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European Urology Today Official newsletter of the European Association of Urology


Vol. 30 No.3 - June/July 2018

2018 EAU National Societies Meeting

ESUT18 in Modena

The Future is Female

Two-day meeting addresses common concerns in urology

Read about the revolutionary three-screen live surgery meeting

Congress examines growing female role in surgery



BCa18: Challenges in standard practice amid new changes Munich meeting provides in-depth assessment of strategies and emerging options By Joel Vega

8-9 June 2018 Munich, Germany

The treatment landscape of bladder cancer, one of the most lethal urological malignancies, is evolving at such a fast pace that specialists encounter clinical dilemmas and challenges which prompt them not only to re-assess current guidelines but also to anticipate new therapeutic options that may enable the delivery of optimal care.

www.bca18.org which is biased by poor data quality and the low level of evidence in the guidelines,” he explained.

Following the launch of a dedicated prostate cancer update meeting last year in Vienna, the EAU Update on Bladder Cancer (BCa18) is the first meeting on bladder cancer to be offered by the EAU with the aim to educate cancer experts across Europe and beyond. With 275 participants, including faculty and exhibitors, from around 48 countries, some of the cancer experts came from as far as China, Burkina Faso, Mexico and South Africa. From across Europe, host country Germany accounted for many of the participants, with Italy, the United Kingdom, Austria and Spain also BCa18 gathers nearly 300 participants in Munich for the latest in bladder cancer updates amply represented by urologists and other medical specialists. “We are moving forward. We now have a lot of new Rodolfo Montironi (IT) discussed the WHO 2016 Held in Munich from 8 to 9 June, the meeting had a biological predictors that are not yet confirmed in classification. “The correct characterisation of the compact format with succinct overview update non-invasive and invasive neo-plasms has diagnostic, prospective randomised trials, but probably are lectures preceding the interactive breakout case prognostic and therapeutic implications, significantly going to be implemented in the decision when discussions to allow a more inclusive and direct giving new adjuvant or neoadjuvant therapies in impacting management of individual patients,” he exchange between faculty and the participants. With a said. Ashish Kamat (US) presented a concise overview muscle-invasive disease,” Bellmunt said. “There is point-by-point review of standard treatments and a on immunotherapy in NMIBC and underscored its role more data coming up about the benefits of giving, voting system on key questions that test the for example, adjuvant chemotherapy in patients to further boost multidisciplinary partnership. He who fail new adjuvants. This means we switch to knowledge and clinical practices of the participants, added there are still hurdles to face and overcome in BCa18 is comprehensive and detailed. another type of chemotherapy. Although everything integrating immunotherapy in urology. is retrospective, not prospective. Perhaps in this way, we can select specific patients just to give The opening session on high risk non-muscle invasive Among the issues he mentioned are the urologist’s capability to maintain an applicable patient additional therapy, and maybe we can improve the bladder cancer (NMIBC) brought to the fore key population, and the clinical appropriateness of outcomes,” he added. questions such as the relevant changes needed in practice setting and demographic considerations. both the EAU and ESMO guidelines on NMIBC with Educational (CME) strategies and adaptability within Necchi, meanwhile, described the treatment Dr. Joan Palou (ES) tackling issues such as the landscape as “continually evolving” and said that in discrepancy between guidelines adherence and actual an evolving treatment landscape also present their own challenges. the next 18 months agents such as ramucirumab, clinical practice. durvalumab, pembrolizumab, atezolizumab, “In a 2017 study by Hendriksen (Eur Urol Focus, 2017), “Urologists should be not too guarded or shy of being avelumab, and nivolumab are the drugs to watch. part when it comes to systemic immuno-oncology These agents are undergoing testing in various trials 87% of the respondents say they use the guidelines, and results are to be expected in the following management. It is a multidisciplinary effort, it is but only 40 to 69% correctly identified prognostic months, with nivolumab’s expected outcomes by the teamwork and we have to collaborate with the factors. Re-TURBT were performed in low risk last quarter of 2019. medical oncologists. Another message is that these patients,” said Palou. “There is over-monitoring of are our patients for which we have been doing the low-risk and under-monitoring of high risk,” he Necchi’s key messages included the role of PD-L1. follow-up and surveillance. It’s not fair to patients added to illustrate the gap between observing the “PD-L1 should be tested with clinical assessment as that since the immune-oncology is administered by guidelines and actual clinical practice. there is value for both mono and combo in PD-L1 someone else, we send them somewhere. The high patients, determined by tolerability concerns, patients would feel lost,” Kamat said. Palou took up risk strategies, transurethral resection and value for combo in PD-L1 low patients,” he (TUR), adjuvant chemotherapy and T1-High grade Surgical and systemic approaches in MIBC pointed out. During the case discussions on disease, among others. “Re-TUR may not be necessary in patients with T1HG/G3, if muscles muscle Following the case discussions, the afternoon session neoadjuvant and adjuvant therapies, Necchi said moved on to surgical and systemic approaches in adjuvant chemotherapy is the first option that tissue is present in the specimen. There are no muscle invasive bladder cancer (MIBC) and advanced should be offered to patients. “There are multiple differences in recurrence, progression and cancerdisease, with Joaquim Bellmunt (ES) assessing the clinical trials available in chemotherapy. Clinical specific survival (CSS), “ he said, noting the initial guidelines on MIBC and Andrea Necchi (IT) tackling trials should be the first to be offered after the first rational for re-TUR is due to the high number of new drugs and therapeutic sequences in locallyintervention instead of the usual chemotherapy tumours left behind after the first re-TUR. Until there advanced stages. is more evidence, we have to re-TUR T1 tumours, which is mandatory to improve the first TUR. An estimated 75% of bladder cancers are nonmuscle-invasive bladder cancer, and the remaining “Doing a better first TUR is more important. We can are either muscle-invasive or metastatic disease, a avoid in the near future to re-TUR so many patients with T1 disease. If we have a patient with a solitary or stage where the disease becomes lethal. For MIBC, Bellmunt said neoadjuvant chemotherapy (NAC) is the a small tumour, and perform a good first TUR with current standard, but the guidelines of both the EAU this patient, then a second TUR is probably not needed. These factors reduce the number of re-TURs, and ESMO are still lacking when it comes to issues a procedure which also has a psychological impact on such as the management of variant histologies. “There is also the lack of predictive biological factors patients,” he explained. for NAC in both guidelines,” said Bellmunt. In the ESMO Guidelines, there are suggested options after NAC failure, whereas in the EAU Guidelines these are missing. He also noted that there is a lack of integration on the management of upper urinary tract (UUT) tumours in the EAU Guidelines, while in the ESMO these are not addressed at all. Despite these gaps, he noted the prospects in new biological markers. June/July 2018

Prospects in molecular classification and immunotherapy On Day 2, urologist Seth Lerner (US), oncologist Thomas Powles (UK) and urologist Maurizio Brausi (IT) took up new developments in bladder cancer classification and treatment. Lerner tackled genomics’ impact on clinical practice, Powles discussed immunotherapy’s role in metastatic BCa, and Brausi examined palliative management issues in unresectable MIBC tumours. “MIBC is associated with a very high mutation rate… and the mutation processes affect survival,” said Lerner in his lecture in which he covered topics such as expression-based molecular subtypes, upper urinary tract tumours, prognostic biomarkers and how it may inform clinical decision-making. “mRNA expression-based subtypes define unique biology and treatments,” said Lerner as he underscored that high mutation numbers are linked to survival rates. “These fusions may render a patient sensitive to targeted therapy,” he added. Powles discussed immune checkpoint inhibitors licensed in metastatic urothelial cancer such as IO, atezolizumab, nivolumab, pembrolizumab, durvalumab and avelumab- drugs with PD-1 and PD-L1 as targets for inhibition. On single-agent immune therapy in platinum refractory disease, Powles mentioned the following key points: • Immune checkpoint inhibitors have superseded chemotherapy in platinum-refractory disease; • All of the drugs are associated with long-term durable remission; • Pembrolizumab is the only agent with a positive randomised phase 3 study; and • The biomarkers are 'consistently' inconsistent. Continued on page 22

7-9 February 2019, Berlin, Germany Page 19

New Event!


Abstract submission now open! Deadline: 1 November 2018

European Urology Today


SATURN Registry enrols 100th patient European Registry evaluates cure rate of surgical procedures in male SUI Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ uroweb.org

Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ uroweb.org

per-operative antibiotics, type of associated procedures (e.g. penile prosthesis), use of suprapubic or transurethral catheter or drain) and post-operative data (e.g., time of presence of suprapubic or transurethral catheter, presence of postoperative retention, scrotal hematoma, perineal or groin pain, haematuria, swelling or other problems). The ICIQ UI Questionnaire SF and EQ-5D-5L questionnaires will be handed over or posted out to the patients at 12 weeks after surgery and then yearly up to and including Year 5 by the Local Consultant or Research Coordinator, if required on the prompt from the central data manager.

Protocol Writing, - and Steering Committee: • Rizwan Hamid, United Kingdom • Nikesh Thiruchelvam, United Kingdom • Frank Van Der Aa, Belgium • John Heesakkers, The Netherlands • Wim Witjes, EAU Research Foundation, The Netherlands

Collaborator Boston Scientific Corporation Study team Principal Investigator: Rizwan Hamid, Assistant Professor of Urology Consultant Urological Surgeon Department of Urology, University College London Hospitals London, United Kingdom

EAU Research Foundation Wim Witjes, Scientific and Clinical Research Director Raymond Schipper, Clinical Project Manager Christien Caris, Clinical Project Manager Joke Van Egmond, Clinical Data Manager Hans Noordzij, Marvin System Assistant

In 2017 the EAU Research Foundation started a European Registry for male SUI patients. Fig. 1: Actual en planned number of recorded patients in e-CRF (status 28 May 2018)

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

European Urology Today

Actual Actual Planned Planned

200 200

Study update To date (cut-off date 28 May 2018), six centres are active which recorded in total 108 patients in the e-CRF. This may be an underestimation of the actual number of recruited patients as not all included patients are yet recorded in the e-CRF.

N=108 N=108

100 100

Primary objective: To evaluate the cure rate of procedures for the treatment of male stress urinary incontinence.

Czech Republic Spain

Secondary objectives: To determine other outcomes of surgical treatment of male stress urinary incontinence for a variety of the devices and to perform a prognostic factor analysis to identify clinical and surgical variables that correlate with (in)continence or revisions; Evaluate the cure rate of procedures for treatment of male stress urinary incontinence.


Study participants A total of 500 male patients undergoing surgery for the treatment of stress urinary incontinence with medical devices such as AUS or sling in a given centre. Study procedures and assessments Study visits for patients undergoing surgery for stress incontinence with medical devices such as AUS or male sling are typically conducted before surgery, and after the surgical procedure at six weeks (activation of AUS in case of AUS surgery), 12 weeks and one year post-surgery. Long-term followup will consist of yearly visits after visit at one year post-surgery up to and including Year 5. Preoperative data (e.g., patient characteristics, Charlson co-morbidity index, 24-hour pad test, urodynamic results), per-operative data (e.g., details on surgery, type of prosthesis, cuff size and location, pressure of regulating balloon, presence of double cuff, type of

The Netherlands

Dr. Roman Zachoval Dr. Esaú Fernández Pascual/ Prof. Dr. Ignacio Martinez Salamanca Dr. Tanja Hüsch/ Prof. Axel Haferkamp Dr. Laetitia De Kort

Prague Madrid

Mainz Utrecht

Jan-21 Jan-21

Sep-20 Sep-20

May-20 May-20

Jan-20 Jan-20

Sep-19 Sep-19

May-19 May-19

Jan-19 Jan-19

Sep-18 Sep-18

May-18 May-18

Jan-18 Jan-18


Is this study open to new sites? Yes. Institutions that perform surgical procedures for treatment of male stress urinary incontinence can participate. There will be no restriction on the number Table 1: Number of patients recorded in e-CRF per study centre of patients enrolled as long as they are consecutive. Country (Sub) Investigator City If you are interested to participate in this project, please contact the study coordinator Dr. Raymond The Netherlands Dr. John Heesakkers/ Nijmegen Schipper at r.schipper@uroweb.org as soon as Dr. Frank Martens possible. Site must be able to complete the Belgium Prof. Dr. Frank Van Der Aa Leuven approvals process promptly.

EAU Research Foundation


N=500 N=500

Sep-17 Sep-17

Editor-in-Chief Prof. M. Wirth, Dresden (DE)

500 500 Number Number of ofpatients patients 400 400 recorded recorded in ine-CRF e-CRF 300 300

Jan-17 Jan-17

European Urology Today

600 600

May-17 May-17

The primary objective of the SATURN study is to evaluate the cure rate of surgical procedures for treatment of male stress urinary incontinence at five years of study follow up. Cure rate will be the main endpoint of the study, and is defined as urinary continence with no need for use of pads or the use of one light security pad. The cure rate after five years of study follow-up will be calculated together with its 95% Confidence Intervals, for the total patient group as well as for each device subtype. For more background of this study see the article of Dr. Rizwan Hamid on page 12.

Hospital Radboud UMC University Hospital Leuven Thomayer Hospital University Hospital Puerta de Hierro Majadahonda University Hospital Mainz University Medical Center Utrecht Total

# Patients recorded in e-CRF 37 50 3 6

0 12 108

Sites to be initiated United Kingdom: Dr. Rizwan Hamid (University College London Hospital, London), EC approval Norway:

Dr. Ole Jacob Nilsen (Rikshospitalet Oslo University Hospital, Oslo), EC approval


Prof. Dr. David Castro-Diaz (University Hospital of the Canary Islands,Tenerife), EC approval Prof. Dr. Ignacio Moncada Iribarren (University Hospital Francisco de Vitoria, Madrid), EC approval Dr. Javier Romero-Otero (University Hospital Universitario 12 Octubre UC, Madrid), EC submission Dr. Salvador Arlandis (University Hospital La Fe, Valencia), EC submission

Czech Republic:

Prof. Dr. Tomáš Hanuš (General University Hospital, Prague), EC approval


Dr. Kari Tikinnen (Helsinki University Central Hospital , Helsinki), EC submission


Prof. Dr. Karel Everaert (University Hospital Ghent, Ghent), EC submission Prof. Dr. Koenraad van Renterghem (Jessa Hospital, Hasselt), EC submission


Prof. Dr. Ricarda Bauer (Ludwig-Maximilians-University, Munich), EC approval Dr. Fabian Queißert (University Hospital Münster, Münster ), EC submission


Dr. Jean-Nicolas Cornu (University Hospital Rouen, Rouen), EC submission Prof. Dr. Emmanuel Chartier Kastler (Pitié Salpêtrière Paris Hospital, Paris), EC submission


Dr. Giorgio Bozzini (Humanitas Mater Dominin, Milan), EC submission

June/July 2018

EAU National Societies Meeting 2018 Addressing emergent urological challenges in Europe By Jarka Bloemberg Around 65 representatives of 39 urological national societies from all over Europe gathered at the Grand Hotel Huis Ter Duin in Noordwijk, The Netherlands, to address challenges in European urology. “The collaboration between the EAU and the European national societies is essential in advancing our medical specialty,” said EAU Secretary General Prof. Chris Chapple (GB) in his welcome remarks. The two-day meeting which commenced on 15 June kicked off with an update of the various EAU Offices by the Executive Committee members: Professors Manfred Wirth (DE), Hein Van Poppel (BE), Chapple and Jens Sønksen (DK). Addressing the representatives, Chapple said, “Without the dynamism of urology, we wouldn’t be where we are today. We would like to work more closely with you, to learn from you, and to add value to what you do in your country.” Young generation The EAU actively supports promising urologists through scholarship programmes and by involving them in the EAU Sections which is, collectively, the clinical core of the EAU. Sønksen, who attended several regional meetings, was impressed by the young generation in the Baltic States and what they have accomplished. “Our aim is to help and support the various national societies, not to constrain. By providing young urologists opportunities to improve their skills and present their work, we offer them a good foundation for their future career,” Sønksen said. Expanding core responsibilities There is an emphasis on the technical side with surgeons, but urologists should be more multi-faceted. “We need to change the way we deal with oncology”, said Chapple. “Urologists should be allowed to prescribe new medication which are no longer as toxic as its predecessors. We should be able to change this on a national level.” Onco-urology was a recurring topic during the meeting. Prof. James N’Dow (GB), Chair of the EAU Guidelines Office, presented a five-year research programme called PIONEER that aims to improve outcomes in prostate cancer by using big data. A consortium of academia where researchers and industry partners are coordinated by the EAU and funded by the European Commission, PIONEER is Europe’s largest public-private partnership in healthcare research.

BCa18: Challenges in standard practice amid new changes . . . . . . . . . . . . . . 1 SATURN Registry enrols 100th patient. . . . . . . 2 EAU National Societies Meeting 2018. . . . . . . 3 FEBU Exams marks 25th jubilee anniversary . . . . . . . . . . . . . . . . . . . . . . . . 4-6

Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 German Society of Urology (DGU) said, “There will be a time that we cannot treat all patients.” In Estonia and Greece, they are struggling to recruit young urologists whereas, in the United Kingdom, they expect equipment shortage vis-à-vis the anticipated number of patients in the future. In Ireland, young urologists generally lean towards robotics, but are not trained adequately in general urology, where the increase in the number of patients is expected to be high. Several national societies expressed that the EAU should exert more political influence and increase the awareness of urology at an EU level. Significantly, more information and knowledge are needed to have a strong strategy on how the EAU can play a major role in supporting the national societies. Future of Urology – Part 2 On Day 2 of the meeting, a digital poll-taking took place to gauge the urological needs of participating countries. A total of 57 representatives shared their views by answering multiple-choice questions. About 72% of the representatives conveyed that urological healthcare in their countries is mainly provided by the public healthcare sector.

Electronic health records will be an important source of data and N’Dow urged national societies to provide support. N’Dow: “The ideal setting is to have all prostate cancer patients registered on the PIONEER platform. Can you imagine one million PCa patients from around the world and their health records are in one database? This goal will not be achieved without your support and participation. We need your help in spreading the word.”

Although situations vary per country, there are similarities in the challenges faced by urologists in Western and Eastern Europe. Due to the increase in the ageing population, one of the biggest concerns is work pressure. In Germany it is expected that there will be 20% more urological patients in 2019. The Chair of the June/July 2018

A huge number of participants communicated that recruitment of young urologists will be a significant challenge in the future. Only 9% think otherwise.

Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . 8-11 SATURN – Registry for male stress incontinence procedures. . . . . . . . . . . . . . . . 12

Opinions on whether all urologists should be supra-specialised in the future were significantly divided: 41% agreed, 34% disagreed and the remaining were neutral. Half of the participants anticipate a division between operating urologists (who perform major surgeries) versus non-operating urologists (who perform minor surgeries or none at all).

Update from the Guidelines Office . . . . . . . . 13 PIONEER: An EAU Guidelines Office-led project. . . . . . . . . . . . . . . . . . . . . 13

Majority of participants agreed that the EAU should recommend a urological curriculum for medical schools (77%) and for urological residents throughout Europe (88%). More than half agreed that exams such as the Fellow of the EBU (FEBU) qualification should be mandatory to practise urology in Europe. About 89% agreed that re-qualification and CME should be compulsory for urologists after residency.

ESU section: Interpreting MRI: Next frontier for urologists . 17 BPO Masterclass in Heilbronn. . . . . . . . . . . . 17 ESU Training and Research group. . . . . . . . . 18 Enthusiastic response for ESU course in Morocco. . . . . . . . . . . . . . . . . . . . . . . . . . 19 UROBESTT: Designed for promising urologists. . . . . . . . . . . . . . . . . . . . . . . . . . . 19 ESU introduces new masterclass on kidney transplant. . . . . . . . . . . . . . . . . . . . . 20 European Urological Scholarship Programme . . . . . . . . . . . . . . . . . . . . . . . . . 20 New ESU e-courses . . . . . . . . . . . . . . . . . . . 21

When asked what is needed to cope with the growing number of urological patients, the top three opinions were: involvement of nurses/mid-level providers (26%); increased recruitment of medical students and residents into urology (23%); and improved quality of education (22%). About 93% conveyed that specialised nurses or other mid-level providers should be encouraged to take over specific tasks normally performed by urologists such as peri-operative counselling (34%), evaluation and treatment of some categories of patients (29%), and prescription and renewal of certain medications (16%). An astounding 93% voted that the EAU should work towards greater patient education and involvement, and 92% voted that the EAU should closely work together with patient groups.

EAU Patient Information Globalisation is also impacting the daily clinical practice in urology. More and more urologists are seeing patients of different nationalities. How significant would it be to provide information about an Prof. Van Poppel speaks of EAU's educational programmes anticipated procedure in a patient’s native language? Prof. Thorsten Bach (DE), representative of EAU Patient Information, said: “If your patient can understand what to expect in a procedure, for example, they will be better prepared for it and, in turn, it will possibly lead to a better outcome for them. The EAU offers the most comprehensive, complete and unbiased Guidelines. These are now translated into the best and most reliable patient information as well. We need your help to continue with the translations in more languages. It’s been a big year for our family Inform your healthcare providers and be aware of of journals. The launch of European what information and translations are available.” Urology Oncology, a new editorial Future of Urology – Part 1 The “Future of Urology” was the concluding topic of the Plenary Sessions on Day 1. During the lecture, Sønksen said: “For 2018, we need more information from national societies to secure the position of urology. What is the biggest challenge for the future of urology in your country?”

EAU and PUA sign landmark agreement. . . . . 7

Prof. Chapple explains the objectives of EAU's section meetings

The meeting was considered by many participants to be truly productive. The EAU will incorporate the valuable insights from the meeting with the objective to further boost urology in Europe and beyond.

ESUT18: Live Surgery from three continents . 15 Ten Questions: Deepansh Dalela. . . . . . . . . . 16 ESUR18 convenes top experts in urological research. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Historic agreement with UAA. . . . . . . . . . . . 22 An outstanding opportunity. . . . . . . . . . . . . 22 Newly restructured ELUTS18 to get to the core of urology. . . . . . . . . . . . . . . . . . . . 23 PCa18: Meeting the challenges in PCa management. . . . . . . . . . . . . . . . . . . . . 24 ERUS18 to offer wide range of education in robotic surgery. . . . . . . . . . . . . . . . . . . . . 24 EULIS: Madrid hosts EULIS-URS Workshop. . 25 Obituary: Olexander Fedorowytsch Vozianov. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 ESUP: Uropathologists to use blood (liquid) biopsy as routine tool. . . . . . . . . . . . 26 EMUC18: Identifying optimal management in MIBC. . . . . . . . . . . . . . . . . . 28 ESUI18: Critically assessing modern imaging techniques . . . . . . . . . . . . . . . . . . . 28


ESUT: Technology strikes big-time in Copenhagen. . . . . . . . . . . . . . . . . . . . . . . . . 29

team for European Urology Focus and now an all time high for the European Urology Impact Factor. To our extended family of authors, reviewers, and readers, thank you. We really are in this together.

Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 31

Our 2017 Impact Factor*

YUO section: Surgery in the 3rd millennium: The future is female. . . . . . . . . . . . . . . . . . . 30 Urological volunteering in Cameroon. . . . . . 30 Lake-side ’Ultrabalaton’ promotes prostate awareness . . . . . . . . . . . . . . . . . . . 31

US researcher wins Diokno prize in urology. . . . . . . . . . . . . . . . . . . . . . . . . . . 32 EAU-JUA Academic Exchange Programme 2018 . . . . . . . . . . . . . . . . . . . . . 33

*Journal Citation Reports ® (Clarivate Analytics, 2018)

Baltic18 features top research in and beyond the region. . . . . . . . . . . . . . . . . 37

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

EAUN section: EAUN Fellowship at MSK . . . . . . . . . . . . . . . 38 Using cannabis in prostate cancer patients. . 39 EAUN supports urology nursing in China and Hong Kong. . . . . . . . . . . . . . . . . . 40

European Urology Today


FEBU Exams marks 25th jubilee anniversary Passing the exam: A test of merit and accomplishment Prof. Dr. Serdar Tekgül European Board of Urology Chairman Examination Committee serdartekgul@ gmail.com The European Board of Urology (EBU) is a regulatory body and acts as the Specialist Section in Urology of the European Union of Medical Specialists (UEMS). In close cooperation with national urological associations, the EBU has come a long way in its mission to set standards in urologic training.

The EBU opened its offices in the Netherlands in 1990. The first European Board Examination in Urology was held in 1992. Over the last 25 years, more than 5,500 urologists have received the FEBU title. The FEBU diploma has no official imprimatur and does not provide the right to practise urology. Yet, the FEBU diploma and title are considered a label for quality and added qualification. Many urologists consider the title as an asset to their portfolio, as

The EBU Oral Examination of 2 June 2018 marked the 25th anniversary. The oral examination is part of the qualification process for the FEBU title. Many years of hard work and dedication are reflected in the very successful organization of the exams. This year there were 120 examiners from 19 countries in four different centres. In total, there were 402 candidates and the

EBU Exams: Stepping-stone for success in a young urologist’s career Why do candidates take EBU exams?

The EBU, in close collaboration with the European Association of Urology (EAU), has certainly played a leading role for many other surgical specialties with its internationally renowned activities. It was more than three decades ago in 1985 that the UEMS Section of Urology was formally created following the foundation of the UEMS in 1958 with the aim of uniting national medical organizations in Europe and to coordinate and harmonize the specialist trainings.

shown by the increasing number of candidates taking the exam.

• To acquire a well-recognized mark of excellence; • To carry a title which provides credibility at every level - institutional, national and international; • To have the opportunity to work outside the home country;

• To assess one’s standing in both national and international levels; • To boost clinical practice; • To stimulate personal improvement and career development; and • In Hungary and Poland, the exam is part of requirements for practice and institutions acknowledge it for its prestige.

pass rate is 91%. The central examination was held in Warsaw and included sessions in nine different languages. Simultaneously, there were three nationally organised examinations. • • • •

Warsaw: 272 candidates/249 passed. Ankara (Turkish): 77 candidates/71 passed. Warsaw (Polish): 38 candidates/32 passed. Budapest (Hungarian): 15 candidates/15 passed.

Running a perfect exam is hardly possible in any profession but we are confident that we have achieved fulfilling our objectives in terms of effectiveness and efficiency. We have the passion to take it further and upgrade our performance based on internal and external feedbacks, enabling us to ensure continued development and high quality.

"The FEBU title is a true test of merit and successfully accomplishing the exam takes the urologist to another level."

Board of examiners in Ankara, Turkey

Meet one of the latest Fellows of the EBU We spoke to Dr. Anna Katarzyna Czech (Krakow, Poland) about her experiences of the FEBU exams. How did you experience the FEBU Examinations? EBU examinations, of course, are stressful particularly the oral part. In my opinion, the most important aspect of EBU examinations is that they stimulated me to thoroughly study all areas of urology, including those that are not usually part of my everyday clinical work. A thorough study means a higher chance to achieve a better examination grade, and more importantly it improves my practice. What did you like about the examinations? I like that FEBU examinations are pan-European and all candidates take the same exam at the same time regardless where they come from and what they practise. This maximizes objectivity, reducing disparities and allowing candidates to obtain the FEBU title which is recognised worldwide. How important is the FEBU title for you? I knew about the EBU examinations and FEBU

Dr. Anna Katarzyna Czech of the University Hospital, Jagiellonian University, Krakow, proudly presenting her diploma

Examiners from Spain at the Central Exam in Warsaw

title even before I started my residency and it was one of the reasons which encouraged me to pursue a career in urology. In Poland, urology is the only medical specialty where it is obligatory to take an international exam to obtain a title which is recognised worldwide as a mark of excellence. Altogether, the FEBU title is very important for me and I am proud of it.

Announcement upcoming events EBU In-Service Assessment: EBU Oral Examination:

7 & 8 March, 2019 29 June, 2019

For more information please visit our website www.ebu.com Group photo Polish Exam Warsaw


European Urology Today

June/July 2018

Successful candidates EBU Oral Examination 2018 FEBUs Hungary Csaba Arthur Molnár Ágnes Csilla Rosecker Noémi Feketéné - Bordás János Dér Erzsébet Hajdú András Kubik Andrea Kinga Kuti

Robert Liss Piotr Taborowski Łukasz Grycko Marcin Radko

András Magyar Ágnes Molnár Miklós Romics Judit Vargha Anna Lilla Vecsei Zsuzsanna Zotter Mohammed Altenni Sebastian Dorel Constantinescu

FEBUs Turkey Serkan Akan Hacı Murat Akgül

Mehmet Kaynar Tanju Keten Erdem Kısa Murat Yavuz Koparal Alper Nesip Manav Sedat Öner Süleyman Öner Asım Özayar

Katharina Bretterbauer, Austria Philipp Buchgeister, Germany Francisco Caramés Masana, Spain Francesca Carobbio, Italy Jose Edmundo Carpio Villanueva, Spain Gaetano Chiapparrone, Italy Raul Cocera Rodriguez, Spain Paolo Corsi, Italy

FEBUs Poland Sławomir Poletajew Sylwia Bender Szymon Kawecki Jacek Czesnin Anna Katarzyna Czech

Ferhat Ateş Ahmet Murat Aydın Tahsin Batuhan Aydoğan Bahri Serkan Aynur Ömer Aytaç Muhammet Şahin Bağbancı Melih Balcı Alp Tuna Beksaç Fatih Bıçaklıoğlu Mustafa Yücel Boz Ender Cem Bulut Mehmet Çağlar Çakıcı Ömer Onur Çakır Orçun Çelik Hüseyin Çelik

Oğuz Özcan Muhammet Fuat Özcan Yavuz Özdemir Çağdaş Gökhun Özmerdiven Kenan Öztorun Eyyup Sabri Pelit İsmail Selvi Nevzat Can Şener Adil Emrah Sonbahar Gökhan Sönmez Mustafa Soytaş Mesut Tek Mustafa Zafer Temiz Ahmet Serdar Teoman Muhammed Tosun

Meritxell Costa Grau, Spain Paolo De Angelis, Italy Ruben De Groote, Belgium Elisa De Lorenzis, Italy Davide De Marchi, Italy Dario Del Fabbro, Italy Pier Andrea Della Camera, Italy Luca Di Gianfrancesco, Italy Francisco de Asís Donis Canet, Spain Nici Markus Dreger, Germany Konstantinos Drosos, Germany Aline Duchateau, Belgium Gaëlle Fiard, France Mille Brunbjerg Folker, Denmark Isabel Galindo Herrero, Spain

Marcin Warzecha Stanisław Wasik Michał Zembrzuski Przemysław Sokołowski Jakub Tworkiewicz Radosław Flisikowski Grzegorz Wagner Łukasz Kupis Aleksander Targonski Marcin Witek Ryszard Skiba Paweł Wołyniec Przemysław Biały Paweł Stajno Grzegorz Nowak

Serhat Çetin Mehmet Çetinkaya Erman Ceyhan Nusret Can Çilesiz Soner Çoban Mehmet Gökhan Çulha Meftun Çulpan Yavuz Onur Danacıoğlu Hasan Deliktaş Mehmet Eflatun Deniz Serkan Doğan Ömer Gökhan Doluoğlu Ozan Efesoy Selçuk Erdem Erkan Erdem

Burçin Tunç Hakan Türk Murat Uçar İsmail Yağmur Çağlar Yıldırım İsmail Önder Yılmaz Mehmet Yılmaz Ömer Barış Yücel FEBUs Warsaw (final-year residents*) Abdalla Alhammadi, France Manuel Alonso Isa, Spain Guillaume Altwegg, France Joel Andersson, Sweden Beatriz Teresa Antón Eguia, Spain

Jesica del Pilar García Pérez, Spain Raphael Gehrer, Switzerland Marco Giampaoli, Italy Cedric Goes, Belgium Carlos González Cáliz, Spain Marijn Goossens, Belgium Tobias Grantzow, Germany Oliver Gross, Switzerland Jorge Guimera Garcia, Spain Alberto Gurioli, Italy Mirjam Harms, Austria Jörg Michael Häufel, Switzerland Mateo Hevia Suárez, Spain Anke Horneff, Germany Davide Inverardi, Italy

Piotr Falkowski Karolina Kropiewnicka-Buczek Mateusz Wojtarowicz Anna Malis Jacek Karaszewski Paweł Winczakiewicz Agnieszka Chomicz Janusz Lisinski

Kasım Emre Ergün Cem Tuğrul Gezmiş Mehmet Reşit Gören Mustafa Ozan Horsanalı Mehmet Ali Karagöz Tolga Karakan Mücahit Kart Bülent Katı

Isabelle Antwerpen, Switzerland Chalil Arif, Greece Mark Andre Behrendt, The Netherlands João Belo de Almeida Dores, Portugal Patrick Betschart, Switzerland Laura Bettin, Italy Lorenzo Bianchi, Italy Piet Bosshard, Switzerland

Jens Kai Jaeger, Germany Justas Janušonis, Germany Charis Alexis Thomas Kalogirou, Germany Benedict Philipp Keller, Germany Dimitrios Kotsiris, Greece Henning Krüger, Germany Christian Ladurner, Italy Yago Lago Escudero, Spain

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

June/July 2018

European Urology Today


Successful candidates EBU Oral Examination 2018


Alba Lara Isla, Spain Grégoire Leon, France Ricardo López del Campo, Spain Laura Lorenzo Soriano, Spain Marlies Maatje, The Netherlands Andrea Mari, Italy Celso Filipe Marialva Rodrigues, Portugal Leopoldo Marzullo, Spain

Anna Katharina Seitz, Germany Hosam Serag, United Kingdom Alexandros Grigorios Sertsios, Spain Nadine Sieger, Germany Luis Miguel Sierra Villavicencio, Spain Tommaso Silvestri, Italy Ulrich Sebastian Sonntag, Germany Jindrich Šonský, Czech Republic

Conrad Claudius Blobel, Germany Janneke Bolster, The Netherlands Eduardo Bolufer Moragues, Spain Angelika Borkowetz, Germany Maximilian Brandt, Germany Morgan Bruschi, Italy Elena Buendia González, Spain Enrique Cao Avellaneda, Spain

Francesco Lembo, Italy Panagiotis Levis, Greece Nikolaos Liakos, Germany José Daniel López Acón, Spain Omar Maghaireh, Germany Viviana Manuel Magno de Azevedo, Portugal Neil Maitra, United Kingdom Viktor Manolas, United Kingdom

Luca Meggiato, Italy Mara Isabella Eva Meier, Switzerland Elisa Meilán Hernández, Spain Vitaly Mezentsev, United Kingdom Jan Mokriš, Czech Republic Diogo Gil Moreira de Sousa, Portugal Alessandro Morlacco, Italy Gregory Nason, Ireland Arjan Nazaraj, Italy Theresa Elisabeth Adele Neuerburg, Germany Lilian Rebekka Neuhaus, Switzerland Paulo Ricardo Oliveira Da Mota, Portugal Petri Tapani Ollikainen, Finland Meritxell Palomera Fernandez, Spain Daniele Panarello, Italy

Daniel Alejandro Tueti Silva, Spain Michael Turgut, Switzerland Mustafa Tutal, Switzerland Lorena Valls González, Spain María Teresa Valls Martínez, Spain Jeroen Van Besien, Belgium Julien Van Damme, Belgium Francesca Vedovo, Italy Ralf Veys, Belgium Maria José Vidal de Albuquerque Freire, Portugal Ferdinando Daniele Vitelli, Italy Camille Vuichoud, France Sharon Waisbrod, Switzerland Elaine Wan Hariharan, United Kingdom Mieke Waterschoot, Belgium

Paolo Capogrosso, Italy Charles Chahwan, France Zubair Cheema, United Kingdom Catalin Constandache, Romania Claudiu Emil Cozman, Ireland Tamás Dobej, Germany Diederick Duijvesz, The Netherlands Kilian Eich, Germany Pierre Einwaller, Germany João Manuel Espinheira Magalhães Pina, Portugal Roman Farra, Slovakia Mahmoud Farzat, Germany Gerasimos Fragkoulis, Greece Javier Fuentes Pastor, Spain Antoni Vicent Fuster Escriva, Spain

Esteban Horacio Mauerhofer, Switzerland Benjamin Meister, Germany Sami Abubaker Omar Mhamed, Germany Jens Möllenbeck, Germany Nelson Morales Palacios, Spain Ashkan Mortezavi, Switzerland Franziska Müller-Semaan, Germany Edward Mwela, Germany Inés Nuño de la Rosa Garcia, Spain Hazem Othman, Germany Frederik Oudshoorn, The Netherlands Prashant Patel, United Kingdom Stefan Pum, Austria Bernhard Ralla, Germany Daniel Ramírez Martín, Spain

