . . . . . . . . . . 24

The future of the underactive detrusor. . . . . 25

Do not forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme before 1 May.

January/February 2019

EAU’s Permanent Historical Collection now on display. . . . . . . . . . . . . . . . . . . . . . . 14

EAU-SUO Scholarship in Phoenix and Rochester . . . . . . . . . . . . . . . . . . . . . . . 24

European Urological Scholarship Programme (EUSP)

Guidelines Office

Functional urology – Preservation of female sexual function. . . . . . . . . . . . . . . . . 13

New UROONCO delivers best topic-based content to HCPs . . . . . . . . . . . . . . . . . . . . . . 23

Both courses will offer a bird’s eye overview of changes in the recommendations of each Guideline and their relevance for clinical practice giving attendees a quick insight into how the different fields are progressing.

Guidelines Controversies session at EAU18 in Copenhagen

EBU section: EBU recertifies the Department of Urology in Winterthur . . . . . . . . . . . . . . . . . 12 Bakırköy Dr. Sadi Konuk Hospital receives EBU certification. . . . . . . . . . . . . . . 12

ESU section: ESU-ESRU undergraduate education in urology. . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1st ESU Urology Boot Camp premieres in Lisbon. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Challenges in kidney transplant spur masterclass design. . . . . . . . . . . . . . . . . . . . 20 ESU-ESUT Masterclass delivers laser fundamentals. . . . . . . . . . . . . . . . . . . . . . . . 21 ESU course delivers PCNL essentials at ATU congress . . . . . . . . . . . . . . . . . . . . . . 22

“Last year’s winner in Copenhagen was Dr. Dimitrios Deligiannis of Greece – can you beat him?”

• Updated Renal, Bladder and Prostate Cancer Guidelines 2018: What’s changed? – Monday, 18 March 08.30-11.30 hrs.

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

For more information and application, please contact the EUSP Office – or check our website

YUO section: First edition of Focus meeting. . . . . . . . . . . VCMS in cooperation with the ESRU. . . . . . . YUO board meeting in Amsterdam. . . . . . . . YAU: Useful platform for international cooperation . . . . . . . . . . . . . . . . . . . . . . . . .

26 26 27 27

Developments in bladder cancer surgery. . . 29 ERUS19: Looking at the future of robotics. . . 31 EAU fosters stronger ties in South America. . 33 EAUN section: Fellowship great professional experience for Maltese nurse. . . . . . . . . . . . . . . . . . . . . 34 Extending international and professional friendship. . . . . . . . . . . . . . . . . . . . . . . . . . . 35 ‘Learn with the best’ congress very successful. . . . . . . . . . . . . . . . . . . . . . . 36

European Urology Today


Cutting-edge Science at Europe’s largest Urology Congress

New ESU courses: Just what the doctor ordered How good training can help combat burnout among urologists Burnout among urologists increased since 2011 despite work-hour limits according to the 2018 study "Prevalence of and Predictive Factors for Burnout Among French Urologists in Training" by Dr. Jérôme Gas (FR), et al. Research results showed that the feeling of being well-trained is a strong protective factor, on top of a wellbalanced lifestyle (e.g. having a pastime, sex life), to help combat prevalence of burnout among young urologists in training. To help address this issue, the European School of Urology (ESU) continuously develops its educational activities to parallel the ever-expanding field of urology. For two decades now, the ESU has been vigilant in providing training essentials to young and experienced urologists. And due to the popular demand for ESU courses, three new courses will be introduced at the upcoming 34th Annual EAU congress (EAU19).

Saturday 16 March

Sunday 17 March

Monday 18 March

Metabolic workup and non-surgical management of stones

Advanced endourology for urolithiasis

Boost presentation skills

With recurrence rates of up to 50% in over five years, urolithiasis is increasingly becoming a prevalent disease on a global scale. Metabolic assessment to identify predisposing factors plays an important role in patient management.

Practical management options, significant literature, and urolithiasis treatment examples in “non-index” patients are the core topics of ESU Course 37: Advanced endourology in the on-standard patients with urolithiasis. This course is a complementary course to ESU Course 44 Flexible uterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips, tricks, and indications, which is chaired by Prof. Dr. Olivier Traxer (FR).

The ESU Course 05: Metabolic workup and non-surgical management of urinary stone disease will address the common findings on dietary and metabolic workup. The course will highlight treatment options (medical and non-medical) for metabolic abnormalities to prevent stone recurrence. Course participants will learn to interpret standard metabolic workup, including history (dietary and medical) and biochemical analyses; and identify patients who will benefit from it the most. Participants will learn about EAU Guidelines recommendation on targeted medical treatment for urinary stone disease prevention. And to bolster their dietary counselling, participants will know more about the influence of dietary changes on metabolic urinary values. The ESU course will take place on Saturday, 16 March from 08:30 to 10:30 and is chaired by Dr. Thomas Tailly (BE).

ESU Course 37 will cover urolithiasis in urinary system anomalies such as calyceal diverticula stones; after bladder substitution/ileal conduit/ reimplantation; duplicate urinary system; and ectopic kidney, to name a few. Leading experts in the field will also delve into urolithiasis during pregnancy; patients with relative contraindications such as spinal malformation/bleeding diathesis; and surgical treatment of complex metabolic patients dealing with brushite and cystine stones. Chaired by Dr. Guido Kamphuis (NL), the course is scheduled on Sunday, 17 March from 14:30 to 17:30.

Engaging, knowledgeable, enthusiastic and flexible are qualities of an effective communicator. To connect with and have an impact on the audience, the speaker needs more than a well-prepared presentation. He/she needs a good stage presence and excellent delivery of his/her lecture in a lively and interesting manner. ESU Course 47: Improving your communication and presentation skills will offer tips and tricks on how to set an engrossing vibe during a presentation; to convey one’s main messages clearly; and to eventually educate and inspire listeners. Chaired by Dr. Domenico Veneziano (IT), this ESU Course will take place on Monday, 18 March from 08:30 to 11:30.

Improve your presentation skills with ESU Course 47 and Presentation training

Other courses worth checking out How to treat metastatic prostate cancer at all disease stages is the core lesson that ESU Course 22: Metastatic prostate cancer aims to impart. Participants will enrich their knowledge on currently available therapies for hormone-naïve and castration-resistant prostate cancer (CRPC) such as various forms of primary androgen deprivation, immunotherapy, chemotherapy, and approved CRPC therapies. Save the date for the course which will be chaired by Prof. Dr. Karl Pummer on Sunday, 17 March from 08:30 to 11:30. Course participants of ESU Course 31: Practical neuro-urology will enrich their knowledge on pathophysiology, and further familiarise themselves with the key points of the management of neurogenic bladder dysfunction. Internationally-known experts in the field will introduce the basic principles of the diagnostic work-up and management of the common micturition dysfunctions in neurological disease. Through real-life clinical cases, this ESU Course will explore pharmacological and surgical options for the management of neuro-urological patients.

ESU Course at the 2018 Annual EAU Congress

European School of Urology Events: • Meetings • Masterclasses • Courses • Hands-on Training

ESU Course 35 will take place on Sunday, 17 March from 14:30 to 17:30, and is chaired by Dr. Andrea Necchi (IT).

Mark the 17th of March on your calendar and note the timeslot 12:00 to 14:00 for this highlyinformative ESU Course which will be chaired by Prof. Francisco Cruz (PT).

Post Graduate Education at Its Best Online Education: • e-Courses • Webinars • Surgical Education • Online Edu Platforms

Results of large immunotherapy trials paved the way of a revolutionary road of treating locally advanced and metastatic urothelial bladder cancer (UBC). For clear-cell renal cell carcinoma (RCC), use of immunotherapy combinations resulted in a shifting paradigm for the first-line therapy of advanced disease. ESU Course 35: How will immunotherapy change the multidisciplinary management of urothelial bladder cancer? will provide participants state-ofthe-art use of immune-checkpoint inhibitors in UBC and RCC; valuable insights and updates on optimal clinical patient management; and an overview of ongoing clinical trials.

ESU Activities are CME accredited

Know more about other ESU courses at EAU19. Explore the Scientific Programme via esu-courses/

Don't miss out! Register now for your favourite ESU course!


European Urology Today

January/February 2019


Glove up and get in the UROlympics arena! Show off your skills and dexterity at the ultimate endoscopic test Knock out fellow fearless contenders during the ultimate endoscopic test, the UROlympics! This exciting second edition will take place during the fast-approaching 34th Annual EAU Congress (EAU19) in the picturesque and electric Barcelona. Get ready to compete with opponents who hail from various countries across the world. Show off your endoscopic skills, beat the clock, and take your place as a deserving UROlympian. How to join The first step is to pick up your ticket at the Cook Medical booth. The ticket is non-transferable; it is yours and yours alone. And voilà! You are officially a contender! Walk further into the EAU19 exhibition area where you will find the UROlympics arena, where the endoscopy combat will happen. Each congress day starting from Saturday, 16 March, you will have the opportunity to set your score during endoscopic tasks provided. The time of the current fastest contender will be displayed around the arena, at the Cook Medical booth and announced via social media. At the end of each day, the contender with the best time will be proclaimed the most skilled. This means that you have more opportunities to showcase your skills the day after and win prizes. What to expect at the finale The UROlympics winners will be honoured during the medal ceremony at the Cook Medical booth. Aside from the coveted UROlympics titles, medals and bragging rights, the winners will receive

educational funds that they can use for EAU events (e.g. travel, accommodation and registration). The first UROlympics The first UROlympics was held during last year’s EAU congress in Copenhagen. The riveting competition came to a close when Dr. Lee Chien Yap (IE) bagged first place, followed by Dr. Guillaume Hugues (FR) in second, and Dr. Birzhan Ashkeyev (KZ) in third. The UROlympians were honoured during the medal ceremony at the Cook Medical booth. Dr. Yap shared, “I thoroughly enjoyed the UROlympics. It was a great way to meet other trainees and delegates at the congress. The competition was exhilarating and nerve-racking. My fellow finalist had an early lead and that put extra pressure on me. My friend and colleague who was watching on the side-lines gave me technical advice and words of encouragement which ultimately helped me focus and win. Given it was St. Patrick's weekend, perhaps a little bit of Irish luck also came my way.” You, too, will have the opportunity to be a proud UROlympian! Glove up and get in the UROlympics arena!

Previous UROlympic winners Drs. Ashkeyev, Yap and Hugues

Fraud alert: Book and register only via the official EAU19 website Opening Ceremony & Networking Reception

Beware of individuals and companies that claim to offer registration for EAU19 and hotel accommodation in Barcelona through fraudulent websites and emails. For a few years now, the EAU has been receiving an increasing number of reports from congress delegates who register and book accommodation via fake websites. In many of these cases, there were no hotel reservations made and delegates often paid a registration fee much higher than the actual prices.

Opening and welcome by Professor C. Chapple Announcement of the new EAU Honorary Members

The fraudulent websites look similar to the official EAU congress website, however, you can easily identify if the website is fake or not by checking its contact details.

Special EAU Award presentations · EAU Willy Gregoir Medal 2019 · EAU Frans Debruyne Life Time Achievement Award 2019 · EAU Crystal Matula Award 2019

You are invited!

EAU19 is officially organised by Congress Consultants B.V. which is based in Arnhem, The Netherlands. Hotel accommodation is officially arranged by K.I.T Group GmbH which is based in Berlin, Germany. The EAU does not work from any other countries and official emails will always come from or or

· EAU Hans Marberger Award 2019

Guarantee your place at EAU19. Avoid high registration costs and false confirmation. Book your hotel accommodation and register for EAU19’s via the official website

· EAU Innovators in Urology Award 2019

Found below are screenshots of some of the fraudulent websites:

· EAU Prostate Cancer Research Award 2019 · EAU Ernest Desnos Prize 2019 Please join us after the Opening Ceremony for the Networking Reception which will give all delegates the opportunity to renew ties with colleagues from all over the world.

Friday, 15 March Red Area: eURO Auditorium 1 18.00 - 19.30 hrs Opening Ceremony 19.30 - 21.00 hrs Networking Reception

January/February 2019

European Urology Today


EAU RF initiates PHOENIX Prospective registry for patients undergoing penile prosthesis implantation for male erectile dysfunction Ass. Prof. Koen Van Renterghem Principal Investigator Hasselt (BE)

koenraad.van. renterghem@

Dr. Federico Deho Principal Investigator Milan (IT)

deho.federico@ Erectile dysfunction (ED) is a condition which is often encountered in - especially ageing - men, with an incidence of up to 53,4 % or even higher in men above 60 years1. Oral treatment became available from 1998 when sildenafil was introduced. This resulted in an improvement in accessibility and it made impotence easier to talk about with health care providers2. To date, PDE-5 inhibitors are considered a first-line therapy in men suffering from erectile dysfunction. When oral treatment is not effective or not suitable, more invasive treatments are available, such as intracavernous injections, intra-urethral treatment and vacuum devices3. Notwithstanding the success of the above therapies, a substantial group of patients is not EAU Research Foundation

responding to or not agreeing with these therapeutic modalities. This can be caused by the non-negligible side effects of these treatment modalities. Moreover, in most patients, erectile dysfunction is a lifelong condition that cannot be cured with therapy. In addition we are dealing with an ageing population, consisting of elderly people in an increasingly better general shape. Thus, a penile implant can be a valuable option to treat those patients. High satisfaction rates According to the EAU Guidelines4, a penile prosthesis implant (PPI) is indicated as a third-line option in patients not responding to or refusing other treatments for their ED. Many papers have been published showing a high satisfaction rate in patients as well as their partners5. These high satisfaction rates are related to the excellent mechanical reliability of the available devices on the market. The available implants produce a highquality erection as well as good technical performance. If this is combined with a perfect surgical procedure, the end result is transcending the outcome of the other therapies by far. Unfortunately, PPIs are not always offered to patients with refractory ED despite the excellent results. This can be explained by a lack of good patient information, unfamiliarity among many urologists, implant cost, insufficient high-quality publications on real and unbiased outcome, etc. To date, few prospective registries have been established6-8. Demonstrate effectiveness PPIs Therefore, it was decided to initiate a prospective registry entitled ‘Prospective Registry for Patients Undergoing Penile Prosthesis Implantation for Male Erectile Dysfunction. EAU -RF 2018-01; Acronym: PHOENIX. The aim is to collect prospective data from different European implant surgeons. This will enable us to create a synopsis on patient and partner satisfaction as well as assess the mechanical reliability of the different PPIs on the market. EAU RF will be using validated questionnaires. The final goal

is to demonstrate that this therapeutic option is an excellent treatment in patients with refractory ED who did not respond to previous treatments. Furthermore it should be possible to identify clinical and surgical factors that correlate with patient outcome, surgical complications and mechanical reliability of the devices available on the market. With the results, treatment recommendations and guidelines can be further improved resulting in better care for this group of ED patients. Participating centres and funders for our Registry still needed We aim at including European Centres who offer PPI for their patients with erectile dysfunction. In this survey we will collect pre-defined parameters related to this kind of surgery. All devices on the market that are used as implant in daily urological practice can be included. No extra visits will be required to collect the data, patients are seen on a regular basis according to standard clinical practice. Patient inclusion should be consecutive. The EAU RF has sent invitations to high-volume implant centres and European urologists from Belgium, Italy, Germany, Denmark, Serbia, Spain, the Netherlands, France and the United Kingdom. The centres have already shown interest to set up such a registry and are willing to participate by contributing their patient data after receipt of the patient’s consent. Companies producing PPIs will be approached to ask whether they wish to fund the registry and the first company has already agreed to partially fund this registry. An investigators meeting will be planned shortly, if possible, during the upcoming Annual EAU Congress in Barcelona. Should you be interested in participating in, or fund this registry, please inform the EAU RF by sending a mail to

Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ References 1. Eardley I et al. The incidence, prevalence and natural history of Erectile Dysfunction. Sex Med Rev. 2013; 1: 3-16 2. Hartmann et al. Erectile dysfunctions in patient-physician communication: optimized strategies for addressing sexual issues and the benefit of using a patient questionnaire. J Sex Med 2007; 4: 38-46 3. Virag R. Intracavernous injection of papaverine for erectile failure. Lancet 1982; 2: 938 4. European Association of Urology. Guidelines on male sexual dysfunction. 2017. 5. Brinkman et al. A survey of patients with inflatable penile prostheses for satisfaction. J Urol 2005; 174: 253-7 6. Pescatori et al. INSIST-ED: Italian society of andrology society registry on penile prosthesis surgery. Arch Ital Urol Androl. 2016; 88: 122-7 7. Henry et al. The who, how and what of real world penile implantation in 2015: the PROPPER registry baseline data. J Urol. 2016; 195: 427-33. 8. Capogrosso P, Pescatori E, Caraceni E, Mondaini N, Utizi L, Cai T, Salonia A, Palmieri A, Deho F. Satisfaction rate at 1-year follow-up in patients treated with penile implants: data from the multicentre prospective registry INSIST-ED. BJU Int. 2018 Jun 29. doi: 10.1111/bju.14462. [Epub ahead of print]

Principal Investigators: Dr. Koen Van Renterghem, Hasselt, Belgium Dr. Federico Deho, Milano, Italy Organisation: EAU Research Foundation

BCa19: Turin welcomes second EAU Update on Bladder Cancer “Thorough and updated overview of BCa for any clinician involved in multidisciplinary care” After a successful inaugural meeting last year in Munich, the EAU is continuing to offer a two-day educational update on the topic of bladder cancer. The meeting is specifically designed to give participants a practical, high-quality and comprehensive update on bladder cancer, using highly interactive group-based case discussions to illustrate the latest treatment options. BCa19 is coming to the North of Italy, to the historic and cultural city of Turin on 17-18 May, 2019. We spoke to Prof. Paolo Gontero (Turin, IT), member of the BCa19 Scientific Committee. An interactive meeting “We’ve designed the BCa19 scientific programme to appeal to any clinician involved in the multidisciplinary care of bladder cancer who wants to have a thorough and updated overview of the disease,” Gontero explains. “The format is designed to provide high quality, comprehensive information with a constant view to the clinical applicability of the contents.” Aside from state of the art lectures that address all the meeting’s participants, the programme features three case discussion sessions. During these sessions, participants are assigned to a session room and they are joined in turn by three faculty groups, each addressing different aspects of bladder cancer.

Visit to register for BCa19! Registration includes accommodation and is heavily discounted if you sign up before February 15. For example, the first case discussion session offers the following three topics: Open vs robotic radical cystectomy, the possible benefit of extended lymphadenectomy in BCa, and a multidisciplinary look at the choice of urinary diversion. Participants can therefore enjoy the educational benefits of a smaller group, as well voting during the case discussions. 6

European Urology Today

BCA19 features pre- and post-meeting testing. Prof. Gontero: “The mission of the meeting is thus to provide a high educational content, always oriented to clinical practice in order to fulfil the interest of clinicians that might have different levels of expertise.” “This year the scientific committee has worked very hard to identify contents, titles of presentations and an outstanding faculty able to fulfil the interest of a multidisciplinary audience. The aim is to foster a high level of interest for all different topics among oncologists, radiotherapists and urologists. We believe that the methodology to conduct a high-standard TURBT is no less interesting for an oncologist or a radiotherapist than systemic immunotherapy is for a urologist.” The character of the meeting BCa19 is hardly the only oncology-related meeting that the EAU has to offer in 2019. It joins PCa19 and RCC19 in the onco-urology update series, as well as the ESOU’s annual section meeting and EMUC19. Prof. Gontero makes the distinction between BCa19 and its ‘cousins’: “ESOU and EMUC are both outstanding meetings addressing the whole spectrum of uro-oncology, the latter with a special view to multidisciplinarity. However, the growing complexity and rapid progress in diagnostics and treatment of oncological diseases is generating the need of specialists devoted to a specific disease and this has translated into the dissemination of so-called bladder cancer clinics worldwide. BCa19 is the EAU meeting entirely devoted to train or to provide an annual update to bladder cancer specialists.” In terms of topics addressed, Gontero pointed out some highlights: “Genetics and, chiefly, molecular staging are changing the landscape of bladder cancer and Eva Prof. Eva Compérat (Paris, FR) and Prof. James Catto (Sheffield, GB) will have the task to explain how these new developments will soon affect clinical practice.”

Optional Live Surgery Session In addition to the full BCa19 scientific programme, Prof. Gontero is offering visitors to Turin the option to attend a special live surgery session, held on May 16, the day before BCa19 starts. Registering for the live surgery session is free of charge for BCa19 delegates, although any extra night in Turin will be at delegates’ own expense. Location: “Molinette Incontra” Congress Centre Città della Salute e della Scienza Corso Bramante, 88 Turin, Italy

17 -18 May 2019 Turin, Italy

The Live Surgery Session “Standard and Innovative Procedures for Bladder Cancer in 2019” is broadcasted on 16 May, 12.00 - 19.00 hrs, from Molinette Hospital, Turin, Italy For more information on the Live Surgery Session, including the programme, visit livesurgery

“Another important issue is represented by the variant hystologies with Dr. Ashish Kamat (Houston, USA) and Dr. Shahrokh Shariat (Vienna, AT) translating these complex cases into practical management. Bladder cancer has recently witnessed technological advances in diagnostics as well as the consolidations and expansion of novel

EAU Update on Bladder Cancer

What to expect: • Three operating theatres broadcasting simultaneous bladder procedures • Comparison of open and robotic cystectomy with neobladder • Demonstration of new technologies like Cellvizio

treatment options. These will be thoroughly covered.” “The surgical topics will be devoted to a thorough discussion of controversial topics such as robotic and open cystectomy, the extent of lympadenectomy and the difficult choice of urine diversion.”

EAU onco-urology series

January/February 2019

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


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

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

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

Case study No. 59 This 34-year-old man was treated for a testicular cancer und underwent left radical orchiectomy. The histopathology was pure seminoma, β-HCG was elevated around 400 and the CT scan at the time is shown below (fig.1). The patient has a strong smoking history. He underwent four courses of PIE chemotherapy (cisplatinum, etoposide and ifosfamide) which were well tolerated. Tumour markers had normalised after the second course of chemotherapy. The post-chemotherapy CT scan is shown in fig.2, showing a rather small left paraaortic residual compared to the original mass, measuring 4x2 cm.

Case provided by Oliver Hakenberg, Department of Urology, Rostock University. E-mail: oliver. Figs. 1 and 2: Abdominal CT scans

Comment on clinical case study No. 58 Comments by Prof. Remzi Mesut and Prof. Shahrokh Shariat Vienna (AT)

Prof. Remzi Mesut

Prof. Shahrokh Shariat

1. What treatment should be undertaken? Even this it most likely a renal cell carcinoma (RCC) with an inferior vena cava (IVC) thrombus, several other tumours can mimic these images: such as adrenal cortical carcinoma (ACC), urothelial carcinoma of the upper tract (UTUC), and other rare tumours. The choice of surgical technique should be individualised to each case. Decisions should be based on: 1. Co-morbidity status of the patient 2. Tumour burden (i.e., metastatic sites and quantity) 3. Tumour features (suggestive of sarcomatoid or other variants) a. Side of the tumour and anatomic challenges b. Extent of IVC thrombus c. Suspicion of IVC wall infiltration d. Associated bland thrombus below the tumour thrombus e. Presence of tumour thrombus pulmonary embolism or not

Figure 1: Retroperitoneal mass before chemotherapy

the IVC below the hepatic veins with an associated bland thrombus below the renal vessels. A complete obstruction of the IVC at the levels of the hepatic veins will most probably result in a Budd-Chiari Syndrome. No signs for that are presented in this case, thus we suspect a complete obstruction below the hepatic veins. This points to the possibility of doing a complete IVC ligation during the surgery, should it be necessary. This would reflect Group C in the classification scheme for IVC interruption based on the degree of venous occlusion and bland thrombus [4]. If one is to ligate the IVC it is recommended not to ligate more than 2 lumbar veins because these veins allow for adequate venous flow in addition to collaterals. The ligation of the IVC has two potential advantages – no risk for an embolus from the bland thrombus below and no need for further IVC reconstruction. Ad 3e: see point 3 2. Are any special measures advisable? First of all, IVC thrombi can grow fast, thus imaging should not be older than 14-30 days [5] Second, MRI is the gold standard for IVC thrombus evaluation, especially to distinguish between tumour thrombus and associated clots and the occlusion grade of the IVC. In this patient, we suspect partial or complete occlusion of the IVC with an associated bland thrombus below.

The anterior-posterior (AP) diameter of IVC and renal vein (RV) are associated with wall invasion. An IVC diameter that is larger than 18 mm and the RV above 14 mm suggest an IVC wall invasion [6]. Preoperative MR imaging can assess IVC wall invasion with a Ad 1) Patients with a poor performance status sensitivity and specificity of around 90% [7]. Without preoperatively have a worse oncological and any AP diameters we cannot determine the IVC wall complicated outcome [1]. This patient is 260-years- invasion. In case of IVC wall invasion, the likelihood of old and no other co-morbidities are reported, thus segmental resection or even prosthetic replacement he is in the best prognosis group regarding this increases. Additionally, IVC wall infiltration has a variable. worse oncological prognosis. While the need for segmental resection and prosthesis can be done Ad 2 and 3b) The tumour burden shows a intraoperatively, surgical planning and patient thrombus up to the diaphragm. Thus, it is a level III counselling are better if adequate preoperative thrombus according to Neves and Zincke [2] and a information is available. clinical stage cT3bN0M0. The retrohepatic IVC thrombus can be further divided into a, b, c, d 3. Regarding the multiple already-existing small levels according to Ciancio [3]. According to the pulmonary emboli (PE), with treatment is images presented, this classification cannot be appropriate? made adequately. However, it is clear that the level Patients with RCC with venous thrombus who present of thrombus goes at least to the hepatic or with PE may be considered poor candidates for suprahepatic level (IIIb or c). This is important as it surgery due to the risk of perioperative determines the surgical strategy such as a need for anticoagulation in patients undergoing prolonged, liver mobilisation and full IVC exposure to ensure complex surgical procedures. Kayalar et al. evaluated adequate proximal vascular control above the a surgical approach with concomitant pulmonary thrombus. embolectomy [8]. A cardiopulmonary bypass was necessary in all nine patients and in four patients Ad 3a) In patients with an IVC thrombus, the right hypothermic arrest was necessary. Therefore Abel et side is more commonly affected. We would al. investigated in a multicentre study of 782 perform a right sided Chevron incision with consecutive patients the impact of preoperative PE in possible extension to the left side. Of course, also a RCC patients with venous thrombus [9|. They found midline laparotomy is possible. that preoperative PE was not associated with a Ad 3c) see point 2 below higher rate of early mortality, recurrence or cancer Ad 3d) In the images presented and also specific survival in patients with RCC and IVC mentioned under point 2, we have a high involvement. A PE diagnosis is not equivalent to suspicion for a partial or complete occlusion of metastatic disease since 59% of patients without

January/February 2019

metastasis but with PE preoperatively remained cancer free during follow up. The consensus recommendations for anticoagulation are similar for incidental and symptomatic PE because most fatal PEs are asymptomatic until late in the clinical course. Summary Surgery is the only curative option with a 5 year-survival of 32-72% in cT3bN0M0 patients with IVC thrombus [10]. This young patient will probably benefit from surgery. We would prefer a Chevron incision. Anticoagulation before surgery and adequate blood products should be planned. A cardiovascular and/or a hepatobiliary surgeon should be part of the team as full liver mobilisation and full cava exposure is necessary. In many cases, the cephalad extent of the IVC thrombus will shrink after ligation of the renal artery - which is one of the first steps during surgery. This case could obviate a vascular bypass. The full exposure of the hepatic vena cava can be facilitated by the piggy-back technique. Additionally, a Pringle maneuver may improve hemostasis. However, to prevent ischemic damage to the liver, the clamp time is limited to 20 minutes. As mentioned above, the associated bland thrombus below triggers us to ligate the IVC below the thrombus. Thus, the reconstruction with closure (Prolene 4.0) has to be done above the level of ligation. One has to avoid the ligation of more than 2 lumbar veins. Finally, radical nephrectomy and lymph node dissection [11] is completed. References 1. Martínez-Salamanca JI, Huang WC, Millán I, et al. Prognostic impact of the 2009 UICC/AJCC TNM staging system for renal cell carcinoma with venous extension. Eur Urol. 2011;59:120–7. 2. Neves RJ, Zincke H (1987) Surgical treatment of renal cancer with vena cava extension. Br J Urol 59:390– 395. 3. Ciancio G, Vaidya A, Savoie M, Soloway M (2002) Management of renal cell carcinoma with level III thrombus in the inferior vena cava. J Urol 168(4 Pt 1):1374–137. 4. Blute ML, Boorijan SA, Leibovich BC et al. Results of Inferior Vena Caval Interruption by Greenfield Filter, Ligation or Resection During Radical Nephrectomy and Tumor Thrombectomy. J Urol. 2007 Aug;178(2):440-5. 5. Woodruff DY, Van Veldhuizen P, Muehlebach G et al. The perioperative management of an inferior vena caval tumor thrombus in patients with renal cell carcinoma. Urol Oncol. 2013 Jul;31(5):517-21. 6. Zini L, Destrieux-Garnier L, Leroy X, Villers A, Haulon S, Lemaitre L, Koussa M. Renal vein ostium wall invasion of renal cell carcinoma with an inferior vena cava tumor thrombus: prediction by renal and vena caval vein diameters and prognostic significance. J Urol. 2008;179:450–4. discussion 454. 7. Adams LC, Ralla B., Bender Y et al. Renal cell carcinoma with venous extension: prediction of

inferior vena cava wall invasion by MRI. Cancer imaging 2018 18:17. 8. Kayalar N., Leibovich BC, Orszulak TA t al.

Figure 2: Post-chemotherapy CT showing relatively small residual mass

Discussion point: 1. What further treatment is advisable?

Case provided by Oliver Hakenberg, Dept. of Urology, Rostock University, Germany. Email: oliver.

Case Study No. 58 continued Surgery was performed for radical nephrectomy and removal of the tumour thrombus. The team consisted of a cardiac, a vascular and a urologic surgeon. There was little shrinkage of the thrombus after ligation of the renal artery so hypothermic arrest was performed after opening of the thorax. The thrombus could be completely removed and distal clot thrombi were removed from both common iliac veins by Fogarty catheters. There was no need for replacement of the vena cava. Surprisingly, histology confirmed a primary sarcoma instead of a renal carcinoma.