Clemens Carl Panhölzl, Austria Vera Lúcia Pereira Marques, Portugal Corina Pérez García, Spain Giacomo Maria Pirola, Italy Carmen Azahara Pozo Salido, Spain Laia Pujol Galarza, Spain Lars Pursche, Germany Mauro Ragonese, Italy Yannic Raskin, Belgium Christine Heinke Reinbrecht, Germany Teresa Renedo Villar, Spain Dirk Rijksen, The Netherlands Juan Antonio Rivero Esteban, Spain Ángela Rivero Guerra, Spain Marco Lucio Romani, Italy

Paul Weißenfels, Germany Stefanie Wenzel, Germany Laura Wiedemann, France Bernhard Wirz, Switzerland Martin Wohlmuth, Austria Alexandra Zachou, United Kingdom FEBUs Warsaw (Urologists) Mohamad Al Taieb Al Farkash, Germany Hussain Al Ghanim, Germany Sameh Alalem, Germany Abdulmajeed Abdullah H Alghamdi, Germany Hamza Aljabali, Germany Mohammad Tayseer Mohammad Almanaseer, Germany Mahmoud Alnesr, Germany

Ibrahim Mohamed Ganaw, Germany Claudia Gasch, Germany María Esther Gordo Flores, Spain Piotr Kamil Grabiec, Germany Anna Grenabo Bergdahl, Sweden Maren Gruner, Germany Kerem Güleryüz, France Pratik Gurung, United Kingdom Mohammed Hassan, Germany Robert Hoekstra, The Netherlands Marián Hollý, Germany Gianmarco Isgro', Italy Axel John, Germany Victor-Emmanuel Jouret, Luxembourg Mohammed Jubain, Germany

Jens Rosellen, Germany Johannes Rüb, Germany Leandro Sala Lafuente, Spain Aigul Salmhofer, Austria Yury Samaseika, Germany Sergey Sarychev, Germany Benjamin Philipp Schilling, Germany David Schmelzer-Ziringer, Austria Uta Johanna Schöning, Germany Joanne Slyth Serrano Uribe, Spain Marco Andrés Sobrón Bustamante, Spain Vladimír Študent, Czech Republic Grigorios Theodoropoulos, Greece Andreas Michael Thoms, Switzerland Flavia Tombolini, Italy

Karim Saba, Switzerland Álvaro Sánchez González, Spain Anna Sánchez Llopis, Spain Mauro Ernesto Sbriglio, Spain Gert Schachtner, Austria Christin Schätze, Germany Ingrid Schauer, Austria Hans Harold Schudel, Switzerland Geraldine Andreina Scott Pabon, Spain Daniel Luís Sebastião Costa, Portugal

Fouad Aoun, Belgium Reem Assi-Huber, Austria Marie Audouin, France Rocío Barrabino Martín, Spain Alvaro Barroso Manso, Spain Sarah Laura Barton, Germany Jaroslav Batiutov, Germany Martin Baunacke, Germany Sami Beji, Denmark Uroš Bele, Slovenia

Gregor Kadner, Switzerland Andreas Karagiannis, Greece Leonidas Karapanos, Germany Ahmed Mohamed Ahmed Khashim, Germany Yvonne Klaile, Germany Undine Knolle, Germany Dmitri Korotõtš, Estonia Viktor Kovácik, Slovakia Alexander Kretschmer, Germany Lukas Kühnelt-Leddihn, Austria

Gina Marcela Torres Zambrano, Spain Giorgi Tsabutashvili, Georgia Pieter Uvin, Belgium Joost van Asten, The Netherlands Kim van Putten, The Netherlands Rajan Veeratterapillay, United Kingdom Filippos Venetsanos, Greece Anneleen Verbrugghe, Belgium Bernd Wiegand, Germany Clemens Georg Wiesinger, Austria

European Urology Today

June/July 2018

EAU and PUA sign landmark agreement Collaboration boosts urology in the Philippines By Asst. Prof. Samuel Vincent G. Yrastorza (PH) Vice President and International Relations Officer Philippine Urological Association The Philippine Urological Association (PUA) signed an en-bloc membership agreement with the European Association of Urology (EAU) during the Annual EAU Congress (EAU18) in Copenhagen, Denmark. The landmark signing was led by EAU Secretary General Chris Chapple (GB) and PUA President Dr. Wilfredo Tagle (PH) which officially recognised PUA as a valued partner of the largest international community in the field of urology.

to come to par with the rest of the world. This year, two PUA residents will participate at the 16th European Urology Residents Education Programme (EUREP 2018) which will take place in Prague, Czech Republic this August. PUA plans to have further collaborations with the EAU to enhance urological knowledge, skills and

About PUA PUA is now on its 50th year and has been a pillar in the Philippine health sector in terms of service and national policies. Its medical and surgical outreach programmes involve the poorest and remotest provinces in the country in dire need of specialists. PUA strives to make its health programmes create an impact on a national scale. For the last 22 years during every Father’s Day weekend, digital rectal exams performed nationally gather participants by the thousands. In the last three years, this annual activity has been expanded to include all aspects of men’s health with 88 centres across the country, increasing awareness in the field and providing free consult and check-up for a whole day. Eleven training institutions supported by PUA produce about 20 new graduates annually with the aim to increase accessibility and availability of urological care in the country.

Workshops organised by the EAU Section of UroTechnology (ESUT), and European-Basic Laparoscopic Urological Skills (E-BLUS) exams were previously conducted in the Philippines. In December 2017, Chairman of the EAU Section Office, Prof. Jens Rassweiler (DE), performed a ceremonial oath-taking of 118 PUA members and by January 2018, they were officially EAU members. Residents-in-training registered as junior EAU members. The association continues to push for the advancement of urologic practice in the country for it EAU International Relations Office

technology not only for the Philippines but for Southeast Asia as well.

PUA signs agreement with the EAU

Throughout the years, PUA has hosted several international meetings of the Asia-Pacific Society for the Study of Impotence Research, the Federation of ASEAN Urological Association, the Asia-Pacific

Oath-taking of 118 PUA members

Association of Pediatric Urology Meetings, Asia-Pacific Society for Sexual and Impotence Research, the Asia-Pacific Society of Urologic Oncologists, and the East Asian Society of Endourology. The PUA also formalised linkages with the other medical societies that impact on urologic practice which include the Philippine College of Surgeons, Philippine Obstetrics and Gynecologic Society, Philippine Society of Nephrology, Philippine Pediatric Society, Philippine Society of Anesthesiologists and the Philippine Society for Transplant Surgeons as well as the Urology Nurses Association of the Philippines. For more information about PUA, please visit www.puanet.org.

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

Oliver.Hakenberg@ med.uni-rostock.de

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

Case study No. 56

Discussion points: • Are further investigations needed? • What options should be offered?

This 79-year-old lady was investigated for intermittent macroscopic hematuria. The CT scan shows a large lesion of the left kidney with presumably hilar and paraaortic lymph node enlargement (Figure 1). No metastatic lesions are seen on the thoraco-abdominal CT. Cystoscopy was normal. The lady is otherwise healthy and fit for her age. She definitely wants treatment.

Case study No. 57 This 86-year-old man presented with macroscopic haematuria and lower abdominal left-sided pain. Cystoscopy and transurethral resection led to the diagnosis of bladder cancer (urothelial carcinoma high grade) with muscular invasion. CT staging (fig.1 and 2) showed a lesion that has probably grown outside the bladder and reached the left pelvic wall. The patient is well educated, understands the problem and would like to have curative treatment, if at all possible. His physical condition is reasonably well for his age, comorbidities are a well-controlled hypertension and he has had a cardiac stent 6 years ago.

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

Figure 1 Figure 1

If bone scan is positive, renal biopsy should be considered Comments by Dr. Umberto Capitanio and Prof. Francesco Montorsi, Milan (IT)

This 79-year-old lady was investigated for intermittent macroscopic haematuria. The CT scan shows a large lesion of the left kidney with presumably hilar and paraaortic lymph node enlargement (Figure 1). No metastatic lesions are seen on the thoraco-abdominal CT. Cystoscopy was normal. The lady is otherwise healthy and fit for her age. She definitely wants treatment. Are further investigations needed ? The imaging suggests the presence of a locally advanced renal cancer with hilar and paraaortic lymphadenopathies. The foremost clinical challenge is related to the histology (renal cell carcinoma [RCC] vs. upper tract transitional cell cancer [UTTCC]). Although the presence of gross haematuria and imaging characteristics may be suggestive for UTTCC, the absence of synchronous

June/July 2018

thoracic, abdominal and bladder localisation through the manifestation of a bulky locally advanced disease could support RCC as primary diagnosis. For this reason, urine cytology should be performed to elucidate this differential diagnosis. Moreover, staging should be completed with bone scintigraphy, since the risk of bone metastases in this specific case ranges between 25 and 40%1. Additional investigations (e.g. CA-IX PET) are up to this day only to be considered in a clinical trial setting2. Given a high rate of false-positive rate up to 40%3, clinical lymphadenopathies should not be considered upfront as nodal metastases and/or proxy of poor prognosis. Finally, proper renal function assessment and referral to a nephrologist might be useful to maximise functional outcomes in the light of future treatments. What options should be offered? If bone scan is negative, surgery is recommended. The patient is symptomatic, non-metastatic, not frail and with good performance status and - finally willing of a definitive treatment. If urine cytology is negative, frozen section during the surgery may be useful to exclude histology (e.g. UTTCC) which may require complete debulking followed by ureterectomy and bladder cuff. In case of RCC at frozen section, radical nephrectomy and lymphadenectomy should be performed.

If bone scan is positive, renal biopsy should be considered to characterise the nature of the primary tumour since surgery could be not indicated in case of metastatic UTTCC. Conversely, in case of metastatic RCC at biopsy, an accurate multi-disciplinary uro-oncological assessment should be carried out to evaluate the balance of risks and benefits among the different approaches (upfront systemic therapy vs. cytoreductive surgery and systemic therapy vs. palliation), also pondering the upcoming results of the SURTIME and the CARMENA trials4.

Figure 2

Discussion points: • Are further investigations helpful? • In view of the patients wish for curative treatment what options are possible? • What treatment would you advise?

References: 1. Larcher A, Muttin F, Fossati N, Dell'Oglio P, Di Trapani E, Stabile A, et al. When to Perform Preoperative Bone Scintigraphy for Kidney Cancer Staging: Indications for Preoperative Bone Scintigraphy. Url 2017;110:114–20. doi:10.1016/j. urology. 2017.08.043. 2. Capitanio U, Montorsi F: Renal cancer. Lancet 387:894–906, 2016. 3. Gershman B, Takahashi N, Moriera DM, et al: Radiographic Size of Retroperitoneal Lymph Nodes Predicts Pathologic Nodal Involvement for Patients with Renal Cell Carcinoma: Development of a Risk Prediction Model. BJU Int n/a–n/a, 2016. 4. Choueiri TK, Motzer RJ: Systemic Therapy for Metastatic Renal-Cell Carcinoma. N Engl J Med 376:354–366, 2017.

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

Case Study No. 56 continued Urine cytology was negative, so was the bone scan. Surgery was planned, but finally cancelled as the patient and her family changed their mind and opted not to undergo major surgery.

European Urology Today


Key articles from international medical journals Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

mCRPC remains chemosensitive? Treatment options in patients with metastatic castration-resistant prostate cancer (mCRPC) previously treated with docetaxel, cabazitaxel and a novel hormonal therapy is limited. This is becoming an increasing challenge as the use of docetaxel and abiraterone moves into the hormone sensitive setting. Re-challenge with a novel hormonal therapy is limited by resistance and docetaxel re-challenge by cumulative toxicities. This multicentre retrospective study evaluated the activity and safety of cabazitaxel re-challenge in a heavily pre-treated patient cohort. Data was collected from 17 centres. Eligible men had been previously treated with docetaxel, one novel hormone treatment and cabazitaxel and then re-challenged with cabazitaxel. From the clinical records of 562 men treated with all three therapies 69 men who also underwent cabazitaxel re-challenge were identified. The type of progression before cabazitaxel re-challenge was radiological (55%, n = 38), clinical without radiological progression (17.4%, n = 12) and PSA progression only (27.5%, n = 19). The main reasons for stopping the first cabazitaxel were treatment completed (73%, n = 49) and toxicity (9%, n = 6). Overall survival and progression-free survival were calculated and data on toxicities were collected.

Tolerability appeared manageable and the proportion of patients experiencing grade III/IV adverse events was slightly lower that during first exposure Patients were re-challenged with a variety of cabazitaxel regimes (25 mg/m2 q3w, 58%; 20mg/m2 q3w, 27%; other [mainly 16 mg/m2 q2w] 14.5%) for a median of six cycles (1-10). 76% received prophylactic granulocyte colony-stimulating factor. During re-challenge, clinical benefit was apparent for 34.3% of the patients (50.0% with the first exposure), stable in 47.8% (46.9% with the first exposure) and 17.9% had a clinical progression (3.1% with the first exposure). Confirmed PSA response of at least 50% was observed in 23.8% of patients (70.8% with the first cabazitaxel). Median OS at initiation of cabazitaxel re-challenge was 13.7 months (95% CI, 9.3-15.7). Tolerability appeared manageable and the proportion of patients experiencing grade III/IV adverse events was slightly lower that during first exposure. There was no grade >¬¬¬III peripheral neuropathy or nail disorders. Unsurprisingly, the activity of cabazitaxel on re-challenge was reduced and these were mainly good initial responders who somewhat unusually remained well enough to consider fourth-line treatment. However, it is clear that cabazitaxel re-challenge may be a treatment option without cumulative toxicity in heavily pre-treated patients with mCRPC who are still fit and had a progression > 3 months after the last injections.

Source: Efficacy of cabazitaxel rechallenge in heavily treated patients with metastatic castration-resistant prostate cancer. Thibault C, Eymard J-C, Birrtle A, et al Euro J Cancer. 2018; 97: 41-48.

Radionuclide target treatment: The magic bullet? Although there have been a number of advances in the treatment of metastatic castration-resistant prostate cancer (mCRPC) over the last 15 years there remains an urgent need for effective therapeutic Key articles


agents that can improve patient outcomes including ameliorating disease-related symptoms and improving quality of life in the terminal stages of disease. Lutetium-177 [177Lu]-PSMA-617 (LuPSMA), is a small molecule inhibitor that binds with high affinity to prostate-specific membrane antigen (PSMA). The short-range 1 mm path length of the beta-particle emitted by 177Lu enables effective delivery of radiation to tumours while minimising damage to surrounding normal tissues. It is a variant of [68Ga]-PSMA-11 In this prospective, phase 2 trial, they investigated the efficacy, safety, and effect on quality of life of LuPSMA in men with progressive mCRPC who had failed standard therapies.

a single-centre, single arm, phase 2 study. Hofman MS, Violet J, Hicks RJ, et al. Lancet Oncol. 2018; http://dx.doi.org/10.1016/S14702045(18)30198-0

PCa was positively associated with short time since diagnoses of lower urinarytract infection or receiving prescriptions for antibiotics

The objective of this study was to investigate the association between lower urinary-tract infections, their associated antibiotics and the In a single-arm, single-centre, phase 2 trial, they screened 43 men with mCRPC and progressive disease subsequent risk of developing PCa. after standard treatments, including taxane-based Authors used data from the Swedish PCBaSe 3.0, chemotherapy and second-generation antito perform a matched case-control study (8,762 androgens. Patients underwent a screening PSMA cases and 43,806 controls). Conditional logistic and FDG-PET/CT to confirm high PSMA-expression. regression analysis was used to assess the Eligible patients had progressive disease defined by imaging (according to Response Evaluation Criteria In association between lower urinary tract infections, related antibiotics and PCa, whilst Solid Tumours [RECIST] or bone scan) or new pain in an area of radiographically evident disease, and were adjusting for civil status, education, Charlson Comorbidity Index and time between lower required to have an Eastern Cooperative Oncology Group (ECOG) performance status score of 2 or lower. urinary tract infection and PCa diagnosis. Thirty eligible patients received up to four cycles of intravenous [177Lu]-PSMA-617, at six weekly intervals. 26 (87%) patients had received previous chemotherapy, 14 (47%) had received second-line cabazitaxel, and 25 (83%) patients prior enzalutamide or abiraterone. The primary endpoint was PSA response defined as a greater than 50% PSA decline from baseline and toxicity according to CTCAE. Additional endpoints were imaging responses (as measured by bone scan, CT, PSMA, and FDG PET/CT) and quality of life (assessed with the EORTC-Q30 and Brief Pain Inventory- Short Form questionnaires), all measured up to three months post completion of treatment.

Collectively, this data suggests the LuPMSA is a useful therapeutic option for men with mCRPC with promising anti-tumour activity… The primary endpoint of PSA decline of 50% or more was achieved in 17 (57%) patients (95% CI 37–75). Interestingly, 29 (97%) of 30 patients experienced some degree of PSA decline. Two (7%) patients achieved a PSA nadir of 0·2 μg/L or lower from 94 μg/L and 15 μg/L, which have been durable at 530 and 379 days of follow-up. 17 (57%) patients had a RECIST evaluable nodal or visceral target lesions on CT at baseline. 14 (82%) of these 17 patients had a confirmed objective response, including a complete and partial response of 29% and 53%, respectively. Clinically meaningful improvements in pain severity and interference scores were recorded at all time points. 11 (37%) patients experienced a ten-point or more improvement in global health score by the second cycle of treatment. Administration of Lu-PSMA was well tolerated, with no immediate adverse effects recorded during injection and no treatment-related deaths. The most common treatment-related toxic effect was dry mouth, (related to PMSA expression in the salivary gland) recorded in 26 (87%) patients. This adverse event was exclusively grade 1 and usually did not require intervention. Other adverse events included grade 1 and 2 transient nausea in 15 (50%), and grade 1–2 fatigue in 15 (50%). Grade 3 or 4 thrombocytopenia possibly attributed to [177Lu]-PSMA-617 occurred in four (13%) patients. These results are broadly consistent with previous retrospective reports. Collectively, this data suggests the LuPMSA is a useful therapeutic option for men with mCRPC with promising anti-tumour activity, low toxicity and improved quality of life in men who have failed to respond to most conventional treatments. This data formed the basis of a recently commenced multicentre randomised phase 2 trial comparing LuPMSA to cabazitaxel (NCT03392428)

...men who were prescribed ≥ 10 antibiotics, were 15% less likely to develop PCa... It was found that lower urinary tract infections did not affect PCa risk, however, having a lower urinary tract infection or a first antibiotic prescription 6-12 months before PCa were both associated with an increased risk of PCa (OR: 1.50, 95% CI: 1.23-1.82 and 1.96, 1.71-2.25, respectively), as compared to men without lower urinary tract infections. Compared to men with no prescriptions for antibiotics, men who were prescribed ≥ 10 antibiotics, were 15% less likely to develop PCa (OR: 0.85, 95% CI: 0.78-0.91). It was concluded that PCa was not associated with diagnosis of a urinary tract infection or frequency, but was positively associated with short time since diagnoses of lower urinary tract infection or receiving prescriptions for antibiotics. These observations can likely be explained by detection bias, which highlights the importance of data on the diagnostic work-up when studying potential risk factors for PCa.

Source: A case-control study of lower urinary-tract infections, associated antibiotics and the risk of developing prostate cancer using PCBaSe 3.0. Russell B, Garmo H, Beckmann K, Stattin P, Adolfsson J, Van Hemelrijck M. PLoS ONE. 2018; 13(4):e0195690. DOI: 10.1371/ journal.pone.0195690. PMID: 29649268

Late-stage prostate cancer increases as PSA testing falls? PSA screening in USA lead to a dramatic increase in prostate cancer incidence between 1988 and 1992. Since the peak prostate cancer incidence has been decreasing with acceleration in the rate of decrease following the 2012 US Preventative Services Task Force (USPSTF) recommendations against routine PSA testing. Claim and counter-claim have surrounded the relationship between PSA screening and prostate cancer mortality-rates. This study evaluated contemporary national-level trends and their relations with PSA testing prevalence and explored trends in incidence according to disease characteristics with stage-specific, delay-adjusted rates.

Annual PSA testing rates from 2005 onwards were derived from the National Health Interview Survey and correlated with coding data. Prior to this the data was modelled. Prostate cancer incidence was based upon the SEER registries Source: [177Lu]-PMSA-617 radionuclide treatment in patients with metastatic castration- and supported by 42 state central cancer registries covering 89% of the US population. resistant prostate cancer (LuPMSA trial):

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de Join point regression was used to examine changes in delay-adjusted prostate cancer incidence rates from population-based US cancer registries from 2,000 to 2014 by age categories, race, and disease characteristics, including stage, PSA, Gleason score, and clinical extension. In addition, the analysis included trends for prostate cancer mortality between 1975 and 2015 by race (using the National Center for Health Statistics) and the estimation of PSA testing prevalence between 1987 and 2005. The annual percent change was calculated for periods defined by significant trend change points.

Further incidence data and death rate trends over the next few years can be used to track the role of PSA screening in declining prostate cancer mortality For all age groups, overall prostate cancer incidence rates declined approximately 6.5% per year from 2007. However, the incidence of distant-stage disease increased from 2010 to 2014. The incidence of disease according to higher PSA levels or Gleason scores at diagnosis did not increase. After years of significant decline (from 1993 to 2013), the overall prostate cancer mortality trend stabilised from 2013 to 2015. Although this flattening of the mortality trend is temporally associated with the fall in PSA testing and the rise of distant-stage disease, care must be taken as the flattening could have been affected by improvements in treatment After a decline in PSA test usage, there has been an increased burden of late-stage disease, and the decline in prostate cancer mortality has levelled off. This change chronologically followed new recommendations in the USPSTF guidelines for PSA-based prostate cancer screening. However, there was no increase in the incidence of patients with other high-risk characteristics (i.e., high PSA level, high Gleason score, and extraprostatic extension) to date. This raises the possibility that improved staging investigations led to the identification of small volume metastasis. Further incidence data and death rate trends over the next few years can be used to track the role of PSA screening in declining prostate cancer mortality.

Source: Annual report to the nation on the status of cancer, part II: recent changes in prostate cancer trends and disease characteristics. Negoita S, Feuer EJ, Mariotto A, et al. Cancer. 2018; http://dx.doi.org/10.10002/cncr.31549

Only hygiene measures were supported by evidence to be recommended for the prevention of urinary tract infections in pregnancy Urinary tract infections (UTIs) are common in pregnancy and account for the highest proportion of primary care antibiotic prescriptions issued to pregnant women in the UK. It is well known that antibiotic use is associated with increased antimicrobial resistance and therefore measures to minimise antibiotic use for UTI prevention have been studied. The efficacy and safety of these measures in pregnancy have not been addressed and therefore the aim of this study was to systematically review the literature to identify and evaluate potential measures to prevent UTIs in pregnant women. Ten databases (EMBASE, AMED, BNI, CINAHL, Medline, PubMed, PsycINFO, Cochrane Trials, Scopus and Science Direct) were systematically searched in


European Urology Today

June/July 2018

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

tebj@medisin.uio.no July 2017 for studies reporting non-antibiotic measures to prevent UTIs in pregnancy. The terms ("urinary tract infection" or UTI or bacteriuria or cystitis) AND (prevention) AND (pregnan) were used. The quality of the publications was appraised using the Critical Appraisal Skills Programme (CASP) checklists for cohort study, case-control study and randomised controlled trial. The results were synthesised using a textual narrative approach.

…the quality of the evidence varied considerably and only hygiene measures were supported by evidence to be recommended in practice Search results yielded 3,276 publications and after reviewing titles and removing duplicates, 57 full text articles were assessed for eligibility and eight were included in the review. Five different approaches (hygiene measures, cranberry juice, immunisation, ascorbic acid and Canephron® N) had been identified, all of which are reported to be safe in pregnancy. The authors concluded that the quality of the evidence varied considerably and only hygiene measures were supported by evidence to be recommended in practice. Future work needs to concentrate on strengthening the evidence base through improved design and reporting of studies with a focus on immunisation, ascorbic acid and Canephron® N.

Source: A systematic review of non-antibiotic measures for the prevention of urinary tract infections in pregnancy. Ghouri F, Hollywood A, Ryan K. BMC Pregnancy Childbirth. 2018 Apr 13; 18(1):99. DOI: 10.1186/s12884-018-1732-2. PMID: 29653573

No benefit of early appropriate empirical treatment on survival rates or other outcomes in patients with cUTI Complicated urinary tract infections (cUTIs) are responsible for a major share of all antibiotic consumption in hospitals. The authors aimed to describe risk factors for treatment failure and mortality among hospitalised patients with cUTIs. A multinational, multicentre retrospective cohort study was conducted in 20 countries in Europe and the Middle East. Data were collected from patients' files on hospitalised patients with a diagnosis of cUTI during 2013-2014. The primary outcome was treatment failure. Secondary outcomes included all-cause mortality 30 days, among other outcomes. Multivariable analysis using a logistic model and the hospital as a random variable was performed to identify independent predictors for treatment failure and 30-day mortality.

Physicians might consider supportive treatment and watchful waiting in stable patients until the causative pathogen is defined A total of 981 patients with cUTI were included. Treatment failure was observed in 26.6% (261/981) of patients; all cause 30-day mortality rate was 8.7% (85/976), most of these in patients with catheterrelated UTI (CaUTI). Risk factors for treatment failure in multivariable analysis, were ICU admission (OR 5.07, 95% CI 3.18-8.07), septic shock (OR 1.92, 95% CI 0.93-3.98), corticosteroid treatment (OR 1.92, 95% CI 1.12-3.54), bedridden (OR 2.11, 95% C: 1.4-3.18), older age (OR 1.02 for 1 year, 95% CI 1.007-1.03), metastatic Key articles

June/July 2018

cancer (OR 2.89, 95% CI 1.46-5.73), and CaUTI (OR 1.48, 95% CI 1.04-2.11). Management variables, such as inappropriate empirical antibiotic treatment or days to starting antibiotics were not associated with treatment failure or 30-day mortality. More patients with pyelonephritis were given appropriate empirical antibiotic therapy than other CaUTI [110/171 (64.3%) vs. 116/270 (43%), p < 0.005]; nevertheless, appropriate empirical antibiotic treatment afforded no advantage in treatment failure rates nor in 30-day mortality in these patients. Investigators concluded that in patients with cUTI there was no benefit of early appropriate empirical treatment on survival rates or other outcomes. Physicians might consider supportive treatment and watchful waiting in stable patients until the causative pathogen is defined.

Source: Risk Factors for Treatment Failure and Mortality among Hospitalised Patients with Complicated Urinary Tract Infection: A Multicentre Retrospective Cohort Study, RESCUING Study Group. Eliakim-Raz N, Babitch T, Shaw E, Addy I, Wiegand I, Vank C, Torre-Vallejo L, Joan-Miquel V, Steve M, Grier S, Stoddart M, Nienke C, van den Heuvel L, Vuong C, MacGowan A, Carratalà J, Leibovici L, Pujol M. Clin Infect Dis. 2018 May 17; DOI: 10.1093/cid/ciy418 PMID: 29788118

Effect of five-day Nitrofurantoin vs. single-dose Fosfomycin on uncomplicated female UTI The use of nitrofurantoin and fosfomycin has increased since guidelines began recommending them as first-line therapy for lower urinary tract infection (UTI). The authors compared the clinical and microbiologic efficacy of nitrofurantoin and fosfomycin in women with uncomplicated cystitis. The investigators conducted a multinational, open-label, analyst-blinded, randomised clinical trial including 513 non-pregnant women aged 18 years and older with symptoms of lower UTI, a positive urine dipstick result, and no known colonisation or previous infection with uropathogens resistant to the study antibiotics. Recruitment took place from October 2013 through April 2017 at hospital units and outpatient clinics. Participants were randomised in a 1:1 ratio to oral nitrofurantoin, 100 mg three times a day for five days (n = 255), or a single 3-g dose of oral fosfomycin (n = 258). They returned 14 and 28 days after therapy completion for clinical evaluation and urine culture collection.

…adverse events were few and primarily gastrointestinal; the most common were nausea and diarrhoea The primary outcome was clinical response in the 28 days following therapy completion, defined as clinical resolution (complete resolution of symptoms and signs of UTI without prior failure), failure (need for additional or change in antibiotic treatment due to UTI or discontinuation due to lack of efficacy), or indeterminate (persistence of symptoms without objective evidence of infection). Among 513 patients who were randomised (median age 44), 475 (93%) completed the trial and 377 (73%) had a confirmed positive baseline culture. Clinical resolution through day 28 was achieved in 171 of 244 patients (70%) receiving nitrofurantoin vs. 139 of 241 patients (58%) receiving fosfomycin (difference, 12% [95% CI, 4%-21%]; p = .004). Microbiologic resolution occurred in 129 of 175 (74%) vs. 103 of 163 (63%), respectively (difference, 11% [95% CI, 1%-20%]; p = .04). Adverse events were few and primarily gastrointestinal; the most common were nausea and diarrhoea (7/248 [3%] and 3/248 [1%] in the nitrofurantoin group vs. 5/247 [2%] and 5/247 [1%] in the fosfomycin group, respectively). The authors concluded that among women with uncomplicated UTI, five-day nitrofurantoin, compared

with single-dose fosfomycin, resulted in a significantly greater likelihood of clinical and microbiologic resolution at 28 days after therapy completion.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

Source: Effect of 5-day nitrofurantoin vs single-dose fosfomycin on clinical resolution of uncomplicated lower urinary tract infection in women: A randomized clinical trial. Huttner A, Kowalczyk A, Turjeman A, Babich T, Brossier C, g.ploussard@ Eliakim-Raz N, Kosiek K, Martinez de Tejada B, gmail.com Roux X, Shiber S, Theuretzbacher U, von Dach E, Yahav D, Leibovici L, Godycki-Cwirko M, Mouton JW, Harbarth S. Jelovsek JE, Barber MD, Brubaker L, Norton P, JAMA. 2018 May 1;319(17):1781-1789. doi: 10.1001/ Gantz M, Richter HE, Weidner A, Menefee S, jama.2018.3627. Schaffer J, Pugh N, Meikle S; NICHD Pelvic Floor Disorders Network. JAMA. 2018 Apr 17;319(15):1554-1565. doi: 10.1001/ jama.2018.2827

Effect of ULS vs. SSLF with or without perioperative behavioural therapy for pelvic Robot versus open radical organ vaginal prolapse on cystectomy: Does the surgical surgical results approach matter? Uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) are commonly performed pelvic organ prolapse procedures despite a lack of long-term efficacy data. The authors compared outcomes in women randomised to (1) ULS or SSLF and (2) usual care or perioperative behavioural therapy and pelvic floor muscle training (BPMT) for vaginal apical prolapse. This 2 × 2 factorial randomised clinical trial was conducted at nine US medical centres. Eligible participants who completed the Operations and Pelvic Muscle Training in the Management of Apical Support Loss Trial were followed up five years after their index surgery from April 2011 through June 2016. Two randomisations were performed: (1) BPMT (n = 186) or usual care (n = 188) and (2) surgical intervention (ULS: n = 188 or SSLF: n = 186).

Among women who had undergone vaginal surgery for apical pelvic organ vaginal prolapse, there was no significant difference between ULS and SSLF in rates of surgical failure The primary surgical outcome was time to surgical failure. Surgical failure was defined as (1) apical descent greater than one-third of total vaginal length or anterior or posterior vaginal wall beyond the hymen or retreatment for prolapse (anatomic failure), or (2) bothersome bulge symptoms. The primary behavioural outcomes were time-to- anatomic failure and Pelvic Organ Prolapse Distress Inventory scores (range, 0-300). The original study randomised 374 patients, of whom 309 were eligible for this extended trial. For this study, 285 enrolled (mean age 57.2 years), of whom 244 (86%) completed the extended trial. By Year 5, the estimated surgical failure rate was 61.5% in the ULS group and 70.3% in the SSLF group (adjusted difference -8.8% [95% CI, -24.2 to 6.6]). The estimated anatomic failure rate was 45.6% in the BPMT group and 47.2% in the usual care group (adjusted difference -1.6% [95% CI, -21.2 to 17.9]). Improvements in Pelvic Organ Prolapse Distress Inventory scores were -59.4 in the BPMT group and -61.8 in the usual care group (adjusted mean difference 2.4 [95% CI, -13.7 to 18.4]). Among women who had undergone vaginal surgery for apical pelvic organ vaginal prolapse, there was no significant difference between ULS and SSLF in rates of surgical failure and no significant difference between perioperative behavioural muscle training and usual care on rates of anatomic success and symptom scores at five years. Compared with outcomes at two years, rates of surgical failure increased during the follow-up period, although prolapse symptom scores remained improved.

Source: Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcomes and prolapse symptoms at 5 years in the optimal randomized clinical trial.

Laparoscopy has been suggested to improve perioperative outcomes in uro-oncology surgeries. Several oncology teams recently shifted towards a robot-assisted laparoscopic approach for radical cystectomy in high-risk bladder cancer treatment although oncologic equivalence has not yet been proven in high-level evidence studies. Robot-assisted radical cystectomy (RARC) has been introduced to decrease substantial morbidity following radical cystectomy and urinary diversion. In the present trial, the authors reported the oncology outcomes after a median follow-up of five years. The initial report published in 2015 failed to identify a large advantage in terms of perioperative outcomes for robot-assisted techniques over open surgery with similar 90-day complication rates, hospital stay, and short-term quality of life assessment. Overall, 118 patients have been included and randomised between the two techniques. Patient characteristics were comparable between both groups. Thirty-two (RARC arm) to 45% of patients received neoadjuvant chemotherapy. Urothelial cancer was found in 95% of patients. Median lymph node yield did not differ according to the surgical approach (29 and 31 nodes) as well as the number of nodepositive patients (16%) and the positive margin rate (3.3-5.2%). The percentage of patients with pT3 or pT4 disease in this trial suggested a skewed selection of patients with earlier stage compared to previous reports from the same group.

“Globally, this article suggests that the survival results are not affected by the type of surgery provided that the patients are operated in a highvolume cancer care centre… The recurrence-free survival was similar between the robot and open surgery arms (p = 0.4), with a risk of five-year of 36% in the RARC arm and 41% in the open surgery arm. Nevertheless, patients undergoing open surgery had a trend toward higher overall rates of distant recurrences (nine lung recurrences versus only one in the robot arm; HR 2.21; p = 0.064). During the entire follow-up, distant metastases were detected in 17 RARC patients and in 22 open surgery patients. Patterns of first recurrence were not strictly comparable in both groups. More extrapelvic lymph nodes and distant recurrences occurred in the open surgery group whereas abdominal recurrences were more frequent after robot approach, including abdominal wall and bowel recurrences. It is worthy to note that no abdominal recurrence was seen at previous port sites. No difference in terms of carcinomatosis and soft tissue recurrence was detected. Bladder cancer-specific and overall survival were similar between the two arms. These interesting analyses highlighted that the patterns of recurrence sites might be different according to the surgical approach, with more abdominal recurrence and less distant first recurrence when radical cystectomy was performed robotically. However, this analysis was unplanned and should be interpreted with caution. These presented oncologic outcomes were the secondary endpoints of the randomised trial whose


European Urology Today


Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ hotmail.com median follow-up is approaching five years. Globally, this article suggests that the survival results are not affected by the type of surgery provided that the patients are operated in a high-volume cancer care centre and are part of a selected group with a low proportion of pT3-pT4 disease.

Source: Randomized trial comparing open and robot-assisted laparoscopic radical cystectomy: oncologic outcomes. Bochner et al. Eur Urol 2018 DOI: https://doi.org/10.1016/j. eururo.2018.04.030

Belatacept immunosupression superior to cyclosporin A in marginal donor kidney transplants The phase III Belatacept Evaluation of Nephroprotection and Efficacy as First-Line Immunosuppression Trial-Extended Criteria Donors Trial (BENEFIT-EXT) study compared more or less intensive belatacept-based immunosuppression with cyclosporine (CsA)-based immunosuppression in recipients of extended criteria donor kidneys.

Mean prostate volume was 107cc (range 80 to 150). Mean operative time was 37 minutes (range 15-97) and mean Aquablation resection time was eight minutes (range 3-15). Adequate adenoma resection was achieved with a single pass in 34 patients and additional passes in 67 patients (mean 1.8 treatment passes), all in a single operative session. Haemostasis was achieved using either a Foley balloon catheter placed in the bladder under traction (n = 98, mean duration 18 hours) or direct tamponade using a balloon inflated in the prostate fossa (n = 3, mean duration 15 hours). No subject required electrocautery for haemostasis at the time of primary procedure.