Concomitant surgery for renal neoplasm with pulmonary tumor embolism. J Thorac Cardiovasc Surg, 2010 139:320. 9. Abel EJ, Woog CG, Eickstaedt N. et al. Preoperative pulmonary embolism does not predict poor postoperative outcomes in patients with renal cell carcinoma and venous thrombus. J Urol 2013 Aug;190(2):452-7. pubmed/23434945 10. Gettman MT and Blute ML Surgical management of renal cell carcinoma invading the vena cava. Curr Urol Rep 2002, 3:37–43. 11. Tilki D., Chandrasekar T., Capitanio U. et al. Impact of lymph node dissection at the time of radical nephrectomy with tumor thrombectomy on oncological outcomes: Results from the International Renal Cell Carcinoma-Venous ThrombusConsortium (IRCC-VTC). Urol Oncol. 2018 Feb;36(2):79.e11-79.e17

European Urology Today


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

Animal caretakers to avoid the spread of K. pneumoniae The objectives of this study were to characterise the population structure, antimicrobial resistance and virulence genes of Klebsiella spp. isolated from dogs, cats and humans with urinary tract infections (UTIs). Klebsiella spp. from companion animals (n = 27) and humans (n = 77) with UTI were tested by the disc diffusion method against 29 antimicrobials. Resistant/ intermediate isolates were tested by PCR for 16 resistance genes. Seven virulence genes were screened for by PCR. All Klebsiella pneumoniae from companion animals and third-generation cephalosporin (3GC)-resistant isolates from humans were typed by MLST. All Klebsiella spp. were compared after PFGE XbaI macro-restriction using Dice/UPGMA with 1.5% tolerance.

Caution must be applied to avoid high-risk clonal lineages as a cause of UTI BlaCTX-M-15 was detected in > 80% of 3GCresistant strains. K. pneumoniae high-risk clonal lineage ST15 predominated in companion animal isolates (60%, n = 15/25). Most companion animal ST15 K. pneumoniae belonged to two PFGE clusters (C4, C5) that also included human strains. Companion animal and human ST15-CTX-M-15 K. pneumoniae shared a fimH-1/mrkD/entB/ycfM/kfu virulence profile, with a few (n = 4) also harbouring the yersiniabactin siderophore-encoding genes. The hospital-adapted ST11 K. pneumoniae clonal lineage was detected in a cat (n = 1) and a human (n = 1); both were MDR, had 81.1% Dice/UPGMA similarity and shared several virulence and resistance genes. Two 3GC-resistant ST348 strains with 86.7% Dice/ UPGMA similarity were isolated from a cat and a human. Authors conclude that companion animals with UTI become infected with high-risk K. pneumoniae clonal lineages harbouring resistance and virulence genes similar to those detected in strains from humans. The ST15-CTX-M-15 K. pneumoniae clonal lineage was disseminated in companion animals with UTI. Caution must be applied by companion animal caretakers to avoid the spread of K. pneumoniae high-risk clonal lineages.

Source: Klebsiella pneumoniae causing urinary tract infections in companion animals and humans: population structure, antimicrobial resistance and virulence genes. Marques C, Menezes J, Belas A, Aboim C, Cavaco-Silva P, Trigueiro G, Telo Gama L, Pomba C. J Antimicrob Chemother. 2018 Dec 10; DOI: 10.1093/jac/ dky499 PMID: 30535393

Gold standard test misses a significant proportion of bacteria Midstream urine culture (MSU) remains the gold standard diagnostic test for confirming urinary tract infection (UTI). Investigators previously showed that patients with chronic lower urinary tract symptoms (LUTS) below the diagnostic cut-off on MSU culture may still harbour bacterial infection, and that their antibiotic treatment was associated with symptom resolution. Here, they evaluated the results of the UK's MSU culture in symptomatic patients and controls. Next, they compared the bacterial enrichment capabilities of the MSU culture with a 50 µl uncentrifuged culture, a 30 ml centrifuged sediment culture, and 16S rRNA gene sequencing. Key articles


This study was conducted on urine specimens from 33 LUTS patients attending their first clinical appointment (mean age = 49 years, standard deviation [SD] = 16.5), 30 LUTS patients on treatment (mean age = 47.8 years, SD = 16.8) whose symptoms had relapsed, and 29 asymptomatic controls (mean age = 40.7 years, SD = 15.7).

Routine MSU culture fails to detect a variety of bacterial species, including uropathogens Investigators showed that the routine MSU culture, adopting the UK interpretation criteria tailored to acute UTI, failed to detect a variety of bacterial species, including recognised uropathogens. Moreover, the diagnostic MSU culture was unable to discriminate between patients and controls. In contrast, genomic analysis of urine enriched by centrifugation discriminated between the groups, generating a more accurate understanding of species richness. It is concluded that the UK's MSU protocol misses a significant proportion of bacteria, which include recognised uropathogens, and may be unsuitable for excluding UTI in patients with LUTS.

Source: Reassessment of routine midstream culture in diagnosis of urinary tract infection. Sathiananthamoorthy S, Malone-Lee J, Gill K, Tymon A, Nguyen TK, Gurung S, Collins L, Kupelian AS,Swamy S, Khasriya R, Spratt DA, Rohn JL. J Clin Microbiol. 2018 Dec 12; DOI: 10.1128/JCM.01452-18 PMID: 30541935

Prophylactic antibiotics effectively prevent UTIs after radical cystectomy A profound number of prophylactic antibiotics are used after radical cystectomy with an ileal orthotopic neobladder (RCIONB) despite a negative effect of infection control. The authors of the present paper investigated the impact of short-term prophylactic antibiotic use on infectious complications after RCIONB. They retrospectively reviewed data from 287 patients who underwent RCIONB for bladder cancer between 2012 and 2016 at a tertiary hospital. The patients were divided into 2 groups according to the pattern of prophylactic antibiotics (185 patients in a long-term group, 25-day use of 3-staged multiple antibiotics versus 102 patients in a short-term group, 24-hour use of cefotetan). The onset of complications, including bacteriuria, febrile urinary tract infection (FU), and bacteraemia, and the microorganisms responsible for infections were compared between the groups.

Short-term use also decreases colonisation with multi-drugresistant organisms Of all 287 patients, bacteriuria, FU, and bacteraemia were identified in 177 (61.7%), 85 (29.6%), and 18 (6.3%) patients, respectively. Bacteriuria was identified more frequently in the short-term group (49.2% vs 84.3%, p  < .001). However, the rates of FU within 60 days of surgery were similar in both groups (28.6% vs 28.4%, p = .969). The rate of FU was not significantly different between the 2 groups. There was no significant difference in the rate of patients with bacteraemia (5.4% vs 7.8%, p = .415). The most frequent microorganisms seen in bacteriuria were Enterococcus faecium and Enterococcus faecalis, in the long-term and short-term group, respectively. Antibiotic-resistant Enterococcus species were more frequently present in the long-term group. Short-term use of prophylactic antibiotics is effective for preventing urinary tract infections after RCIONB and decreasing colonization with multi-drug-resistant organisms.

Source: Impact of a change in duration of prophylactic antibiotics on infectious complications after radical cystectomy with a neobladder. Kim CJ, Kim KH, Song W, Lee DH, Choi HJ.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

Medicine (Baltimore). 2018 Nov; 97(47):e13196. DOI: 10.1097/MD.0000000000013196 PMID: 30461620.

What is the risk of only performing targeted prostate biopsy? Multiparametric (mp)MRI has excellent sensitivity for detecting ISUP grade group 2 prostate cancer and is increasingly used to locate suspicious lesions before biopsy. In the PRECISION study the detection of ISUP grade group 2 or more aggressive cancers was significantly higher in men who underwent MRI and targeted biopsy than those who underwent systemic biopsy alone. However, PRECISION didn’t investigate whether combining systemic biopsy and targeted biopsy would increase the detection of clinically significant disease. The PROMIS study had previously assessed the negative predictive value of mpMRI which was calculated as 89% for ISUP grade group 3 or higher but just 76% for ISUP grade group 2 or higher cancers. This suggests that some significant cancers might be missed by targeted biopsy alone. This prospective multicentre study compared in the same patients the detection of ISUP grade group 2 or higher cancers, obtained by 12-14 core systematic biopsy and 3-6 core targeted biopsy.

Some significant cancers might be missed by targeted biopsy alone 275 men with an indication for a first prostate biopsy and a PSA ≤ 20 ng/ml were enrolled in 16 centres. Men with cT3 disease were excluded. A mpMRI was performed with a planned interval of less than 3 months before biopsy. An operator masked to multiparametric MRI results did a systematic biopsy by obtaining 12 systematic cores and up to two cores targeting hypoechoic lesions. In the same patient, another operator targeted up to two lesions seen on MRI with a Likert score of 3 or higher (three cores per lesion) using targeted biopsy based on multiparametric MRI findings. Patients with negative multiparametric MRI (Likert score ≤ 2) had systematic biopsy only. The primary outcome was the detection of clinically significant prostate cancer of ISUP grade group 2 or higher, analysed in all patients who received both systematic and targeted biopsies and whose results from both were available for pathological central review, including patients who had protocol deviations. Of 275 patients, 24 (9%) were excluded from the analysis. 53 (21%) of 251 analysed patients had negative (Likert ≤ 2) multiparametric MRI. ISUP grade 2 prostate cancer was detected in 94 (37%) of 251 patients of which 5.2%would have been missed had systematic biopsies not been performed. Four grade 3 post-biopsy adverse events were reported (3 cases of prostatitis, and 1 case of urinary retention with haematuria). ISUP ≥ 2

ISUP ≥ 3

Systematic Bx

29.9% (24.3-36%)

15.1% (10.9-20.2%)

Targeted Bx

32.3% 19.9% (26.5-38.4%) (15.2-25.4%)


37.5% 21.1% (31.4-43.8%) (16.2-26.7%)

Added value of Systematic Bx 5.2% (2.8-8.7%)

1.2% (0.2-3.5%)

Added value of targeted Bx

7.6% (4.6-11.6%)

6.0% (3.4-9.7%)

P values (for the difference between the detection rate obtained by systematic and targeted biopsy alone)



In MRI-FIRST detection of clinically significant prostate cancer did not differ between targeted biopsy and systematic biopsy although detection improved when both were combined. Suggesting pre-biopsy mpMRI can improve the detection of clinically significant prostate cancer. Interestingly when a more aggressive definition of clinically significant prostate cancer (ISUP grade group 3+) was used this disappeared and significantly fewer non-clinically

g.ploussard@ significant prostate cancers were detected. Taken with the data from PROMIS this study suggests that abandoning systemic biopsy in men undergoing their first prostate biopsy will result in a significant under-detection of ISUP grade group 2 cancers. The question is does this matter?

Source: Use of prostate systemic and targeted biopsy on the basis of multiparametric MRI in biopsy-naïve patients (MRI-FIRST): a prospective, multicentre paired diagnostic study. Rouviere O, Puech P, Renard-Pena R, et al. Lancet Oncol. 2019; 20: 100-9.

ADT with Radiotherapy but for how long for locally advanced prostate cancer? Although it has been clear that the addition of androgen suppression to radiotherapy for prostate cancer improves oncological outcomes the optimal duration is not clear. Until 2009, 36 months of adjuvant androgen suppression after prostatic and pelvic nodal radiotherapy was considered to be standard of care, despite the toxicity associate with long-term androgen deprivation therapy (ADT). In 2003 the Trans-Tasman Radiation Oncology Group (TROG) took the most effective treatment group of its 96.01 trial, 6 months of neoadjuvant androgen suppression before and during radiotherapy (known as short-term androgen suppression [STAS]), as the control group for its next trial, the Randomised Androgen Deprivation And Radiotherapy (RADAR) trial. The primary objective of this trial was to determine whether an intermediate duration of adjuvant androgen suppression (ITAS) would be superior to STAS in terms of prostate cancer-specific mortality but without compromising quality-of-life outcomes. This 10 year follow-up of the RADAR trial assess if 12 months of adjuvant ADT improves the outcome of men receiving 6 months of neoadjuvant ADT before and during radiotherapy

18 months of ADT plus radiotherapy appears to be more effective than STAS This randomised, phase 3, 2 × 2 factorial trial, enrolled 1071 men with locally advanced prostate cancer (either T2b-4, N0 M0 tumours or T2a, N0 M0 tumours provided Gleason score was ≥ 7 and baseline prostate-specific antigen [PSA] concentration was ≥ 10 µg/L). Participants were allocated by stratified computer-generated randomisation in a 1:1:1:1 ratio to four treatment groups. Patients in the control group received 6 months of neoadjuvant androgen suppression with leuprorelin (22·5 mg every 3 months, intramuscularly) and radiotherapy alone (shortterm androgen suppression [STAS]); this treatment was either followed by another 12 months of adjuvant androgen suppression with leuprorelin (22·5 mg every 3 months, intramuscularly; intermediate-term androgen suppression [ITAS]), or accompanied by 18 months of zoledronic acid (4 mg every 3 months, intravenously) starting at randomisation (STAS plus zoledronic acid), or both (ITAS plus zoledronic acid). All patients received radiotherapy to the prostate and seminal vesicles, starting from the end of the fifth month of androgen suppression; dosing options were 66, 70, and 74 Gy in 2-Gy fractions per day, or 46 Gy in 2-Gy fractions followed by a high-dose-rate brachytherapy boost dose of 19·5 Gy in 6·5-Gy fractions. The primary endpoint was prostate cancer-specific mortality and was analysed according to intention-to-treat using competing-risks methods.


European Urology Today

January/February 2019

Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ At 10-year follow-up, no interactions were observed between androgen suppression and zoledronic acid so the treatment groups were collapsed to compare treatments according to duration of androgen suppression: 6 months of androgen suppression plus radiotherapy (6 ADT+RT) versus 18 months of androgen suppression plus radiotherapy (18 ADT+RT) and to compare treatments according to whether or not patients received zoledronic acid. When analysed by duration of androgen suppression, the adjusted cumulative incidence of prostate cancer-specific mortality was 13·3 % (95% CI 10·3–16·0) for 6 ADT+RT versus 9·7% (7·3–12·0) for 18 ADT+RT, representing an absolute difference of 3·7%(95% CI 0·3–7·1; sub-hazard ratio [sHR] 0·70 [95% CI 0·50–0·98], adjusted p = 0·035). PSA progression occurred in 436 men (246 in the 6 ADT+RT group vs. 190 in the 18 ADT+RT group) and cumulative incidences were 45·9 % (95% CI 41·9–49·9%) for 6 ADT+RT and 34·0% (30·2–37·7) for 18 ADT+RT (sHR 0·65 [95% CI 0·54–0·79], adjusted p = 0.0001). The addition of zoledronic acid did not affect prostate cancer-specific mortality. 18 months of ADT plus radiotherapy appears to be a more effective treatment option for locally advanced prostate cancer than STAS, but the addition of zoledronic acid is not beneficial. Evidence from the RADAR and the French Canadian Prostate Cancer Study IV trials which was published last year and evaluated 18 vs. 36 months of ADT suggests that 18 months of androgen suppression with moderate radiation dose escalation is an effective but more tolerable option than longer durations of androgen suppression for men with locally advanced prostate cancer including intermediate and high risk elements

Source: Short-term androgen suppression and radiotherapy versus intermediate-term androgen suppression and radiotherapy, with or without zoledronic acid in men with locally advanced prostate cancer (TROG 03.04 RADAR): 10-year results from a randomised, phase 3 factorial trial. Denham JW, Joseph D, Lamb DS, et al. Lancet Oncol. 2018;

Is there a role for circulating tumour DNA in mCRPC? Despite improvements in the management of metastatic castration-resistant prostate cancer (mCRPC) it remains an incurable disease. To better understand the molecular evolution of the disease, it is important to be able to readily and serially profile the somatic genomic alterations. However, repeated genomic profiling of advanced solid tumours, particularly metastatic prostate cancer tissue, is challenging due to the frequent presence of bone lesions and difficulty in accessing deep intraabdominal spread by invasive biopsies. In addition profiling primary tissue may not be informative as the tumour evolves with an increase in somatic alterations present in biopsies from metastatic deposits.

… the ability of ctDNA profiling to capture genomic alterations in patients with mCRPC … Characterising the circulating tumour DNA (ctDNA) in circulating cell free DNA (cfDNA) may fulfil the need for a non-invasive assay that can be repeated to assess treatment response and resistance at the time of disease progression. In addition, ctDNA profiling is not confounded by the sampling bias of a biopsy of a single metastatic lesion and may capture tumour heterogeneity. This study evaluated the ability of ctDNA profiling to capture potentially actionable genomic alterations in patients with mCRPC and evaluated the association with outcomes and evolution with therapy. Key articles

January/February 2019

Patients with mCRPC from multiple institutions underwent cfDNA genomic profiling using Guardant360, which examines major cancerassociated genes. Clinical factors, therapy information, failure-free survival, and overall survival (OS) were obtained for select patients. Patients selected for the analysis of clinical outcomes included those who underwent ctDNA profiling within 4 weeks before or 4 weeks after initiating treatment with a new line of systemic therapy for mCRPC. ctDNA profiles were also collected from patients who underwent analysis at multiple time points. The association between genomic alterations and outcomes was investigated based largely on failure free survival. Of 514 men with mCRPC included, 482 (94%) had ≥ 1 circulating tumour DNA (ctDNA) alteration. The most common recurrent somatic mutations were in TP53 (36%), androgen receptor (AR) (22%), adenomatous polyposis coli (APC) (10%), neurofibromin 1 (NF1) (9%), epidermal growth factor receptor (EGFR), catenin beta-1 (CTNNB1), and AT-rich interactive domain-containing protein 1A (ARID1A) (6% each); and BRCA1, BRCA2, and phosphatidylinositol-4,5bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) (5% each) The most common genes with increased copy numbers were AR (30%), MYC (20%), and BRAF (18%). Clinical outcomes were available for 163 patients, 46 of whom (28.8%) were untreated for mCRPC. A higher number of ctDNA alterations, AR alterations, and amplifications of MYC and BRAF were associated with worse failure free survival and/or OS. On multivariable analysis, MYC amplification remained significantly associated with OS. Prior therapy and serial profiling demonstrated the evolution of alterations in AR and other genes. Encouragingly ctDNA was frequently detected in men with mCRPC and alterations appear similar to tumour alterations identified in previous studies. Interestingly a higher number of gene alterations is associated with poor clinical outcomes (shorter FFS) on subsequent therapy. In other tumour this is associated with improved response to check-point inhibitors. It is not yet possible to select treatment based upon the ctDNA but this may be possible in the future.

Source: Circulating Tumour DNA alterations in patients with metastatic castration-resistant prostate cancer. Sonpavade G, Agarwal N, Pond GR, et al. Cancer. 2019;

Systemic targeted therapy by PSMA radioligand Precisely targeting tumour cells by the use of radioligand therapy is appealing. The PSMA-targeted radioligand therapy is one of the most promising ligand. However, the initial therapy programmes using such therapies have been applied in compassionate use programmes, without strong outcomes reported in the current literature. The present study evaluates the treatment outcomes, toxicity, and predictive factors after 177-lutetiumlabeled PSMA therapy in 100 consecutive patients previously highly treated for metastatic castrationresistant prostate cancer. More than half of the patients had received three or more treatment regimens for metastatic castrationresistant prostate cancer (mCRPC) and all received the therapy on compassionate programme. Overall, 319 cycles were given with a median of two cycles per patient. Forty and twelve patients received four and six cycles, respectively, which highlighted a not negligible number of long responders. The treatment course was completed without evidence of progression in 19 patients, with a median time on treatment of 3.8 months. No non-haematological grade 3-4 adverse events were reported. Most frequent adverse events were transient xerostomia, fatigue, loss of appetite, and diarrhoea. Anaemia was the most frequent grade 3-4 adverse event occurring in 9%, followed by neutropenia (6%) and thrombocytopenia (4%). PSA decline was > 30%, > 50%, and 90%, in 47%, 38%, and 11% of patients, respectively. Median progression-free survival was only 4 months, and median overall survival approached 13 months.

experienced sustained tumour control. The presence of visceral metastasis was the only predictive factor for poor PSA response under therapy (26% versus 45% of responders in the absence of visceral metastases). Overall survival was also correlated with the serum LDH level which biologically reflected the tumour burden.

Mr. Philip Cornford Section editor Liverpool (GB)

Therapy for highly treated metastatic castration-resistant prostate cancer


In this large series of patients, the authors reported an interesting response rate, in mCRPC patients already treated by several approved therapy lines. The initial PSA decline appeared as a good surrogate for improved survival in this mCRPC population. Treatment-emergent adverse events were acceptable, and no treatment was stopped because of side effects. Globally, these findings are hopeful. However, the single-centre and retrospective design of this study limits their generalisation. Ongoing phase III trials have been launched assessing the benefit from 177-lutetium-labeled PSMA therapy with best standard of care to draw any firm conclusion.

Source: Treatment outcomes, toxicity, and predictive factors for radioligand therapy with 177-lutetium-labeled PSMA therapy in metastatic castration-resistant prostate cancer. Heck et al. Eur Urol 2018 DOI: eururo.2018.11.016

TRUS versus MRI-guided biopsies The recent PRECISION trial published in early 2018 has led to a significant change in prostate cancer recommendations with the use of MRI even before initial biopsy. Nevertheless, the recent MRI-FIRST trial has maintained the systematic TRUS biopsy scheme as an important diagnostic tool, in addition to targeted biopsies in biopsy-naïve patients. In the present study, the design was quite similar to that used in the French MRI-FIRST trial. In 3 years, all consecutive patients with an elevated PSA (> 3 ng/ml) were included into a prospective, multicentre, powered comparative effectiveness study. Four centres in the Netherlands were involved. They underwent a pre-biopsy 3T MRI followed by systematic biopsy and targeted cores in case of abnormal MRI (PIRADS 3-5). All targeted biopsies were performed using the in-bore approach. When a lesion was seen at TRUS, targeted cores was also taken.

13% of patients with negative MRI underwent repeat biopsies with the diagnosis of significant PCa in 3 men (3/39). Two conclusions can be drawn. Firstly, both pathways are identical in MRI-positive patients with comparable rates of clinically significant PCa after TRUS or MRI pathways. It is worthy to note that the use of MRI pathway led to the non-detection of 20% of insignificant PCa, detected by systematic biopsies. No clear superiority of in-bore biopsies compared with TRUS biopsy has been reported in MRI positive patients. Secondly, the avoidance of TRUS biopsy in case of negative MRI appears clinically relevant, with very few significant PCa missed, and with the possibility to reduce the costs. Interestingly, the proportion of men avoiding biopsy was almost twice that reported in PROMIS and PRECISION trials. This high percentage of negative MRI may be explained by the low prevalence of significant PCa in a contemporary screening cohort. More importantly, the high-quality of MRI standards could also be part of the explanation, in both university and non-university settings (good agreement between readers). This study shows that confidence in MRI acquisition and reading may be generalizable in routine practice, and that the absence of systematic biopsies should be discussed in men with elevated PSA, in case of negative MRI and low PSA density.

Source: Head-to-head comparison of TRUS biopsy versus MRI with subsequent MRI-guided biopsy in biopsy-naïve men with elevated PSA: a large prospective multicentre clinical study. Van der Leest et al. Eur Urol 2018 eururo.2018.11.023

Targeted biopsies alone or in combination with systematic biopsies?

The PRECISION trial has demonstrated the superiority of the MRI pathway (targeted biopsies alone or no Avoidance of TRUS biopsy in case biopsies in case of negative MRI) over the systematic biopsy approach. Nevertheless, the comparison of negative MRI appears clinically between targeted biopsies alone and in combination relevant with systematic biopsies had not been assessed. In the present multicentre, paired diagnostic study, the authors have assessed the performance of both Clinically significant prostate cancer was defined by the presence of any grade 4 (ISUP 2 or more). The MRI systematic and targeted biopsies in biopsy-naive and TRUS pathways were then compared. All biopsies patients. were centrally reviewed in pathology. Interestingly, two operators performed the biopsies. PIRADS 3-5 lesions were reported in 51% of patients. The first one was masked to the results of MRI and performed the 12-core scheme. The second operator The overall detection rate by combining both targeted 1-2 cores per MRI lesion. No targeted biopsy pathways was 53%, with 30% of significant prostate was performed in case of negative MRI (Likert score cancers. When analysing separately the clinically 1-2). The primary endpoint was the detection of significant PCa rates according to the biopsy scheme, clinically significant prostate cancer (csPCa) defined differences between both pathways were minimal in by a ISUP > 1 cancer. case of PIRADS 5. For PIRADS 3-4 lesions, it reached 12% favouring the MRI pathway. The overall PCa rate was 39% after MRI biopsy compared with 48% after TRUS biopsy. These rates were 23% and 25%, respectively, when considering only significant PCa. The relative sensitivity of the MRI pathway was 1.09 and 0.57 for significant and any grade PCa, respectively, compared with TRUS pathway. Avoiding biopsies in case of normal MRI would decrease by 49% the number of men needed to biopsy and would miss only 3% of significant PCa. However, 20% of any grade PCa would have been detected by TRUS biopsy. If PSA density was used as criterion for biopsy in negative MRI patients, no significant PCa would have been missed when using a cut-off of PSA density at 0.15 ng/ml/gr.

MRI reader concordance agreement was 88% between the first non-university centre and the second centrat-centre reading. The overall PSA decline was significantly associated overall complication rate was 6% including 3% of survival. Patients who completed the treatment course complicated urinary tract infection. During follow-up,

Assessment of performance of both systematic and targeted biopsies in biopsy-naive patients The MRI interpretation was done by a single radiologist at the local site, with complete access to clinical data. No centralised reading was performed but quality of MRI interpretation was checked before the start of the study. Overall, 275 patients were enrolled in 16 centres with 251 finally included. MRI was negative in 21% of cases. The csPCa detection rate was 37% in the whole cohort. Systematic biopsies only, targeted biopsies only, and their combination detected 14%, 20%, and 66%, respectively, of these cancers. The csPCa detection rate by systematic biopsies and targeted biopsies was 29.9% and 32.3%, respectively, without any significant difference (p = 0.38). Using targeted biopsies alone would have missed 5.2% of these cancers.


European Urology Today


The rate of late complications was low, with no procedure-related adverse events after month 6.


Source: Randomized controlled trial of aquablation vs. transurethral resection of the prostate in benign prostatic hyperplasia: one-year outcomes. Gilling P, Barber N, Bidair M, Anderson P, Sutton M, Aho T, Kramolowsky E, Thomas A, Cowan B, Roehrborn C

There is lack of evidence-based optimisation of the protocol for low-intensity shockwave therapy for erectile dysfunction. Furthermore, the safety and efficacy of repeating shockwave therapy have not been explored.

Urology, 2018 Dec 12. pii: S0090-4295(18)31308-6. doi:10.1016/j.urology.2018.12.002. [Epub ahead of print] number, NCT02505919

Thus, the authors compare the efficacy and safety of 6 and 12 treatment sessions within a 6-week treatment period and investigate the effect of repeat treatment after a 6-month period in a 2-phase study.

When considering only the detection of ISUP3-5 cancers, the detection rate was significantly improved by using targeted biopsies (detection 20%) compared with systematic biopsies (15%, p = 0.0095). The added value of targeted biopsies in this setting has been calculated at 6%. Using both biopsy techniques increased the detection rate to 21% only. The detection of non-clinically significant PCa was significantly higher for systematic biopsy (19.5%) than for targeted biopsy (5.6%, p < 0.0001). Targeted biopsies identified csPCa in 12% of patients having a Likert 3 lesion, 29% in case of Likert 4, and 74% in case of Likert 5 lesion. In case of negative MRI, 17% and 11% of PCa and csPCa, respectively, were detected on systematic biopsies. No difference in terms of targeted biopsy detection rates was reported between centres using cognitive guidance or MRU-ultrasound fusion guidance. Taken together with the PRECISION trial findings, these results reinforce the role of targeted biopsies in MRI-positive biopsy-naïve patients. Nevertheless, in this sub-population of patients at high risk of clinically significant PCa, the added value of systematic biopsy in this MRI-FIRST trial supports its persistent relevance of this nonguided technique in addition to the targeted cores. The added value of both techniques varies according to the definition of PCa significance. Thus, systematic biopsies do not improve the biopsy performance for high grade ISUP 3-5 detection but it still remains of great value for ISUP 2 cancer detection which appears to date as the most consensual definition of csPCa.

The investigators conclude that the one-year outcomes after TURP and aquablation were similar and the rate of late procedure-related complications was low.

Long-term rate of mesh sling Total number of shockwave therapy removal following midurethral sessions affects efficacy of erectile mesh sling insertion among dysfunction treatment women with stress urinary Patients with vasculogenic erectile dysfunction that incontinence responded to phosphodiesterase type 5 inhibitors There is concern about outcomes of midurethral mesh sling insertion for women with stress urinary incontinence. However, there is little evidence on long-term outcomes. The authors examined long-term mesh removal and reoperation rates in women who had a midurethral mesh sling insertion for stress urinary incontinence.

Guides women and their surgeons in making decisions about surgical treatment This population-based retrospective cohort study included 95,057 women aged 18 years or older who had a first-ever midurethral mesh sling insertion for stress urinary incontinence in the National Health Service hospitals in England between 2006 and 2015. Women were followed up until 1 April 2016.

Source: Use of prostate systematic and targeted The primary outcome was the risk of midurethral biopsy on the basis of MRI in biopsy-naïve patients (MRI-FIRST): a prospective, multicentre, mesh sling removal (partial or total) and secondary outcomes were reoperation for stress urinary paired diagnostic study. Rouvière et al. Lancet Oncol 2018

Randomised controlled trial of aquablation versus transurethral resection of the prostate in BPH: one-year outcomes

incontinence and any reoperation including mesh removal, calculated with death as competing risk. A multivariable Fine-Gray model was used to calculate subdistribution hazard ratios as estimates of relative risk.

The study population consisted of 95,057 women (median age, 51 years; interquartile range, 44-61 years) with first midurethral mesh sling insertion, including 60,194 with retropubic insertion and 34,863 with transobturator insertion. The median follow-up time was 5.5 years (interquartile range, This paper reports 1-year safety and efficacy outcomes 3.2-7.5 years). The rate of midurethral mesh sling removal was 1.4% (95% CI, 1.3%-1.4%) at 1 year, after either aquablation or TURP for the treatment of 2.7% (95% CI, 2.6%-2.8%) at 5 years, and 3.3% lower urinary tract symptoms related to benign (95% CI, 3.2%-3.4%) at 9 years. Risk of removal prostatic hyperplasia. declined with age. The 9-year removal risk after transobturator insertion (2.7% [95% CI, 2.4%This double-blind, multicentre prospective 2.9%]) was lower than the risk after retropubic randomised controlled trial assigned 181 patients insertion (3.6% [95% CI, 3.5%-3.8%]; with BPH-related moderate-to-severe lower subdistribution hazard ratio, 0.72 [95% CI, urinary tract symptoms to either electrocautery0.62-0.84]). The rate of reoperation for stress based prostate resection (TURP) or aquablation. urinary incontinence was 1.3% (95% CI, 1.3%-1.4%) Efficacy endpoints included reduction in at 1 year, 3.5% (95% CI, 3.4%-3.6%) at 5 years, and International Prostate Symptom Score and 4.5% (95% CI, 4.3%-4.7%) at 9 years. The rate of improvement in uroflow parameters. The primary any reoperation, including mesh removal, was 2.6% safety endpoint was the occurrence of Clavien(95% CI, 2.5%-2.7%) at 1 year, 5.5% (95% CI, Dindo persistent grade 1 or grade 2 or higher 5.4%-5.7%) at 5 years, and 6.9% (95% CI, complications. 6.7%-7.1%) at 9 years.