…The investigators concluded that Aquablation is feasible and safe in treating men with men with large prostates (80-150 cc) The average length of stay following the procedure was 1.6 days (range same day-6 days). The observed Clavien-Dindo (CD) grade 2 or higher event rate at 1 month was 29.7%. Bleeding complications were recorded in 10 (9.9%) patients during the index procedure hospitalisation prior to discharge and included six (5.9%) peri-operative transfusions. The investigators concluded that Aquablation is feasible and safe in treating men with men with large prostates (80-150 cc). The six-month efficacy data are being accrued and will be presented in future publications.

Source: Aquablation procedural outcomes for BPH in large prostates (80-150cc): Initial experience. Desai M, Bidair M, Bhojani N, Trainer A, Arther A, Kramolowsky E, Doumanian L, Elterman D, Kaufman RP Jr, In this post hoc analysis, patient outcomes were Lingeman J, Krambeck A, Eure G, Badlani G, assessed according to donor kidney subtype. In total, Plante M, Uchio E, Gin G, Goldenberg L, 68.9% of patients received an expanded criteria donor Paterson R, So A, Humphreys M, Roehrborn C, kidney (United Network for Organ Sharing definition), Kaplan S, Motola J, Zorn KC.

for incontinence improvement was the absence of prior urethral stricture. The type of device did not significantly affect the functional outcomes. The main limitations of this study are the retrospective design, the heterogeneity of previous prostate surgery, and the lack of inclusion criteria uniformity. Moreover, experience of surgeons could not be controlled. The expected improvements in sling implantation have not been objectively reported given the comparable operative times and intraoperative complication rates. Both procedures were equally fast and a substantial advantage provided by the novel needle configuration could not be identified. The relatively high rate of urinary retention after AdVanceXP implantation differed from already published series from single reference centres. Hypercontinence was not negligible with 4% of unilateral transection during follow-up.

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk the fact that no information on reason for a prolonged catheterisation was available, this article suggested that, even correlated with more frequent short-term incontinence, longer catheterisation, if required for surgical reasons, was not associated with a higher risk for one-year incontinence.

Source: The impact of time to catheter removal on short-, intermediate- and long-term urinary These findings suggested that this complication was continence after radical prostatectomy. probably underestimated and occurred two-fold more Tilki et al. in daily practice. This should be part of patient counselling before surgery. However, given the withdrawal of the AdVance device in Europe, discussion between the two devices does not really exist anymore.

Source: The AdVance and AdVanceXP male sling in urinary incontinence: is there a difference? Hüsch, et al. World J Urol 2018 https://doi.org/10.1007/s00345-0182316-5

Duration of catheterisation and time to continence after radical prostatectomy

World J Urol 2018

Functional changes in kidneys from ECDs The dramatic increase in the waiting list has made it necessary to reconsider donor criteria, and organs from expanded criteria donors are increasingly being used. Short and medium-term results are often comparable. The authors of this study wanted to examine whether differences exist in the function and/or morphology of transplanted kidneys originating from expanded criteria donors (ECDs) and ideal donors one and five years after transplantation.

Significant morphological changes in kidneys from expanded donors despite good short time function.

The duration of ideal bladder catheterisation after radical prostatectomy remains debatable. Maintaining it could prevent extravasation, subsequent fibrosis, 10.1% received a donation after cardiac death kidney, BJU Int. 2018 Apr 25. doi: 10.1111/bju.14360. [Epub urinoma, and anastomotic strictures. Conversely, early and 21.0% received a kidney with an anticipated cold ahead of print] removal might reduce infections and increase quality ischemic time ≥24 h. Over seven years, time-to-death of life. Kidney function and histopathologic findings were or graft loss was similar between belatacept- and analysed and compared one and five years after CsA-based immunosuppression, regardless of donor The impact of this duration on continence recovery transplantation in 97 patients having ECD kidneys and AdVance or AdVanceXP? kidney subtype. In all three donor kidney cohorts, has not been thoroughly evaluated. In the present in 178 patients who had received ideal donor kidneys estimated mean GFR increased over months 1-84 for article, the authors reviewed data from almost 7,000 (IDK). Serum creatinine levels were significantly belatacept-based treatment but declined for The AdVanceXP is the second generation of male men undergoing radical prostatectomy in one single higher (p = 0.001) and estimated glomerular filtration CsA-based treatment. slings for urinary incontinence treatment, and has reference institution. Patients with baseline urinary rates were significantly lower (p = 0.003) in patients been introduced to provide better stability by adding incontinence and radiotherapy were excluded from having ECD kidneys as compared with those with IDK anchors and to facilitate the implantation by analysis. Four high-volume surgeons were involved to five years after transplantation. Morphological No differences in the safety profile of modifying the implantation needle. However, reduce confounding factors such as surgeon changes in the transplanted kidneys, such as tubulitis experience and centre volume. Open surgery was (p = 0.025) and interstitial inflammation (p = 0.002), belatacept were observed by donor substantial modifications have not been added compared to the previous AdVance device that has performed in 62% of cases (robot 37%). The preferred were significantly more frequently present in ECD kidney subtype been withdrawn from the European market. Few option was an early removal of the catheter for all kidneys than in IDK kidneys one year after studies have comparatively assessed both devices. In surgeons. However, intra- or postoperative events transplantation. The estimated differences in GFR significantly favored the present article, the authors evaluated these two could delay this removal at surgeon’s discretion. each belatacept-based regimen versus the CsA-based sling generations in a large multi-institutional series The authors concluded that despite similar kidney regimen in the three subgroups (p < 0.0001 for overall with a mid-term follow-up. function one year after kidney transplantation In multivariate analyses, a treatment effect). No differences in the safety profile between patients having ECD and IDK, pronounced of belatacept were observed by donor kidney subtype. Between 2012 and 2012, 294 patients underwent male longer catheterisation time was morphological differences in the transplanted kidneys sling surgery including 63% of AdVanceXP. Safety and can be detected between the two groups. independently predictive for an Source: Efficacy and safety outcomes of efficacy points were assessed by validated questionnaires in a prospective approach. No strong extended criteria donor kidneys by subtype: Source: Post-transplantation morphological and increased risk of short- and midSubgroup analysis of benefit-ext at 7 years after difference in baseline characteristics was observed functional changes in kidneys from expanded term urinary incontinence transplant. Florman S, Becker T, Bresnahan B, except a higher median age in the AdVance group. criteria donors. Borda B, Németh T, Ottlakan A, Chevaile-Ramos A, Carvalho D, Grannas G, Mean operative time was 70 minutes. No major Keresztes C, Kemény É, Lázár G. intraoperative complication occurred. Postoperative Muehlbacher F, O'Connell PJ, Meier-Kriesche Continence recovery was assessed by selfPhysiol Int. 2017 Dec 1;104(4):329-333. course did not differ between the two groups. HU, Larsen CP. administered questionnaires at different time points, doi: 10.1556/2060.104.2017.4.4 However, higher rates of urinary retention were Am J Transplant. 2017, 17(1):180-190. and continence was defined by the use of zero to one reported with AdVanceXP. Unilateral transection of the pad per day. Duration of catheterisation was sling was necessary due to persistent retention in 8 evaluated as qualitative data with three different Effects of recurrent UTIs on AdVanceXP patients (4.3%) versus 1 AdVance patient cut-offs: < 8 days, 8-14 days, > 14 days. Aquablation procedural graft after kidney transplants (0.9%). Reoperation for persistent incontinence was outcomes for BPH in large less frequent in the AdVanceXP group (5.9% versus Urinary continence rates were 27%, 80%, and 91% at 9.2%) but difference did not reach statistical one week, three months, and one year after radical Urinary tract infections (UTIs) are common following prostates significance. prostatectomy. Short-term (one week) continence kidney transplantation (KT). Recurrent UTI after renal rates differed significantly according to the time of transplantation are a problem in some patients but This trial presented safety and feasibility data from a bladder catheterisation: 31%, 27%, 18% in patients their significance is poorly understood. These findings suggested that multicentre prospective study of Aquablation in with catheterisation time of < 8, 8-14, > 14 days, treatment of symptomatic men with large volume respectively. Patients with catheterisation > 8 days The authors compared graft outcomes, patient this complication was probably benign prostatic hyperplasia (BPH). were significantly older, had longer operating times, outcomes and multidrug-resistance rates between underestimated and occurred two- more blood loss, and higher comorbidity index, patients without any UTI, non-recurrent UTI (NR-UTI) Between September and December 2017, 101 men compared to patients with early removal. (urine sample containing > 105 bacterial colonyfold more in daily practice with moderate-to-severe BPH symptoms and prostate forming units/mL) and recurrent UTI (≥ 2 UTIs in any volume of 80-150 cc underwent Aquablation in a In multivariate analyses, a longer catheterisation time 6-month period or ≥ 3 UTIs in any 12-month period) prospective multicentre international clinical trial. was independently predictive for an increased risk of Regarding the efficacy outcomes, unfortunately only after renal transplantation in a retrospective cohort Baseline demographics and standardised short- and mid-term urinary incontinence. The main half of the total patient number was available for study (1999-2014) at Barnes-Jewish Hospital (St Louis, postoperative management parameters were carefully long-term follow-up. Mean follow-up time was 35 effect was reported at one week but dissipated over MO). All adult KT recipients were included. However, recorded in a central independently monitored months in the AdVanceXP group and 53 months in the time. Age and nerve-sparing procedures were also those experiencing mortality within 30 days of KT database. Surgeons answered analogue scale AdVance group. No significant differences in the correlated with continence recovery whereas body were excluded. questionnaires on intraoperative technical factors and quality of life were detected between the two groups. mass index had a moderate effect. postoperative management. Adverse events through Approximately 80% of patients would have had the Of 2,469 included recipients, 1,835 (74.3%) had no one month were adjudicated by an independent Overall, rates for severe incontinence were small (2% UTI, 465 (18.8%) had non-recurrent UTI and 169 operation again, whatever the device used. In a clinical events committee. multivariate analysis, the only independent predictor after one year). Despite the retrospective design and (6.8%) had recurrent UTI. Recurrent UTIs were Key articles



European Urology Today

June/July 2018

associated with poorer graft survival compared with patients with non-recurrent UTI [HR 1.45; 95% CI 1.23-1.83; p < 0.001) and those without UTI (HR 2.11; 95% CI 2.02-3.80; p < 0.001). This relationship persisted after adjusting for confounding factors in Cox regression (HR 2.01; 95% CI 1.53-2.66; p < 0.001).

Recurrent urinary tract infections after renal transplantation reduce both patient and graft survival There was no difference in patient survival between patients without UTI and those with non-recurrent UTI (HR 1.21; 95% CI 0.91-1.63; p = 0.181). However, recurrent UTI was associated with poorer patient survival compared with non-recurrent cases (HR 1.87; 95% CI 1.21-2.89; p = 0.005). Recurrent UTIs were more likely to be caused by multidrug-resistant Gram-negative organisms (risk ratio 1.49; 95% CI 1.31-1.70; p < 0.001). The authors concluded that recurrent UTIs in renal transplant recipients are definitely associated with poorer graft and patient outcomes and should be aggressively treated if possible.

grazoprevir was initiated when the results became positive, and therapy was maintained for 12 weeks. Among 38 patients who were potentially eligible to participate in the trial, 22 attended an educational presentation, and 14 provided written informed consent and had their waiting-list profile changed to indicate eligibility to receive an HCV-infected kidney. Per protocol, 10 patients received HCVinfected kidneys. The median age of the recipients was 59 years; half the recipients were men and two were black. The median time from eligibility on the waiting list for hepatitis C–infected kidneys to transplantation was 58 days. The median Kidney Donor Profile Index score (on a scale from 0 to 100%, with higher values indicating a greater risk of graft failure for an individual kidney) was 42%. On day 3 after transplantation, all recipients had detectable HCV RNA; viral loads ranged from less than 15 IU per ml (detectable but unquantifiable) to 193,000 IU per ml. Elbasvir–grazoprevir was initiated in all recipients. Nine recipients had HCV genotype 1a infection; none had identifiable NS5A resistance. All recipients were cured of HCV; a cure was defined as a sustained virologic response 12 weeks after the end of treatment.

The median 6-month serum creatinine level was 1.1 m/dl (97 μmol/l), the estimated glomerular filtration rate was 62.8 ml/min per 1.73 m2. One recipient had delayed graft function, transiently elevated aminotransferase levels developed in two recipients, and a transient new class I donorTA. Nephrol Dial Transplant. 2017 Oct 1;32(10):1758-1766. specific antibody level (1800 mean fluorescence (doi: 10.1093/ndt/gfx237) intensity units) developed in one patient. Proteinuria (at an estimated level of 2 g per day of urinary protein excretion) developed in one patient who had IgA nephropathy before transplantation; Transplant trial of HCVin this patient, focal segmental glomerulosclerosis infected kidneys into was detected on biopsy after a sustained virologic response was reached 12 weeks after the end of uninfected recipients treatment.

Source: Effects of recurrent urinary tract infections on graft and patient outcomes after kidney transplantation; Britt NS, Hagopian JC, Brennan DC, Pottebaum AA, Santos CAQ, Gharabagi A, Horwedel

Waiting times for kidney transplants exceed three to five years in many countries but high-quality kidneys from deceased donors with hepatitis C virus (HCV) infection are discarded. Direct-acting antiviral agents, which are associated with high HCV cure rates and manageable side effects, have created the potential to substantially increase the number of kidney transplants by making HCV-infected kidneys available to HCV-negative candidates on the waiting list. In this pilot study, the concept was tried. In an open-label, single-group trial at the University of Pennsylvania (Transplanting Hepatitis C Kidneys into Negative Kidney Recipients [THINKER]; ClinicalTrials.gov number, NCT02743897) the authors sought to determine the safety and efficacy of transplantation of kidneys from HCV genotype 1– viremic donors into HCV-negative patients, followed by elbasvir–grazoprevir treatment. An external data and safety monitoring board had reviewed all aspects of the trial. The authors vouch for the completeness and accuracy of the data and analysis and for the adherence of the trial to the protocol, available with the full text of this letter at NEJM.org.

Expanding selection criteria to HCVpositive donors for HCV-negative recipients in renal transplantation Adults who were undergoing dialysis and who had long anticipated waiting times for a kidney transplant were eligible for inclusion in the trial, and patients with conditions that substantially elevate the risks of liver disease, allograft failure, or death were excluded. A physician-led, three-step, informedconsent process was implemented. Deceased-donor criteria ensured selection of high-quality kidneys. Since elbasvir–grazoprevir was not approved by the Food and Drug Administration (FDA) for patients with HCV genotypes 2 or 3, and a direct-acting antiviral agent for the treatment of patients with those genotypes who have renal failure has not been approved by the FDA, donors were limited to those who had positive qualitative HCV nucleic acid test results and HCV genotype 1. The authors developed a new protocol for donor genotyping concurrent with organ allocation. Intravenous glucocorticoids and rabbit antithymocyte globulin were administered to all recipients, followed by oral tacrolimus, mycophenolate mofetil, and prednisone. The HCV viral load was measured in recipients on postoperative day 3; elbasvir– Key articles

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The author group concluded that their pilot trial showed that transplantation of HCV genotype 1– infected kidneys into HCV-negative recipients, followed by the use of direct-acting antiviral agents, can provide potentially excellent allograft function together with a cure of HCV infection.

Source: Trial of transplantation of HCVinfected kidneys into uninfected recipients; Goldberg DS, Abt PL, Blumberg EA, Van Deerlin VM, Levine M, Reddy KR, Bloom RD, Nazarian SM, Sawinski D, Porrett P, Naji A, Hasz R, Suplee L, Trofe-Clark J, Sicilia A, McCauley M, Farooqi M, Gentile C, Smith J, Reese PP. Published as a letter to the editor, N Engl J Med. 2017, 376(24):2394-2395. (doi: 10.1056/NEJMc1705221)

Asymptomatic calyceal stones: To survey or to treat? Patients with incidental diagnosis of calyceal renal stones have become relatively a common reason for urology referrals. What is the adequate management depends on many factors which may depends on patients’ preference, on surgeons’ favourite procedure, available technology and clinical (of patient and stone) parameters. Nevertheless, surveillance is usually the most common option until patients may experience symptoms like new onset of pain, infection and/or haematuria that may ultimately require transfer to the Emergency Department and trigger the eventual active treatment. However, there are still equivocal indications from current literature regarding patients at major risks who might benefit from upfront treatment and who were instead offered a wait-and-see option. Among the recent papers published on this topic is a British report showing results from a cohort of 238 patients diagnosed of asymptomatic calyceal stone(s) and observed from 2005 to 2016; the same protocol was used for all the patients by using a non-contrasted CT scan and a plain X-ray at diagnosis in order to identify the radiopaque stones that could be followed up with just an annual X-ray (nearly 90%). The remaining radiotransparent stones instead were followed up by alternating US with a CT scan.

There were a total of 301 renal units with a prevalence of lower pole calyceal stones only (43%), and a mean stone size of 10.8 mm. The majority of renal units (58.8%) remained on active surveillance during the 63 months of mean follow-up; spontaneous stone passage occurred in the 14.6% of the renal units, while intervention was required in 26.6%. Shockwave lithotripsy was the most common treatment option (57.5%) with ureteroscopy and percutaneous lithotripsy reserved in a lower percentage of cases (25% and 12.5%, respectively); a further 5% of intervention included stent or nephrostomy tubes insertion.

This study...may be helpful in the follow-up strategy of patients with asymptomatic calyceal stone... Renal units causing stone-related symptoms and/or requiring intervention were 39.5%; pain (15.3%), infection/sepsis (9.6%) and haematuria (5.3%) were the most common symptoms. In the multivariate analysis, factors significantly associated to symptoms development and/or need of intervention were younger age (< 50 years) and stone growth > 1 mm/year. In the renal units experiencing a spontaneous passage of stones, younger age was again a factor significantly associated, as well as smaller stones < 1 cm. This study, though retrospective, may be helpful in the follow-up strategy of patients with asymptomatic calyceal stone, by warning that younger patients with a higher stone-growth may require earlier intervention without waiting for symptoms to appear.