Rate of late procedure-related complications low for both treatments BPH symptom score improvements were similar across groups with 12-month reduction of 15.1 points after TURP or aquablation. In both groups, mean maximum urinary flow rates increased markedly postoperatively, with mean improvements of 10.3 cc/ sec for aquablation versus 10.6 cc/sec for TURP (p = .8632). At 1 year, PSA was reduced significantly (p < .01) in both groups by 1 point; the reduction was similar across groups (p = .9125). Surgical retreatment for BPH rates for TURP were 1.5% and aquablation 2.6% within 1 year from the study procedure (p = NS). Key articles


Low-intensity shockwave therapy for erectile dysfunction: Comparing 2 treatment protocols and the impact of repeating treatment

Prof. Oliver Hakenberg Section Editor Rostock (DE)

Among women undergoing midurethral mesh sling insertion, the rate of mesh sling removal at 9 years was estimated as 3.3%. These findings may guide women and their surgeons when making decisions about surgical treatment of stress urinary incontinence.

were randomised into 2 groups: low-intensity shockwave therapy sessions once (group A, n = 21) or twice (group B, n = 21) per week for 6 consecutive weeks (phase 1). Patients who completed 6-month follow-up were offered 6 additional sessions (phase 2); group A received 2 sessions per week and group B received 1 session per week. Patients were followed for 6 months. Authors used the International Index for Erectile Function erectile function domain (IIEF-EF) score, minimally clinical important differences (MCIDs), Sexual Encounter Profile question 3 (SEP3) score, and triplex ultrasonographic parameters. In phase 1, groups A and B showed improvement in IIEF-EF score, MCID, SEP3 score, and mean peak systolic velocity compared with baseline. MCIDs were achieved in 62% of group A and 71% of group B, and the percentage of yes responses to SEP3 was 47% in group A and 65% in group B (p = .02). Mean peak systolic velocity at baseline and at 3-month follow-up were 29.5 and 33.4 cm/s for group A and 29.6 and 35.4 cm/s for group B (p = .06). In phase 2, group A showed a greater increase in the percentage of yes responses to SEP3 (group A = +14.9; group B = +0.3). When the impact of the total number of sessions received was examined, MCIDs in IIEF-EF score from baseline were achieved in 62%, 74%, and 83% of patients after 6, 12, and 18 sessions, respectively. No treatment-related side effects were reported. The total number of low-intensity shockwave therapy sessions affects the efficacy of erectile dysfunction treatment. Retreating patients after 6 months could further improve erectile function without side effects. 12 sessions can be delivered within 6 weeks without a 3-week break period. The investigators conclude that patients can benefit more in sexual performance from 12 sessions twice per week compared with 6 sessions once a week. Shockwave therapy can be repeated up to a total of 18 sessions.

oliver.reich@ general internists from 1 January 2011 to 31 December 2014. They examined the association between physician sex and 30-day mortality and re-admission rates, adjusted for patient and physician characteristics and hospital fixed effects (effectively comparing female and male physicians within the same hospital). As a sensitivity analysis, we examined only physicians focusing on hospital care (hospitalists), among whom patients are plausibly quasi-randomized to physicians based on the physician’s specific work schedules. It was also investigated whether differences in patient outcomes varied by specific condition or by underlying severity of illness. The main outcome measures were patients’ 30-day mortality and re-admission rates. A total of 1,583,028 hospitalisations were used for analyses of 30-day mortality (mean [SD] patient age, 80.2 [8.5] years; 621,412 men and 961,616 women) and 1,540,797 were used for analyses of re-admission (mean [SD] patient age, 80.1 [8.5] years; 602,115 men and 938,682 women). Patients treated by female physicians had lower 30-day mortality (adjusted mortality, 11.07% versus 11.49%; adjusted risk difference, –0.43%; 95% CI, –0.57% to –0.28%; p < .001; number needed to treat to prevent 1 death, 233) and lower 30-day re-admissions (adjusted readmissions, 15.02% versus 15.57%; adjusted risk difference, –0.55%; 95% CI, –0.71% to –0.39%; p < .001; number needed to treat to prevent 1 readmission, 182) than patients cared for by male physicians, after accounting for potential confounders. The findings were unaffected when restricting analyses to patients treated by hospitalists. Differences persisted across 8 common medical conditions and across patients’ severity of illness.

Mortality and re-admission rates may differ between patients treated by male or female physicians The authors concluded that elderly hospitalised patients treated by female internists have lower mortality and re-admissions compared with those cared for by male internists. These findings suggest that the differences in practice patterns between male and female physicians, as suggested in previous studies, may have important clinical implications for patient outcomes.

Source: Comparison of hospital mortality and re-admission rates for Medicare patients treated by male versus female physicians. Y. Tsugawa, A. B. Jena, J. F. Figueroa, E. J. Orav, D. M. Blumenthal, A. K. Jha. JAMA Intern Med. 2017;177(2):206-213

Source: Low-intensity shockwave therapy for erectile dysfunction: a randomized clinical trial comparing 2 treatment protocols and the impact of repeating treatment. Kalyvianakis D, Memmos E, Mykoniatis I, Kapoteli P, Memmos D, Hatzichristou D

Comorbidity and frailty are distinct risk factors for waiting list mortality

J Sex Med. 2018 Mar;15(3):334-345. doi: 10.1016/j. jsxm.2018.01.003. Epub 2018 Feb

Kidney transplantation (KT) candidates often present with multiple comorbidities. These patients also have a substantial burden of frailty, which is also associated with increased mortality. However, it is unknown if frailty is merely a surrogate for comorbidity, itself an independent domain of risk, or if frailty and comorbidity have differential effects. Better understanding the interplay between these two constructs will improve clinical decision-making in KT candidates.

Does treatment outcome depend on physician gender?

Studies have found differences in practice patterns between male and female physicians, with female physicians more likely to adhere to clinical guidelines and evidence-based practice. However, whether Source: Long-term rate of mesh sling removal patient outcomes differ between male and female following midurethral mesh sling insertion physicians is largely unknown. In this study, the among women with stress urinary incontinence. authors aimed to determine whether mortality and Gurol-Urganci I, Geary RS, Mamza JB, Duckett J, re-admission rates differ between patients treated by El-Hamamsy D, Dolan L, Tincello DG, van der male or female physicians.

Meulen J.

JAMA. 2018 Oct 23;320(16):1659-1669. doi: 10.1001/ jama.2018.14997.

Prof. Oliver Reich Section editor Munich (DE)

They took a 20% random sample of Medicare fee-for-service beneficiaries 65 years or older, hospitalised with a medical condition and treated by

Importantly, comorbidity is less of a concern in already high-risk patients who are frail The authors aimed to test whether comorbidity is equally associated with waiting list mortality among frail and non-frail KT candidates and to test whether measuring both comorbidity burden and frailty improves mortality risk prediction.


European Urology Today

January/February 2019

The authors studied 2,086 candidates on the KT waitlist (November 2009 - October 2017) in a multicentre cohort study, in whom frailty and comorbidity were measured at evaluation. They quantified the association between Charlson comorbidity index (CCI) adapted for end-stage renal disease and waiting list mortality using an adjusted Cox proportional hazards model and tested whether this association differed between frail and non-frail candidates. At evaluation, 18.1% of KT candidates were frail and 51% had a high comorbidity burden (CCI score ≥ 2). Candidates with a high comorbidity burden were at 1.38-fold (95% CI 1.01-1.89) increased risk of waiting list mortality. However, this association differed by frailty status (p for interaction = 0.01): among non-frail candidates, a high comorbidity burden was associated with a 1.66-fold (95% CI 1.17-2.35) increased mortality risk; among frail candidates, there was no statistically significant association (HR 0.75, 95% CI 0.44-1.29). Adding this interaction between comorbidity and frailty to a mortality risk estimation model significantly improved prediction, increasing the c-statistic from 0.640 to 0.656 (p < 0.001).

This study shows that not only do transplant recipients have a higher incidence of cancer but they also have a higher cancer-related mortality even after adjustment for stage and treatment.

Multicentre results of partial gland ablation with HIFU for clinically confined prostate cancer

Source: Survival after a cancer diagnosis among solid organ transplant recipients in the United States. D'Arcy ME, Coghill AE, Lynch CF, Koch LA, High-intensity focused ultrasound (HIFU) therapy is among the minimally-invasive treatment options Li J, Pawlish KS, Morris CR, Rao C, Engels EA. Cancer. 2019 Jan 9. doi: 10.1002/cncr.31782. [Epub ahead of print]

Weak associations between biofilms build-up in indwelling ureteric stents and stentrelated symptoms

for the management of localised prostate cancer still under evaluation. Thanks to the recent widespread use of prostate multiparametric MRI, indications for focal therapies have been increasing as well as reports in literature with promising outcomes.

One of the latest studies published on this field includes the experience of three centres of reference in Canada where 150 patients were treated with the Sonablate® 500 HIFU platform in a timespan of nearly 5 years (January 2013- September 2017). All patients received a partial gland ablation (PGA), It is well known that the insertion of a ureteral catheter may cause urinary symptoms in up to 80% of including in this definition either a focal ablation or hemi-ablation or even hockey-stick ablation (ablation patients, impairing their quality of life, sometimes severely. There have been many studies trying to shed of 75% of the gland); all of them were diagnosed as a localised–intermediate risk prostate cancer (cT1-T2b; more light on the aetiology of this phenomenon: one unilateral disease with no more than 3 lesions in the of the most accredited theories regards the length of Non-frail candidates with a high comorbidity burden same lobe on MRI; extensive Group Grade 1 or any GG the stents, especially if the distal coil crosses the at KT evaluation have an increased risk of waiting list midline of the trigone. ≥ 2). Interestingly, majority of patients had a GG 2-3 mortality. Importantly, comorbidity is less of a concern (i.e. Gs 3+4 and 4+3) at diagnostic biopsy, accounting in already high-risk patients who are frail. Other scholars have been investigating the role of the for nearly 80% of the cohort. biofilms building up on the surface of the stents. A Source: Comorbidity, Frailty, and Waitlist recent paper prospectively analysed the association of Most of the patients received MRI prior to the treatment except the first 16 patients (19%) of the Mortality among Kidney Transplant Candidates stent bacterial colonisation by using different cohort when MRI facilities were not yet available. of All Ages. Pérez Fernández M, Martínez methodologies (including biofilm mass, numbers of Positive MRI (PIRADS ≥ 3) prompted targeted biopsy Miguel P, Ying H, Haugen CE, Chu NM, bacteria assessed by cultivation, and numbers of Rodríguez Puyol DM, Rodríguez-Mañas L, bacteria estimated by quantitative real-time PCR) and in 57 patients, but no details have been provided with respect on how many of these visible lesions were Norman SP, Walston JD, Segev DL, McAdamsthe German version of the Ureteral Stent Symptoms confirmed at biopsy. Mean patient age was 64.9 DeMarco MA. Questionnaire (USSQ), a validated tool to report years, mean baseline PSA was 6.8 ng/ml and mean Am J Nephrol. 2019 Jan 9;49(2):103-110. doi: health-related quality of life in patients with follow up time was 24 months. 10.1159/000496061 indwelling stent.

Transplant recipients have a higher incidence and cancerrelated mortality despite potentially curative treatment Transplant recipients have an elevated risk of cancer because of immunosuppressive medications used to prevent organ rejection, but no study has comprehensively examined associations between transplantation status and mortality after a cancer diagnosis. The authors assessed cases in the US general population (n = 7,147,476) for 16 different cancer types as ascertained from 11 cancer registries. The presence of a solid organ transplant prior to diagnosis (n = 11,416 cancer cases) was identified through linkage with the national transplantation registry (1987-2014). Cox models were used to examine the association between transplantation status and cancer-specific mortality, adjusting for demographic characteristics and cancer stage.

Associations remain significant after adjustment and were stronger among patients with local-stage cancers For the majority of cancers, cancer-specific mortality was higher in transplant recipients compared with other patients with cancer. The increase was particularly pronounced for melanoma (adjusted hazard ratio [aHR], 2.59; 95% confidence interval [95% CI], 2.18-3.00) and cancers of the breast (aHR, 1.88; 95% CI, 1.61-2.19), bladder (aHR, 1.85; 95% CI, 1.58-2.17) and colorectum (aHR, 1.77; 95% CI, 1.60-1.96), but it also was increased for cancers of the oral cavity/pharynx, stomach, pancreas, kidney, and lung as well as diffuse large B-cell lymphoma (aHR range, 1.21-1.47). Associations remained significant after adjustment for first-course cancer treatment and generally were stronger among patients with local-stage cancers for whom potentially curative treatment was provided, including patients with melanoma (aHR, 3.82; 95% CI, 2.94-4.97) and cancers of the colorectum (aHR, 2.77; 95% CI, 2.07-3.70), breast (aHR, 2.08; 95% CI, 1.50-2.88), and prostate (aHR, 1.60; 95% CI, 1.12-2.29), despite the lack of an association for prostate cancer overall. Key articles

January/February 2019

Significant association of the presence of haematuria with both biofilm mass and detection of minerals They recruited 94 patients (74 male and 20 female) with as primary end point the association between the biofilm masses and the USSQ total scores at the time of the stent removal; secondary end point included the association between the different modalities to quantify the bacterial colonisation and the USSQ (including the overall scores and the single domains/items scores). Patients were asked to fill the questionnaires out at specific time-points, i.e. at 1 and at 4 weeks post stent insertion, the latter being the day before surgery (URS/RIRS) when the stents were removed and sent for biochemical analysis. Authors also performed a mineral analysis of the biofilms in an attempt to identify and quantify crystal subtypes and their association to the outcomes. Interestingly, although the primary end-point failed to show any statistical significant relationship between the whole amount of biofilm and the USSQ scores, authors could find a significant association of the presence of haematuria (as self-reported/ noticed by patients) with both the biofilm mass and the detection of minerals. This finding may suggest that larger amounts of biofilm masses - and consequently of crystals - exposes the urothelium to continuous micro-trauma that may end up with bleeding. Other significant associations involved the number of bacteria identified in the biofilms with pain and the need for analgesia; authors explained these findings by the potential inflammatory reaction of the urothelium to the biofilm masses. However, authors also highlighted that these correlations – though statistically significant - were weak, suggesting that the main driver of stent-related symptoms is just the presence of an external body inside the urinary tract by provoking a pure mechanical irritation.

Source: Influence of biofilms on morbidity associated with short-term indwelling ureteral stents: a prospective observational study. Betschart P, Zumstein V, Buhmann MT, Albrich WC, Nolte O, Güsewell S6, Schmid HP, Ren Q, Abt D. World J Urol. 2018 Nov 27. doi: 10.1007/s00345-0182569-z. [Epub ahead of print]

Oncologic outcome in this patient setting is not yet well standardised, so that authors could not apply a clear definition to assess recurrence-free survival homogeneously. Overall, they identified 37 treatment failures on the basis of the results of the confirmatory TRUS biopsy, as long as the histology revealed a persistency or progression of/to a clinically significant cancer defined as a cancer with GG ≥ 2. It is worthwhile to notice that the post-treatment biopsies could be performed in only 87 patients, so that the recurrence rate accounted to a 42.5, just considering this subgroup of patients. Retrospectively, authors could define a PSA decrease rate of 65.1% with a post treatment mean nadir of 2.7 ng/ml. Functional outcomes were assessed retrospectively and non-validated tools were used, so it could not be assessed properly. It is noticeable that 4 patients developed urethra-rectal fistula; on the other hand, all these cases could be managed conservatively with indwelling catheter for 5.5 weeks, and 3 of them occurred during the first year of the PGA programme, so these could be accounted to the learning curve.

Need to design studies more properly to identify indications more appropriately Of the patients with a histology proven recurrence (n = 37) 16 received a whole-gland re-treatment, 6 radiotherapy, 2 androgen blockage and 16 salvage radical prostatectomy. Of the 16 receiving salvage re-treatment, only 5 received confirmatory biopsy showing persistence of tumour in 3; no information was provided in terms of the clinical-pathological characteristics of these further failures. Overall, this publication confirms the interest around focal therapy as a promising treatment option; however, there is an urgent need to design studies in this field of prostate cancer more properly, to identify the indications more appropriately, and to standardise definition of recurrence. Moreover, as one of the supposed main advantage respect to more aggressive treatments (namely surgery and radiotherapy) is the reduced risk of side effects, scholars and practitioners dedicated to prostate focal therapy should include validated patient-reported outcome measurements at specific time-points of the follow-up.

Source: Oncologic and Functional Outcomes of Partial Gland Ablation with High Intensity Focused Ultrasound for Localized Prostate

Cancer. Bass R, Fleshner N, Finelli A, Barkin J, Zhang L, Klotz L. J Urol. 2019 Jan;201(1):113-119. doi: 10.1016/j. juro.2018.07.040.

Living donor nephrectomy: Are endoscopic staplers the safest devices for renal vascular ligation? It is well known that in 2006 both the FDA and the manufacturer of the Hem-o-Lok issued a global warning related to some fatalities of living donor nephrectomy recipients allegedly due to a functioning failure of the clips applied. Accordingly, their use in this setting of (healthy) patients was contraindicated - although it was continuously used for the rest of the cases - and endostaplers (GIA or TA types) were instead recommended as gold standard. However, some comparative reports were published after that year and therefore a group of Chinese authors recently considered it worthwhile to conduct a systematic review to pull out outcomes from existing literature. They selected 8 comparative studies, all retrospective in nature and all but one with < 50 patients per group: Hem-o-Lok clips were used in all the 8 reports, while endoGIA and endoTA were used in 4 reports each.

Systematic reviews cannot reverse the contraindication of Hem-o-Lok usage in living donor nephrectomy recipients Interestingly, they found that there was no difference in death, failure and haemorrhage rates, and these outcomes were consistent after sensitivity analysis by removing outcomes from a very large study. In particular, overalls of 6 and 14 fatalities were recorded for clips and staplers, respectively, without a statistical significance. The authors, however, highlighted the fact that most of these events were not related to malfunctioning of the devices. As secondary end-points, they found that Hem-o-Lok devices were associated with a higher estimated blood loss and warm ischaemia time. Although the former was likely due to the need of a fine dissection of every single vessel, the latter could not be entirely explained by the recharge time for the application of multiple clips, as proposed by authors, and did not exceed 14 minutes. On the other hand, endoscopic staplers were associated with shorter length of the vascular pedicles, suggesting that Hem-o-Lok may be more helpful in case of more difficult vascular anastomosis, particularly when expected (e.g. right donor nephrectomy); also, costs are much higher with staplers than with clips, suggesting that in developing countries clips should be considered as a cheaper alternative. Overall, this systematic review cannot reverse the contraindication of Hem-o-Lok usage in living donor nephrectomy recipients. A limitation that the authors did not consider is the publication bias, i.e. a number of fatalities due to clips application that was not reported in published studies and thus could not be included in their pulled analysis. On the other hand, the reason why use of clips is considered safe in the rest of the nephrectomy recipients still remains unclear. It is common belief that the application of the clips very close to the aorta exposes them to higher pressures that may cause dislodgement. However, the authors correctly reported that in vitro studies did not confirm such a condition as clips leakage-point was shown to be between 300 and 1800 mmHg, well above the maximum range of human arterial pressure. Finally, this systematic review may raise concerns whether even staplers malfunctioning may have been overseen, as fatalities have also been reported with their usage.

Source: Staplers or clips?: A systematic review and meta-analysis of vessel controlling devices for renal pedicle ligation in laparoscopic live donor nephrectomy. Liu Y, Huang Z, Chen Y, Liao B, Luo D, Gao X, Wang K, Li H. Medicine (Baltimore). 2018 Nov;97(45):e13116.


European Urology Today


EBU recertifies the Department of Urology in Winterthur High quality standards in urological training Dr. Mustafa Tutal Staff Urologist Dept. of Urology Kantonsspital Winterthur Winterthur (CH) mustafa.tutal@

Prof. Hubert John Head of the Department Dept. of Urology Kantonsspital Winterthur Winterthur (CH) The Department of Urology in Winterthur, founded in 1990, is one of the leading urological clinical and research centres in Switzerland. It is a recognised training centre for specialisation in urology as well as in its subspecialties. The department has a 22-30 bed capacity, a day care unit and a well-organised outpatient clinic. There are more than 2,800 inpatient and outpatient surgical treatments and about 10,500 outpatient admissions per year. There is a lively cooperation with in-house departments such as general surgery, gynaecology and the intensive care unit. Moreover, the department is a European certified tumour centre, including oncology and radio oncology. The department offers the entire spectrum of urology, with the exception of sex-change surgery. In addition, it is a leading centre for robotic surgery with rapidly increasing intervention numbers in recent years. The department has a professional and collegial atmosphere. The Head of the Department is very

dedicated to the training and advancement of the residents. Each resident is closely supervised by a personal staff mentor and is advised on professional matters as well as matters around the working environment and career planning. Residents’ training There are 6 residents in the department. In addition, internships for medical students are offered. The training of the residents is clearly structured with a written training concept for the recognised 4 years of training, until the resident obtains the title of urologic specialist, issued by the FMH (Foederatio Medicorum Helveticorum). The training gradually leads to the acquisition of clinical, professional and finally surgical skills. The residents work in various subject fields, such as support of patients on the ward, outpatient clinic, operating room including robotic surgery assistance, urological emergency, urodynamics and other fields. All residents are subject to regular, protocolled qualification meetings in the presence of their mentor and the Head of the Department. Additionally, residents are systematically involved in research projects (there are currently 25 ongoing projects). In this context, as a result, Master and doctoral theses can be completed. The residents present their research results at national and international meetings of urological societies, such as the Swiss Urological Association (SGU), the German Urological Association (DGU), the European Association of Urology (EAU) or the American Urological Association (AUA). The research projects are presented and evaluated during regular internal research meetings of the department. The department has a clinical and research cooperation with several Swiss and European hospitals. Residents follow weekly training sessions, where they deepen and communicate their knowledge in subject-specific workshops and journal clubs. The residents also participate in the weekly multidisciplinary tumour board meeting as well as in regular conferences with nephrologists and pathologists. It is mandatory for residents to participate in the educational events run by the SGU, such as the Urology Arena or the SGU Annual Congress.

EBU Certified Centres

Staff members of the Urology Department at Kantonsspital Winterthur

The department provides annual Master Classes on various operative subjects during which the residents meet with foreign surgical teams. In addition, since 2009, the department of the Kantonsspital Winterthur has implemented numerous exchange projects with national and international urological departments in Berne, Tübingen, London, Paris, Vienna, Stockholm and other cities. The residents are encouraged to participate in the EBU In-Service Assessment. The EBU written exam is mandatory in the Swiss residency training programme. There are regular subject-specific teaching courses for medical students in the department. The Swiss residency training programme in urology: • • • •

takes six years; includes one year of general surgery; includes a surgery 'base exam'; consists of at least one year of urology training in a category A1 institution and two years in a category A2 institution; • includes at least one change of urology training institution; • consists of one optional year in one of the following departments: obstetrics and gynaecology, endocrinology/diabetology, general surgery and traumatology, visceral surgery, vascular surgery, neurology, dermatology, nephrology or oncology;

• offers a final exam (written EBU exam and practical FMH exam); • offers guidelines, defining the knowledge and surgical skills to be reached by the end of the residency. Every candidate has to manage an e-logbook which is regularly evaluated with the Head of the Department. Recertification After the EBU initially certified our department in 2012, recertification took place in 2018 for another 5 years. It is our stated goal to continue developing the standards of residents’ training and to raise the quality of training to an excellent level. Therefore we maintain fruitful contacts with other departments and institutions, be it national or international. One of the most important institutions for us is the EBU. On the one hand, certification is an important quality seal and a confirmation of our efforts; on the other hand, we take the individual evaluation points of the EBU very seriously and have already implemented improvement measures. We will continue to improve the training standards and remain in close contact with the EBU to optimise the Residency Training Programme in Urology in the future.

Bakırköy Dr. Sadi Konuk Hospital receives EBU certification State-of-the-art urology clinic ready for the future Prof. Dr. Ali Ihsan Tasçı ˛ Training and Research Hospital Dept. Urology and Kidney Transplantation Istanbul (TR) aliihsantasci@ With its modern technology and robust scientific substructure, the Bakırköy Dr. Sadi Konuk Training and Research Hospital - located in the European part of Istanbul - is one of the most important health institutions in our country with a capacity of 612 beds and more than one million patients per year. Introduction urology clinic Initially started to function as tropical diseases hospital with 100 beds in 1970, the Bakırköy Dr. Sadi Konuk Training and Research Hospital subsequently functioned as a general state hospital from 30 September 1985 onwards.

The urology department of the university hospital contains all subspecialties of urology and with its professional staff, including the Head of Department, three associate professors, five senior urologists and six certificated urologists, excellent patient care can be offered. The urology department contains a total of 31 beds including 23 beds for adult and paediatric patients and 8 beds for renal transplantation patients. It also has an outpatient urology unit providing diagnosis and treatment to more than 5,000 patients per year. Urological procedures are performed in three operation rooms, including one robotic surgery room. In 2017 1,664 surgical operations and 64 renal transplantations were performed and in the outpatient clinic service was provided to 106,101 patients. Five general urology outpatient clinics and one subspecialty outpatient clinic provide services five days a week in the fields of stone disease, andrology, functional urology and female urology, reconstructive urology, paediatric urology and uro-oncology.

Patients are diagnosed and treated according to current standards of care in the outpatient urology unit. Diagnostics and treatments include ultrasonography, TRUS-guided prostate biopsy, SWL, urodynamics, biofeedback, uroflowmetry, urethral dilatation, cystoscopy, nephrostomy tube insertion, intravesical chemotherapy and immunotherapy applications, intravesical treatments, spermiogram, and intracavernosal treatments as well as tests and MR-fusion biopsy in the radiology clinic. Complete speciality spectrum Our clinic, which is one of the most important urology centres in our country and Istanbul, follows the worldwide improvements in the medical field and pioneers them. The urology department includes the whole spectrum of the specialty, but mostly endourology, uro-oncology, reconstructive urology and kidney transplantation. More than 200 robotic surgeries are performed each year. Robotic surgery operations were started in 2009 and more than 1,500 patients have meanwhile been

It was incorporated in the 75th year Gynaecological Diseases and Children Hospital in 1998. After having been established as a training and research hospital in September 2000, it was given the name Bakırköy Dr. Sadi Konuk Training and Research Hospital. Resident training was initiated in the urology clinic in 2002. It is a University of Health Sciences since 2017. Founder and present director of the urology clinic is ˛ Prof. Dr. Ali Ihsan Tasçı. EBU Certified Centres


European Urology Today

The Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey

operated. Since January 2016, kidney transplantation with robotic surgery (our centre has the highest number in Europe) and perineal radical prostatectomy with robotic surgery (we are the only centre in the world to use it routinely) operations have been performed successfully. Perineal urethroplasty and reconstructive urological surgeries and renal transplantation surgeries with a living donor are carried out with high success rates. Additionally, treatments are given based on high international standards by staff experienced in subspecialties, such as urinary system stone disease, BPH surgery, andrology, paediatric urology, functional urology and female urology. Post-specialty robotic surgery and laparoscopic surgery training has been given to national and international fellows. National and foreign academic publications in the field are closely monitored and we regularly provide scientific contributions. In cooperation with national and international associations, robotic surgery, laparoscopic surgery, stone surgery, reconstructive urology and urodynamics courses have been organised and successfully completed.

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January/February 2019

Continued from page 12

Residents training Our urology training programme is nationally accredited according to high national and international standards and aims to develop the conscience, behaviour, decision-making skills and talents required for modern-day urological practice. We offer a total of five years’ training, including 54 months urology training and 6 months rotations (3 months general surgery, 1 month nephrology, 1 month anaesthesia, 1 month radiology). Currently 11 residents are working at the unit. The urology training programme was designed in line with the University of Health Sciences Faculty of Medicine, Specialty in Medicine Training Curriculum and the Turkish Republic Medical Specialty Board regulations. All residents are trained in standard procedures, including diagnostic steps, and operative and conservative treatments based on present urological guidelines. All residents are trained so that they can treat both adult and paediatric patients after graduation. Additionally, all residents are encouraged to write research articles for national and international urology journals. The programme gives residents interested in an academic career in the urology field with the opportunity to participate in research and training activities. Conferences Residents are encouraged to write articles and participate in training sessions organised three times

a week. There are state-of-the-art lectures given by supervisors and training officers, seminaries mainly covering current guidelines, a journal club to discuss current articles published in esteemed journals, case conferences evaluating cases in all fields of urology, operation techniques and tips & tricks with regard to all urological operation methods, discussing complications and their surgical details. They can also participate in multidisciplinary uro-oncology and transplantation meetings, commonly held with other specialities once a week. Apart from these, residents are also encouraged to participate in the monthly meetings organised by the Turkish Urology Association and to play an active part in regional, national and international training courses and meetings held by Turkish urology, Eurasian uro-oncology, endo-urology and andrology associations. Every resident must attend EAU Congress at least once during his/her residency to present a study. Fifth year residents are also encouraged to participate in the European Urology Residents Programme (EUREP) held in Prague every year - and the National Turkish Board of Urology (TBU) courses, concluded by the European Board of Urology (EBU) and TBU exams. Training evaluation All residents record their surgical and scientific activities in the University of Health Sciences Faculty of Medicine resident report card and EBU logbooks. Based on these logbooks and report cards, knowledge

levels and acquired skills are evaluated by a supervisor every six months and by the Head of Department every year. Residents must take mini-exams on EAU guidelines once a month and a clinical exam twice a year. EBU in-service assessment exams are mandatory since 2017. Residents who have successfully completed these exams are invited to complete specialty theses and take a urology specialty exam.

Our urology clinic residents obtained the highest scores in the national medical specialty exam. We achieved many national and international successes when it comes to meeting high resident training standards, which is proven by the EBU-RTPU certification. The May 2018 EBU certificate, which is valid for a period of five years, will help us evaluate and further optimise our training programme.

Resident Specialty Training in Urology in Turkey Our urology specialty training lasts five years in total with legal extensions. This period is completed in three stages: 1st and 2nd year resident stage, 3rd and 4th year resident stage and expert candidate residents. 1st and 2nd year resident (24 months): the first training step consists of studying basic information on surgical techniques and applications, residents follow senior residents in the hierarchical order. 3rd and 4th year resident (24 months): the specialist candidate follows the resident (5th year resident) in hierarchical order in patient care and treatment; this is the

completion stage in basic surgical technique and applications training. 5th year resident (specialist candidate resident) (12 months): this resident has completed the training on basic surgical techniques and applications, patient operations and follow-up and is now working on gaining experience in terms of knowledge and skills. Rotations: • general surgery (3 months) • nephrology (1 month) • radiology (1 month) • anaesthesia and reanimation (1 month).

Functional urology – Preservation of female sexual function Sexual activity in women decreases after radical cystectomy Prof. Jørgen Bjerggaard Jensen Chairman, Scandinavian Urothelial Cancer Group Aarhus (DK) bjerggaard@

Moreover, it is of course very important not to compromise the oncological safety while performing radical surgery for urothelial cancer. A local relapse because of residual tumour will carry a high risk of cancer death as opposed to residual tumour tissue following radical prostatectomy, for which both salvage radiotherapy and hormone treatment can be very effective.

In the non-fertile female patient, which is the vast majority of female patients, during radical cystectomy the internal genitals are also removed, which will not influence the practical sexual function. However, the Radical cystectomy is a cornerstone of the treatment of invasive bladder cancer. Whereas the main focus of cystectomy itself can be performed with or without concomitant urethrectomy. In most female patients, this procedure is oncological safety, the urologist the urethra is removed routinely unless an orthotopic performing it should also consider the influence on neobladder is planned. This in contrast with male postoperative sexual function in both genders. patients, in whom the urethra is preserved in the One of the most comprehensive surgical procedures in majority of patients. The main reason for this urology is radical cystectomy with urinary diversion1. difference is oncological safety. Preservation of the During this extensive procedure, radical reconstruction urethra in the female patient will compromise radical of the urinary tract is performed. This procedure has a excision of the bladder neck area whereas the bladder major influence on urinary function. However, for the neck area is almost always removed in the male patient involved, it also has a potentially large impact patient undergoing cystoprostatectomy5. on sexual function, as the genital structures are affected, either directly by the surgical procedure, Preservation of the perivesical nerves for the sphincter indirectly by changed function due to damage to is important in both genders if a neobladder is nerves, or a combination of both. planned to ensure continence. It is also important in order to preserve erectile function in the male patient. In the male patient, apart from the bladder and lymph nodes, only the prostate is directly removed The impact of damage to these nerves on the female during radical cystectomy. Damage to the autonomic sexual function is less clear6. Since erectile function of nerves responsible for the erectile function is a the clitoris is not crucial for the sexual act and the well-known risk, causing erectile dysfunction in sensory nerves are not damaged, the impact on most patients2. This impact on erectile function is autonomic function is more or less restricted to very thoroughly described in the literature both lubrication by sexual arousal. following radical cystectomy and - even more comprehensively - following radical prostatectomy3. On the other hand, the surgical extirpative procedure Treatment of the somatic part of the postoperative can result in severe anatomical changes, as the traditional removal of urethra in the female patient erectile function is also well-known whereas the potential psychological consequences of the lack of will inevitably involve resection of the anterior vaginal wall. Reconstruction afterwards will either narrow the ability to perform sexually without medical aid is less intensively investigated. vagina or even shorten it if folding of the posterior wall anteriorly is performed. The female cystectomy patient The influence on sexual function in female cystectomy Influence on sexual activity and function Only few studies are available regarding postoperative patients is much more scarcely reported. The lack of female sexual function following radical cystectomy. attention for this topic, which can also be seen in research on the psychological influence of the It is clear that a large majority of these patients were procedure on male patients, could be an explanation. sexually active before surgery whereas the sexual activity decreases significantly postoperatively There are some good, validated evaluation tools that could be used even though the primary measurement (figure 1). In some to an extent where sexual activity is tools may not be as solid as those for the erectile abandoned altogether – not because of lack of desire function in male patients4. or ability to obtain arousal but because of anatomical changes making the sexual act painful or even impossible. Based on a high and even increasing age and multiple co-morbidities of the female patients For patients in whom sexual function is altered, but undergoing radical cystectomy, the operating still possible from an anatomical point of view, lack of surgeon may be reluctant to pay attention to the pre- and postoperative sexual function from an sufficient lubrication is by far the most important complaint7. anatomical perspective. January/February 2019

Narrowing (or even strictures) of the vagina should be dilated and the patient can be instructed to do this themselves whereas severe shortening of the vagina is more difficult to treat postoperative by simple manipulation. This is therefore a very good argument for reconstruction of the vagina after removal of the anterior wall in a longitudinal direction instead of the flap-and-fold manoeuvre with the posterior wall. It is also important to restrict the resection of the anterior wall to the tissue immediately surrounding the urethra and not to do very extensive removal Reported sexual activity before and after radical cystectomy in including the sidewalls of the vagina. This should only female patients. Adapted from [7]. be done in the rare cases of clear tumour involvement in this area8.

“It is also important to restrict the resection of the anterior vaginal wall to the tissue immediately surrounding the urethra…” Lubrication problems should be dealt with through counselling and instruction concerning the use of artificial lubrication. The urologist should also consider the oestrogen level if the postmenopausal female patient has very fragile mucosa of the vagina as estimated during gynaecological examination. Intra- and postoperative considerations For optimal postoperative counselling and intervention, it is imperative to offer the patient a proper gynaecological examination to estimate any postoperative anatomy that needs attention and to evaluate the mucosa. In patients with unifocal small tumours with sufficient distance to the urethra, preservation of the urethra to better preserve the anatomy of the vagina could be considered, even if a neobladder is not planned. It should be discussed with the patient and outweighed against the small increase in the risk of local recurrence. The patient with unifocal disease with no history of CIS should be offered this solution if they are still sexually active. This surgery could be ideal especially for patients undergoing neoadjuvant chemotherapy, as the risk of local recurrence is lower whereas the risk of influence on sexual function is already higher because of the chemotherapy9. References 1. Alfred Witjes J, Lebret T, Compérat EM, Cowan NC, De Santis M, Bruins HM, Hernández V, Espinós EL, Dunn J, Rouanne M, Neuzillet Y, Veskimäe E, van der Heijden AG, Gakis G, Ribal MJ. Updated 2016 EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Eur Urol. 2017 Mar;71(3):462-475. doi: 10.1016/j.eururo.2016.06.020. Epub 2016 Jun 30. PubMed PMID: 27375033.

2. Chappidi MR, Kates M, Sopko NA, Joice GA, Tosoian JJ, Pierorazio PM, Bivalacqua TJ. Erectile Dysfunction Treatment Following Radical Cystoprostatectomy: Analysis of a Nationwide Insurance Claims Database. J Sex Med. 2017 Jun;14(6):810-817. doi: 10.1016/j. jsxm.2017.04.002. Epub 2017 Apr 29. PubMed PMID: 28460994. 3. Garcia-Baquero R, Fernandez-Avila CM, AlvarezOssorio JL. Functional results in the treatment of localized prostate cancer. An updated literature review. Rev Int Androl. 2018 Nov 22. pii: S1698031X(18)30085-2. doi: 10.1016/j.androl.2018.06.002. [Epub ahead of print] Review. PubMed PMID: 30473332. 4. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D, D'Agostino R Jr. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000 AprJun;26(2):191-208. PubMed PMID: 10782451. 5. Nagele U, Kuczyk M, Anastasiadis AG, Sievert KD, Seibold J, Stenzl A. Radical cystectomy and orthotopic bladder replacement in females. Eur Urol. 2006 Aug;50(2):24957. Epub 2006 Jun 21. PubMed PMID: 16806663. 6. Thurairaja R, Burkhard FC, Studer UE. The orthotopic neobladder. BJU Int. 2008 Nov;102(9 Pt B):1307-13. doi: 10.1111/j.1464-410X.2008.07975.x. PubMed PMID: 19035897. 7. Booth BB, Rasmussen A, Jensen JB. Evaluating sexual function in women after radical cystectomy as treatment for bladder cancer. Scand J Urol. 2015 Dec;49(6):463-467. doi: 10.3109/21681805.2015.1055589. Epub 2015 Jun 19. PubMed PMID: 26087867. 8. Pederzoli F, Campbell JD, Matsui H, Sopko NA, Bivalacqua TJ. Surgical Factors Associated With Male and Female Sexual Dysfunction After Radical Cystectomy: What Do We Know and How Can We Improve Outcomes? Sex Med Rev. 2018 Jul;6(3):469-481. doi: 10.1016/j.sxmr.2017.11.003. Epub 2018 Jan 19. Review. PubMed PMID: 29371143. 9. Koie T, Ohyama C, Yamamoto H, Imai A, Hatakeyama S, Yoneyama T, Hashimoto Y, Yoneyama T, Tobisawa Y. Differences in the recurrence pattern after neoadjuvant chemotherapy compared to surgery alone in patients with muscle-invasive bladder cancer. Med Oncol. 2015 Jan;32(1):421. doi: 10.1007/s12032-014-0421-x. Epub 2014 Dec 4. PubMed PMID: 25471790.

European Urology Today


EAU’s Permanent Historical Collection now on display Secretary General opens new showcases at EAU Central Office in Arnhem Prof. Philip Van Kerrebroeck Chairman, EAU History Office Maastricht (NL)

p.vankerrebroeck@ On January 7, EAU Secretary-General Chris Chapple officially opened the new exposition of the EAU permanent historical collection at the EAU Headquarter building in Arnhem (NL). This new exposition was installed after a recent major extension of the number of showcases that made it possible to display significantly more objects. The current exhibition space amounts to a total of 10 showcases with each 5 layers. The current exposition is composed of urological instruments, a variety of medicine-related objects, documents and books, that belong to the permanent collection of the EAU History Office. The collection is mainly made up of the Jos De Vries collection that was purchased by the EAU in 2015, augmented with several individual donations and long-term loans by members of the EAU.

of 18th and 19th century stone forceps for lithotomy. The next shelf presents the famous and rare surgical 1743 textbook by Heister and is accompanied by two beautiful French urethrotomes from the beginning of the 19th century, one of which was even made by the famous instrument maker Charrière. The same showcase also contains The Edinburg Stereoscopic Atlas of Anatomy with two examples of anatomical plates of the urogenital system and finally shows the Urology textbook by Albarran together with an early Leitner speculum. The presentation continues with a large overview of early examples of diagnostic cystoscopes as originally developed by Nitze. Several German and French types of cystoscopes by different instrument manufacturers illustrate the different steps toward modern endoscopy. However, not only European developments are presented but also the different American contributions are shown. A beautiful and complete Brown Buerger cystoscope is shown as well as an early McCarthy cysto-urethroscope. Also the history of endoscopic lithotripsy is illustrated with numerous early lithotripters. One of the major highlights is an original Civiale blind lithotrite, build between 1830 and 1867, and bought by the late Dr. De Vries at Christie’s auction in 1994 for £260! As a link to ‘modern’ Urology a Storz ‘residents scope’, recently donated by Prof. Frans Debruyne, former EAU Secretary General, is exposed together with an early

Members of the EAU History Office have at this occasion selected items for the EAU collection and planned the exposition to allow for the individuals working at the EAU headquarters and visitors to get acquainted with the treasures of the EAU permanent collection. Telling the story of urology The new exposition starts on the third floor with an overview of the history of urology through surgical instruments and other objects that illustrate the development of urological diagnostics and therapies, with a focus on endoscopic procedures. The story begins with a (replica) set of Roman surgical instruments and continues with an ensemble Prof. Chapple, flanked by EAU History Office Chairman Prof. Van Kerrebroeck and former History Office Chairman Dr. Johan Mattelaer opens the exhibition

EAU History office

On the second floor, two further showcases welcome visitors to the EAU Central Office. One is devoted specifically to paediatric urology and contains several instruments that were used by Dr. De Vries. The last showcase is probably the most spectacular of the whole exposition as it is an accumulation of ‘special’ objects from the EAU collection. For example a Victorian tropical enema in brass and pewter is prominently present accompanied by 3 splendid wooden specula. The next shelf is already a major eye catcher as two naked 18th century ivory ladies from Five of the ten showcases at the EAU Central Office China are exposing themselves in the company of a penis sheath from New Guinea! The special exposition concludes with a beautiful copper enema set, two type of additional optic that allowed for following clysters, an ear piercing kit and finally an early 19th endoscopic procedures. Several resectoscopes of more century amputation box. recent date are also present and probably provoke memories for more senior urologists that will have The EAU History Office is proud to present this worked with these types of instruments several exposition that combines information on the decades ago. history of Urology with aesthetic pleasure. We hope that as many colleagues as possible will have On the same floor are two separate showcases. The the opportunity to visit the EAU headquarters and first one is devoted to a couple of specific and have a look! sometimes charming aspects of Urology. An original 18th century etching shows the patient’s position for We also would like to make an appeal to colleagues undergoing a perineal lithotomy. As a tangent that have objects related to the history of urology, to connection, an original 18th century stone forceps is consider a donation to the EAU collection. We would hanging together with the etching. A separate shelf be happy to incorporate them into the permanent focuses on the Desnos prize, the annual prize for the collection and attach your name to it as a permanent History of Urology that is given by the EAU since 2018. souvenir. Any suggestions can be sent to: This prize is named after Ernest Desnos, the French urologist who was the first to publish about the history of Urology. Some of his textbooks are shown as well as the major work by Sergio Musitelli, the Italian historian who was the first recipient of the Desnos prize. As a practical connection two woven linen catheters from the 2nd half of the 19th century are also shown. A next shelf allows for a spectacular view on a series of four unique 19th century pewter urinals. The second separate showcase on this floor is devoted to part of the Pryor collection. Dr. Pryor donated his collection on Andrological Urology to the EAU, and out of this large collection, some unique specimen are exposed. They retrace the history of medical therapy, conservative approach and surgery for erectile dysfunction with an impressive overview of different types of medication and several types of penile implants. Also experimental prostheses for sperm retrieval are presented.

The collection transcends urology and also includes medical items of historical and cultural significance. Shown here are a Papua New Guinean penis sheath and two antique Chinese ivory figures, once used by patients to indicate their pain without submitting to the shame of physical examination

Auspicious experience in Tunisia for EAU Tunisian Urological Association solicits EAU expertise Dr. Walid Kerkeni Tunisian Urological Association member Tunis University School of Medicine Tunis (TN) walidkerkeni@ The Tunisian Urological Association (ATU) is looking to build closer relations with the EAU. Therefore, and to cooperate better with European urologists, the ATU invited both ESU and ESUT to its 2018 annual meeting. The 18th Tunisian Congress of Urology was held in Hammamet on 18, 19 and 20 October 2018. On the first day, an ESU course took place. Profs. Rolf Muschter and Panagiotis Kalidonis lectured on percutaneous nephrolithotripsy (PCNL). They detailed EAU Guidelines recommendations on PCNL, PCNL instrumentation, the step-by-step access using only fluoroscopy (prone position), the access using both ultrasound and fluoroscopy (supine position), the mini-perc technique and finally some tips and tricks in PCNL. The course ended with an interactive case discussion with the audience.

"One hundred and twenty urologists from different countries ... participated in the PCNL course..." E-BLUS training On 19 October, one of the most important ESUT hands-on-training courses, the European Basic Laparoscopic Urological Skills (E-BLUS) training took place. Thirty urologists, including residents and senior urologists, participated in this 4-hour course. They came from different countries, such as Tunisia, Algeria, Morocco, Libya, Ivory Coast, Mali and Burkina Faso. Two local tutors, Dr. Karim Belhaj and Dr. Wassim Chaabene, were present to assist the trainees.

One hundred and twenty urologists from different countries (Tunisia, Algeria, Morocco, Libya, Senegal, EAU Section of Uro-Technology (ESUT)


European Urology Today

advantages of retroperitoneoscopy and his experience of retroperitoneoscopic adrenalectomy. Local retroperitoneoscopy specialists (Profs. Riadh Ben Slama, Mehdi Jaidane and Braiek Salem) shared their experience and expertise on the topic. Tunisian urologists have indeed acquired a lot of experience and skills in laparoscopic adrenalectomy during the past years, using either retroperitoneoscopy or transperitoneal laparoscopy. The session was very productive and interactive and the topics were comprehensively discussed.

Burkina Faso, Mali and Ivory Coast) participated in the course. Prof. Ali Serdar Gözen, chair of the ESUT training group, represented ESUT during the Tunisian meeting.

Presentation by Prof. R. Muschter on PCNL

Prof. A. Gözen speaking during the session on andrenal gland surgery

The participation of ESU and ESUT in the 18th Tunisian Urology Congress was notably valuable and especially interactive.

Firstly, an introduction to EAU membership and its advantages for young urologists was given. After that Prof. Gözen informed in a short presentation about ESUT activities and the E-BLUS programme. Then, the participants were divided into two groups. Training exercises included all basic movements and tasks in laparoscopic urology including peg transfer, cutting a circle, needle guidance and single knot tying. As a first experience in Tunisia, the course proved beneficial to all trainees and was a successful initiative, according to ATU office members.

ATU office members, headed by their president Prof. Rafik El Kamel, interacted very productively with ESU and ESUT delegates in order to strengthen the ties between the ATU and EAU. All the attendees agreed that a strong collaboration needs to be established over the next years.

Adrenal gland surgery In the afternoon of the same day, an English speaking session took place. The topic was adrenal gland surgery. The session began with a presentation of a Tunisian original anatomical study by Dr. Ahmed Saadi. Dr. A. Saadi presented the results of 40 cadaverous dissections of adrenal glands and described variations of anatomical position and vascularisation. Then, Prof. A.S. Gözen lectured on the

It is not always as easy as it seems...

January/February 2019

Antibiotic prophylaxis: To be or not to be? How to deal with antibiotic resistance Prof. Franck Bruyere President, French Infectious Disease Association of the AFU CHRU de Tours Hôpital Bretonneau Dept. of Urology Tours (FR) Surgical antibiotic prophylaxis is only one of the tools to reduce the risk of post-operative infections. Historically, antibiotic therapy was used by doctors to reduce the risk of infection that may occurs after surgery. Unfortunately, the massive increase of antibiotic resistance and the inappropriate prescription of antibiotics that increases the risk of post-operative infection (as shown in recent literature), urge us to change our habits. Altemeier’s classification Historically, Altemeier's classification, aimed at classifying the interventions according to the risk of infection, made it possible to give advice with regard to antibiotic prophylaxis. In urology the use of Altemeier's classification is controversial. For example, radical prostatectomy and simple prostatectomy may both be classified as Altemeier II, but have diametrically different infectious risks. Transurethral resection of the prostate (TURP), classified as Altemeier II, has a lower risk of infection than simple prostatectomy, but more important than after radical prostatectomy. New technologies can also reduce the risk of post-operative infection. Indeed, the endoscopic resection of very large prostatic volumes by enucleation laser or bipolar is known to have infectious risks equivalent to endoscopy, which are much lower than those of classic simple prostatectomy. Recommendations Establishing recommendations is a careful process that can be guided by 2 situations. In the first, ideal situation, there is a large volume of literature with a

high level of evidence, which makes it possible to write strong recommendations pro or contra prophylactic antibiotic therapy. The second situation, which occurs very frequently, is the absence of a sufficient high level of evidence. This prevents the establishment of strong recommendations, or recommendations based on expert opinion. The literature of high-level studies on antimicrobial prophylaxis in urology mainly concerns TURP and prostate biopsy. These studies demonstrate the benefit of a first or second-generation cephalosporin dose during induction of anaesthesia before TURP. In almost all other urological interventions, the literature remains poor with regard to the phrasing of high level recommendations1.

“There is an urgent need to reduce the use of antibiotics” Recent data The increase in the resistance of bacteria to antibiotics is worrying. This increase in resistance is mainly due to the unnecessary consumption of antibiotics. Surgical antibiotic prophylaxis represents a significant part of total antibiotic prescription. It is therefore necessary to reduce the use of antibiotics, including prophylaxis. It used to be generally accepted that antibiotic prophylaxis was necessary, unless a study showed no effect. The current increasing rates of resistance with the absence of effective new antibiotic classes requires us to change this paradigm. In this situation, we should NOT prescribe prophylactic antibiotics before surgery, unless a study has shown the benefit of pre-operative antibiotics to reduce the risk of post-operative infection. AFU infectious diseases committee (CIAFU) Therefore, since 8 years the infectious diseases committee of the AFU (CIAFU) and the French Society of Anaesthesia Resuscitation (SFAR) have been publishing written recommendations2. It is recommended not to prescribe antibiotics routinely before total prostatectomy for cancer or partial or total nephrectomy, regardless of the risk factors for the patient. It is recommended not to prescribe antibiotics in case of scrotal or penile surgery

App "RECOMMENDATIONS" developed by the Infections Committee of the AFU 3

in the absence of prosthesis. In contrast, transurethral resection of the prostate or bladder as well as ureteroscopy for stone extraction requires antibiotic prophylaxis with a 1st or 2nd generation cephalosporin. In order to allow case-by-case decision-making, jointly by anaesthesiologists and urologists in daily practice, the AFU decided not to define any particular exception or risk factor requiring a change of practice. Of course, alternatives are given in case of allergies. An annual, extensive surveillance of targeted interventions (prostatectomy, TURP) is carried out by a network. A recent module on antibiotic prophylaxis allows us to determine the incidence rate of post-operative infections in France. The number of post-operative infections does not seem to be larger than in countries which routinely practise antibiotic prophylaxis. France unfortunately holds a high position in the ranking of consumption of antibiotics in Europe and is trying to limit their use by publishing recommendations on antibiotic prophylaxis but also on the general use of antibiotics. New tools To facilitate evidence-based daily decisions of practitioners in the operating room, laminated sheets summarising these recommendations are available.

Recently, also a smartphone application (reco CIAFU) was made available that allows the practitioner to find the right therapeutic for the right intervention by a simple click3. The postoperative infectious risk in urology is not merely a matter of using a surgical antibiotic prophylaxis. An appropriate indication, attitude in the operating room, an ideal technique, a good haemostasis, a limited operating time and optimum surveillance are all essential to reduce the number of postoperative infections. Using antibiotic therapy routinely testifies of a lack of awareness of the infectious risks and the urgent need to reduce the consumption of antibiotics. References 1. 2. recommandations-de-bonnes-pratiques-cliniqueslantibioprophylaxie-en-chirurgie AND wp-content/uploads/2018/08/Antibioprophylaxieversion-2017-CRC_CA_MODIF.pdf 3. applications-medicales-en-ligne.html#reco-ciafu

EUSP Office is looking for new board members Are you an EAU Active member with a prominent research background and great affinity with education? Do you have broad knowledge of different urological subspecialties and excellent mentoring skills? Then you might be the person we are looking for! The European Urological Scholarship Programme (EUSP) Office aims to stimulate clinical and experimental research in Europe and to promote exchange amongst European urologists. The scholarship programmes of the EUSP allow young urologists and researchers to boost their careers by exchanging urological knowledge in the best European institutions. After their successful terms, four board members of the EUSP Office will step down. The EAU is now searching for new members. Could you be one of them?

How to apply Send your resume with a motivation letter to EUSP coordinator, Ms. Angela Terberg, at So make sure you send your application before 28 February 2019. The selected candidates will be informed after the Annual EAU Congress in Barcelona.

January/February 2019

European Urology Today


NIMBUS, a pivotal trial for BCG therapy Initial trial report presented at EAU annual meeting 2019 Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL)

National Coordinators: • Germany: Marc-Oliver Grimm • The Netherlands: Toine Van Der Heijden • France: Marc Colombel • Spain: Luis Martinez-Piñeiro • Belgium: Tim Muilwijk • Italy: Andrea Gallina • Turkey: Levent Türkeri

No. of No. of recruited recruited patients patients

w.witjes@ The NIMBUS trial assesses whether a reduced number of BCG instillations is not inferior to a standard number and dose of intravesical BCG treatment in patients with high-grade non-muscleinvasive bladder cancer (NMIBC). Intravesical instillation of BCG is a widely accepted strategy to prevent recurrence of non-muscle-invasive bladder cancer (NMIBC). However, the optimal number of induction instillations and the optimal frequency and duration of maintenance instillations is not known. The NIMBUS objectives are to evaluate time-to-firstrecurrence, number and grade of recurrent tumours, rate of progression to a higher stage (T2 or higher) and treatment-related toxicity.

N=306 N=295 N=295

Study Principal Coordinators: • Levent Türkeri, Marmara University Medical School, Istanbul (TR) • Marko M. Babjuk, Charles University 2nd Faculty of Medicine, Prague (CZ)

Enrolled patients in NIMBUS study until 21 January 2019

Study status The NIMBUS trial is actively recruiting in Germany, Aim of the NIMBUS study the Netherlands, France, Belgium and Spain. Centres The aim is to enrol 824 patients with HG Ta-T1 NMIBC, in Italy and Turkey are starting up. We expect the first with or without CIS, who did not receive any BCG patients from these countries to enrol at the intravesical instillation therapy previously. The NIMBUS beginning of 2019. Until now, we succeeded to study is a multicentre prospective, randomised, parallel recruit a total of 306 patients from Germany (141), group, not-blinded trial to compare the efficacy and the Netherlands (104), France (52), Belgium (8) and safety of two adjuvant treatment schedules: Spain (1) (cut-off date 21 Jan 2019). 1) induction cycle BCG-full dose; weeks 1 through 6 plus maintenance cycles at months 3, 6 and 12 (weeks 1, 2, 3); total 15 full doses. 2) Induction cycle BCG-full dose (reduced frequency); weeks 1, 2, 6 plus maintenance cycles at months 3, 6 and 12 (weeks 1, 3); total 9 full doses.

EAU Research Foundation

EAU Research Foundation: • Anders Bjartell, Chairman • Wim Witjes, Scientific and Clinical Research Director • Raymond Schipper, Clinical Project Manager • Christien Caris, Clinical Project manager • Ilse Christ, Clinical Research Associate • Joke van Egmond, Clinical Data manager • Xandra Helmonds, Financial Officer • Hans Noordzij, Marvin Management Assistant

Study team Are you interested in participating in the NIMBUS study? Please contact:

Protocol Committee: • Marko Babjuk, Prague (CZ) • Luis Martinez-Pineiro, Madrid (ES) • Joan Palou Redorta, Barcelona (ES) • Anup Patel, London (UK) • Levent Türkeri, Istanbul (TR) • Marc-Oliver Grimm, Jena (DE) • Wim P.J. Witjes, Arnhem (NL)

EAU RF Central Research Office PO Box 30016, 6803 AA Arnhem, The Netherlands Email : Phone : +31(0)26 389 0677 To find out more about the EAU RF and its ongoing projects, please visit or check Twitter (#EAUrf) for updates.

Poster presentation at the Annual EAU Congress in Barcelona An initial report of the NIMBUS trial will be presented at the Annual EAU Congress in Barcelona. Session Title: Non-muscle invasive bladder cancer: Role of markers for diagnosis, prognosis and surveillance. Poster Session 50 Date and location: Sunday 17 March 2019, 14.00-15.30, Green Room 20

SATURN registry enrols 200th patient European registry evaluates the cure rate of surgical procedures for treatment of male SUI Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL)

Number Number of patients of patients recorded recorded in e-CRF in e-CRF

N=500 (planned) N=500 (planned)

actual ----- trend


Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ Introduction Artificial urinary sphincter (AUS) implantation has been the standard of care for refractory male stress urinary incontinence (SUI) for many years. New surgical procedures with devices such as slings (fixed and adjustable) are increasingly used. Currently, there are no clear recommendations regarding patient factors to identify the best surgical treatment options for SUI: AUS or sling.

EAU Research Foundation


European Urology Today

Page 2 of 2

actual ----- trend

Page 2 of 2

Number of patients enrolled in SATURN until January 2019

Objectives SATURN registry The objectives of the SATURN registry are to evaluate the effects of surgical treatment of SUI with current available devices and to determine prognostic factors which may help to identify clinical and surgical variables that correlate with (un)favourable outcomes. The aim is to recruit 500 male patients undergoing surgery for treatment of SUI with AUS or sling.

10 centres recorded a total of 218 patients in the e-CRF. This may be an underestimation of the actual number of recruited patients, as not all included patients are recorded in the e-CRF as yet.

Sites to be initiated Czech Republic: Prof. T. Hanuš (General University Hospital, Prague), EC approval Finland: Dr. K. Tikinnen (Helsinki University The cure rate is defined as urinary continence with no Central Hospital, Helsinki), EC submission need for the use of pads or the use of 1 light security France: Dr. P. Costa (University Hospital Nimes, pad. Patient Reported Outcome Measures (PROMS), Nimes), Prof. Dr. A. Ruffion (CHU, Lyon), quality of life (QoL); incontinence, and clinical data EC submission are collected from study visits at baseline (BL) before Germany: Prof. R. Bauer (Ludwig-Maximilianssurgery; at the time of surgery; 6 weeks (activation of University, Munich), Dr. T. Pottek (Vivantes Klinikum AUS); 12 weeks and 1 year post-surgery. Mid-term Am Urban, Berlin), Dr. F. Queißert (University follow-up consists of annual patient contacts after one Hospital Münster, Münster), Prof. M. Fisch year post-surgery up to and including year 5. (Asklepios Klinik Harburg, Hamburg), EC submission Italy: Dr. G. Bozzini (Humanitas Mater Dominin, Study update Milan), EC submission To date (cut-off date 21 Jan 2019), 14 centres are active, Norway: Dr. M. Pedersen (UNN, Narvik)

Spain: Dr. I. Puche-Saz, (Hospital Universitario Virgen de las Nieves, Granada), Prof. I. M. Iribarren (University Hospital Francisco de Vitoria, Madrid), EC approval Dr. E. Lledo Garcia (Hospital General Universitario Gregorio Marañón, Madrid), Dr. S. Arlandis (University Hospital La Fe, Valencia), Dr. C. Ochoa V. (Hospital Universitari Germans Trias i Pujo, Barcelona), EC submission United Kingdom: Dr. M.J. Drake (Spire Bristol Hospital, Bristol), Dr. H. Hashim, (Bristol Urological Institute, Bristol), Dr. S. Reid (Northern General Hospital, Sheffield), EC submission Is this study open to new sites? Yes it is. Institutions that perform surgical procedures for treatment of male stress urinary incontinence can participate. There will be no restriction on the number of patients enrolled as long as they are consecutive. For more information, please visit the EAU RF website If you are interested in participating in this registry, please fill in the feasibility questionnaire at or contact the study coordinator Dr. Raymond Schipper at as soon as possible. The site must be able to complete the approval process promptly. Primary objective: to evaluate the cure rate of procedures for treatment of male stress urinary incontinence. Secondary objectives: • To determine other outcomes of surgical treatment of male stress urinary incontinence for a variety of devices; • To perform a prognostic factor analysis to identify clinical and surgical variables that correlate with (in)continence or revisions.