Source: The natural history of asymptomatic calyceal stones. Darrad MP, Yallappa S, Metcalfe J, Subramonian K. BJU Int. 2018 Apr 19. doi: 10.1111/bju.14354. [Epub ahead of print]

The new kid in the block: The Korean REVO-I robotic system Since Intuitive commercialised the Da Vinci system for the robotic surgery in 2000, there have been lots of rumours of new robots manufactured by other companies which would have contributed in reducing the costs and improving technologies. However, none of them has succeeded in finalising their prototypes except only one –the Italian Alf-X- which has anyway was only met with poor enthusiasm across the world. Among the most awaited prototypes was the Korean REVO-I system which has been recently tested in a cohort of prostate cancer patients selected to undertake a Robotic-Assisted Radical Prostatectomy (RARP). The REVO-I robotic platform is substantially a replica of the Da Vinci system with slightly smaller instruments and camera diameters (7.4 vs. 8.4 mm; 10 vs. 12 mm, respectively), and -hopefully- on a significant lower price even though it is not yet available.

The study was conducted after a latest prototype of the robotic platform was successfully tested on animals, so that between the end of 2016 and the beginning of 2017, 17 patients underwent a RARP by using the REVO-I system. More interestingly, the surgeon performed the Retzius-Spering (RS) approach according to Bocciardi since this was the preferred access with > 400 procedures recorded before the start of the study.

...the Korean robotic platform has been approved by the national Food and Drug Administration... The aim of the study was to demonstrate the safety and efficacy of the new robotic platform, so that it could be considered as an IDEAL phase 2-a study. In case of failure of the robotic platform, a second was available as a replacement; if this platform is also unable to work properly, the procedure would have been completed by using a Da Vinci system or a conversion to a laparoscopic approach. Nevertheless, all the procedures could be completed with the same robot without substantial malfunctioning. Regardless of the complexity of RS-RARP, oncologic and functional results were comparable to those published in literature, but somehow lower to the cohort of RARP performed by the same surgeon with the Da Vinci platform. For example, positive surgical margin (PSM) rate in pT2 cancers was 18% vs. 12.5%, and the three-month incontinence (defined as 0-1 pads/day) rate was 88.2% vs. 95% with respect to their historical cohort of Da Vinci RS-RARP, respectively. The authors explained this difference was due to the low number of patients recruited in the study; on the other hand, it is likely that this cohort was composed by highly selected patients as only 17 were recruited in the span of six months in a high-volume centre, with an (ideal) mean size of 25.3 gr of prostate glands. Moreover, no lymphadenectomy was conducted in any case to avoid risky malfunctioning while manipulating the iliac vessels. Other issues recorded were loss of sharpness of scissors, occasional fogginess of the camera for cauterisation and time-to-resume when the robot automatically stopped when the surgeon was operating too quickly. However, all these issues are expected to be resolved in a next version of the robot. Thanks to these results, the Korean robotic platform has been approved by the national Food and Drug Administration, which could be a first step before a wider distribution to the rest of the world. A new economic and technological war (or era, maybe) has just begun!

Source: Retzius-sparing robot-assisted radical prostatectomy using the Revo-i robotic surgical system: surgical technique and results of the first human trial. Chang KD, Abdel Raheem A, Choi YD, Chung BH, Rha KH. BJU Int. 2018 Apr 12. doi: 10.1111/bju.14245. [Epub ahead of print]

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


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European Urology Today


SATURN – Registry for male stress incontinence procedures ESFFU, EAU RF collaborate on registry project Mr. Rizwan Hamid University College London Hospitals Dept. of Urology London (UK)

hamid_rizwan@ hotmail.com The artificial urinary sphincter (AUS) has been used since 1972 for the treatment of severe urinary incontinence [1]. After several technical evolutions that led to significant improvement of surgical and functional results, the device reached maturity in 1987 with the release of the narrow-back cuff (NBC) AMS800 device (AMS, Minnetonka, MN, USA) [2]. The device is largely unchanged in current practice apart from small changes (e.g., antibiotic coating). Some innovative devices such as FlowSecure and Zephyr ZSI 375 have been presented as potential alternatives, but only a few preliminary results are available [3,4]. Current evidence It is currently estimated that > 150 000 patients worldwide have been implanted with an AUS, the vast majority with AMS800 [5]. This large number of cases, potentially with extremely long follow-up, is barely reflected in the literature, and most data on AUS outcomes come from older retrospective cohort studies. Randomised controlled trials (RCTs) were not performed due to the lack of a comparator [5]. Nonetheless, AUS implantation has been the standard of care for refractory male stress urinary incontinence (SUI) for a considerable time.

histories of the two techniques and the differing profiles of the most suitable patients, the equivalent grading of their recommendation obscures an uncertain picture. Need for registry At present there are no randomised controlled trials available to evaluate various surgical options of the treatment of male stress urinary incontinence. Hence, it was thought that there is a need to prospectively collect data on interventions for the treatment of stress urinary incontinence in males mainly AUS and male slings. It was envisaged that over a period of time we will not only have a large database from multiple European centres to compare the outcome and safely prolife of these procedures but also will be able to direct clinical research in this field to improve patient outcome. After discussions amongst the members of the EAU Section of Female and Functional Urology (ESFFU) and the EAU Research Foundation (EAU RF), a steering committee under the auspices of ESFFU Board and EAU-RF was set up to establish such a registry. The members of this team are listed in the article below. Industry collaboration This is the first non-cancer registry to be established by the EAU Research Foundation. We held meetings with a number of manufacturers who produce anti incontinence surgical products. This registry is funded by an unrestricted educational grant from Boston Scientific Corporation. Primary objective To prospectively collect a pre-defined dataset from male patients undergoing AUS or male sling as a treatment for stress urinary incontinence from multiple centres in Europe for evaluation of shortand long-term efficacy and safety of these procedures along with impact on Quality of Life.

Stress urinary incontinence after radical surgery There has been a significant improvement in the understanding of male pelvic anatomy. This, coupled with continuing innovation in surgical technique with the advent of robotic surgery, has led to much better oncological and functional outcomes; however, stress urinary incontinence is still an important problem after radical surgical treatment of prostate cancer [6]. This is particularly relevant, as majority of men will live for more than 10 years after surgical treatment of prostate cancer.

Secondary objectives To define the areas of clinical research in the field of male urinary incontinence from long-term analysis of the dataset.

Increasing surgical options In recent years, new surgical alternatives have been introduced claiming to be safe and effective [7,8]. Among these new devices, male slings are increasingly used and have been given the same level of recommendation (grade B) as AUS, according to the European Association of Urology guidelines [5]. However, given the respective

There are no extra study visits required for the patients. The patient fills in the ICIQ & EQ-5D, for evaluation of the impact of incontinence on Quality of Life questionnaire before the operation. The subsequent forms will be posted out to them at 12 weeks after surgery and then yearly by the local participating centre, if required on the prompt from the central data manager.

EAU Section of Female and Functional Urology

Study design This is a voluntary collection of prospective pre-defined parameters for the treatment of male stress urinary incontinence with artificial urinary sphincter and male sling. One of the uniqueness of the study is that all types of anti-incontinence procedures could be recorded.

centres across Europe. The participation is by open invitation to all ESFFU members along with other urologists undertaking these procedures. The EAU RF has already sent a call to European colleagues via European Urology Today. There is no restriction on the number of patients enrolled as long as they are consecutive. The aim is to have a long-term collection of the dataset from as many centres as possible. Current status of enrolment The project started in October 2016 with the first patient enrolled from Prof. J. Heesakkers. Up to now six centres have been initiated with the 100th patient enrolled a few weeks ago by Prof. Frank Van Der Aa. The details of the centres and the number of patients enrolled by each centre are enumerated in the article of Witjes and Schipper on page 2. Callout to urologists As one would expect from a new registry (especially first non-cancer registry under the EAU), the initial uptake has been somewhat slow but now more and more centres have shown interest and are applying to be involved. One of the aims of this project is to include as many centres across Europe as possible and not restrict the registry to high-volume centres. We would urge the urologists undertaking male anti-incontinence surgery wishing to participate in SATURN registry to contact the EAU-Research Foundation on researchfoundation@roweb.org or by filling in the Feasibility Questionnaire at https://www.surveymonkey.com/r/9X9HRHP. Further details on how to facilitate participation in this registry are described in the accompanying article. References [1] Scott FB, Bradley WE, Timm GW. Treatment of urinary incontinence by an implantable prosthetic urinary sphincter. J Urol 1974;112: 75–80.

[2] Light JK, Reynolds JC. Impact of the new cuff design on reliability of the AS800 artificial urinary sphincter. J Urol 1992;147:609–11. [3] Knight SL, Susser J, Greenwell T, Mundy AR, Craggs MD. A new artificial urinary sphincter with conditional occlusion for stress urinary incontinence: preliminary clinical results. Eur Urol 2006;50:574–80. [4] Alonso Rodriguez D, Fes Ascanio E, Fernandez Barranco L, Vicens Vicens A, Garcia Montes F. One hundred FlowSecure artificial urinary sphincters. Eur Urol Suppl 2011;10:309. [5] Lucas MG, Bosch JLHR, Cruz F, et al. Guidelines on urinary incontinence. European Association of Urology Web site. http://www. uroweb.org/gls/ pdf/18_Urinary_Incontinence_LR_1%20October %20 2012.pdf. Updated 2012. [6] Franck Lissbrant I, Ventimiglia E, Robinson D, Törnblom M, Hjälm-Eriksson M, Lambe M, Folkvaljon Y, Stattin P. Nationwide populationbased study on the use of novel antiandrogens in men with prostate cancer in Sweden. Scand J Urol. 2018 ;52:2:143-150 [7] Bauer RM, Gozzi C, Hubner W, et al. Contemporary management of postprostatectomy incontinence. Eur Urol 2011;59:985–96. [8] Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn 2010;29:213–40.

Cutting-edge Science at Europe’s largest Urology Congress

Apply now and win!

Open invitation for participation in the registry The data collection is to be undertaken from multiple

Will you be an EAU Award Winner in Barcelona? Provide sustainable patency.

EAU Crystal Matula Award 2019 For a young promising urologist under the age of 40 who has the potential to become one of the future leaders in academic European urology. National Societies can nominate a candidate for this award or eligible candidates can apply by contacting their national urological society directly. EAU Hans Marberger Award 2019 For the Best Paper published on Minimally Invasive Surgery in Urology. This paper must have been published or accepted for publication between 1 July 2017 and 30 June 2018.




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

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

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European Urology Today



June/July 2018

Update from the Guidelines Office Latest publications and continuous training of panel members and associates to raise the bar Guidelines Panel Meetings With the successful publication of the 2018 EAU Guidelines behind us, late Spring and Summer sees the various Guidelines panels begin work on the 2019 update. June sees meetings from the Urolithiasis panel in Athens, the Urological Trauma panel in Dublin, the Paediatric Urology panel in Istanbul and the Urinary Incontinence panel in Rome. These meetings will include discussions on changes to guidelines text, as well as the results of recent scope searches. Systematic Review Training Workshop The Steigenberger Hotel at Schiphol Airport was the venue for a well-attended Guidelines Office Systematic Review Workshop at the end of April. The intensive two-day event saw established Guidelines Panel members, experienced associates, and newer recruits participate in a programme of events, which featured presentations from the faculty in the morning and practical sessions in the afternoon. The training covered topics such as the development of a search strategy, abstract and full text screening, Guidelines Office

Dr. S. McLennan presenting on the systematic review process

data abstraction, and data analysis and interpretation. Particular highlights, included Prof.Dr. R. Sylvester’s in-depth presentation on assessing risk of bias, Dr. S. Maclennan’s comprehensive overview of the Systematic Review Process, Dr. A. Nambiar’s illuminating introduction to the GRADE approach to

The attendees of the systematic review workshop - working on a practical task

quality of evidence assessment, and Dr I. Omar’s masterful overviews of the Revman and Covidence software packages. The Guidelines Office Chairman, Prof. Dr. J. N’Dow, opened the event and kept attendees on their toes by posing them questions throughout the training session.

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.

PIONEER: An EAU Guidelines Office-led project €12 million EU grant secured from Innovative Medicines Initiative for Prostate Cancer Big Data Project European men living with PCa through the use of ‘big data’ by: • improving disease understanding and delivering a core set of clinically relevant standardised PCa-related outcomes;

What is PIONEER? The IMI Prostate Cancer Big Data For Better Outcomes Project (PIONEER) is an EAU led Innovative Medicines Initiative (IMI), public-private collaboration which brings together a complementary group of world-leading experts in clinical research, leading European prostate cancer (PCa) professionals, patient organisations (ECPC, Europa Uomo, UCAN) and private EFPIA partners.

• optimising diagnosis and therapeutic management of PCa patients across different stages of the disease and across multiple geographies by delivering valuable insights from real-world data and sharing best practices; • providing unique tools for standardisation and analysis of complex PCa data sets from a variety of sources, using different data models and different terminology, whilst comprising different layers of information (e.g. genetic, omics, biomarkers);

The challenge • developing a large and harmonised repository of Prostate cancer is the most common cancer diagnosed PCa data that can be used to improve evidencein men in Europe and the third commonest cause of based decision-making for all PCa patients, and death from male cancer in Europe, representing 1 in enable a wide variety of data re-use scenarios; 10 of all cancer deaths in men. Prostate cancer healthcare costs were estimated at €8.43 billion per • the dissemination and widespreadyear in the EU in 2009 and accounted for 7% of all implementation of PIONEER’ results; cancer costs in Europe. Furthermore, the socioeconomic burden associated with PCa is predicted to dramatically increase in the coming years due to Europe’s aging population.

• addressing the barriers related to data sharing and data protection.

data harmonisation), PIONEER will attempt to transform the field of PCa with particular focus on improving PCa-related outcomes, health system PIONEER’s solution efficiency and the quality of health and social care PIONEER’s unique approach is to firstly identify critical delivered to all PCa patients and their families. In evidence gaps in PCa through a detailed prioritisation addition, PIONEER will provide standardised care exercise including all stakeholders (i.e. clinicians, pathways for all clinical centres across Europe. patients, researchers, industry etc.), ensuring that PIONEER’s deliverables will be relevant to all key The use of these data sets during and beyond stakeholders. PIONEER will be based on the FAIR guiding principles, meaning they will be Findable, Accessible, PIONEER will then standardise and integrate Interoperable and Reusable (FAIR) both for human existing ‘big data’ from high quality and and machine-driven activities. This will increase their multidisciplinary data sources from PCa patients interoperability with current and future multifactorial across different stages of the disease into a single PCa datasets. Finally, PIONEER will use ‘big data’ to innovative data platform which leverages the test new prognostic/predictive algorithms to provide existing data platforms, tranSMART and OHDSI, new hypothesis for future high quality prospective from previous IMI projects. studies, and where appropriate, for implementation into daily clinical practice. This will result in a unique and comprehensive dataset that consists of the most relevant PCa clinical PIONEER’s perceived outcomes trials and registries, large epidemiological cohorts, By applying advanced data analytics, and developing electronic heath records, and real-world data from a data-driven platform of unparalleled scale, quality different European (and non-European) patient and diversity PIONEER aims to empower meaningful populations. Based on a unique set of methodologies improvement in clinical practice, PCa disease-related and advanced analytical methods (i.e. OMOP Common outcomes and health-economic outcomes across the Data Model and eTRIKS Harmonisation System for European healthcare landscape.

Currently, there are a number of critical knowledge gaps/issues in relation to the screening, diagnosis and treatment of PCa patients, these include: • lack of standardisation of definitions of PCa across all stages of the disease; • insufficient knowledge of the risk factors for PCa; • insufficient knowledge of patient characteristics, including genetic profiles, for optimal stratification of patients at time of diagnosis; • lack of meaningful engagement of all key stakeholders, including patients, when defining core disease outcome sets; • lack of effective implementation of knowledge gained into clinical practice including knowledge informed by real-world data. Ultimately, this lack of knowledge means that prediction of which patients may be managed safely without treatment is suboptimal, whilst prediction of which patients will have the best outcomes with specific treatments remains poor. PIONEER’s objectives PIONEER’s vision is to ensure the optimal care for all June/July 2018

PIONEER consortium members - 32 partners from across 9 countries

European Urology Today


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

Abstract submission now open Deadline: 1 November 2018



European Urology Today

June/July 2018

ESUT18: Live Surgery from three continents Modena meeting attracts more than 600 participants for latest in uro-tech By Loek Keizer ESUT18 marked a real achievement for the EAU Section of Uro-Technology. In a scientific programme that was dominated by live surgery and pre-recorded case discussions, surgeons from South Korea, China, India and Brazil joined their colleagues in Modena from their operating theatres as they performed procedures through a live link-up. ESUT Chairman Prof. Evangelos Liatsikos (Patras, GR) was satisfied with the attendance of the meeting, which was also combined with the annual meeting of the Italian Endourology Association (IEA). Around half of the participants came from Italy. “Modena is not a major transport hub, so we knew that everyone who attended was seriously motivated to learn!” Prof. Liatsikos joked. The meeting took place on 24-26 May at the Faculty of Medicine and Surgery of the University of Modena and Reggio Emilia, with many of the procedures being performed on premises or at the university’s other sites. Associate Prof. Bernardo Rocco (Modena, IT) was closely involved with the organisation of the meeting and the coordination of the live surgery cases in Modena. He and IEA Chairman Prof. Giampaolo Bianchi (Modena, IT) were in effect the local hosts, welcoming participants from 37 countries to the city of Ferrari.


“Live surgery is a demonstration of the real decision-making process” “Surgery is moving in the same direction. At the time of my grandfather, who was also a surgeon, forceps, scissors and a scalpel was enough. Now, if you don’t have cutting-edge tech, you cannot provide your patient with the best available approach. Having said that, while this meeting emphasises new technology, this is mostly an opportunity to see the world’s best surgeons using this technology. The surgeon makes a choice, and must be informed on which technology matches the preferred approach and technique.”

The three-screen approach to live surgery in action. In this case, the audience are watching live cases from Modena and Beijing

Patient selection is vital for a successful meeting, and the (often only last-minute) availability of suitable patients for the desired procedures can be a challenge, particularly if the meeting wants a variety of surgeons and approaches in similar cases. Prof. Liatsikos was nevertheless pleased: “We wanted to show different types of surgery, by different surgeons but on the same topic, and in Modena we were able to do that.”

“We even had the opportunity, which is certainly not very common, to allow the surgeon to select a patient of choice. In some cases, the surgeon was allowed to select from a small group of patients for one that would best match the technique he was going to demonstrate.” Prof. Rocco kicks off the first of many live surgery sessions

Having three simultaneous cases for such a large part of the meeting is “not a brand-new, novel idea” according to Prof. Rocco, “but we chose this format to allow not only more cases, but also for longer periods of time.” Rather than just “tuning in” during critical cases in the procedure, the audience could follow along for one and half hours in some cases.