Continued on page 17

January/February 2019

Continued from page 16

Poster presentation at the Annual EAU Congress Barcelona, Spain An initial report of the SATURN registry will be presented at the Annual EAU Congress in Barcelona. Session Title: Old and new slings and things for male incontinence Poster Session 56 Date

Sunday 17 March 2019 15.45-17.15 hrs.


Green Room 11

Country Belgium

Czech Republic Germany Italy Netherlands, The Norway Spain

United Kingdom Collaborator Boston Scientific Corporation Study team Principal Investigator Ass. Prof. Rizwan Hamid University College London Hospitals, Dept. of Urology London (UK)

(Sub) Investigator Prof. F. Van Der Aa Prof. K. Everaert Prof. K. Van Renthergem Dr. R. Zachoval Dr. T. Hüsch/Prof. A. Haferkamp

City Leuven Ghent Hasselt Prague Mainz

Hospital University Hospital Leuven University Hospital Ghent Jessa Hospital Hasselt Thomayer Hospital University Hospital Mainz

# Patients recorded in e-CRF 76 0* 2 18 3

Dr. M. Tutolo Dr. J. Heesakkers/Dr. F. Martens Dr. Laetitia de Korte Dr. O.J. Nilsen Dr. Esaú Fernández Pascual/ Prof. Dr. Ignacio Martinez Dr. Javier Romero-Otero Salamanca Prof. D. M. Castro Diaz Dr. R. Hamid Dr. N. Thiruchelvam

Milan Nijmegen Utrecht Oslo Madrid

Ospedale San Raffaele Radboud UMC University Medical Centre Utrecht Rikshospitalet University Hospital Puerta de Hierro - Majadahonda Hospital Universitario 12 de Octubre Hospital Universitario de Canarias Royal National Orthopaedic Hospital CUH - Addenbrooke's Hospital Total

0* 59 21 0* 14

Madrid La Laguna Stanmore Cambridge

* recently initiated Protocol Writing and Steering Committee • Nikesh Thiruchelvam (UK) • Frank Van Der Aa (BE) • John Heesakkers (NL) • Wim Witjes, EAU Research Foundation (NL)

EAU Research Foundation • Wim Witjes, Scientific and Clinical Research Director • Raymond Schipper, Clinical Project Manager • Christien Caris, Clinical Project Manager

20 3 0* 2 218

• Joke van Egmond, Clinical Data Manager • Hans Noordzij, Marvin System Assistant

Two new research projects greenlit thanks to EAU RF grant Year-long projects from Italy and Netherlands contribute to onco-urological research By Loek Keizer In the summer of 2018, the EAU’s Research Foundation (EAU RF) opened the application for a new seeding grant, with the aim of supporting highly innovative and original research by a junior investigator. A total of 30 applicants submitted their 1-year research projects that were designed to collect or strengthen preliminary data and to qualify for future external competitive funding, hoping to obtain one of the two funding grants of €25,000 each. After a careful selection, followed by personal interviews during the 10th European Multidisciplinary Congress on Urological Cancers (EMUC18) in Amsterdam, the EAU RF is pleased to announce the two recipients who will be granted €50,000 in total for their 1-year research project and will present the results at EAU20. Dr. Nicola Fossati (Milan, IT) will be testing the validation of a new urine test (Expressed Prostatic Secretions (EPS) Metabolomic) to predict the presence of clinically significant Prostate Cancer (defined as Gleason score ≥ 7 (3+4)) at initial prostate biopsy in men with suspicion of PCa. The second winner is Dr. Tahlita Zuiverloon (Rotterdam, NL) who will conduct further research in the discovery and functional evaluation of actionable targets for novel treatments in high-risk non-muscle-invasive bladder cancer. EAU RF Chairman Prof. Bjartell (Malmö, SE) was pleased with the high quality of the projects submitted and was impressed by the two selected projects. “We are delighted to support again two highly-innovative research projects that combine

Fig. 1: Hierarchical clustering analysis of peak intensities of identified metabolites in urine EAU Research Foundation

January/February 2019

CRISPR library

Transduced cells


the Erasmus MC fellowship I was able to do high-end research Bladder cancer cells independently as a postdoctoral fellow in the Identify genes USA for two years. During associated with this period I designed and invasive growth/progression completed multiple large theCRISPR-screen CRISPR-screen to identify genes associated with invasion/progression Fig. Experimental 2: Experimentaldesign design ofofthe to identify genes associated with invasion/progression CRISPR-screens independently, of which a publication is expected in Dr. Tahlita Zuiverloon, advanced scientific study with the clear aim to working in the same institution. Fossati: “The project 2019. My affinity with the Rotterdam, NL advance clinical practice.” will involve clinicians and researchers. Patients will clinic as well as with basic research enables me to be recruited at San Raffaele Hospital. Patient The role of EPS-metabolomic for early diagnosis create a large and diverse enrolment and acquisition of the informed consent of PCa network to effectively will be under the responsibility of the Principle Via, the EAU website, and EAU Investigator and other two urologists. A researcher of perform translational meetings, Dr. Fossati learned about the new grant research that is required the micro sequencing facility will extract polar and possibilities for young researchers and applied before a-polar metabolites and will create a mass metabolite for this project.” the October deadline: “We were honoured to be spectral library. Finally, the biostatisticians unit will selected for the final interview. Considering the high Zuiverloon continues: perform statistical analysis.” number of applications for the EAU RF, we did our “Currently patients who best to present our project and our preliminary The project will be conducted in the following phases: fail BCG treatment do not results. I’m very happy for the final approval, and I Dr. Nicola Fossati, Milan, IT D1: Informed consent - Ethical Committee approval have any other treatment would like to thank all the members of our team at options than a radical (0-2 months) San Raffaele hospital.” cystectomy. Organisations like the EAU, AUA and IBCN D2: Patient enrolment (3-11 months) support the discovery of predictors of progression in D3: Data collection and samples processing “Given the limited specificity of prostate specific high-risk non-muscle-invasive bladder cancer (3-11 months) antigen (PSA), the adoption of PSA-based screening patients via identification of novel biomarkers. D4: Data analysis (9-12 months) has led to a significant over-diagnosis of low risk and Thanks to the systematic approach in my project indolent tumours. There is a need to identify patients “This is a highly novel and challenging project which we aim to achieve two goals. First is the identification at higher risk of clinically significant PCa”, says of markers of progression and secondly we aim to brings an exciting new technology such as Fossati. “Using advances in purification techniques, identify targets for novel treatment options.” metabolomic in the PCa biomarkers discovery field. we have been able to preliminarily isolate EPSBy validating the new metabolic biomarkers in metabolomic after prostatic massage and we have EPS-urine (obtainable in a non-invasive fashion) with This project is needed to create a robust set of found a molecular signature predictive of clinically preliminary data that will form a solid base for future a high sensitivity and specificity for PCa, we can significant PCa.” funding applications. This grant will allow at least 2 provide an additional level of accuracy, beside PSA PhD students or research masters to continue level and other clinical parameters as well as Potential sources of biomarkers for PCa include working on the project. mp-MRI, to calculate the individual risk of clinically whole-cell analysis as well as cell-free components, significant PCa. Finally we believe that the EPSsuch as proteins and nucleic acids. In addition to metabolic profile as biomarker will have the potential The predictors of progression have been identified by traditional serum or plasma, urine has been proposed to optimise the diagnosis of clinically significant PCa.” whole-exome and whole-transcriptome sequencing as an easily available source for prostatic biomarkers. on a large clinical HR-NMIBC patient cohort. Findings To date, several urinary biomarkers have been of the CRISPR-screen are validated independently to Predicting progression in high-risk NMIBC patients identified and considered for use in PCa. All of these eliminate putative gene alterations and to select the For Dr. Zuiverloon, the EAU newsletter was the first tests have shown comparable accuracy in predicting true drivers of progression. Identification of drivers of time she read about the EAU RF grant possibility. high-grade PCa (defined as a biopsy Gleason score ≥ progression represents opportunities to develop After her application, she got selected to present her 7 (3+4)). Since the prostate has a unique metabolite alternative treatment options for HR-NMIBC patients. project in Amsterdam. “The board of the EAU profile, metabolic biomarkers may be used in clinical Research Foundation was genuinely interested in the As the selected gene alterations for investigation are practice. However, no study has ever tested the role of project and asked good questions. The first predicated on therapeutic drug ability, direct clinical EPS-metabolomic profile for early diagnosis of validation can be pursued in a phase I clinical trial in impression was very good.” clinically significant PCa. case a gene and its associated drug are validated in The research project of Dr. Zuiverloon aims to identify vitro and in vivo. EPS-urine, enriched upon the prostatic massage, is an drivers of progression in high-risk non-muscle-invasive ideal source of tumour-specific biomarkers. Despite its bladder cancer (HR-NMIBC) patients. To this end, gene EAU RF Chairman Prof. Bjartell is confident of the potential applications, only EPS-proteome has been knockout CRISPR-screens combined with invasion future potential of the seeding grant programme: investigated as a rich source of biomarkers, whereas assays will be performed in bladder cancer cell lines to “After 2 successful projects last year, we are confident EPS-metabolomic profile has not been studied yet. functionally investigate which of the gene alterations in supporting these new studies. Today, there are many The aim of Fossati’s project is to prospectively validate previously identified as the strongest predictors of unmet needs in the field of independent urological the accuracy of EPS-metabolomic signature to predict progression are actual drivers of progression. research. The EAU RF strives towards a future, in which clinically significant PCa. European urology research is abounding, relevant, “I was trained as a biomedical scientist in addition to high-quality, and yielded through a consolidated Now that the study is approved, the project will take my medical doctor’s degree”, says Zuiverloon. collaborative infrastructure. By supporting these 2 advantage of the already established multidisciplinary “Currently, I work as a physician-scientist with a projects we feel that the EAU RF contributes to collaboration between different research groups strong focus on bladder cancer research. Thanks to high-quality research in an effective way.” European Urology Today


ESU Update

ESU-ESRU undergraduate education in urology Inception, overview and results of the project Dr. Juan Gómez Rivas ESRU Chairman YUO Board Member ESU Board Member Hospital Universitario La Paz Madrid (ES) juangomezr@

Dr. Joan Palou ESU Chairman Fundació Puigvert Barcelona (ES)


Urology is a branch of medicine which deals with the dysfunction of the urinary system and the male genitalia. Regardless of the career paths they want to pursue, junior doctors will meet patients with urological problems in the wards, emergency departments and especially in primary care. Until now there has been no agreed undergraduate curriculum in Europe.

Furthermore, a recent survey presented by the European Association of Urology (EAU) showed the low level of awareness in general population regarding what “urology” means, what a “urologist” does or in symptoms regarding urological diseases. This issue is of particular concern as urological conditions are on a rise due to the ageing European population. Prevention and early diagnosis are crucial to save lives and to control increasing costs. Urological diseases are extremely common; they cause a lot of discomfort and at times, can be life-threatening. It is time for Europe to change its attitude towards urology and invest in educational campaigns to increase urological knowledge and break taboos. With this background, members of the European School of Urology (ESU) and the European Society of Residents in Urology (ESRU) created an undergraduate working group. Its goals are to archive the current status of undergraduate urology curriculum in Europe and create recommendations and policies for undergraduate education based on this status. The first task done by this group was to design an 18-item online survey with a primary endpoint of assessing the actual status of urological exposure during medical school and the differences in undergraduate curriculums in Europe. The survey was designed via the survey tool SurveyMonkey and in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines. The poll was distributed to medical students, urology trainees and young urologists from 23 European countries via e-mail and social media.

“It is time for Europe to change its attitude towards urology and invest in educational campaigns to increase urological knowledge and break taboos.” A total of 312 medical students, trainees and urologists responded to the survey. The top five countries that provided input were Spain, Portugal, United Kingdom, Belgium and Denmark. It is remarkable that the male and female response rates were equal, which is a reflection of the change in gender trends in medicine.

Hours dedicated to subspecialty

Urology is introduced during the fourth or fifth year of medical school in 75% of universities in Europe. Urology is mandatory in 84% and taught as an individual subject in 56% of the universities. The distribution of hours is an even 50/50 between theoretical and practical classes. In most universities, urology is studied as subspecialty (31%), by organs (31%) and less common according to symptoms (20%). With regard to subspecialty, students spend most of their time on oncology, anatomy/physiology and benign disease (e.g. benign prostatic hyperplasia or urinary tract infection). Regarding organs, the students mainly focus on the kidney, prostate and bladder; and on symptoms, the majority of their time is dedicated to lower urinary tract symptoms (including acute urinary retention), haematuria and scrotal pain.

Hours spent on knowing more about symptoms

Hours focused on studying organs


European Urology Today

During the time spent in practice, medical students dedicate most of it in clinical cases discussions and performing physical examination on patients, and less observing/learning urological procedures. Although the quality of the urology curriculum is highly valued by the responders to the survey (a score of 7 out of 10), surprisingly, urology does not influence their training decision-making at the end of medicine school (a score of 4.5 out of 10). Based on these results, we conclude that the exposure and experience of medical students’ in urology differ between European countries and institutions. Although the quality of urology curriculum is highly valued, urology as specialty does not influence their training decision making at the end of medical school. Organisations in Europe and especially the ESU-ESU working group should work together to elaborate recommendations on urological undergraduate education.

ESU Event Calendar Date

Event name


FEBRUARY 2019 22-23 2nd ESU-ESOU Masterclass on Non muscle invasive bladder cancer

Prague (CZ)

MARCH 2019 15-19

34th Annual EAU Congress

Barcelona (ES)

APRIL 2019 3-4 5-6 12 18-19 tbc 25

E-BLUS during SEP-UP Programme, UROFAIR ESTs2 during SET-UP Programme ESU course on Update in urologic oncology during the national congress of the Urological Association of Serbia ESTs1 during the Mediterranean Minimally Invasive Surgery in Urology ESU course on Oncourology during the 5th North-Western conference of the Russian Society of Urology ESU course during the national congress of the Moroccan Urological Association

Singapore (SG) Bangkok (TH) Belgrade (RS) Alexandria (EG) St Petersburg (RU) Rabat (MA)

MAY 2019 16 16-17 17-18 25

ESU course during the national congress of the Dutch Association of Urology 4th ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction 2nd EAU Update on Bladder cancer (BCa19) ESU course on New perspectives in the management of upper tract tumours during the 6th Baltic Meeting in conjunction with the EAU

Rotterdam (NL) Heilbronn (DE) Turin (IT) Tallinn (EE)

JUNE 2019 6 ESU course during the national congress of the Slovak Urological Association 7-8 1st EAU Update on Renal Cell Cancer 12 ESU course during the national congress of the Spanish Urological Association 14 ESU course during the national congress of the Polish Urological Association 14 ESU course on Urinary tract infection during the national congress of the Ukrainian Urological Association 14-15 3rd ESU-ESUT Masterclass on Urolithiasis 21 ESU course during the national congress of the Urology Society from Republic of Moldova 23-29 ESU – Weill Cornell Masterclass in General urology

Martin (SK) Prague (CZ) Bilbao (ES) Katowice (PL) Kiev (UA) Patras (GR) Chisinau (MD) Salzburg (AT)

JULY 2019 15-18

ART in Flexible - Step 1

Berlin (DE)

SEPTEMBER 2019 6-11 11-13 tbc

17th European Urology Residents Education Programme (EUREP) ESU-ERUS courses during the 17th Meeting of the EAU Robotic Urology Section (ERUS) ESU course on Endourology during the national congress of the Russian Society of Urology

Prague (CZ) Lisbon (PT) Rostov-on-Don (RU)

OCTOBER 2019 2-5 6th Confederación Americana de Urologia Residents Education Programme (CAUREP) 10 ESU course on Clinical and histopathological basics and main research questions in kidney cancer during the 26th Meeting of the EAU Section of Urological Research (ESUR) 11 ESU course during the national congress of the Turkish Urological Association 11-12 3rd EAU Update on Prostate cancer (PCa19) 31- 1/11 ESU-ESFFU Masterclass on Functional urology during the European Lower Urinary Tract Symptoms meeting (ELUTS19)

Buenos Aires (AR) Porto (PT)

Antalya (TR) Prague (CZ) Prague (CZ)

NOVEMBER 2019 11 14-17 21-22 tbd

ESU course on Prostate and bladder cancer; Insight into research and lecturing during the national congress of the Scientific Society of Urologists of Uzbekistan ESU courses during the 11th European Multidisciplinary Meeting in Urological Cancers (EMUC) 6th ESU-ESUT Masterclass on Lasers in urology 2nd ESU-ESTU Masterclass on Kidney transplant

Tashkent (UZ)

Vienna (AT) Barcelona (ES) Madrid (ES)

DECEMBER 2019 3-5 tbd

ART in Flexible - Step 2 4th ESU-ESUT Masterclass on Focal therapy for localised prostate cancer

Berlin (DE) Paris (FR)

January/February 2019


1st ESU Urology Boot Camp premieres in Lisbon Boot camp offers basic technical skills training to 1st year residents Dr. Tiago Oliveira Dept. of Urology Santa Maria University Hospital Lisbon (PT)

tiagoribeirooliveira@ Co-authors: Dr. Afonso Castro, Boot Camp trainee, Lisbon (PT), Dr. Ben Van Cleynenbreugel, Leuven (BE), Mr. Shekhar Biyani, Leeds (GB), Mr. Sunjay Jain, Leeds (GB) Urology is one of the specialties which has significantly progressed in recent decades, not only from a scientific point of view but also from a surgical technology aspect.

Training essentials

A modern urologist has to master a vast array of techniques; from open surgery to minimally invasive procedures such as laparoscopy or endoscopy. However, it is widely recognised that the learning curve for these techniques can be considerably steep. Therefore, the training of urology residents becomes even more demanding. For this reason, and given the growing evidence on modern adult teaching techniques and the availability of more realistic training models, there is increasing interest in the development of validated technical skills training courses. In collaboration with EAU Section of Uro-Technology (ESUT) and the EAU Section of Urolithiasis (EULIS), the European School of Urology (ESU) has developed a series of hands-on-training programmes throughout the years to standardise the teaching and accreditation of technical skills training. The European training in Basic Laparoscopic Urological Skills (E-BLUS) and the Endoscopic Stone Treatment step 1 (EST s1) include a series of validated exercises with the objective of providing and assessing basic laparoscopic and endourological skills. In the long run, these programmes will constitute the first steps of an organised and standardised training curriculum in urology.

One-on-one tutelage

(TURP), transurethral resection of bladder tumour (TURBT), tension-free vaginal tape (TVT), Botox, scrotal surgery, bowel anastomosis, and laparoscopy, with an emphasis on individual hands-on training. ESU urology boot camp programme On November 17th 2018, Lisbon was host city to the first ESU Urology Boot Camp. The course was a joint venture of the ESU, the Portuguese Association of Urologists (APU), and the Center for Postgraduate Training in Urology (CFU). Based on the innovative training approach implemented in Leeds, the aim was to provide basic technical skills to first-year urology residents, within the framework of a standardised ESU training programme.

"The intensive course programme provided participants the opportunity to acquire and train several urological skills in eight hours of hands-on training..." The course was organised into four separate training modules: Laparoscopy, Upper Urinary Tract Endoscopy, Transurethral Resection and Lower Urinary Tract Endoscopy. With a series of different high fidelity models and a considerable amount of state of the art urological equipment, a total of 16 renowned Portuguese urologists provided standardised hands-on training on laparoscopy, flexible and semi-rigid ureterorenoscopy, TURP, TURBT, flexible and rigid cystoscopy, bladder catheterisation and suprapubic catheter placement. The intensive course programme provided participants the opportunity to acquire and train several urological skills in eight hours of hands-on training, each participant with a dedicated model and individually guided by a trainer. This was a unique opportunity for first-year urology residents to learn a series of different technical skills that are of paramount importance in daily clinical practice. The quality of the models and equipment, the motivation and competence of the faculty and the use of ESU’s validated training models warranted the clear success of the course amongst the participants.

January/February 2019

What Boot Camp participants say Dr. Andreia Bilé (PT) Egas Moniz Hospital, Lisbon

good tips and tricks which will be handy in our clinical practice!

Being a urology resident presents us with constant challenges, not only in our clinical activities but also in proficiency in handling devices that we come across with while learning.

The boot camp was an inspiring event that motivated and prepared us for the urology residency. I can only thank the organisers for such a great event and I truthfully recommend it to future young urology residents!

This boot camp illustrates how shared knowledge combined with innovative technology may contribute to better welfare of our patients. Nowadays, we have several realistic medical practice models within our reach. By using them, we speed up our learning, which ultimately leads to the improvement of patient outcomes.

Simulation training in laparoscopy

Future perspectives The Organising Committee of this pilot project, Dr. Ben Van Cleynenbreugel (BE), Mr. Biyani (GB), Mr. Jain (GB) and Dr. Tiago Oliveira (PT), expect to develop a broader training programme and to implement a standardised urology boot camp throughout Europe, via close collaborations with the European Association of Urology and several national urological associations. The objective is to provide first-year urology residents a platform to acquire and train basic urological technical skills, based on a standardised curriculum, prior to starting urological clinical activities. The focused training can help improve clinical proficiency and self-confidence.

With the aim of providing basic technical and non-technical skills for first-year urology registrars in the United Kingdom, Mr. Shekhar Biyani (GB) and Mr. Sunjay Jain (GB) of the Department of Urology of St. James’s University Hospital in Leeds, developed a five-day novel training programme, the Urology Simulation Boot Camp. Currently in its 4th edition, the Urology Simulation Boot Camp includes 10 hours of non-technical skills training (simulated scenarios followed by interactive debrief sessions); and 30 hours of technical skills simulation training in cystoscopy, ureteroscopy, transurethral resection of the prostate

Residents and their esteemed tutors

As far as this very boot camp is concerned, we, as first year residents, feel fortunate to have been taught by skilled tutors. They provided us with tips and tricks to enhance our performance using cutting-edge technology in laparoscopy, endoscopy of the urinary tract and transurethral resection. To witness and to be a part of this pioneer dynamic learning experience; to have specialists share their own struggles and how they overcame said struggles were certainly the highlights of this remarkably well-organised boot camp. Dr. António Pinheiro (PT) Prof. Doutor Fernando Fonseca Hospital, Amadora The ESU Urology Boot Camp was the best practical event that I have attended this year. With the intensive and fast-paced learning activities, the boot camp was very demanding but also very rewarding. It was well-organised and amply supplied with models. We learned the basic techniques and surgeries, and also practised them under the guidance of the best senior urologists on a one-on-one basis. We learned and applied our newly-acquired knowledge on practical models without the real-life risk of complications. We received a lot of

Dr. João Lima (PT) Coimbra University Hospitals, Coimbra The ESU Urology Boot Camp was definitely a unique experience and opportunity. Not only did I understand more and practise the basics of cystoscopy, ureterorenoscopy and laparoscopy in models; but I also handled the resectoscope and performed my very first TURP on a model and not on a human being. The strong point of the boot camp is the one-onone tutelage, which provides you constant insight on your skills, and tips and tricks that only the experienced can teach you. Dr. Vanessa Andrade (PT) São José Hospital, Lisbon To achieve better outcomes, it is important to have a good explanation about the procedures and to practise as much as possible. The ESU Urology Boot Camp was a great opportunity to have a tutor help us improve our knowledge and guide us during hands-on trainings on different urological techniques and procedures. This course was well-organised and offered a very nice, informal environment which allowed us to talk and directly ask the tutors. I think the boot camp’s objectives were achieved with success and should take place every year. I wish I could have training moments like this for all urological techniques.

Up close during EST 1 cystoscopy exercises

European Urology Today



Challenges in kidney transplant spur masterclass design A report and participant impressions of the new ESU-ESTU masterclass By Erika De Groot The growing waiting list for kidney transplant; the imperative need for progress in preservation techniques; and customisation of immunosuppression to adapt to donor and receptor characteristics are some of the main challenges that spurred the design and fulfilment of the 1st ESU-ESTU Masterclass on Kidney Transplant. The European School of Urology (ESU) and the EAU Section of Transplantation Urology (ESTU), through the expertise and guidance of Course Directors Prof. Enrique Lledó García (ES) and Prof. Francisco Javier Burgos Revilla (ES), created this masterclass to provide a comprehensive coverage on emerging surgical technologies, frontline updates on immunosuppression and immunology, and oncological issues of donor and receptor.

internationally-known and experienced speakers were going to lead the masterclass, I was even more motivated to join.” “What drew me in to apply for the masterclass was the review of the state-of-the-art updates on kidney transplantation. It was also a plus that it was held in my hometown,” shared Dr. Ramiro Cabello Benavente (ES) of the Hospital Universitario Fundación Jiménez Díaz. “I wanted to know more about the conjunction of the medical and surgical aspects of renal transplant in an immersive learning experience,” stated Dr. Oscar Rodríguez Faba (ES) of Fundació Puigvert.

Dr. Bohdan Bidovanets (UA) of the Ternopil Regional Oncology Clinic said, “It is difficult to say which part of the programme had the greatest influence on why I decided to participate. Every faculty lecture In this article, four participants shared their insights and was relevant and clarified different aspects of impressions. Read on to know more about their transplantation. All of these made the masterclass masterclass experience last November in Madrid, Spain. interesting and comprehensive.” Reasons for joining “Since 2018, I’m responsible in restarting the kidney transplant programme at the Federal University of Bahia in Brazil as the programme was at least 15 years inactive,” stated Dr. Fábio Sepúlveda Lima (BR). “Attending the masterclass was a great opportunity for me to receive updates on the major concepts in kidney transplantation. And when I learned that

Skills to refine and techniques to learn Dr. Sepúlveda commended the masterclass for delivering essentials as urologists always gravitate to resolving surgical issues and improving clinical practice. “In addition to the excellent lectures on surgical techniques, the scientific programme also addressed the most important clinical issues in kidney transplantation such as immunosuppression, pathology, rejection, oncology, and quality of life.”

Enthusiastic participants with the expert faculty

about organ perfusion and preservation; surgical complications; management of transplant patients with tumours; and complicated vascular anatomy. And to Dr. Rodríguez, he intended to learn more about robotic renal transplant and the implementation of the pulsatile perfusion machine. Personal masterclass highlights “The talk on the present status of protocols of non-heart beating donors in Europe was definitely the most impressive. The development and spread of robotic kidney transplantation was also very interesting. We hope that more patients could be submitted to minimally invasive procedures. The role of pulsatile hypothermic machine perfusion as a prognostic factor of kidney graft function did change my practice,” attested Dr. Sepúlveda. According to Dr. Cabello, the highlights of the masterclass included the basic management of LifePort

To Dr. Cabello, he was set on learning all he could

“My top highlights were when the masterclass covered the improvement of the procurement techniques in non-heart beating donors; implementation of the robotic surgery; the and design of protocols for management of urological tumours in renal transplant recipients,” shared Dr. Rodríguez. “All the information offered at the masterclass was very interesting,” stated Dr. Bidovanets. “The masterclass highlights for me were coverage on the kidney transplantation; renal and non-renal tumours (both in donor and recipient); technical aspects of the orthotropic transplantation and vascular difficulties; and choosing the appropriate kidney preservation option.”

“When I joined the masterclass, I aimed to learn about the precise techniques of living and non-heart-beating donor nephrectomies,” shared Dr. Bidovanets. “I also wanted to know more about the methods of kidney preservation and selection of the best option on case-to-case basis. And of course, enrich my transplantation skills and boost my knowledge on supportive treatment.” Masterclass offers visual aid through semi-live surgeries

machine perfusion; current updates on kidney biopsy (i.e. pre-transplant biopsy as a baseline, perform two cores with 16G needle, obtain >10 glomerulus and two arteries); examining the biopsy under the microscope with the pathologist, performing the biopsy early and checking if patients had any previous treatment(s); and the focus on oncologic issues (e.g. tumours in kidney transplant donors and recipients). Dr. Cabello also expressed his reservations with focal therapy as a standard option for kidney transplant patients as more studies are needed.

Activities during the roundtables and workshop on kidney preservation

Interested in applying for a masterclass(es) to boost your knowledge and skills? There are plenty to choose from. Visit to know more.

Preliminary ESU programme in Barcelona ESU Courses Adrenals • Adrenals for urologists Andrology • Office management of male sexual dysfunction • The infertile couple - Urological aspects Female urology • Prolapse management and female pelvic floor problems • Advanced vaginal reconstruction General urology • How to proceed with hematuria • Ultrasound in urology • Updated renal, bladder and prostate cancer guidelines 2019: What has changed? • Non-oncology guidelines: Incontinence; Bladder/Paediatric stones; Male LUTS • Improving your communication and presentation skills • How to write introduction and methods • How to write results and discussion Infections • Dealing with the challenge of infection in urology Kidney transplantation • Renal transplantation: Technical aspects, diagnosis and management of early and late urological complications Male LUTS • Management of BPO: From medical to surgical treatment, including setbacks and operative solutions (SOS) • Male urinary incontinence management



European Urology Today

Neurogenic and non-neurogenic voiding dysfunction • Chronic pelvic pain in men and women • Practical neuro-urology • Lower urinary tract dysfunction and urodynamics Paediatric urology • Paediatric urology for the adult urologist. Congenital problems of the urinary tract: Obstruction and reflux and longterm outcome • Paediatric urology for the adult urologist. Congenital disorders of the external genitalia, DSD and longterm outcome Penile and testicular cancer • Testicular cancer • Penile diseases Prostate cancer • Robot-assisted laparoscopic prostatectomy • Retropubic radical prostatectomy – Tips, tricks and pitfalls • Focal treatment in prostate cancer • Prostate cancer imaging: When and how to use it • Prostate cancer screening and active surveillance – Where are we now? • Prostate biopsy - Tips and tricks • Metastatic prostate cancer • Oligometastatic prostate cancer • Prostate cancer update: 2018-2019 • Surgery or radiotherapy for localised and locally advanced prostate cancer Renal tumours • Robot renal surgery • Treatment of small renal masses • Advanced course on laparoscopic renal surgery Trauma • Urinary tract and genital trauma Urethral strictures • Advanced course on urethral stricture surgery

ESU Hands-on Training Courses Urolithiasis • Percutaneous nephrolithotripsy (PCNL) • Update on stone disease • Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips and tricks, indications • Metabolic workup and non-surgical management of urinary stone disease • Advanced endourology in the non-standard patients with urolithiasis Urological surgery • Surgical anatomy for laparoscopic and robotic assisted radical prostatectomy and cystectomy • Laparoscopy for beginners • Advanced course on upper tract laparoscopy: Kidney, UPJ, ureter and stones • Basic penile scrotal surgery and first steps in endourology • Prosthetic surgery in urology • Lymphadenectomy in urological malignancies Urothelial tumours • Practical management of non-muscle invasive bladder cancer (NMIBC) • New perspectives in the management of upper tract tumours • Laparoscopic and robot-assisted laparoscopic radical cystectomy • Management and outcome in invasive and locally advanced bladder cancer • Nerve-sparing cystectomy and orthotopic bladder substitution - Surgical tricks and management of complications • How will immunotherapy change the multidisciplinary management of urothelial bladder cancer?

Laparoscopy • ESU/ESUT Hands-on Training in Basic laparoscopy • E-BLUS exam Diagnostics and follow-up • ESU/ESFFU Hands-on Training in Urodynamics • ESU/ESUT/ESUI Hands-on Training in Fusion biopsy • ESU/ESUT/ESUI Hands-on Training in Prostate MRI reading for urologists • ESU/ESUT/ESUI Hands-on Training in Abdominal ultrasound Functional urology • ESU/ESFFU Hands-on Training in Sacral neural modulation Endoscopy • ESU/ESUT/EULIS Hands-on Training in Endoscopic stone treatment – step 1 • ESTs1 exam Non-technical skills • ESU Hands-on Training in Non-technical skills in surgery

January/February 2019


ESU-ESUT Masterclass delivers laser fundamentals An overview report and testimonials from the participants By Erika De Groot

Dr. Safdar Javed (PK) of Allied Hospital (PMC); and Dr. John O’Kelly (IE) of the Royal College of Surgeons in Fundamental updates on laser applications in urology Ireland. which included treatment of benign prostatic obstruction, bladder and upper tract urothelial Why did you apply to this masterclass? carcinoma, renal stones and urinary tract strictures Dr. O’Kelly: “I joined this masterclass to learn more were the core of the recently-concluded 5th about Holmium Laser Enucleation of the prostate ESU-ESUT Masterclass on Lasers in Urology, which (HoLEP) and management of upper tract urothelial was organised by the European School of Urology carcinoma (UTUC) using laser as these operations (ESU) and the EAU Section of Uro-Technology (ESUT). are currently not commonly performed in Ireland. The calibre of the masterclass faculty was also a Held from 22 to 23 November in Barcelona, the factor.” high-level masterclass offered participants the opportunity to examine the use of contemporary laser Dr. Javed: “I work in a university hospital in Pakistan systems such as the Holmium laser, 532-nm laser, where two diseases – benign prostatic hyperplasia Thulium laser, Diode laser, Neodidium and other (BPH) and urolithiasis – constitute 50% of the total lasers. The live and semi-live surgeries were designed number of urological surgeries performed. When I to provide a complete and realistic spectrum of learned that this laser masterclass will also focus on clinical laser applications. Internationally-known key these diseases, I decided to apply.” opinion leaders shared their valuable insights and best practices. Dr. Carl: “I applied for the masterclass because I wanted to know the latest developments in the field, We interviewed three participants to know more about particularly with greenlight laser as I have extensive their reasons for applying for the masterclass; what experience with it for more than decade (I started they intended to learn from it, and their personal with 70 watts). Unfortunately, greenlight laser was highlights. These participants are namely Dr. Stefan not evaluated enough during all sessions but I did Carl (DE) of the Urologische Gemeinschaftspraxis; learn more about other lasers.” What did you want to learn at the masterclass? Dr. Carl: “Our hospital bought a holium laser two months ago. This inspired me to learn about the new techniques in laser-enucleation of the prostate and en-bloc resections in bladder tumours. The masterclass did not disappoint and completely met my expectations. The live surgeries were flawless and provided me detailed insights on the operations and possible complications.”

Masterclass setup is conducive to learning

Dr. Javed: “I wanted to know more about techniques for HoLEP, retrograde intrarenal surgery (RIRS) and mini percutaneous nephrolithotomy (PCNL).”

Prof. Dr. Thorsten Bach’s lecture on HoLEP and also Prof. Dr. Olivier Traxer’s presentations, which included many useful tips and tricks.” Dr. Carl: “From my point of view, the masterclass highlights were the live surgeries featuring HoLEP, en-bloc resection of bladder-tumour and the operation of the ureteral-stricture; and the roundtable discussions with case presentations which were very helpful for my daily routine work. All in all, it was a very good masterclass.” Searching for opportunities to enrich what you know and fine-tune your skills? An ESU masterclass(es) could be what you are looking for. Visit to see which masterclass(es) will suit your needs.

All eyes on laser techniques

Dr. O’Kelly: “I was interested to see the technique for HoLEP. The live surgeries and the description of the technique were excellent. Regular deliberations with the faculty boosted the learning experience.” For you, what are the highlights of the masterclass? Dr. Javed: “I truly enjoyed examining techniques during the live surgeries. Also the friendly and productive interaction between the faculty and participants was conducive to learning. I want to commend Mrs. Jacobijn Sedelaar-Maaskant and Mrs. Wendy Dennissen of the ESU for the excellent organisation of the masterclass. Well done!” Dr. O’Kelly: “For me, the highlights of the masterclass were the live surgeries demonstrating HoLEP, en bloc resection and UTUC management; the case-based discussions which generated interesting debates; and the lectures. I enjoyed all of them, especially

Art Nouveau influence in the Sant Pau halls

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

2nd ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer

16-17 May 2019, Heilbronn, Germany

21-22 February 2019 Prague, Czech Republic

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

January/February 2019

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

European Urology Today



ESU course delivers PCNL essentials at ATU congress A report on topics, scientific programme, PCNL tips and tricks The recently concluded 18th Congress of the Tunisian Association of Urology (ATU) has attracted more than 300 participants from Tunisia, Algeria, Morocco, Senegal, France, Germany, India and Greece last October in Hammamet, Tunisia. Its scientific programme included many relevant topics such as urolithiasis, hypofertility, bladder tumour chemotherapy, and adrenal gland surgery; and the course on percutaneous nephrolithotripsy (PCNL) which was organised by the European School of Urology (ESU). About the ESU course Led by Prof. Rolf Muschter (DE) and Prof. Panagiotis Kallidonis (GR), the course commenced on 18 October with an overview of ESU activities: masterclasses; programmes such as EUREP (European Urology Residents Programme); e-courses focusing on topics such as metastatic prostate cancer, mechanisms and management of the overactive bladder, and more; and webinars presented by international key opinion leaders. Afterwards, Prof. Kallidonis discussed the recommendations of the EAU Guidelines on PCNL. This was followed by a lecture by Prof. Muschter, who gave an itemize review of equipment needed for a

No empty seat left during the ESU Course

successful PCNL. He tackled instrumentation topics such as suite organization; imaging of stone and renocalyceal system; access needle and guide/safety wire; tract dilation; instruments; stone fragmentation and retrieval; and nephrostomy. The ESU course successively delivered a detailed description of PCNL techniques in prone and supine positions. Prof. Kallidonis discussed the place of mini-PCNL in percutaneous procedures in great detail. He stated that in choosing an endourology approach based on stone size is similar to choosing your vesicle based on the distance. For the large stones, Eager participants fill the room Prof. Kallidonis opts for 21-30F; for smaller stones, he prefers Retrograde Intrarenal Surgery (RIRS) instead of 8.5 - 18Fr. carries a higher risk of perforation but a lower risk of dislocation. Avoid dislocation during dilation, use Tips and tricks fluoroscopy. The wire can dislocate when inserting Participants received handy PCNL tips and tricks such as: dilators and instruments, and when removing dilators and instruments. Use fluoroscopy and have an On patient positioning: “Bend” the patient to achieve assistant to secure the wire. as much room as possible between the ribs and pelvic bones. On endoscopy and fragmentation: The sheath is one’s safe access to the stone and pelvicalyceal system. However, it can perforate and dislocate. Therefore, On visualization: Use small volumes of contrast medium and try to avoid extravasation. In ultrasound have the sheath carefully secured at all times. Use low guided puncture, one pressure irrigation and avoid too much pressure on must take his/her time to the stone. Modern fragmentation devices do not find the optimal position. require much pressure. Once the stone or calyx is located, rotate the Try to avoid working without vision and remember scanner if required. that lithotriptors can cause perforation. Fragments that are too big cannot pass through the sheath, nor On access: Never use a is it possible to remove them. Fragmentation requires blunt or bended needle. time and patience is needed. Forward the needle fast towards the kidney and As it is not always possible to avoid complications, the slow in the kidney. ESU course also offered effective ways to deal with complications such as if bleeding does not stop, the On guide wire and nephrostomy tube can be closed to achieve tamponade dilation: A rigid wire (this requires attention and high-frequency care).

Fine-tuning their basic laparoscopic urological skills

E-BLUS Morning sessions on 19 October were dedicated to the European training in basic laparoscopic urological skills (E-BLUS) programme. Prof. Dr. Ali Serdar Gözen (DE) gave a quick welcome presentation followed by the E-BLUS training wherein two groups of 11 participants spent 90 minutes honing their skills in basic laparoscopy. The ESU course concluded with take-home messages, interactive discussions on local patient cases, and a quiz with participation from local faculty members Dr. Mohamed Yassine Binous (TN) and Dr. Salem Braiek (TN). As in previous years, we are honoured to host ESU courses in our congresses. We express our appreciation for the support of Prof. Muschter and Prof. Kallidonis. The large attendance of residents and junior urologists this year exceeded our expectations. This demonstrated that the course was not only well-attended but also appreciated by Tunisian urologists. Assoc. Prof. Mohamed Yassine Binous Vice President, Tunisian Association of Urology

3rd ESU-ESUT Masterclass on Urolithiasis

ESU - Weill Cornell Masterclass in General urology

14-15 June 2019, Patras, Greece This Masterclass has been accredited by the EACCME® with 10 European CME credits (ECMEC®s)

23-29 June 2019, Salzburg, Austria An application has been made to the EACCME® for CME accreditation of this event


European Urology Today

January/February 2019

New UROONCO delivers best topic-based content to HCPs EAU Edu Platform offers urological cancer updates By Jarka Bloemberg and Erika De Groot With the abundance of online sources in the age of Google, reliable and concise content is king. Hence the inception of the new and improved EAU Edu Platform. An initiative by the European Association of Urology (EAU) in collaboration with the European School of Urology (ESU) and European Urology (EU), this educational platform showcases the latest developments in various fields of urology with the main objective of providing clear, accurate and topic-related content. The increase in online scientific content in the past years is continual and massive. To make this colossal content easily accessible, compact and always relevant, the EAU Edu Platform aims to provide healthcare professionals (HCPs) with frontline updates beneficial to their clinical practice. Expect a mix of scientific and educational content ranging from the latest scientific articles, videos, e-courses, webinars and valuable insights of key opinion leaders on new urology developments and meeting highlights (both EAU and non-EAU; both European and non-European). First platforms The first topic-based platform launched early December was UROONCO, which covers three topics: Prostate Cancer, Kidney Cancer, and Bladder Cancer. UROONCO was initially an Elsevier undertaking but the management and coordination was taken over by the EAU in July 2018. The platform was completely rebuilt and revamped in a contemporary, interactive and user-friendly way designed with HCPs in mind, such as urologists with varied levels of expertise; nurses, researchers and patients can benefit from the information found on the platform as well. So far, this approach has been proven successful. Collectively, UROONCO received a

EAU Edu Platform The online learning platform for GU cancers

whopping 2,500 unique site visits in just two weeks since its launch beginning of December.


The early success of the new educational platforms strongly depends on the selective curation of relevant and newsworthy content. This is the task of the editorial board. Each topic is overseen by dedicated editorial board members. They are experts in their field, experienced reviewers and published authors in highly-regarded scientific journals who handpick the best content for the platform on a monthly basis. By providing their perspectives on new research and developments in concise commentaries, visitors have a better idea of the impact of these new developments to their clinical practice.

"The main objective is to provide clear, accurate and topic-related content." More to come In January 2019, the final design stages of the platforms for Male LUTS (Lower Urinary Tract Symptoms), Bedwetting and Nocturia will be completed. The designated editorial boards are already working on the first updates. If the success of the first platforms is steady, topic expansion can be expected. Another ambition for 2019 is to pursue accreditation from EU-ACME (European Urology- Accredited Continuing Medical Education) for the whole platform. Together with the EU-ACME board, the first steps are being looked into. Granted that ESU e-courses are already credited, UROONCO will run CME-accredited activities such as monthly assessments through multiple-choice questions in the near future. To know more about UROONCO, feel free to explore

GUA-CCA19 1st Georgian Urological Association Caucasus Central Asia Meeting 4-5 October 2019, Tbilisi, Georgia




Visit for the best curated content in GU cancers Powered by

EAU Education Online proudly presents:

A New EAU Guidelines E-Course:

Non-muscle-invasive bladder cancer (NMIBC) How well do you know the EAU Guidelines? Educate and test yourself with this new course in the series of EAU Guidelines E-courses. The online course features questions formulated by experts in the field, reviewed by

In conjunction with the European Association of Urology (EAU)

the EAU Guidelines Office and the Young Urologists Office. Non-muscle-invasive bladder cancer (NMIBC) Learning Objectives • Review the most updated EAU guidelines on Non-muscle-invasive bladder cancer (NMIBC) • Learn how to make informed decisions in treatment of Non-muscle-invasive bladder cancer (NMIBC) Patients • Test your knowledge on the latest developments in Non-muscle-invasive bladder cancer (NMIBC) according to the EAU Guidelines

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More info:

January/February 2019

European Urology Today


Social media in office urology - this will make you think Discover your online identity • • • • •

The number of internet users worldwide in 2018 is 4 billion, up 7% this year. The number of social media users worldwide in 2018 is 3,2 billion, up 13% this year. More than 3 billion people use social media each month. Facebook has 2,1 billion users. Every second, 11 people use social media for the very first time.

Dr. Stefan Czarniecki ESUO Board Member Warsaw (PL)

@DrCzarniecki Think about these numbers for a moment - the internet is changing! One of the pivotal events happening right now is the emerging dominance of social media on the internet and in human communication. Social media continue to transform the way we communicate with regard to practically every aspect of our lives. The internet is becoming less of an entanglement of website addresses displaying meticulously curated content aimed at good SERP results by a nimble but costly combination of SEO, SEM, and PPC (SERP - Search Engine Result Position, SEO - Search Engine Optimisation, SEM - Search Engine Marketing, PPC - Pay Per Click Advertising). Nowadays the users are creating the content – and that is what social media is all about. And, generally speaking, the content is predominantly self-curated. Impact on healthcare professionals This means that - whether you like it or not - content related to you will be generated on social media EAU Section for Urologists in Office (ESUO)

without your consent, curation, or control. You can try to fight it but you won’t win, the phenomenon has already conquered the whole world. If you haven’t noticed it, it’s not because it is not important since nothing seems to have changed, but rather because it’s so large that you are missing the motion of the entire online space moving in the direction of social media.

"The innate inability to effectively manipulate social media content means it has the potential to represent an accurate and reliable representation of a physician...." Real time news The diurnal rhythm of the internet is in a constant ebb and flow, through all of the time zones of the world, over and over again without end. It’s @LoebStacy Tweeting live in late-night New York to the smell of my Warsaw morning coffee, and @declangmurphy starting his day checking in online in Melbourne half a day later. We are no longer watching the evening news to catch up, if we’re interested in the topic (whatever it is) we instantaneously know about it as it happens on social media. Institution website Institution websites with chiseled but dry biographies of their talented medical staff will continue to exist, just as banks will continue to locate their branches along prominent city avenues. For the sake of credibility. But when did you last physically visit your bank? If you’re one of the 4 billion global internet users who have spent a total of 1 billion years online

in 20181, you may answer: there’s an app on my phone for that. It’s great that your bank has a branch on Times Square, but if I actually need my bank, I will use my phone. Online reputation boosting The era in which pseudo prominent urologists took the regulation of their reputation into their own hands by claims of excellence and perfection through unparalleled talent and volume is threatened. Their websites optimised to capture the attention of search engines with text littered with key phrases of promise of imminent diagnostic or surgical success – perhaps a dying breed. Will social media regulate this malign online phenomenon? Are these headlines here to stay? “Doctor faces lawsuits over double-booked surgeries” – Boston Globe “The celebrity surgeon who used love, money, and the pope to scam an NBC News reporter” - Vanity Fair “Fake Doctor Ran Greek Hospital” - The National Herald The humility and service ingrained in our profession must prevail, despite the temptations to do otherwise – not only because “[…] physicians who are aware of and acknowledge their limitations are often appreciated by their patients. A doctor's humility enhances the patient-physician relationship. Admitting shortcomings or even mistakes is the opposite of arrogance”. Checks and balances Where are the checks and balances in the online world? Where is the modern version of a genuine word-of-mouth opinion? Well, in a distracted and geographically scattered world, they’re found online. On social media! Therefore, as long as there is social media there is hope. The innate inability to effectively manipulate this content means that it has the potential to represent an accurate and reliable representation of a physician and his/her practice in the online world.

Take control Thus, it is wise to take control of your online identity in order to provide a platform for this genuine content to be published as a result of real-life physicianpatient encounters. Yes, it may be smart to set up a personal website. Yes, professional profiles on Facebook (Facebook Page, not a personal profile), Twitter, Instagram make sense. Video channels are an excellent way to be present online in your specialty. Some may consider writing blogs (perhaps). No, being passive about the way your identity is listed on “user review” websites is not a good idea. Where to start Whatever you decide, experts will agree that the very first step is to discover what your online identity really is. Find your online self. Actually, do it regularly, perhaps once a month, after setting your webbrowser to private mode. Google your name! References 1. 2. doctor-faces-lawsuits-over-double-booked-surgeries/ z1xpRvOYGScrutF758KO6H/story.html 3. 4. 5. 6. Growing Your Practice on Social Media, Jamin Brahmbhatt, MD, SMSNA 2017

EAU-SUO Scholarship in Phoenix and Rochester Report on a wonderful and instructive experience Dr. Fabio Zattoni Urology Unit Academical Medical Centre Hospital Udine (IT)

fabiozattoni@ I was very pleased when I learnt that I had been selected for the 2018 EAU-SUO (Society of Urologic Oncology) Scholarship. It consisted of attending the SUO meeting in Phoenix (US) followed by a 2-week programme at the Mayo Clinic (Rochester, US). The 19th Annual Meeting of the SUO in Phoenix gave me an extraordinary opportunity to come into contact with experts from diverse professional and cultural backgrounds, who are working in top hospitals in the US. In this highly instructive meeting, attendees participate in discussions led by internationally renowned urological oncologists, medical oncologists and scientists. State-of-the-art translational topics on prostate, kidney and bladder cancer as well as strategies in urological oncology are discussed. One presentation gave me a particularly fascinating insight into the influence of physical activity and diet on cancer risk and progression. Improving skills and flexibility While I was at the Mayo Clinic, I was able to both observe the consultants during clinical practice and operations in the surgery theater, and attend several meetings and research activities. More specifically, I was involved in translational research on advanced prostate cancer. The study results will be published soon. 24

European Urology Today

The Mayo Clinic offers a state-of-the-art facility, an advanced level of health care and a top of the class, pragmatic approach to therapeutic treatments. As a result of the EAU-SUO Scholarship I have not only improved my professional skills as a doctor but I have also become more flexible about operating in different clinical environments, collaborating with peers and staff members. I learned to look at medical cases from different angles. The needs of the patient come first This exchange programme was an excellent opportunity to foster the relationship with my mentor, Dr. Robert J. Karnes and with young, passionate researchers. Additionally, it allowed me and my institution to make new connections for further research collaborations. The final take-away from this experience is probably the most important. I was reminded of the core clinical values. ‘The needs of the patient come first’, as they say at the Mayo Clinic. In order to do that, we need Respect, Integrity, Compassion, Healing, Teamwork, Innovation, Excellence and Stewardship. I was inspired by all these principles, all of which I experienced fully during my scholarship.

Fellow in front of the Mayo Clinic

January/February 2019

The future of the underactive detrusor Recognition of critical bladder changes and identification of biomarkers are essential Dr. Luis Vale Centro Hospitalar de São João Dept. of Urology Porto (PT)


Dr. Tiago Antunes Lopes Centro Hospitalar de São João Dept. of Urology Faculty of Medicine, University of Porto Porto (PT) tiagoantuneslopes@

Prof. Francisco Cruz Chairman, ESFFU Dept. of Urology, Centro Hospitalar Sao João Faculty of Medicine of Porto Porto (PT) Detrusor underactivity (DU) was defined by the International Continence Society (ICS) as “a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span”, based on urodynamic testing1. Later a new definition of a symptomatic complex associated with DU was proposed, based on a reverse analogy to DO (urodynamic diagnosis) and overactive bladder (OAB, a symptom complex): underactive bladder (UAB). This is “a symptom complex usually characterised by prolonged urination time with or without a sensation of incomplete bladder emptying, usually with hesitancy, reduced sensation on filling, and a slow stream”2. This clinical definition is far from being accepted worldwide. Moreover, it does not include any key symptom such as urgency. And likely, such a feature may never be identified. In fact, in a recent survey in which LUTS in DU and control subjects were compared, UAB symptom complex was predominantly characterised by voiding symptoms such as weak/ interrupted stream, hesitancy, straining to void and decreased bladder sensation3. However, it is clear that in patients with UAB frequency, nocturia and incontinence may also be present, blurring the clinical picture4,5. Ideal questions for surveys Therefore, it is important that we concentrate on identifying the ideal questions for future research on DU, in order to separate DU from other conditions. These questions can then be used in surveys to estimate the prevalence of the condition across the world. A first attempt to estimate the impact of DU using specific questions was recently carried out in US. Three questions: “How often do you have to strain/push to empty your bladder?”, “During the day, how strong was the feeling that you did not fully empty your bladder after you urinated?” and “Do you feel like you have difficulty emptying your bladder?” were sent by email to 25,000 individuals of 60 years and older. Around 40% of the responders answered affirmatively to at least one of these questions. Severe bother was reported by almost all responders who answered positively to all 3 questions (Fig. 1).

Moreover, future studies using PFS should be stratified by age and sex. Future research should also be oriented on uncovering non-invasive tests that may be used for population-based studies. Bladder voiding efficiency (BVE: voided volume/[voided volume + PVR (postvoid residual) volume] × 100%) might be an ideal test, at least in women. In a recent study, it was concluded that BVE criteria could be applied to clinical practice, replacing PFS in the diagnosis of DU in women with LUTS5. When compared to PVR volume alone, BVE, combining PVR volume and voided volume, seems clearly superior. The addition of flow parameters (Qmax) might further refine the non-invasive urodynamic tests in the diagnosis of DU. Natural history of DU Another critical area for future research is the description of the natural history of DU. Thomas and co-workers identified 69 male patients with DU who were followed by watchful waiting (WW) for a minimum of 10 years. They concluded that 15% of the patients showed a progression of the condition requiring de-obstructive surgery such as TURP. However it was not clarified whether patients at risk could be identified at an early stage of the disease. In contrast, another study carried out by the same institution may suggest a different natural history of DU. Men submitted to TURP due to bladder outlet obstruction (BOO) who developed LUTS de novo 10 years after, were submitted to a new PFS investigation. The results showed that despite de-obstruction, 1/3 of the men had developed DU. This observation might indicate that some male patients develop critical bladder changes that inevitably lead to progression to DU, even in the absence of BOO6. Recognition of those critical bladder changes and the identification of biomarkers to select men at risk seem fundamental areas of translational research. Discovering DU biomarkers and treatments The last critical area in the future of DU is the investigation of its aetiopathogenesis. This knowledge is a fundamental step if DU biomarkers and DU treatments are to be discovered and used in daily practice. Looking at the literature, this field seems rather forgotten, perhaps because of the difficulties in carrying out adequate clinical research or using representative experimental models. Also, the overlap between DU and BOO in men has made progression in this area more difficult as in many cases it is unclear whether detrusor underactivity represents a true bladder change or a response to a chronic prolonged obstruction. Ageing causes well-known changes in the morphology of detrusor smooth muscle cells. Electron microscope studies of human bladders by Elbadawi and co-workers showed that during normal ageing, smooth muscle bladder cells develop dense bands along the cytoplasmic membranes, lose caveolae, form large vacuoles in the sarcoplasm and exhibit residual intermediate cell junctions. These changes are believed to impair smooth muscle contraction7. Electron microscope changes were recently investigated as predictors of detrusor activity following de-obstructive surgery. Bladder biopsies of patients with a large number of abnormal detrusor ultrastructural features - variation in muscle cell size, muscle cell shape, collagenosis and abnormal fascicles - had lower probability to urinate successfully following TURP8.

An estimation of the prevalence of DU is obviously more complex compared to UAB, as it requires pressure-flow studies (PFS). Therefore, future research needs to shed some light on critical aspects of urodynamic tests. One is the establishment of the widespread use of cut-offs. Without that, prevalence is difficult to establish as previous studies showed large variations, with values ranging between numbers as low as 9% and as high as 48%. EAU Section of Female and Functional Urology

January/February 2019

Fig. 1: Results of a recent US study on detrusor underactivity

MiRNAs in BOO These studies underline the dictum that structure determines function, and underscore the role of detrusor muscle biopsy for ultrastructural analysis as a useful tool for selecting patients with DU who may not benefit from surgery. However, an electron microscope is not a practical tool in daily clinical practice.

Diabetes is an increasing health problem in the western world and an important cause of detrusor underactivity. Hyperglycaemia leads to autonomic neuropathy (axonal degeneration and segmental demyelination) through generation of free radicals and formation of advanced glycation end-products15. Interestingly, animal models using streptozotocininduced diabetes have shown decreased levels of nerve growth factor in the dorsal root ganglia cells In an attempt to identify patients with BOO who might associated with raised postvoid residuals16. develop DU, Gheinani et al. investigated the The future of DU regulatory role of miRNAs in BOO-induced lower Specific treatment of DU is at present unavailable, urinary tract dysfunction (LUTD)9. They performed an integrated analysis of miRNA and mRNA paired leading many clinicians to have a negative view on expression profiling in the bladder biopsies of human treatment of the condition. At this moment, typical DU patients using sequencing–derived transcriptome management is to correct the underlying conditions, data. The results revealed unique miRNAs such as BOO and diabetes, as much as possible and characteristics of BOO/DU. These findings also to circumvent the problem by using intermittent represent an association between bladder dysfunction catheterisation. So far, very few drugs are under and the underlying biological processes putting BOO investigation for DU. These include modulators of the in motion at a molecular level. muscarinic receptors, purinergic agonists or neuronal protectors as fampridine already used for some Nevertheless, future research cannot ignore classical neurological diseases. However, we believe that none observations linking BOO with cholinergic denervation of them will be available to help DU patients in the of the bladder. Denervation of obstructed rabbit and next five to ten years. Research consortiums involving human bladders was confirmed biochemically upon academia, scientific societies and industry, possibly measuring acetylcholinesterase activity in control under the umbrella of the European Community and versus obstructed bladder samples10. This process may European organisations, may contribute strongly to be irreversible and prevent effective detrusor speeding up the entire process. Everybody needs to contractions, even after successful de-obstruction. The be aware that the ageing of the population in western latter observation may explain why, in a study lasting societies will strongly increase the DU problem. more than two decades, patients submitted to TURP after a period of watchful waiting showed less References improvement in lower urinary tract symptoms than 1. Abrams, P., L. Cardozo, et al., The standardisation of patients submitted to TURP immediately11. terminology of lower urinary tract function: report from Role of sensory impairment Research on DU also needs to clarify the role of sensory impairment in the development of the condition. This is particularly relevant, since one of the symptoms most commonly reported by patients with DU is a decreased sensation of bladder filling. Bladder sensory input is generated through a crosstalk between the urothelium and the suburothelial sensory fibres. Thus, DU may arrive from an impairment of this key step of the micturition reflex. Jiang and Kuo investigated urothelial barrier deficits, sub-urothelial inflammation and sensory proteins expressed in the bladder mucosa of patients with DU. These patients showed a lower expression of P2X3 receptors and endothelial nitric oxide synthase (eNOS) and a higher expression of β3-adrenoceptor than controls12. In rats with DU, a decreased release of ATP was observed and the urinary levels of the neurotransmitter correlated with the frequency of voiding contractions. Another sensory input triggering bladder contractions comes from the urethra and is called the urethrovesical reflex. Urethral anaesthesia of humans with lidocaine prevents the bladder to generate normal voiding contractions13. The recent identification of neuronal-like cells in the proximal urethra that may recognise the urine flow and contribute to the build-up of urethral sensory input, further increase the interest of researchers in the role of the urethrovesical reflex in DU14. Some of the neuronal-like cells release serotonin and the administration of this monoamine to the urethra is able to stimulate local sensory fibres and trigger effective bladder voiding contractions, even in animals with detrusor underactivity.

the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn, 2002. 21(2): p. 167-78. 2. Chapple, C.R., N.I. Osman, et al., The underactive bladder: a new clinical concept? Eur Urol, 2015. 68(3): p. 351-3. 3. Gammie, A., M. Kaper, et al., Signs and symptoms that distinguish detrusor underactivity from mixed detrusor underactivity and bladder outlet obstruction in male patients. Neurourol Urodyn, 2018. 4. Aldamanhori, R. and C.R. Chapple, Underactive bladder, detrusor underactivity, definition, symptoms, epidemiology, etiopathogenesis, and risk factors. Curr Opin Urol, 2017. 27(3): p. 293-299. 5. Gammie, A., M. Kaper, et al., Signs and Symptoms of Detrusor Underactivity: An Analysis of Clinical Presentation and Urodynamic Tests From a Large Group of Patients Undergoing Pressure Flow Studies. Eur Urol, 2016. 69(2): p. 361-9. 6. Thomas, A.W., A. Cannon, et al., The natural history of lower urinary tract dysfunction in men: minimum 10-year urodynamic follow-up of untreated bladder outlet obstruction. BJU Int, 2005. 96(9): p. 1301-6. 7. Elbadawi, A., S. Hailemariam, et al., Structural basis of geriatric voiding dysfunction. VI. Validation and update of diagnostic criteria in 71 detrusor biopsies. J Urol, 1997. 157(5): p. 1802-13. 8. Blatt, A.H., S. Brammah, et al., Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes? J Urol, 2012. 188(6): p. 2294-9. 9. Gheinani, A.H., B. Kiss, et al., Characterization of miRNA-regulated networks, hubs of signaling, and biomarkers in obstruction-induced bladder dysfunction. JCI Insight, 2017. 2(2): p. e89560. 10. Levin, R.M., N. Haugaard, et al., Obstructive response of human bladder to BPH vs. rabbit bladder response to partial outlet obstruction: a direct comparison. Neurourol Urodyn, 2000. 19(5): p. 609-29. 11. Wasson, J.H., D.J. Reda, et al., A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med, 1995. 332(2): p. 75-9. 12. Jiang, Y.-H. and H.-C. Kuo, Urothelial Barrier Deficits, Suburothelial Inflammation and Altered Sensory Protein Expression in Detrusor Underactivity. J Urol, 2016. 197(1): p. 197-203. 13. Shafik, A., A.A. Shafik, et al., Role of positive urethrovesical feedback in vesical evacuation. The concept of a second micturition reflex: the urethrovesical reflex. World J Urol, 2003. 21(3): p. 167-70. 14. Coelho, A., R. Oliveira, et al., Evidence for an urethrovesical crosstalk mediated by serotonin. Neurourol Urodyn, 2018. 15. Fedele, D., Therapy Insight: sexual and bladder dysfunction associated with diabetes mellitus. Nat Clin Pract Urol, 2005. 2(6): p. 282-90; quiz 309. 16. Sasaki, K., M.B. Chancellor, et al., Diabetic cystopathy correlates with a long-term decrease in nerve growth factor levels in the bladder and lumbosacral dorsal root Ganglia. J Urol, 2002. 168(3): p. 1259-64.