24-26 May 2018 Modena, Italy

“ESUT is the most important society for urotechnology,” Prof. Rocco agreed. “Technology nowadays is so vital for us that it is important to give the appropriate attention to it. In the days of Enzo Ferrari, the racing driver made a huge difference to his team’s performance. Nowadays, you need the best car to get the first place in F1.”

Prof. Bianchi shed some light on the behind the scenes selection process: “Honestly, as a major regional hospital we had so many patients available that selection was no trouble at all. In fact, we even had the chance of choosing the patients for the right approach for both transperitoneal and retroperitoneal partial nephrectomy, depending on the position of the nodules.”

Mixed procedures, all surgical cases Truly remarkable of the ESUT18-IEA meeting was the sheer volume of surgical cases. The 53 cases were a mix of “local” live surgery from Italy, long-distance surgery and real-time, pre-recorded and livemoderated cases. Large parts of the scientific programme featured three live cases occurring (and presented) simultaneously. The audience wore headsets that allowed them to choose which procedure to follow. Teams of moderators commented on each case and questioned the surgeons on the finer points of their technique.


One case that was particularly noteworthy according to the organisers was Prof. Bianchi’s robot-assisted radical prostatectomy on the PrECE nomogram with real-time Cellvizio scan and ex-vivo confocal control. The real-time scan was performed by Dr. Alberto Breda (Barcelona, ES). Prof. Rocco commented: “I’m proud of this particular procedure because we presented an innovative approach to prostate cancer. We merged our predictive nomogram, developed with the Global Robotics Institute of Dr. Vip Patel, with MRI and generated a virtual 3D-model that could be overlaid in the imaging system of the da Vinci robot.” “Simultaneously, using the confocal microscope we had a chance to confirm in-vivo and ex-vivo about that we were doing the right thing, and a chance to share the images with the centralised pathologist. This was the result of much work from our group, and Prof. Bianchi’s performance was the most important novelty of the meeting.”

Long-distance live surgery: a model for the future? “Personally, I like the format,” Prof. Liatsikos said. “Audience interaction might be a little more limited if The most important development at ESUT18 was the inclusion of long-distance surgery, mixed in with the everyone is wearing headphones, but at bigger meetings with tightly-planned live surgery slots, there is simply no time for asking questions at all. We need active moderators for each case, and the groups were augmented with ‘young provokers’ who kept the commentary coming.” Liatsikos indicated that he had received a lot of different feedback about the format, and that this will all be evaluated in time for the next ESUT meeting, planned for 2020.

Around a dozen moderators were present for each live surgery session, commenting on three simultaneous cases

local cases from the Modena regional hospital(s) and the pre-prepared, live-presented cases. Procedures were broadcast in from China, South Korea, India and Brazil.

“We are considering doing more live surgery from the surgeon’s local institute” “We tried this for the first time,” Prof. Liatsikos explained. “We wanted to make the meeting global, featuring contributions from all around the world.” “For a start, it decreases the cost, as you don’t need to pay for these surgeons to come to the meeting. You expose the audience, who would otherwise never have a chance to visit a centre in (for example) China to see how surgeons there are doing a perfect job. Particularly in the case of China, communication with colleagues there via social media is rather limited, so we are offering a real peek into their operating theatres.” Prof. Bianchi said that the international contribution was valuable for the ESUT18-IEA participants. “People are not that familiar with what is happening in South America and Asia, so an opportunity to watch these procedures from centres that clearly fall outside of our usual circuit is a good thing. Anything we learn from our colleagues improves our knowledge and allows us to give our patients a better outcome.” Asked if live surgery was a sustainable educational tool, Prof. Rocco was reflective:

“You’re asking the right person. My co-authors and I recently published a paper on this subject in World Journal of Urology, which was related to the experience of another group that challenged laparoscopy. We examined some 12-14 years of live cases from Prof. Pansadoro’s Challenges in Laparoscopy and Robotics Congress, 200 patients who were treated in ‘live surgery’ conditions. Harm was almost completely limited, with not a lot of complications.” “I think that live cases are important because you see what the surgeon does in real time, how he or she approaches the problem. This is a demonstration of the real decision-making process. In a non-live setting, each one of us can come across as the best surgeon in the world. Live, you see every complication, every split-second choice, and the consequences. There is a real added value for learning.” Rocco emphasised in clear terms that patient safety is critical. “We have to discuss if the future is for meetings with visiting surgeons who perform on the host city’s patients, or if remote broadcasts of the cases to a centralised meeting is better. In that regard, this meeting was interesting because it featured both.” “If we were to just have remote cases, you lose conviviality, and the informal meeting with the surgeons that you saw performing the day before. In a remote set-up you might not be able to easily ask questions. But if you’re face to face with the surgeon at lunch, you can approach him or her better and informally or more sensitively. It’s important to establish personal relationships, propose fellowships, and so forth. Otherwise there is a risk of creating unapproachable surgical ‘gods’ in the clouds, and the distance between the best surgeons and others becomes bigger.”

An ESUT trademark The meeting was case-heavy, featuring only a few discussions and specialised talks. “Surgeons like action!” Prof. Liatsikos said. “It’s an ESUT trademark that people like, they don’t want to just listen to talks.”

Prof. Liatsikos shares these thoughts on the future of live surgery meetings: “I’m a big fan of live surgery. Naturally, it needs to comply to all the ethical guidelines that we already have [the EAU Policy on Live Surgery Events]. In future, I think we might consider doing more live surgery from a surgeon’s local institute only.”

The choice of procedures included stone surgery, transplantation, benign prostate cases and oncology. Liatsikos: “It’s a balance. At some meetings, some 80% of the cases might be oncology-related. The choice of procedures has to do with what is new. As the section of uro-technology, we want to showcase anything new.”

“We have to make sure that transmission quality is sufficient, and in this case it’s not always the distance that is the main issue. Until we have a guaranteed sufficient transmission quality, we cannot risk doing an event that is long-distance only. But, like all technology, every year telecommunications are improving!”

June/July 2018

Profs. Liatsikos and Bianchi open the meeting on behalf of the ESUT and IEA, respectively

European Urology Today


• What do you think is the biggest challenge in urology? There is a communication gap which is not specific to urology but across medical fields. There is a communication gap among physicians from different specialities, between physicians and patients, etc. • If you were not a urologist, what would have you been? I could have been a photographer or a high school teacher. Teaching gives me a lot of satisfaction and happiness. • What attracted you to urology? Urology has something unique among the surgical specialities with many niches you can specialise in. I also found the right mentors and my father is also a urologist back in India. • What is the most rewarding aspect of being a doctor? You deal with human life but despite all the diagnostics and medical technology at the end of the day it’s an interaction between two human beings— you and your patient. • How do you avoid burnout? It’s easy for physicians to have burnout. But one can talk to friends and colleagues. In my case, I talk it out with my wife who’s also a physician and she understands the things I go through. • If you could change something in the healthcare system, what would it be? As I mentioned earlier that would be to bridge the gaps among healthcare stakeholders. For example, insurances often play a big role in deciding what treatment doctors can offer to patients. I would like to see a better consensus among these stakeholders so that the care would be less fragmented. • What´s the last wonderful book you have read? “The Last Lecture” by Prof. Randy Pausch who distilled the lessons, virtues and his thoughts into a book, which is a good reflection on things. • What’s the last thing that surprised you? I stayed with my cousins recently and met their eight-year-old boy. His mom tried to instruct him and this little guy replied: “I have to do this on my own. You’re interrupting my work flow.” It’s surprisingly funny the things kids can remind us. • What’s your favourite hour in a day and why? The hours after work when I come back home and talk with my wife about the day and having a cup of coffee together— that recharges my energy. • What is the one thing you wished you have said to your patient but did not? We can do a better job in counselling patients. We try our best, despite all the pressures, but there is always room for improvement.


TEN QUESTIONS Interview & Photography by Joel Vega

Age: 28 Specialty: Urology City: Detroit (MI, USA) Current Position/Awards: Resident urologist, Department of Urology, Henry Ford Hospital; Youngest Recipient of 2018 EAU Hans Marberger Award, 33rd Annual EAU Meeting, Copenhagen; Winner of Best Poster, 31st EAU Annual Meeting 2016, Munich (DE), Best Poster North American Robotic Urologic Symposium 2017, Las Vegas, NV, USA.

ESUR18 convenes top experts in urological research A unique collaboration between clinicians and researchers Brainstorm with internationally-known urologists and scientists from diverse fields, and receive the latest updates in urological research during the 25th Meeting of EAU Section of Urological Research (ESUR18), organised in collaboration with the EAU Section of Uropathology (ESUP). This meeting is set to take place in historic Athens, Greece from 4 to 6 October 2018. Prof. Antonia Vlahou (Meeting Chair), Prof. Dr. Kerstin Junker (ESUR Chair) and Prof. Rodolfo Montironi (ESUP Chair) make up the esteemed ESUR18 faculty. New developments Expect nothing but frontline research on epigenetic regulation and reprogramming in bladder, prostate and kidney cancers, and more. Familiarise yourself with state-of-the-art research in biomarker development, implementation in clinical trials and the role of different types of liquid biopsies. You can also look forward to learning more about cellular interaction and plasticity, which are the main components in tumour progression and therapy resistance. The significance of the microbiome as an important regulator in many tumour and therapyrelated pathophysiological processes will be discussed at ESUR18 as well.

Register now for the early fee! Deadline: 13 August 2018 Two heads are better than one ESUR18 offers you the exclusive opportunity for a unique collaboration: Clinicians will learn more about the latest research strategies, and researchers will be more familiarised with urological challenges. Enhance your knowledge with the newest trends in research from key opinion leaders. The meeting encourages you to discuss your own data with fellow experts. 16

European Urology Today

Two EU-supported networks, TRIBBLE and TransPot, will present their innovative research; the Young Academic Urologists (YAU) and the EAU Research Foundation will showcase their clinical research projects during ESUR18. ESU Course on Prostate Cancer Continue to boost your knowledge with the highly-regarded course “Clinical and histopathological basics and main research questions in prostate cancer”, which is organised by the European School of Urology (ESU). The course will be held on Thursday, 4 October from 12.00 to 14.00. ARTP Award The participant with the best abstract in the field of prostate cancer research will be granted the ARTP Award, courtesy of the L’Association pour la Recherche sur les Tumeurs de la Prostate (ARTP).

ESUR meetings help address these challenges by becoming the link among various fields and to encourage interdisciplinary collaborations for optimal patient care and clinical practice.

All the ESUR18 info you need Mark the 4th to the 6th of October in your calendar and join us in the Greek capital for the latest updates in urological research.

ESUR18 25th Meeting of the EAU Section of Urological Research 4-6 October 2018, Athens, Greece In collaboration with the EAU Section of Uropathology

Current challenges in urological research One of the major challenges in urological research is to translate experimental data into clinical practice. When basic research is incorporated into new strategies, development of the treatment of urological diseases will further progress. Implementation of biomarkers in clinical trials is needed in the customisation of patient treatment. Through biomarkers, tumour subtypes can be identified as these have varying outcomes and treatment responses. The understanding of molecular and cellular processes of tumour development and progression can lead to the development of more effective systemic treatments. Hence, another major challenge is to bring researchers and clinicians together to understand the clinical problems and to come up with solutions from basic science.

For the complete Scientific Programme visit www.esur18.org June/July 2018

Interpreting MRI: Next frontier for urologists Understanding MRI images through ESU’s HOT courses Dr. Jochen Walz Dept. of Urology Institut PaoliCalmettes Cancer Centre Marseille (FR) walzj@ ipc.unicancer.fr A few decades ago, urologists had difficulties reading and interpreting computerised tomography (CT) scans. Today, possessing these skills is conventional, almost expected. And like any medical field, to learn and to adapt to emerging and proven technologies and research will mean numerous benefits for patients and daily clinical practice. For urologists, the next frontier is proficiency in Magnetic Resonance Imaging (MRI) interpretation.

performance of their diagnostic pathways improve. They can discuss and work together with radiologists more optimally and, as a result, provide more accurate diagnoses. As a consequence, urologists and radiologists can set-up a dedicated prostate cancer diagnostic team together to provide reliable feedback, learn from one another and contribute to the improvement of the MRI quality standards, locally and generally speaking. MRI reading and fusion biopsy courses The reason behind the inception of MRI-related Hands-on Training (HOT) courses was to make the skill-building readily available to urologists. These courses are essential resources to urologists who aim to be on the forefront in diagnosing prostate cancer and gain invaluable knowledge in MRI and MRI/ ultrasound fusion technologies. Organised by the European School of Urology (ESU) with the EAU Section of Uro-Technology (ESUT) and

MRI benefits for urologists There is a growing necessity for MRI interpretation as a urological activity as it plays an increasingly important role in the diagnosis of prostate cancer. MRI is already the recommended standard for repeat biopsy and potentially becomes a standard for first biopsy as well. But it is crucial that urologists can read and interpret these prostate MRIs to identify suspicious lesions in the prostate and distinguish high-quality MRI images from poorer images. When urologists are educated about MRI reading, their interpretation skills increase and with this, the

Tutor gives pointers during HOT course in MRI Fusion Biopsy

course. With the guidance of esteemed faculty members, they go through the test answers together. These HOT courses were well-received at several EAU meetings, including the recent Annual EAU Congress in Copenhagen. The general feedback was incredibly positive, as these courses were also created to complement other lectures to ensure a well-rounded learning experience for participants. The courses will be incorporated in many upcoming national meetings to be held across Europe.

Learning by doing

the EAU Section of Urological Imaging (ESUI), the “ESU/ESUT/ESUI Hands-on Training Course in MRI Fusion Biopsy” provides an overview on MRI reading, the basics on techniques and different prostate biopsy approaches. During the course, technical considerations, transrectal and transperineal approaches are also examined. Participants have the opportunity to apply learned concepts on different fusion biopsy machines. At the end of the course, they will further understand the advantages, the handling of MRI ultrasound fusion biopsies and the limitations. The “ESU/ESUI Hands-on Training Course in Prostate MRI reading for urologists” is designed to give participants a chance to interpret MRI images and receive individual real-time feedback. Participants are given warm-up exercises prior to the test cases to familiarise them with the sequences and scoring systems. They are required to bring and use their laptops for the reading of the test cases during the

In development The first MRI-related online training course is currently being developed to further increase the knowledge obtained during the MRI-reading HOT course. There is a possibility to access an MRI-reading course on a commercial MRI-reading platform. The feasibility to provide a simulation for prostate biopsy for the fusion HOT course with certification is presently being explored.

During HOT course in Prostate MRI reading for urologists

BPO Masterclass in Heilbronn 3rd ESU-ESUT Masterclass on BPO delivers insights on key techniques Dr. Jan-Thorsten Klein Universitätsklinikum Ulm Dept. of Urology & Pediatric Urology Ulm (DE) jan-thorsten.klein@ uniklinik-ulm.de After a successful launch in 2016, the 3rd ESU-ESUT Masterclass on Operative Management of Benign Prostatic Obstruction (BPO) took place last May 4 to 5 in Heilbronn, Germany with 40 participants from across Europe. Surgical treatment of benign prostate obstruction is one of the fundamental skills of the urologist. The ESU-ESUT Masterclass on Operative Management of Benign Prostatic Obstruction (BPO) focuses on current surgical techniques and delivers the theoretical background necessary for modern BPO patient management as well. The programme combined live surgery cases, recorded ‘semi-live’ procedures, and theoretical lectures which covered topics in modern BPO surgery. On Day 1, after a brief introduction by ESUT Chairman Evangelos Liatsikos and programme host Jens Rassweiler, the first surgeries were performed. The concept of this masterclass is not only to show the different surgical techniques but to provide the participants with all the possible tips and tricks to optimise their surgical results.

and the surgeon’s decision-making process regarding effective patient selection. During the lectures the next group of patients were prepared. After the case presentations, the go-ahead was given for the second part of the live surgeries. The techniques shown again included resection and ablations. The gold standard monopolar TUR-P was shown quite effectively. And a demonstration of how ejaculation can be preserved during mTUR-P provided an insightful glimpse into the dedicated field of transurethral prostate surgery. Third round of live surgeries After a second expert theory session focussing on the basis of HF-surgery, irrigation solutions and the use of lubricants in transurethral surgery, and a comprehensive presentation on the various instruments used for the different techniques, the third round of live surgeries begun. The session demonstrated enucleation techniques using either Holmium or Thulium lasers. The surgeons showed all essential steps of the procedures and the tips and tricks to avoid pitfalls. Upcoming techniques were discussed in semi-live demonstrations in the third part of the lectures. Different approaches were shown and discussed such as robot-assisted laparoscopic adenomectomy or with laparoscopy alone. A fitting closure on the segment regarding laser techniques was the use of the green light laser as an enucleation tool. The last live session demonstrated that the type of energy source for enucleation techniques is

All surgeries were directly transmitted from the operation room to the brand new auditoriuma modern amphitheatre with a direct link between the surgeon and the auditorium which enabled the audience to directly ask the surgeon regarding surgical techniques. The session started with a TURis resection of the prostate and as a counterpart, a bipolar resection. Following the first live surgery was the segment of expert theory sessions- a second fundamental part of the masterclass- which covered the guidelines on BPO June/July 2018

A packed room of eager participants

circumstantial. Prostate enucleation using bipolar energy showed that the key to a proper enucleation of the prostate is to encounter and work in the correct layer and to identify and respect anatomical landmarks. Discussing with a trainer during a workshop

The last lectures showed a glimpse of future technologies and the newest surgical techniques for BPO. The use of devices like the Aqua-ablation water beam resection was demonstrated in a semi-live case, and the indication for Uro-Lift or prostate embolisation was thoroughly discussed. Finally, how the many developments have led to modern transurethral prostate surgery was illustrated. Mentored training Day 2 began with the report of the clinical results of the patients treated during the Day 1 surgical session. The patients were visited during the morning ward rounds, pictures were taken and the results were projected on the screen, showing the colour of the irrigation tubes and the urine bags, including the clinical follow-up of the patients. There were no revisions. One patient had clot retention that required manual irrigation for clot removal. Overall, the results were excellent for all eight surgeries. Overnight the auditorium was converted into a training facility with seven workstations equipped with VR-simulators on bipolar TUR-P and green light laser treatment, and a variety of wet-lab TUR-simulators. Additionally, there were also four theoretical workstations where different topics were discussed in a kind of ‘Meet the Trainer’ manner. After a short introduction, the participants were trained in the various surgical approaches in BPO surgery using the hands-on models. The mentors also discussed with the trainees the different approaches and techniques. Every 20 minutes the participants (in small groups) rotated to the next workstation for intensive circuit training in BPO surgery and theory. Every group had the opportunity to work in all workstations and after three hours, the intensive training ended with a final discussion round. With the overwhelmingly good feedback and evaluation of the participants, there will definitely be a 4th ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction.