European Urology Today


Young Urologists/Residents Corner First edition of Focus meeting New meeting aims to improve outcomes in onco-urological cancers Dr. Guillaume Ploussard Chairman EAU-YAU Prostate Cancer Working Group Member, Organising Committee FOCUS Meeting Toulouse (FR)

Dr. Paul Sargos Member EAU-YAU Urothelial Cancer Working Group Member, Organising Committee FOCUS Meeting Bordeaux (FR) paulsargos@

Co-authors: Dr. Mathieu Roumiguié and Dr. JeanBaptiste Beauval, Members of the Organising Committee of the FOCUS Meeting The 1st edition of the annual FOCUS (Forum d’OnCoUrologie du Sud) meeting took place on 11 and 12 October 2018 in the ‘pink’ city of Toulouse. The south-west region of France is known for its epicurean way of life, rugby culture and its conviviality! FOCUS is a national congress aiming to address onco-urological topics which focus on the optimisation of both functional and oncological outcomes. We organised a 2-day meeting with national and international experts with many interactive discussions on the important issues within prostate, urothelial, kidney, penis and testis cancer and were happy to attract approximately 150 participants for the first edition.

Young urologists show interest The EAU Young Urology Office and the Young Academic Urologists boards have strongly supported this initiative. We would like to thank all these members sincerely including, of course, Prof. Selcuk Silay, our EAU-YAU chairman. FOCUS was also supported by national scientific societies involved in uro-oncology, including the French Association of Urology (AFU) and its Cancerology Committee (CC-AFU), and the Groupe d’Etude des Tumeurs Uro-genitales (GETUG). Thus, the scientific committee included both regional experts and CC-AFU Chairmen (Prof. Méjean, Prof. Rouprêt, Dr. Rozet, Prof. Bensalah, Dr. Murez). Scientific programme with six sessions The scientific programme, prepared by a multidisciplinary team of urologists, oncologists and radiation oncologists, was designed with a focus on peri-treatment strategies aimed to improve outcomes in prostate, testis and kidney or bladder cancers, with six scientific sessions and 2 industry-sponsored symposia. Prof. Michel Soulié, Head of the Urology Department of the Toulouse University Hospital (FR), has supported this ambitious event since the beginning of the adventure and chaired this first edition. His warm introduction set the tone for a friendly meeting. Sexual function preservation To mention just one example, one of the prostate cancer sessions focused on sexual function preservation and encompassed outstanding presentations by Dr. Thomas Bessede on the surgical anatomy of neurovascular bundles, by Dr. Richard Gaston on the maximal peri-prostatic preservation during robot-assisted radical prostatectomy, and by Prof. Olivier Chapet on optimised radiotherapy doses to improve erectile function preservation. The ‘European Corner’, involving several YAU members, enticed interactive debates on the management of

oligo-metastatic patients in Kidney (Dr. U. Capitanio, Milan, IT) and prostate cancer (Dr. P. Ost, Ghent, BE). On Friday morning, a Joint Session including key opinion leaders from GETUG, AFU and EAU-YAU was led by Dr. Guilhem Roubaud, medical oncologist from Bordeaux (FR) and Idir Ouzaid (YAU Kidney cancer working group), urologist from Paris (FR). The kidney and prostate cancer management in 2018 (discussion of CARMENA, STOMP, HORRAD trials), the EAU-YAU team during a social event at the ’Hotel-Dieu’, an ancient hospital in the centre of recent changes in Toulouse (Drs. Ouzaid, Sargos, Xylinas, Capitanio, Mathieu, Ost, Ploussard) guidelines and the potential disparities among countries and health care systems were critical analysis he concluded that a step forward can discussed. be made by implementation of these recent data in the current update of the guidelines. Indeed, at the Insights into metastatic prostate cancer end of his talk, he revealed that, for the first time Among the distinguished guest speakers was Prof. ever, an EAU recommendation will be included in the Fred Saad, Head of the Department of Urology in the guidelines on making an MRI before taking biopsies CHUM, Montreal (CH). He delivered a brilliant lecture in the treatment. Breaking news and applause from on the management of hormone-sensitive and the audience! castration-resistant metastatic prostate cancers in the light of recent data from phase III randomised trials Save the date recently presented at international meetings. Save the date: the second edition of the FOCUS Numerous uncertainties and future hopes were meeting is scheduled for 17 and 18 October 2019 addressed for this field, which is in continuous under the umbrella of EAU-YAU and the motion. presidency of Prof. Arnaud Mejean, Chairman of the French Cancerology Committee, principal Prof. Nicolas Mottet, chairman of the EAU Prostate investigator and first author of the CARMENA Cancer Guidelines, gave a lecture on the ‘Integration article. of MRI in the management of prostate cancer’, with special reference to the recent PRECISION study. In his Toulouse is waiting for you!

VCMS in cooperation with the ESRU Education day ‘Minimal Invasive Surgery in Urology’ Irina Filz Von Reiterdank Chairman VCMS Nederland Utrecht (NL) The Dutch Surgical Society for Medical Students (DSSMS, or in Dutch ‘VCMS’) focuses on students with a special interest in surgery. Its local departments were founded in the eight Dutch academic centres. The aim is to offer supplementary extracurricular education in surgical specialisms to medical students in their bachelor phase. The national board (‘VCMS Nederland’) oversees the local branches, provides supplementary surgical education for medical students in a Master Academy and organises national events for members and external interested parties. This educational activity is provided in cooperation with surgical specialists, residents and commercial companies. During the Master Academy, senior medical students (‘co-assistenten’) are offered extracurricular surgical education. This year, the Master Academy has about 120 members. During the course of this year, seven Saturdays will be devoted to three areas: Surgical Anatomy and Imaging, Surgical Knowledge, and Surgical Practice and Skills. Surgical practice and skills On Saturday 15 December 2018 the module centred on Surgical Practice and Skills took place. This day was organised at the LUMC (Leiden University Medical Centre) with the topic: ‘Minimal Invasive Surgery in Urology’. The structure of this day was composed in 26

European Urology Today

cooperation with Dr. J. Gómez Rivas (Chairman ESRU), T. Brouwers (Project Manager Education and Training, EAU Office, NL) and Dr. P.J. Zondervan (urologist, UMC Amsterdam, NL). Several lectures were given and VCMS members could gain some hands-on experience during the workshops. Dr. C.A. Goossens-Laan (urologist, Alrijne Hospital, Leiden, NL) began the day with an introduction to laparoscopy. It covered the anatomy of the perineum, the physiology of the pneumoperitoneum and haemostatic principles during laparoscopical procedures. After the introductory lecture, there were two rounds of workshop in parallel groups, aiming to stimulate small-scale education. During the first two workshops the working principles of the endoscope, the cystoscope and lithotripsy were investigated. Donald Schweitzer (Master Academy member and student-researcher urology) guided the VCMS members in the simulated treatment of endoscopic renal stones with the aid of flexible uretherorenoscopes.

National Board VCMS. From left to right: Amaran Suntharan, Manou Huijben, Roger Lodewijkx, Irina Von Filz, Bas Dalmeijer, Loes Hartveld, Justin Van Loon

in the urological field and compared perioperative results of minimal invasive surgery techniques. Dr. R.F.M. Bevers (urologist, LUMC, NL) took the attendants through radical nephrectomy step by step, including the positioning, different approaches (trans-peritoneal versus retro-peritoneal) and known Interesting plenary lecture (anatomical) stumbling blocks. After the plenary After lunch, Drs. E.J. Van Gennep (urologist, LUMC, NL) gave a lecture on laparoscopic and robotic surgery lectures, the groups were switched and attended the other workshop. These were the trappings of the laparoscope, the Da Vinci robot and exercises with eye-hand coordination for students during training sessions in laparoscopy simulation boxes as well as with the different stitching techniques during conventional suture, laparoscopic suture and suture with the Da Vinci robot. The latter was under the guidance of Dr. O.R. Brouwer (resident urologist, Antoni van Leeuwenhoek, NL) and Drs. Van Gennep.

Plenary lecture room

Networking The day ended with a networking activity during which students and specialists could share their experiences of the day. The broad range of theoretical

urological knowledge and practical skills was highly appreciated by our members. We thank everyone who has contributed to the success of this VCMS Master Academy education day. For more information on VCMS, the Master Academy and national events, please visit Nederland.

Practice makes perfect

January/February 2019

Young Urologists/Residents Corner YUO board meeting in Amsterdam Finishing a fruitful year, opening the window for 2019 Dr. Leonardo Tortolero Blanco Hospital IMED Levante Benidorm (ES) The year 2018 was one of the most fruitful ones for the YUO (young urologists office) of the EAU so far because its two main arms - ESRU (European Society of Urology Residents) and YAU (Young Academics Urologist) - accomplished some great achievements and successfully carried out several projects in this period. During a board meeting held in Amsterdam and led by Dr. M. Sedelaar (NL) (chairman of the YUO), Juan Gomez Rivas (ES) presented a summary of the ESRU activities in 2018. He highlighted the realisation of the YUORDay18 during the Annual EAU Congress in 2018 and also the open collaboration with ESU with regard to training and education projects such as the Endo-urology Olympics. And we should not forget, of course, the efforts to create the Non-Technical Skills for Surgeons (NOTSS) course.

YAU annual report Later this year we expect the long-awaited annual report of the YAU (Young Academic Urologists), a group made up of 88 young talented European urologists with great academic and scientific talents, grouped into 11 subgroups by area of knowledge, e.g. the recently created urotechnology group led by Domenico Veneziano from Italy. In 2018, 44 scientific publications were indexed and a few awards were won. YAU subgroup members active as reviewers of urological journals will take on a role as academic references, supported by young colleagues with a high, worldwide urological scientific production. This seems to be the start of a great tradition, since 4 out of the last 5 Matula prize winners were a member of YAU and the winner of this prize in 2018 was the YAU chair, Prof. Selcuk Silay (TR). Goodbye We would like to highlight the fact that the Italian member of the YUO Board, Giulio Patruno, has unfortunately finished his term in the YUO Board. He received a farewell gift and, most importantly, recognition for his contributions and valuable work for the group. For some of the group members, it was an emotional goodbye. We will certainly miss him!

YUORDay18 Guidelines Cup The results of the first edition of the Guidelines Cup during YUORDay18 were really promising and received well by the audience. We look forward to the realisation of the second edition of the Guidelines Cup to be held in 2019. There will be some improvements, such as a preceding online phase. The final phase will take place during the YUORDay19 in Barcelona with attractive prizes for the winners. YUORDay19 is presenting an attractive programme for residents and young urologists which should not be missed during the 34th Annual EAU Congress in March 2019 in YAU achievements in 2018 Barcelona.

YUO Board Meeting in Amsterdam, December 2018

Prof. Selcuk Silay, the Matula Award winner in 2018, and 3 former Matula Award winners.

Giulio Patruno receives a present from YUO Chair Dr. M. Sedelaar

YAU: Useful platform for international cooperation Young urologists combine business with pleasure during EMUC meeting in Amsterdam Dr. Tom Marcelissen Chairman, YAU Functional Urology Working Group Maastricht (NL)

The Young Academic Urologists (YAU) is a group of talented and renowned young European urologists (< 40 years old). Its main goal is to promote high-quality studies in order to provide strong evidence for the best urological practice, to promote educational programmes in order to boost European training standards and to create a platform for close international cooperation for the future urology leaders in Europe (and beyond).

How to use YAU resources efficiently Next, Umberto Capitanio, Chairman of the Renal Cancer Group, showed how to conduct an influential study using YAU sources. Being a YAU member creates the opportunity to easily connect with the Guidelines Office, the Sections Office and the ESU, the natural partners within the EAU for the development of clinical, educational and investigational projects. Lisette ‘t Hoen, urology resident and member of the Neuro-urology Guidelines Panel, informed us about the journey of systematic review and meta-analysis. Each step from hypothesis to publication was outlined in detail, which gave us good insight into the (sometimes tedious) process. After the presentations, the nine YAU subgroups proceeded with the individual brainstorm sessions. Time for pleasure All groups shared new ideas with great enthusiasm, encouraging each other to develop new research

Current and future role of YAU The YAU members have a meeting twice a year, and this year’s fall meeting was situated in Amsterdam during the 10th EMUC meeting. The meeting was opened by the chair, Prof. Selcuk Silay, who gave an inspiring talk on the current and future role of YAU. Next, the chairs of the subgroups presented the achievements of their groups. This year, a total of 44 publications was reached, a new record in the history of YAU! Also, the number of female YAU members is steadily increasing, with currently approximately 15% of all members being women. Although this number is still small, we encourage more women to join our team and hope to see this number grow in the future. January/February 2019

Sixty five YAU members gathered in Amsterdam

YAU Reconstructive Working Group brainstorming

projects. After the brains were completely drained, it was time for diner and good conversation. Not only is the YAU a great research network, it is also a place to

meet friends and have a good time. I am really looking forward to the next meeting during the 34th Annual EAU Congress in Barcelona!

Call for ‘Nightmare Cases’ For a new series in the YUO section of European Urology Today we need your contribution!

even worse case yourself? If so…

Have you ever encountered a patient case that was extremely challenging but were able to resolve it against all odds?

• What was the case? • What did you do? • Was it resolved? If yes, how?

Have you ever had a case which seemed common at first but the situation changed in an instant and you had to deal with every urologist’s worst nightmare?

We can learn from these cases to help us treat our patients better and enhance our everyday practice in the future.

Have you ever attended a Nightmare Case session and although you felt that the presented cases were truly problematic, you encountered an

Please send the details of your personal Nightmare Case and photos to: Dr. Zsuzsanna Zotter,

Dr. Geert De Nayer (BE) reporting on the activities of the YAU Working Group Robotics

European Urology Today


EUREP19 17th European Urology Residents Education Programme 6-11 September 2019, Prague, Czech Republic Unique and exclusive training opportunity General information Participation and contribution This teaching programme has been developed and created exclusively for all European urological residents. The EUREP provides an almost complete update and overview of modern urological practice presented by a distinguished European faculty. The EUREP is an initiative of the European School of Urology in collaboration with the European Board of Urology. The written part of the FEBU exam (Fellow of the European Board of Urology) will take place at a later date in different cities throughout Europe. Further information will be available on Format The format is a full six-day course comprising five modules. Each day is made up of two sessions that last around seven hours. Morning sessions feature state-of-the-art lectures, while afternoon sessions offer interactive case discussions, video, and test-your-knowledge sessions. The hands-on-training sessions will take place around the modules. The training which is sponsored by Olympus helps the participants sharpen their skills and offers hands-on interaction with state-of-the-art equipment. Venue of the EUREP Meeting The EUREP will be organised in Prague, Czech Republic. The venue at the Clarion Congress Hotel provides excellent facilities and the four-star hotel has all the necessary facilities needed for both the scientific programme and social activities. Travel Arrival date: Thursday 5 September Departure date: Wednesday 11 September after the modules end at 12.30.

Important information for applicants! The EAU/ESU will cover the cost of accommodation for European residents in a shared room as well as the cost of the course (incl. lunches, coffee breaks). However, all participants in EUREP will be responsible for their own travel costs.

Preliminary programme 2019

Registration information

Module 1 Urological cancer

Important dates Online registration opened on 7 January 2019. The selection process will be made after the close of registration on 1 May 2019. A total of 360 participants will be selected. Participants will be notified by email if they have been selected. If selected, the deadline for cancellation is 1 August 2019. After this time a cancellation fee of €500 will be charged.

Testis & Penile cancer Treatment of localised and metastatic testicular cancer Treatment of localised and metastatic penile cancer Non-muscle invasive bladder cancer Diagnosis, staging and risk stratification Management of low, intermediate and high risk disease Upper urinary tract cancer

Selection criteria Registrations can only be submitted through the online registration system. The registration will only be considered complete if the registration is accompanied by: • A letter from the head of department indicating the date that the participants training will end • A copy of your passport

Muscle invasive bladder cancer Surgical and non-surgical treatment options Neoadjuvant and adjuvant chemotherapy

As an essential part of the European Urology Residents Education Programme (EUREP) in Prague, intensive hands-on training will be delivered. This year's programme consists of hands-on interaction with state-of-the-art equipment in laparoscopy, ureteroscopy (URS) and transurethral resection (TUR) -all of which sponsored by Olympus. The workshop provides the participants with a unique opportunity to train basic techniques with complex training models and under expert supervision. Thanks to the intense tutoring scheme -with a personal tutor per training station- a fast learning effect can be expected. The courses in laparoscopy are specifically designed for individuals with minimal or no prior experience in laparoscopic suturing. Tutors will, of course, gladly adapt tasks for more experienced individuals. Basic techniques will be trained in a dedicated step-by-step programme including Scientific secretariat ESU Office 28

European Urology Today


F. Liedberg (SE)

S. Shariat (AT)

Renal cancer Diagnosis and management Treatment of localised renal cancer Management of locally advanced and metastatic disease

Module 2 Prostate cancer and male voiding LUTS Prostate cancer Screening, early detection and staging Treatment for localised disease Active surveillance, surgical treatment, radiation, focal therapy Locally advanced and metastatic prostate cancer Treatment of castration resistant prostate cancer and new agents

Additional criteria 1. EAU membership. Priority is given to those who are or become a member before the registration deadline 2. Year of training. Priority is given to residents in their final year of training (i.e. training should be finished before September of the following year based on the information received from the proof of status) 3. It is required to obtain CME credits by completing European Urology multiple choice questions (MCQ’s). For further information please check 4. First come – first served 5. English skills 6. Target per country 7. It is only allowed to attend the EUREP course once

A. Briganti (IT), Chair

S. Ahyai (DE)

S. Joniau (BE)

T. Steuber (DE)

Male voiding LUTS Medical treatment of male voiding LUTS Surgical treatment of male voiding LUTS

Module 3 Andrology, stones and upper tract endourology Andrology Physiopathology diagnosis and treatment of erectile dysfunction Penile curvature Priapism and metabolic syndrome Male infertility diagnosis and treatment Surgery for male infertility and vasectomy Male hypogonadism

For further detailed information regarding the registration rules for the 17th EUREP course we strongly recommend that you visit

Stones Aetiology, management and prophylaxis of urolithiasis ESWL treatment of urolithiasis Percutaneous and open surgery

Registration non-European residents If you are a non-European resident that is interested in taking part in the 17th EUREP course please go to for the rules and regulations regarding participation.

E. Liatsikos (GR), Chair

S.S. Minhas (GB) I. Moncada (ES)

C.M. Scoffone (IT)

Upper tract endourology Stents in the urinary tract Ureteroscopic stone manipulation Endourology in UPJ obstruction

Module 4 Functional urology Essential terminology Initial assessment Fundaments of urodynamics Stress urinary incontinence and pelvic organ prolapse Overactive bladder Reconstruction and diversion Assessing the neuropathic patient General management of the neuropathic patient Post-prostatectomy incontinence Complex issues; pain, fistula and mesh exposure

Hands-on-training workshops Sharpening Your Skills: TUR, URS, and Laparoscopy

M. Hora (CZ), Chair

intracorporeal suturing depending on individual skill level. The training curriculum for the ureteroscopy workshop is designed by Prof. Olivier Traxer of Tenon Hospital, Paris. Residents will learn about the proper use of flexible ureteroscopes using a variety of stone disposables in order to remove kidney stones. The course in transurethral resection of the prostate gives residents the great opportunity to learn more about the basics of high-frequency surgery, the instruments needed, as well as tips and tricks for daily surgery.

G. Kasyan (RU), Chair

J. Heesakkers (NL) G. Karsenty (FR)

K.D. Sievert (AT)

Module 5 Paediatric urology, trauma and infection Paediatric urology Essentials of obstructive uropathy Congenital malformations of the external genitalia Infections Urinary tract infections

H. Abol-Enein (EG), Chair

B. Burgu (TR)

Y.F. Rawashdeh (DK) F. Wagenlehner (DE)

Trauma Diagnosis and management of kidney, bladder and urethral trauma

Participants can only participate in 1 session Lap plus a TUR or URS. Places for URS and TUR are limited. More information about the different training modules can be found at The hands-on-training workshops are sponsored by an unrestricted educational grant from:

T +31 (0)26 389 0680 F +31 (0)26 389 0674

“If you meet the criteria we would encourage you to register for this opportunity, “ Prof. Palou, course director January/February 2019

Developments in bladder cancer surgery Open versus minilaparoscopy versus robot-assisted cystectomy Prof. Jørgen Bjerggaard Jensen Chairman, Scandinavian Urothelial Cancer Group Aarhus (DK) bjerggaard@ Radical cystectomy is the gold standard treatment in non-metastatic MIBC and high-risk NMIBC. Since the first reported case of radical cystectomy, the gold standard approach has been the open procedure whereas the recent development in robot-assisted surgery has made robot-assisted radical cystectomy the preferred approach in many high-volume centres. The annual number of robot-assisted radical cystectomies in Denmark recently superseded the number of open procedures on a national level1-2. This shift might be less pronounced in other countries with less structured centralisation and several small centres performing cystectomy, as the learning curve of robotic surgery is long. Moreover, the additional cost of the robotic procedure cannot clearly be justified from an evidence-based point of view at present. Thus, the lack of solid evidence of the clinical benefit of this shift towards robotic procedures, together with additional immediate procedure cost in combination with tradition and surgeon preference, are probably the major causes of the lack of implementation in all European countries. When comparing the robotic procedure to the classic open cases, it is important to recognize that an open cystectomy is not just that. Like other major urological procedures, it is influenced by many factors including, maybe most importantly, the operating surgeon3. Moreover, outcome of cystectomy has dramatically changed since the early years of the introduction of open radical cystectomy as standard treatment for localised invasive bladder cancer around 19504. The perioperative mortality and morbidity have dramatically decreased5. This explains why it is not possible to use historical cohort series as evidence of the superior clinical benefit of the ‘new kid on the block’ by direct comparison of new robotic series with older open series. Unfortunately, most publications comparing open to robotic cystectomy in small before-and-after series are potentially hampered by multiple biases or consist of contemporary series comparing one open surgeon to another robotic surgeon. What most urologists know, but rarely make scientific reports on, is the fact that the results of two different surgeons might differentiate significantly more than the results of two different surgical approaches. Randomised clinical trials on robotic cystectomy A few small-scale studies have investigated the difference between open and robotic approach in a randomised clinical trial (RCT)6-9. Although these RCTs are apparently well-designed, they are unfortunately often underpowered and, even more importantly, randomise between open cystectomy and the wrong surgical approach. Thus, all published RCTs to date have randomised the open cystectomy against robot-assisted cystectomy with subsequent open extracorporeal urinary diversion. Hence, all the benefits of a minimally invasive approach are potentially lost by doing a laparotomy at the end of the procedure for the urinary diversion. And as most major postoperative complications are related to the reconstructive part and not the extirpative part, these studies are comparing open reconstruction to open reconstruction10. It is no surprise that the complication rate is rather identical when comparing these identical procedures. It would be much more relevant to compare open cystectomy to robot-assisted cystectomy with total intracorporeal urinary diversion. Even though other pitfalls regarding surgeon differences etc. in surgical studies may remain, this would give a much more correct comparison. However, the question is always: when to perform such a study? During the learning curve is at least problematic; and when the new procedure has become standard, it might not be ethically correct to randomise against the older potentially more harmful treatment. This gives a very small window of opportunity to initiate such a correct high-volume study. Current evidence of benefit When we look at the data we can gather from the few RCTs on open versus robot-assisted plus open/ extracorporeal hybrid procedures, we can clearly see January/February 2019

that bleeding is significantly less in the robotic extirpation – even though the urinary diversion is performed open6-9. The difference could potentially be even more pronounced if the intra-abdominal pressure was not lost during the last part of the procedure. The time to perform an open cystectomy is slightly shorter than with the robotic procedure. However, this might be less important for the clinical outcome as the surgical procedure produces a lower surgical stress response compared to the classic open procedure when performed as complete robotic or even the hybrid procedure. The most important outcome, oncological long-term prognosis, has not been different between study arms in these small series, either because of true non-superiority or non-inferiority or because of underpowering of these small series. Interestingly, one of the studies showed that a significantly higher number of lymph nodes were removed in the robotic extirpative arm compared to the open procedure, as more patients in the robotic arm underwent extended lymph node dissection6. Moreover, fewer patients receiving blood transfusion following robotic surgery will theoretically give fewer recurrences. This is well recognised in colon cancer surgery and recent reports have indicated the same in major urological surgery11-12. Larger series designed to confirm this hypothesis are however still required.

"...a significantly higher number of lymph nodes were removed in the robotic extirpative arm compared to the open procedure..." Minilaparotomy cystectomy An aspect that most urologists tend to overlook is that robot-assisted cystectomy forces the open surgeon to minimise the trauma of the open procedure. Thus, Rawal et al. and later Jensen et all. showed that performing open cystectomy through a minimal incision could benefit the patients significantly by reducing morbidity and length of stay compared to classic open cystectomy through a long incision13-14. This ‘minimally invasive’ complete open procedure is a very good alternative to the hybrid robot-assisted cystectomy with extracorporeal diversion, whereas additional benefit in heavily obese patients could be achieved by a complete robotic procedure with intracorporeal diversion (figure 1). In the very obese patient, the benefits of a complete robotic procedure do not require the proof of scientific randomised studies – experience suffices here. The ‘minilaparotomy’ approach should be considered by the urologist performing open cystectomy if the robot-assisted procedure is not available or even as standard in the slim patient. Even better, if lack of introduction of total robot-assisted cystectomy with intracorporeal urinary diversion is caused by a long learning curve and few patients per centre, centres should consider centralisation of the patients to fewer centres with a higher volume. Small patient numbers cannot justify a lack of development in surgical techniques.

3. Salonia A, Burnett AL, Graefen M, Hatzimouratidis K, Montorsi F, Mulhall JP, Stief C. Prevention and management of postprostatectomy sexual dysfunctions. Part 1: choosing the right patient at the right time for the right surgery. Eur Urol. 2012 Aug;62(2):261-72. doi: 10.1016/j.eururo.2012.04.046. Epub 2012 May 3. Review. PubMed PMID: 22575909. 4. Leadbetter WF, Cooper JF. Regional gland dissection for carcinoma of the bladder; a technique for one-stage cystectomy, gland dissection, and bilateral ureteroenterostomy. J Urol. 1950 Feb;63(2):242-60. PubMed PMID: 15403829. 5. Shabsigh A, Korets R, Vora KC, Brooks CM, Cronin AM, Savage C, Raj G, Bochner BH, Dalbagni G, Herr HW, Donat SM. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009 Jan;55(1):164-74. doi: 10.1016/j.eururo.2008.07.031. Epub 2008 Jul 18. PubMed PMID: 18675501. 6. Bochner BH, Dalbagni G, Sjoberg DD, Silberstein J, Keren Paz GE, Donat SM, Coleman JA, Mathew S, Vickers A, Schnorr GC, Feuerstein MA, Rapkin B, Parra RO, Herr HW, Laudone VP. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Eur Urol. 2015 Jun;67(6):10421050. doi: 10.1016/j.eururo.2014.11.043. Epub 2014 Dec 8. PubMed PMID: 25496767; PubMed Central PMCID: PMC4424172. 7. Khan MS, Gan C, Ahmed K, Ismail AF, Watkins J, Summers JA, Peacock JL, Rimington P, Dasgupta P. A Single-centre Early Phase Randomised Controlled Three-arm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL). Eur Urol. 2016 Apr;69(4):613-621. doi: 10.1016/j.eururo.2015.07.038. Epub 2015 Aug 10. PubMed PMID: 26272237. 8. Parekh DJ, Messer J, Fitzgerald J, Ercole B, Svatek R. Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol. 2013 Feb;189(2):474-9. doi: 10.1016/j.juro.2012.09.077. Epub 2012 Sep 24. PubMed PMID: 23017529. 9. Nix J, Smith A, Kurpad R, Nielsen ME, Wallen EM, Pruthi RS. Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol. 2010 Feb;57(2):196-201. doi: 10.1016/j.eururo.2009.10.024. Epub 2009 Oct 20. PubMed PMID: 19853987. 10. Hautmann RE, de Petriconi RC, Volkmer BG. Lessons learned from 1,000 neobladders: the 90-day complication rate. J Urol. 2010 Sep;184(3):990-4; quiz 1235. doi: 10.1016/j.juro.2010.05.037. PubMed PMID: 20643429. 11. Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane

Visualisation of the right iliac vessels following extended lymph node dissection during radical cystectomy through a minilaparotomy of 7 cm

Database Syst Rev. 2006 Jan 25;(1):CD005033. Review. PubMed PMID: 16437512. 12. Cata JP, Lasala J, Pratt G, Feng L, Shah JB. Association between Perioperative Blood Transfusions and Clinical Outcomes in Patients Undergoing Bladder Cancer Surgery: A Systematic Review and Meta-Analysis Study. J Blood Transfus. 2016;2016:9876394. doi: 10.1155/2016/9876394. Epub 2016 Jan 31. Review. PubMed PMID: 26942040; PubMed Central PMCID: PMC4752988. 13. Rawal S, Raghunath SK, Khanna S, Jain D, Kaul R, Kumar P, Chhabra R, Bhushan K. Minilaparotomy radical cystoprostatectomy (Minilap RCP) in the surgical management of urinary bladder carcinoma: early experience. Jpn J Clin Oncol. 2008 Sep;38(9):611-6. doi: 10.1093/jjco/hyn079. PubMed PMID: 18772171. 14. Jensen JB, Pedersen KV, Olsen KØ, Bisgaard UF, Jensen KM. Mini-laparotomy approach to radical cystectomy. BJU Int. 2011 Oct;108(7):1125-30. doi: 10.1111/j.1464-410X.2010.09958.x. Epub 2011 Jan 11. PubMed PMID: 21223476. 15. Lin-Brande M, Nazemi A, Pearce SM, Thompson ER, Ashrafi AN, Djaladat H, Schuckman A, Daneshmand S. Assessing trends in urinary diversion after radical cystectomy for bladder cancer in the United States. Urol Oncol. 2018 Nov 25. pii: S1078-1439(18)30449-6. doi: 10.1016/j.urolonc.2018.11.003. [Epub ahead of print] PubMed PMID: 30482434. 16. Personal experience while attending several urological conferences over the last decades.

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Influence on choice of urinary diversion Interestingly, few urologists stop and reconsider the reason of the shift in urinary diversions from a large proportion of neobladders earlier to a vast majority of urinary diversions performed as ileal conduits now15. This may proof to be the best reason to keep the robots around for the benefit of future patients. With this new toy that can satisfy the urologist’s need to try new technologies, there is no reason anymore to persuade the bladder cancer patient to accept a far from perfectly functioning orthotopic neobladder instead of the safe, simple solution of an ileal conduit. Thus, it is interesting to observe that the focus of earlier days on a high percentage of neobladders in each cystectomy centre has more or less evolved into a focus on a high percentage of patients operated by robot-assistance, while there is hardly any interest in the best type of diversion for the patient16. References: 1. Hansen E, Larsson H, Nørgaard M, Thind P, Jensen JB. The Danish Bladder Cancer Database. Clin Epidemiol. 2016 Oct 25;8:439-443. eCollection 2016. Review. PubMed PMID: 27822081; PubMed Central PMCID: PMC5094647. 2. dablacadata_-aarsrapport_2017_v2_endelig.pdf

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Becoming a member is now fast and easy! Go to and click EAU membership to apply online. It will only take you a couple of minutes to submit your application, the rest is for you to enjoy!

European Urology Today


CEM19 EAU 19th Central European Meeting in conjunction with the Austrian Society of Urology and the Bavarian Society of Urology 9-10 May 2019, Vienna, Austria An application has been made to the EACCME® for CME accreditation of this event

EAU Update on Bladder Cancer

17 -18 May 2019 Turin, Italy

EAU onco-urology series


EAU Update on Renal Cell Cancer

6th Baltic Meeting in conjunction with the EAU

7-8 June 2019 Prague, Czech Republic

24-25 May 2019, Tallinn, Estonia

EAU onco-urology series An application has been made to the EACCME® for CME accreditation of this event

Call for Abstracts Deadline 1 April 2019


European Urology Today

January/February 2019

ERUS19: Looking at the future of robotics Creating consensus in robotic urology The 16th Meeting of the EAU Robotic Urology Section (ERUS19) will take place from 11 to 13 September 2019 in Lisbon, the breathtaking capital of Portugal. The meeting venue is the Lisbon Congress Centre which is located on the waterfront, close to the city centre and historical highlights. ERUS19 will kick off with the meeting of ERUS and Young Academic Urologists (YAU), and some European School of Urology (ESU) courses. As we are on the verge of new robotic systems entering the market, the Technology Forum promises to be an interesting, informative event that will surely provide a look into the future of robotics.

Submit your abstract now! 1 February 2019 – 1 June 2019 As the ERUS meeting has historically grown to become the most important live-case robotic urological surgery meeting, the 2019 Lisbon edition aims to live up to this standard. Over 15 live surgeries will be performed by the most experienced surgeons on three robotic systems at Hospital Da Luz Lisboa, the largest private hospital in Portugal. This year’s focus will be on both oncological and non-oncological urological surgeries, since the latter became an important aspect of the urological robotic scene.

We hope to be able to show a mix of straightforward live as well as more complex cases, such as radical nephrectomy with vena cava thrombosis and complex retroperitoneal lymphadenectomy. Since there is a growing Dr. Kris Maes number of salvage President of the ERUS2019 prostatectomy after Local Organising Committee various types of focal therapy, we plan to dedicate a session to this topic as well. Extra time will be spent on image-guided robotic surgery: Indocyanine green (ICG) and near-infrared fluorescence, 99Tc-PSMA tracing and implementation of three-dimensional model technology for better surgical planning and performance in prostate and kidney surgery. All new technologies in the field will be discussed.

Register now! Deadline: 2 September 2019

On behalf of the local organising committee, we invite you to participate at this meeting and its courses. It will be a pleasure to meet you in Lisbon for ERUS19!

curves and surgical outcomes. Do not forget to submit your work for the evergrowing abstract and poster session. The mixture of high-level scientific lectures with moderated live surgeries have made the ERUS meeting one of the most attractive meetings of its kind.

Robotic Live Surgery

For more information check the ERUS19 website and video Link to ERUS 2019: Link to video ERUS 2019: com/watch?v=iKKqB-YJmvs&t=5s

ERUS19 16th Meeting of the EAU Robotic Urology Section Creating consensus in robotic urology

"In working groups, we will aim to reshape the available scientific data on several topics to create a readyto-use consensus."

11-13 September 2019, Lisbon, Portugal In conjunction with: • Junior ERUS-YAU Meeting • European School of Urology (ESU) Courses • ESU/ERUS Hands-on Training in Robotic Surgery

In this year’s edition, focus will be given to the theme “creating consensus in robotic urology”. In working groups, we will aim to reshape the available scientific data on several topics to create a ready-to-use consensus. The Lisbon edition of the ERUS will also be the first to include the single-port surgery in its programme. In robotic surgery, ERUS has taken a leading role in the development of structured training programmes, the creation of EAU-ERUS host centres and high level training facilities which improved learning



5th Meeting of the EAU Section of Urolithiasis

13th World Congress on Urological Research

3-5 October 2019, Milan, Italy

10-12 October 2019, Porto, Portugal An application has been made to the EACCME® for CME accreditation of this event

In collaboration with the EAU Section of Uropathology

Call for Abstracts Deadline 5 June 2019

January/February 2019

European Urology Today


EAU Update on Prostate Cancer

11-12 October 2019 Prague, Czech Republic

EAU onco-urology series

ELUTS19 European Lower Urinary Tract Symptoms meeting

31 October - 2 November 2019 Prague, Czech Republic

ESUI19 8th Meeting of the EAU Section of Urological Imaging 14 November 2019 Vienna, Austria In conjunction with the 11th European Multidisciplinary Congress on Urological Cancers

14-17 November 2019, Vienna, Austria

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

Implementing multidisciplinary strategies in genito-urinary cancers 11th European Multidisciplinary Congress on Urological Cancers In conjunction with the • 8th Meeting of the EAU Section of Urological Imaging (ESUI) • European School of Urology (ESU) • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) 32

European Urology Today

January/February 2019

EAU fosters stronger ties in South America Synergy with SCU and SPU boosts knowledge-sharing By Erika De Groot American novelist and poet, Louisa May Alcott, once said "It takes two flints to make a fire." The European Association of Urology (EAU) together with renowned urological associations Sociedad Colombiana de Urología (SCU) and Sociedad Peruana de Urología (SPU) ignited stronger links and further amplified the level of urological care in South America. Their collective primary aim is to boost knowledgesharing through a synergy of activities. These activities include participation in annual meetings; courses organised by the European School of Urology; training and skills workshops; keynote or state-ofthe-art lectures, among many others. Close cooperation with the SCU The SCU ratified its online en bloc membership agreement with the EAU in 2013. The association is currently led by its president, Dr. Fabián Daza Almendrales (CO). During SCU’s LIII Congreso Curso Internacional de Urología last September, EAU Adjunct Secretary General for Education, Prof. Dr. Hein Van Poppel (BE), shared his insights on partial nephrectomies and examined surgery as the initial approach in high-risk prostate cancer. About 500 delegates participated in

the congress held in Cartagena, Colombia. The EAU is honoured to contribute to the next SCU congress, which will take place from August 15 to 18 in Barranguilla, Colombia. Ties go further than EAU’s contributions to the last few SCU congresses; it is also reflected in the growing membership and contributions made by the SCU.

The participants of the course will be getting new and practical information for use in practice. Also the aim of the follow-up is to ensure a better connection of theory and practice. Applicants should have: • A letter of motivation stating the applicant’s interest for the course • Recommendation letter from the applicant’s immediate superior or supervisor • Proven fluency in English • Readiness to submit essay-type articles in preparation for the course The YUO board will review all applications on a first-come, first-served basis and selected participants will come from countries across Europe.

On During the Annual EAU Congress to be held in Barcelona two courses will be offered to young urologists and nurses. The EAUN Leadership Course will be Sunday, 17 March from 12.30 to 15.30 hrs., while for urologists the Leadership for Medical Professionals Course will be on Monday 18 March from 08.30 to 11.30 hrs. Young urologists The YUO is working on its Personal Development Programme where courses will focus on management and communication skills, leadership, finances, etc. The first part of this programme is a course on Leadership for Medical Professionals, designed for young (under 45 years) urologists and related health professionals who have the potential to be future leaders in national and international urology.

Prof. Van Poppel at SCU’s congress last September with the SCU Board

courses, including the much-awaited Annual EAU Congress in Barcelona this March. Interested to know if the EAU has affiliations in your country? Visit eau-in-your-country/. To know more about membership benefits, check out the overview via

SPU is guided by the leadership of its current president, Dr. Alexis Michaele Alva Pinto (PE). The number of EAU-SPU members is growing, and it has

YUO and EAUN offer Leadership for Medical Professionals Courses in Barcelona

Then the EAU Young Urologists Office (YUO) may have the right programme for you in Barcelona during the Annual EAU Congress.

Additional advantages Collaborations such as these also further raise the international profile of both associations and provide distinct advantages to its members.

EAU members, and, because of the en-bloc agreements, SCU and SPU members receive SPU collaboration numerous benefits such as free downloads of the The flourishing relationship between the SPU and the latest EAU Guidelines (including its translations), and advanced access to the new and improved UROsource EAU began with a Memorandum of Understanding formalising the collaboration in October 2017. The year – the largest knowledge base in urology with almost after, the online active international and online junior 60,000 items of scientific content. To further broaden international membership en-bloc agreement became their urological expertise, members are entitled to official in May. free subscriptions to esteemed scientific journals such as European Urology (one of the most widely-cited At SPU’s XXVIII International Congress of Urology held medical journals in the world), its sister journals EU last August in Lima, Peru, EAU Secretary General Prof. Focus and EU Oncology. Members can also take Chris Chapple (GB) presented nine lectures on advantage of reduced fees for EAU meetings and urodynamics; role of combination therapy diagnosis in the pharmacological treatment of lower urinary tract symptoms in men; intravesical obstruction and management of urethral diverticulum in women, to name a few.

Leadership skills courses for urologists and nurses

Do you wish to refine your management and leadership skills or sharpen your decision-making abilities? Do you want to improve your leadership communication skills?

openly expressed its enthusiasm, anticipation and confidence to the make the most of this partnership.

Nurses During the interactive course Nurses in a leadership role: Cultivating your leadership we will guide you in finding your role as leader, especially when the ultimate responsibility is not yours. The programme will focus on leadership, effectiveness and communication in relation to patients, teams, colleagues, surgeons and other superiors. There is room to reflect on your preferred leadership style and to exchange your personal experiences with peers from all over Europe. So bring a case of a challenge you are currently facing in your hospital!

EAU and SCU Board Members: (from left) Drs. Jacome, Aranibar, Chapple, Senior, Plata, Almendrales, and Van Poppel


Incl. Live Surgery

7th Meeting of the EAU Section of Uro-Technology in conjunction with the Lithiasis-Endoscopic-LaparoscopicRobotic Section of the Spanish Urological Association (AEU) 30 January - 1 February 2020 Barcelona, Spain

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

How to join? Participants will come from countries across Europe. For both courses a small token fee of €62.50 will be required to ensure attendance by selected applicants. Please send an email to Angela Terberg, at, clearly stating that you are interested in the EAUN leadership course or in the YUO leadership course.

To ensure that the course is sustainable, a follow-up will be provided after the congress.

January/February 2019

European Urology Today


Fellowship great professional experience for Maltese nurse European networking boosts knowledge in onco-urological patient care Helen Attard Bason Health Department Mater Dei Hospital Dept. of Urology Msida (MT)

habason@ Since February 2018 I work as a uro-oncology practice nurse navigator. I have taken up this post after having worked as a nursing officer in a urology ward for 8 years. The practice nurse navigators have been established in Malta as part of a national cancer plan for the Maltese Islands (2017-2021), set out to address the emerging new challenges in cancer control. Nurse navigators offer individualised assistance to patients, families and caregivers to help overcome healthcare system barriers, provide education and resources to facilitate informed decision-making and timely access to quality health and psychosocial care throughout all phases of cancer care. EAUN fellowship I was lucky to have been granted a fellowship programme by the EAUN for the second time. In September 2016 I had the opportunity to visit the NKI-AVL Oncology Hospital in Amsterdam (see European Urology Today October-December 2016). At that time I was in charge of a urology ward in Malta and responsible for the coordination of intravesical therapy for bladder cancer patients. At NKI-AVL oncology hospital I did not just to observe and exchange clinical practice; my one-week experience with Ms. Corinne Tiller (one of the clinical nurse specialists) gave me the drive to choose a new path in my career: the role of a uro-oncology practice nurse navigator. Experience in urology and management My management role inspired me to identify gaps between acute urology and oncology care, but the interest to work in the field of uro-oncology was mostly inspired by the EAUN and the opportunities to network and meet with inspiring urological practitioners during the annual conferences, the fellowship programmes and the European School of Urology Nursing (ESUN) bladder and prostate cancer courses, which I attended in 2017 and 2018. Care pathway coordination Since I embarked on my new career pathway, I have been working on local clinical pathways for urological cancers namely prostate, bladder, kidney, penile and testicular. In July I started coordinating the care pathways of prostate, bladder and kidney cancer patients: from being present during the breaking of the news to offering psychological support and information required to both the patient and his/her relatives, both in the acute and the oncology hospital (Mater Dei Hospital and Sir Anthony Mamo Oncology Centre). Robot-assisted laparoscopic prostatectomy at UCLH I applied to the EAUN to visit the uro-oncology centre of the UCLH to see how this important uro-oncology facility manages these services. I believe such first-hand experience can boost my knowledge and understanding and improve my competences as a uro-oncology practice nurse with focus on prostate cancer. Our hospital has a close training cooperation with UCLH. Moreover, some of our patients are referred to UCLH to have their robot-assisted laparoscopic prostatectomy. Furthermore, I also believe that as patients become more demanding and the complexity of the health care delivery system increases, the need to intensify knowledge through research, networking and exchange of best practice becomes increasingly important. Successful EAUN fellowship at UCLH My visit at UCLH was well organised by Ms. Hilary Baker (Lead Clinical Nurse Specialist (CNS) for Urological Cancers. At Westmoreland Street I was mentored by uro-oncology CNSs Nora Chu and Jonathon Soviana who are responsible for prostate European Association of Urology Nurses


European Urology Today

What I have learnt from this experience Not only have I reached my visit objectives, I have also reflected on the importance of networking in nursing. I analysed the level of care that we deliver in our country compared with other European countries. I tried to share information - clinical, administrative or research-based – which is necessary for and beneficial to improving our health care system.

cancer patients. At the MacMillian Centre I was well taken care of by Janet Forgenie and Hazey Mc Bain, CNSs for prostate, bladder and penile cancers. My fellowship programme schedule was as follows: Monday, 3 December Welcome, Post Cystectomy Nurse Led Clinic, MRI prostate Multi Disciplinary Prostate Meeting, Nurse-led Follow Up Clinic Post MRI

An important and impressive observation is the connection between the urology team at UCLH and the GP in the community. Another important observation is the way the CNS ran their clinic, the way they explained everything related to prostate cancer, from the stage of the disease, the investigations and the management, to the information given to help patients decide on their treatment options.

Tuesday, 4 December Prostate Clinic (one stop clinic, new diagnosis, treatment decisions, active surveillance) Wednesday, 5 December MacMillian Centre Clinic, observing advanced prostate cancer management Thursday, 6 December Post Surgical School, Nurse Led Post RALP Clinic Friday, 7 December Multi Disciplinary Team (MDT) Meeting (Wimpole St.), Surgical School, Post MDT Meeting Clinic with the uro-oncology team The host institution The new state-of-the-art University College Hospital (UCH) is located on Euston Road, urology services are provided at UCH at Westmoreland Street, while treatment and other support services for cancer patients and their families are offered at The UCH Macmillan Cancer Centre at Huntley Street. The urology services at Westmoreland Street include: • Inpatient Stone Team Services (patients being admitted for operations) • Robotic Surgery inpatients • Andrology inpatients • Male reconstructive inpatient surgery • Adolescent urology inpatients • Urological Cancer patients • Functional restorative and female urology inpatients • All urology outpatients clinics My experience It is impressive how urological cancer care is provided in this hospital. There is a close collaboration between the UCLH team and the GP. Patients travel all over the UK to receive the specialist cancer care that UCLH offers. I was also impressed to see how many patients choose to take part in clinical research studies. The nurse-led clinics are lead quite professionally by CNSs. It was evident how knowledgeable the nurses are, as well as being good listeners and supportive to their patients. They took time to explain everything their patients wanted to know about their prostate cancer and all the investigations, including the MRI in the post-MRI meeting clinic.

Me, Ms. Nora Chu and Mr. Jonathon Saviano at the Surgical School

The Surgical School Every Friday, the surgical education session is held at UCLH Westmoreland Street for patients who will be having a prostatectomy. It is also part of an enhanced recovery programme. The session is intended to facilitate post-operative recovery and care. Information is given about the operation, postoperation care and care at home. It has been shown that patients who attend Surgical School recover faster because they are aware of each milestone along their pathway. It was evident from the way patients asked questions and were involved in the discussion that this educational session is beneficial for them. This session was very useful and enabled me to enrich my knowledge about various topics, such as the way the operation is performed, pelvic floor exercises (or Kegal exercises) and the management of erectile dysfunction.

The experience I gained will surely boost my knowledge with regards to uro-oncology and the way I will organise patient care. I would again encourage all EAUN Members to apply for a fellowship programme. My sincere gratitude goes to the EAUN for giving me this great opportunity. Finally I would like to thank everyone in the team involved in organising my visit at UCLH for their warm welcome, especially Ms. Hilary Baker, Ms. Nora Chu and Mr. Jonathon Saviano who really went out of their way to mentor me and make my visit a valuable learning experience.

University College London Hospital at Westmoreland Street

Fellowship Programme European Association of Urology Nurses

Communication skills and extensive knowledge The communication skills of the nurses and the extensive knowledge on prostate cancer, facilitated the relationship with the patient and led to patient satisfaction and less anxiety. There was time to discuss their concerns and their care pathway before any other investigations and surgical interventions were performed. Another nurse-led clinic I attended was the postprostatectomy clinic. The nurse was very professional in her holistic assessment of her patients. She mainly focused on post- operative incontinence, sexual dysfunction and coping skills. Effective communication Effective communication was also evident between the physician and the uro-oncology nurse specialist whom I followed throughout my visit at UCLH. There is a close working relationship with an open attitude and a feeling of mutual respect and trust which facilitates the decisions taken by the CNS. I also had the opportunity to assist Mr. Timm Briggs (consultant urological surgeon) at Westmoreland St. during one of his clinics (Post MDT Clinic) as well as Dr. Mark Prentice, Clinical Fellow in Clinical Oncology, at the MacMillian Centre. I was really welcomed in their clinic, for which I am very grateful. The team took their time to explain everything I wanted to know and ask with regard to management of the prostate cancer patient, both at the stage of active surveillance and at the advanced prostate cancer stage.

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 31 August 2019 • 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

European Association of Urology Nurses

January/February 2019

Extending international and professional friendship The EAUN increases collaboration by visiting several conferences of national nursing associations Susanne Vahr Lauridsen, PhD EAUN Chair Rigshospitalet Dept. of Urology Copenhagen (DK)

• Educate everyone who takes care of a patient with an indwelling catheter to follow guidelines on catheter care • A dipstick test is worthless to detect UTI in patients with indwelling catheters • Urine culture should only be performed in patients with symptomatic UTI • If the catheter has been in situ for more than 7 days, it should be changed before collecting urine for culture • It is useless to perform urine culture routinely after antibiotic treatment

It is a central EAUN aim to foster the highest standards of urological nursing care throughout Europe and to facilitate the continued development of urological nursing in all its aspects. We acknowledge that the EAUN can learn a lot from the national urological nursing associations. Therefore, representatives from each urological nursing association in Europe are invited to a joint meeting, on the occasion of the annual EAU and EAUN meeting, to share knowledge and experiences in urological nursing.

"...the session addressing urinary tract infections (UTI) and indwelling catheters from the perspective of a urologist, a microbiologist, a general practitioner and a nurse showed how dedicated the participants were..."

Danish urological nursing conference In 2018, EAUN representatives also visited several national conferences to further explore potential areas of collaboration. The first stop was the Danish national urological nursing conference (FSUIS) held in September 2018. Nurses taking care of patients with urological disorders in hospitals and home care participated. The programme addressed several interesting topics. In particular, the session addressing urinary tract infections (UTI) and indwelling catheters from the perspective of a urologist, a microbiologist, a general practitioner and a nurse showed how dedicated the participants were to learn about evidence-based nursing interventions regarding prevention of infections. Take-home messages were:

Norwegian conference in September The next stop was the Norwegian Urology Nurses conference (FSU) also held in September, 2018. The Norwegian association was founded as early as 1986 and aims at increasing the professional competences

European Association of Urology Nurses

The EAUN lecture at SUNA discussed Stopping smoking in relation to radical cystectomy

of its members and stimulating professional involvement. To that end, the FSU selects a local committee to plan a conference every year. This way the long distances are overcome as the conference is brought to the nurses in different parts of Norway. Local speakers are chosen and thereby evidencebased interventions are connected to local practices, familiar to all participants. This is an excellent way to promote the exchange of experience and good practice between the members. This year the EAUN chair was pleased to receive an invitation to speak about ‘Recommendations for care of an indwelling catheter according to EAUN guidelines’. SUNA in San Diego I travelled from the rainy and cold northern Europe to a very sunny and warm San Diego in October, when I was invited as Chair of the EAUN to attend the American Society of Urologic Nurses and Associates conference (SUNA) UroLogic Conference. The SUNA conference started with a wide range of preconference workshops addressing cystoscopy, urodynamics, vulva disorders and women’s sexual health. I participated in the latter and it proved to be a very interesting workshop, presenting evidencebased interventions to female patients with sexual disorders. BAUN in Bournemouth The British Association of Urology Nurses (BAUN) holds its annual conference in early winter. This year it was held on England’s south coast at the Bournemouth International Centre on 26 and 27 November 2018. To demonstrate the increasing collaboration between the BAUN and international societies, the EAUN Chair was invited to give the EAUN lecture - which is now part of the BAUN programme. The title of the lecture was ‘Will bladder cancer patients stop smoking in relation to radical cystectomy?’, which sought to outline preliminary results from an ongoing study. Unfortunately, illness prevented me from attending and, on my behalf, the lecture was given by Jerome Marley, former BAUN President and currently a temporary EAUN Board

EAUN Chair Susanne Vahr Lauridsen (DK) and former EAUN Chair Bente Thoft Jensen (DK) at the SUNA conference in San Diego (US)

Member. At BAUN, Jerome continued ongoing discussions with BAUN and Andrea Nixon, Chair of the Australian and New Zealand Urology Nurses Society (ANZUNS) with regard to the cooperation on the development of a urological nursing curriculum. More information will be available soon, e.g. at the upcoming EAUN19 Meeting in Barcelona (www. - registration is now open). The EAUN Chair Elect, Paula Allchorne (UK), was also invited and provided a presentation as an inspirational leader in urology. According to the reports the BAUN conference was as exciting as it usually is! Each new year begins with January, named after Janus who both looked back and forward. Looking forward I know that it will certainly be a pleasure to continue working with all of our urological colleagues across Europe and further afield as we address issues that are common to us all. I am especially excited to continue working with the presidents from FSUIS, Rikke Knudsen, and from FSU, Heidi Nikolaisen, as well as working again with Gwen Hooper from SUNA and Jane Brocksom, the newly elected BAUN President. In the spirit of Janus, it is also very appropriate to send our best wishes to outgoing BAUN President Julia Taylor and sincerely thank her for her enthusiasm and collegiality.


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European Urology Today


‘Learn with the best’ congress very successful Scientific programme with practical courses and live surgery in Portugal Linda Söderkvist EAUN Board Member Karolinska University Hospital Dept. of Urology Stockholm (SE) l.soderkvist@

Jeannette VerkerkGeelhoed EAUN Board Member St. Antonius Ziekenhuis Dept. of Urology Nieuwegein (NL)

Full-day programme for nurses A full-day programme with various topics on patient safety in the operating room, prevention and infection control, patient positioning and dangers in laparoscopy from a nurse’s perspective, laparoscopic instruments and the future role of nurses in surgery (to mention a few) was offered specifically to operating room nurses on the first day of the congress. Around one hundred and thirty nurses were registered for the meeting and took part in the congress.

"This three-day congress addressed both laparoscopic surgeons in urology surgery and operating room nurses and combined a scientific programme with both practical courses and live surgery." From 8 to 10 November 2018, the first edition of the joint laparoscopy course meeting ‘Learn with the best’ took place in Lisbon, Portugal, at the Lisbon Marriott hotel. EAUN proudly contributed four speakers to the nurses day. This three-day congress addressed both laparoscopic surgeons in urology surgery and operating room nurses and combined a scientific programme with both practical courses and live surgery. Dr. Rui Farinha from Centro Hospitalar de Lisboa Central, EPE / Hospital de São José in Lisbon was one of persons in the organising committee who initiated contact with the EAUN. He invited the EAUN to collaborate in creating a laparoscopic surgery training programme for operating room nurses at the ‘Learn with the Best’ congress. European Association of Urology Nurses

On behalf of the EAUN we would like to thank Birgitta Keil (DE) and Jane Petersson (DK) for contributing to the first edition of ‘Learn with the Best’ and the nurses programme, Dr. Rui Farinha for inviting the EAUN to contribute to this successful nursing programme and Ana Pais (PT) for her valuable support.

The team that presented in Lisbon at the EAUN-supported nurses laparoscopy course. From left: Linda Söderkvist (DE), Jeannette Verkerk-Geelhoed (NL), Birgitta Keil (DE) and Jane Petersson (DK) Presentations at the ‘Learn with the best’ congress in Lisbon (PT)

Four members of the EAUN, including two Board Members, were invited as faculty for the nurses’ programme. We shared our field of expertise together with the Portuguese and Spanish nurse speakers. We were all a bit nervous that there might be a language barrier to understand us as international faculty, since we presented our topics in English, and the rest of the congress was in Portuguese. But it turned out that there was nothing to worry about, since we soon discovered that the nurses do understand a lot of English but prefer to speak their own language, for instance when they are giving a presentation. Enjoyable and informative congress As EAUN Board Members we were warmly welcomed by the organising committee and we enjoyed taking part in this congress. It was a great opportunity for all of us, both faculty and local nurses, to network and learn from each other with regard to our daily work with patients in the operating room.

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

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

L. Söderkvist (SE) and J. Petersson (DK) demonstrating laparoscopic insturments

Future-proofing urological nursing for the 21st century 20th Meeting of the European Association of Urology Nurses prepares for coming challenges EAUN19 will offer urology nurses food for thought and strategies for keeping their roles and practices up to date in a changing work environment. Does nursing change as surgical technique advances? How can new generations of nurses be trained and what skills can younger nurses bring to the table? How can nurses evaluate their work and make sure that advances ultimately benefit the patients?

Register now for the late fee! Deadline: 15 March 2019 These questions will be addressed in the second EAUN19 plenary session in Barcelona. The 20th International EAUN Meeting is 2019’s biggest urology nursing event, offering three days of scientific sessions, a variety of training opportunities and courses and much, much more. Emerging priorities This plenary session is designed to help nurses prepare for coming challenges that they might face, and to start thinking strategically on how to overcome them. Increasing demands on nurses and healthcare in general. Developing new patient-centred services requires planning that in turn might require wider skills or new ideas about organisation. An awareness of nurses’ own wellbeing also ultimately benefits the patient, allowing urology nurses to ultimately better support the health of others.

Training a new generation of nurses, and integrating this generation in the existing workforce also brings a variety of challenges but also opportunities. New research on millennials examines the (perceived) differences as professionals, and whether they want to continue to become nurses at all. On the other hand, increased computer literacy and other skill sets may well be an asset as nursing practice and patient demands change in the coming years.

Join the conversation at #EAUN19 d’Hebron, or the University Hospital Clinic of Barcelona. Each has unique insights to offer! EAUN19 also gives delegates the chance to partake in the Urowalk, a planned walk that takes in some of

Barcelona’s many sights. An EAUN Dinner is also offered, serving Catalan cuisine at Restaurant Barceloneta, offering views of the fishing port Moll Dels Pescadors. All-in-all, EAUN19 is set to be the most complete and educational meeting yet. We look forward to welcoming you to Barcelona!

In its scientific programme, EAUN19 also offers poster and video sessions, state-of-the-art lectures and thematic sessions covering a whole range of urology nursing topics. Additional courses In addition to the scientific programme, EAUN19 is offering participants two special courses. Together with the EAU Section of Uro-Technology and the European School of Urology, the EAUN is holding a hands-on training session for nurses on flexible cystoscopy on Friday, March 15. Registration is open.

16-18 March 2019, Barcelona

On March 18, there is an additional course for nurses: Nurses in a leadership role: Cultivating your leadership. The course will focus on leadership, effectiveness and communication in relation to patients, teams, colleagues, surgeons and other superiors. The course takes place from 12:30 to 15:30 and participation costs €62.50. Please contact Ms. Angela Terberg ( to indicate your interest.

Join the top of Urology Nursing!

20th International EAUN Meeting 16-18 March 2019, Barcelona, Spain

For the complete Scientific Programme visit Hospital visits and more A regular and essential part of the EAUN meeting is a visit to local hospitals. These offer insights into the nursing practices and patient management that can then be adapted and applied in participants’ home institutions. In Barcelona, delegates can expect to visit the Fundació Puigvert, University Hospital Vall 36

European Urology Today

January/February 2019

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