Surgeons and performed surgeries: • Bipolar TURIS (Live) A. Martov, Moscow (RU) • Bipolar TUR-P (Live) J. Rassweiler, Heilbronn (DE) • Thulium laser enucleation of the prostate (Live) A. Gross, Hamburg (DE) • Holmium laser enucleation of the prostate (Live) F. Montorsi, Milan (IT) • Monopolar TUR-P (Live) H. Leyh, Garmisch-Partenkirchen (DE) • Ejaculation protective TUR-P (Live) S. Aloussi, Neunkirchen (DE) • Bipolar enucleation of the prostate (Live) M. Fiedler, Heilbronn (DE) • TURIS enucleation of the prostate (Live) P. Dell`Orto, Milan (IT) Semi-Live Cases: • GL-Enucleation of the prostate (Semi-Live) V. Misrai, Toulouse (FR) • Laparoscopic adenomectomy (Semi-Live) A. Gözen, Heilbronn (DE) • Laparoscopic Robotic adenomectomy (Semi-Live) V. Pansadoro, Rome (IT) • Aquaablation (Semi-Live) T. Bach, Hamburg (DE)

Training in various BPO surgical approaches

European Urology Today


ESU Training and Research group Achieving new heights for EAU Mr. Bhaskar Somani Scientific, Training and Research Co-coordinator Southampton (UK)

bhaskarsomani@ yahoo.com Co-Authors: Prof. Ali Gözen, International course coordinator and training programme supervisor Dr. Ben Van Cleynenbreugel, ESU training research group lead Dr. Domenico Veneziano, ESU curriculum development and EUREP HOT coordinator The European School of Urology (ESU) pioneered the “Training and Research” group to develop the training standards of the ESU’s Hands-on Training (HOT) programmes. This initiative was accomplished through close collaboration with the EAU Section of Uro-Technology (ESUT), EAU Section of Urolithiasis (EULIS) and other EAU sections. Over the last decade, new training protocols in laparoscopy and endourology have been launched. While European training in Basic Laparoscopic Urological Skills (E-BLUS) is now established in Europe and the rest of the world as the basic laparoscopy course and examination [1], the Endoscopic Stone Treatment step-1 (EST-s1) is now validated and established with successful course delivery and examinations conducted in Europe [2,3]. With growing incidence and prevalence of kidney stone disease, there is a need for a training protocol

passed, particularly the excellent ratings for the trainers, organisation and participants’ experiences. Feedback from 796 participants of 1,450 HOT courses from 54 countries confirmed this rating in both A new course for Endoscopic Stone Treatment step-2 European and non-European countries [5]. ESU’s (EST-s2) is currently under development which will mission to standardise and harmonise training across focus on ballistics and stone fragmentation. The potential of the course was explored during the recent Europe has led to an even platform for simulationbased training and assessment for residents with a ESUT meeting and there are plans to validate the dedicated one-on-one training per one-hour slot. course in 2018. which is scientifically valid, universally accepted and can set a benchmark for training in endourology [4].

"..the Endoscopic Stone Treatment step-1 (EST-s1) is now validated and established with successful course delivery and examinations conducted in Europe." Candidates who have successfully completed EST-s1 will have the opportunity to participate in EST-s2 in Berlin and Prague later this year with the goal to validating the protocol. Similar HOT courses dedicated to the lower tract are also being developed and this will lead to standardised training for transurethral resection of prostate (TURP). The cognitive task analysis (CTA) is now completed and the preliminary validation will be carried out during the 16th European Urology Residents Education Programme (EUREP18) this August. The reach of ESU’s HOT courses has gone beyond Europe. With over 24 E-BLUS courses carried out worldwide in 2017, EST-s1 was successfully completed in Poland, Austria, Spain and Turkey and gained growing interest from all over the world. The next step is expansion in Asia. Courses are already planned later this year in Singapore, Thailand and China. With gradual methodological improvements in the HOT curriculum, positive feedback grows as time

The course will be incorporated in the EUREP meeting as EUREP is a quintessential platform to increase the number of experts who can deliver these programmes and courses in any part of the world. The feedback received from the initial course was excellent. This will provide a flagship training programme for all trainers and possibly become mandatory before they take up their HOT roles. The trainee demographics from EUREP show that the objectives of these courses are met with excellent feedback. While European trainees dominate the demographics, participation from a number of non-European countries illustrate ESU’s continued collaboration with national societies, and dissemination of simulation training at a broader scale. Exciting times lie ahead with new simulation-based curriculums being developed and a greater push for standardising the training methodologies and the

References 1. Brinkman WM, Tjiam IM, Schout BMA, Muijtjens AMM, Van Cleynenbreugel B, Koldewijn EL, Witjes JA. Results of the European Basic Laparoscopic Urological Skills examination. Eur Urol 2014;65:490–496. 2. Veneziano D, Ahmed K, Van Cleynenbreugel B V, Gozen A, Palou J, Sarica K, Liatsikos E, Sanguedolce F, Somani B K. Development of the novel Endoscopic stone treatment step 1 (EST s1) training/assessment curriculum: A collaborative work of EULIS, ESUT, YAUWP and ESU training groups. Journal of Endourology 2017 Jul 10. doi: 10.1089/end.2017.0248. 3. Veneziano D, Ploumidis A, Proietti S, Tokas T, Kamphuis G, Van Cleynenbreugel B, Gozen A, Breda A, Palou J, Sarica K, Liatsikos E, Ahmed K, Somani B K. Adding validity evidence to the Endoscopic Stone Treatment step-1 (EST s1): a novel training and assessment tool from collaboration of ESU, EULIS, ESUT and EUREP. Eur Urol Suppl, 2018; 17(2):e1822-e1825. 4. Pietropaolo A, Proietti S, Geraghty R, Skolarikos A, Papatsoris A, Liatsikos E, Somani B K. Trends of ‘Urolithiasis: Interventions, Simulation and Laser technology’ over the last 16 years (2000-2015) as published in the literature (PubMed): A systematic review. WJU, 2017 Nov;35(11):1651-1658. 5. Somani B K, Van Cleyenbreugel B, Gozen A, Palou J, Barmoshe S, Biyani S, Gaya J M, Hellawell G, Pini G, Rodriguez Faba O, Sahchez Salas R, Macek P, Skolarikos A, Wagner C, Eret V, Haensel S, Siena G, Schmidt M, Klitsch M, Vesely S, Ploumidis A, Proietti S, Kamphuis G, Geraghty R, Veneziano D. The ‘EUREP hands-on-training format’: 4-years of hands-on-training improvements from the European School of Urology (EAU). Eur Urol Focus, 2018 Mar 14. pii: S2405-4569(18)30080-4. doi: 10.1016/j.euf.2018.03.002. [Epub ahead of print]



5th ESU-ESUT Masterclass on Lasers in urology

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

22-23 November 2018, Barcelona, Spain An application has been made to the EACCME® for CME accreditation of this event


As demand for courses and lectures increases, so does the need for trainers in endourology and/or laparoscopy who can carry out the training in a quality-controlled, standardised fashion. With this in mind, the “Training the trainers” course was launched with great success. This completed the first session of the trainer recruitment and certification which took place in Leeds, United Kingdom, overseen by Mr. Bhaskar Somani, Dr. Ben Cleynenbreugel and Mr. Shekhar Biyani.

trainers. There has never been a better time for simulation-based endourology or laparoscopy training for trainers and trainees.

European Urology Today

13-14 December 2018, Paris, France An application has been made to the EACCME® for CME accreditation of this event

June/July 2018

UROBESTT: Designed for promising urologists Laying a solid foundation for the future of urology The URO Berlin Skills Teaching and Training (UROBESTT) is designed to expand the capabilities of young, promising urologists. The meeting is set to take place from 7 to 9 February, 2019 in Berlin, Germany. Elements from the previous European Urology Forum such as the challenger sessions, skill-enhancing handson trainings, and a diverse selection of clinical cases from the participants themselves are integrated into the meeting’s well-rounded Scientific Programme. Guaranteed, UROBESTT is a meeting to look forward to.

Meeting professional needs and wishes of young urologists

Dr. Michiel Sedelaar (NL), Chairman of the Young Urologists Office (YUO), Scientific Committee UROBESTT Every aspect of the UROBESTT is specifically tailored towards the needs and wishes of young urologists. The meeting is a culmination of top-of-the-line learning opportunities, knowledgeable speakers, hands-on training, and excellent educational values. The venue and setup of the meeting encourage learning and productive interaction with peers to make more urology friends for the future. And from an EAU-YUO standpoint, UROBESTT brings a great opportunity for talent scouting!

Laparoscopy or open surgery? Benefits and risks

Patient selection and techniques in performing endosurgical procedures

Functional outcomes and the right expectations from patients

Dr. Joan Palou (ES), Chair European School of Urology, Course Director UROBESTT

Prof. Olivier Traxer (FR), Board Member European School of Urology, Course Director UROBESTT

Dr. Henk Van Der Poel (NL), Board Member European School of Urology, Scientific Committee UROBESTT

In the radical treatment of upper urinary tract tumours, we perform a nephroureterectomy and a lymphadenectomy. To perform these, we converted to laparoscopy because it is minimally invasive, with less incisions and pain, and patients recover better. However, there is a dilemma. It is minimally invasive compared to a classic open surgery but there is a threat of cell spillage which can result to an increased risk of cell implantation and/or more local recurrences of peritoneal carcinomatosis. So in the instance of cell spillage, do we convert to open surgery or do we continue with laparoscopy?

Indications regarding patient selection and the techniques on how to perform the endosurgical procedures are the core of the lecture. This topic is new with novel indications and contemporary instruments.

Thursday, 7 February: Laparoscopic and open management of upper tract muscle invasive urothelial cancer: The role of neoadjuvant chemotherapy, nodal dissection, management of the bladder cuff and the addition of perioperative intravesical instillations.

Thursday, 7 February: Upper tract urothelial cancer endosurgical approaches: Which patients to select for endosurgical procedures.

Patient selection is of utmost importance. First, we need to determine which patients are the most suitable and who can benefit the most from these procedures. Then we focus on the how to perform said procedures; from the most effective techniques to the most appropriate equipment to use.

We need to let our patients know about functional outcomes to effectively and accurately inform them on what to expect from pelvic surgery. Functional outcome is the main driver in most surgical procedures we perform as urologists. Measuring and evaluating it are essential in continuing improvement in treatment. We already do this now for prostatectomy and cystectomy when we use imaging technologies to predict how our patients will function after the procedures. Friday, 8 February: Functional outcomes after pelvic surgery.

Enthusiastic response for ESU course in Morocco Participants examine role of mpMRI in prostate biopsies Dr. Francesco Sanguedolce Course leader Barcelona (ES)

fsangue@ hotmail.com

The strategic links between the European Association of Urology (EAU) and the Association Marocaine d’Urologie (AMU) throughout the years have led to the tradition of including the course organised by the European School of Urology (ESU) in the annual AMU congresses. This year, I had the privilege to lead the ESU course “Prostate biopsies: Tips and tricks”, which headlined the AMU congress that took place in scenic Skhirat, a tranquil and picturesque seaside town near Rabat. Participants of the ESU course recognised the importance of enhancing their knowledge on prostate multiparametric magnetic resonance imaging (mpMRI) and its relevance in detecting prostate cancer (PCa). The content and delivery of the course might inspire them to apply changes in their daily clinical practice and, in turn, impact national protocols and encourage more investments in technology. Course highlights Based on cutting-edge updates from PROMIS and PRECISION studies, the course focused on how the driven pathway of mpMRI may reduce unnecessary biopsies and biopsy-related complications, and June/July 2018

increase detection of clinically significant prostate cancers. The preliminary lecture covered a general overview of what a prostate mpMRI is and the importance of the PI-RADS v2 score in the clinical setting. Relevant studies on the role of mpMRI in prostate biopsy were analysed in detail. The second part of the course centred on the different ways of undertaking a targeted biopsy, including the latest techniques on fusion ultrasound-MRI biopsy. The final lecture was dedicated to the clinical implications of the prostate mpMRI in terms of interventions-planning for the treatments of localised PCa, wherein clinical cases were examined and discussed with the participants. The course concluded with a clinical case presented by Dr. Imad Ziouziou (MA) which further stimulated enthusiastic discussions. Dr. Ziouziou said: “The ESU course during the AMU congress was an excellent opportunity to share and exchange ideas on various advances in the field and their application. Due to its high-quality programme, the ESU course is a scientific activity that is definitely ‘not-to-be-missed’ by Moroccan urologists.”

The expo floor at the congress

Individual needs As the course progressed, interest during the discussions heightened. The latter parts of the course illustrated the contrast between real life and the ideal scenarios presented in published clinical trials; from varying, local healthcare conditions across the world to outcomes of prominent studies which may not be applicable in other places.

I would like to express my sincerest appreciation to the ESU Office, Prof. Haj-Ahmed El Alj, President of the AMU, for the warm welcome, and to Prof. Anwar Padhani (GB) and Dr. Veeru Kasivisvanathan (GB) for some of the materials used in the presentations. I look forward to the vital updates that the ESU course will bring at AMU’s annual congress in 2019.

For example, it was interesting to know that the rate of overdiagnosing PCa is quite low in Morocco. Most of the patients, especially those from non-urban areas, only consult with their urologists when symptoms of prostate cancers are already evident, usually indicating PCa at advanced stages.

Presenting during the ESU course at the AMU

Acknowledgment It was an honour to meet esteemed colleagues from this part of the world. I treasure this experience which is one of the most memorable I have had with the EAU family.

Dr. Ziouziou presents a clinical case

European Urology Today


ESU introduces new masterclass on kidney transplant Updates on organ preservation, technologies, immunosuppression and more Join us in Madrid, Spain from the 15th to 16th of November for the premiere of 1st ESU-ESTU Masterclass on Kidney Transplant. This high-level Masterclass is designed to provide you a comprehensive coverage on organ preservation, emerging surgical technologies, frontline updates on immunosuppression and immunology, and oncological issues of donor and receptor. Your learning will be enriched with informative presentations, pre-recorded surgeries, and a cutting-edge hands-on training. Internationallyknown urologists, nephrologists and pathologists who make up the faculty will guide you every step of the way.

You will also examine challenging real-life cases and learn about typical complications in kidney transplant to help prevent them from happening in your own practice. Then conclude your day with vital tips and tricks on urological prosthesis in kidney transplant patients from the best in the field. Immunosuppression and pathology The momentum of the Masterclass will not diminish on its second day as you will begin with learning about the current status of immunosuppression and what lies in the future. One of the present challenges is to customise immunosuppression to adapt to the characteristics of both donor and receptor, resulting in minimised secondary effects and maximal benefits.

On donors and other related topics Day one of the Masterclass will kickstart with presentations on non-heart beating donors, expanded criteria donor kidneys and evaluation of patients with oncologic diseases. You will have numerous opportunities to ask your questions, share your insights and deliberate with speakers and fellow participants.

You will also know more about the current aspects in diagnosis and treatment on donor-organ rejection. When and how do you perform a biopsy of renal graft? That, too, is a topic which will be explored during the Masterclass. Expect lively debates on these topics and more.

Further your education on kidney preservation through intensive round-table discussions and workshops. These will be proceeded with interesting, informative presentations on pulsatile hypothermic perfusion and normothermia. Afterwards, fine-tune your skills as you learn by doing during the hands-on training at the laboratory.

Day two will continue with presentations on artificial Intelligence applied in innovative ways. Medical issues such as hypertension, kidney transplant and infections, erectile dysfunction, and infertility will be tackled. The afternoon programme will include eye-opening lectures on prostatecancer management of kidney-transplant patients (localised and locally advanced); urothelial cancer in kidney-transplant patients; and renal tumours.

Later in the day, you will get the chance to observe valuable techniques in orthotopic, paediatric and kidney-pancreas transplants; and through semi-live surgeries in robotic procedures. Will the latter produce a better outcome compared to open and conventional surgery as less invasive techniques has advantages?

Improvement and development of preservation techniques are also challenges. Renal perfusion technologies are of outmost importance, especially in relation to expanded criteria donors. What could be beneficial are maintenance of the graft to tolerate warm ischemia and modulation of ischemic injuries, with the use of some external substances or gene-regulated modulation of ischemic consequences. Imagine what current challenges we can help resolve when we jointly increase what we know in kidney transplantation.

See you in Madrid This Masterclass will offer the ideal setting for your optimal theoretical and practical training. Optimise your decision-making process and enhance your management of commonly encountered complications, and join us at this inaugural Masterclass. Chairmen Prof. Dr. Enrique Lledó García (ES) and Prof. Francisco Javier Burgos-Revilla (ES), and the rest of the esteemed faculty look forward to welcoming you in the Spanish capital. Mark your calendar and see you there!


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

Current challenges in kidney transplant Donor figures and characteristics are changing over time, and the number of candidates on the waiting list is increasing. The key is to aim for balance. The potential solution? Developing results in xenotransplantation or other alternatives.

European Urological Scholarship Programme SLK Klinikum Heilbronn fellowship hones resident’s skills Marko Vukovic Urology resident Clinical Centre of Montenegro University Belgrade (RS) markovukovic09@ gmail.com The Urology Department of the SLK Klinikum Heilbronn, University of Heidelberg is a urological centre of excellence in several areas, especially in robotic surgery and retroperitoneoscopy. This institution is a certified prostate centre and a recognised training centre in minimal invasive surgery for urology fellows around the world. Purpose of the visit SLK Klinikum is a huge complex located in Heilbronn, a city in northern Baden Württemberg, Germany. With approximately 123, 000 residents, it is the sixth largest city in the state and is an important industrial centre. The city is located by the river Neckar and boasts of beautiful parks and valleys, which makes Heilbronn a favourite. SLK Klinikum is the teaching hospital of Heidelberg University and its Urological department is chaired by Prof. Jens Rassweiler, a well-known expert in minimal invasive urology and pioneer in many techniques and procedures. Fellows around the world visit this centre to gain knowledge on minimal invasive surgery and endourology, since the department is one of the centres where minimally invasive surgical technique was established and further developed. Today, Prof. Rassweiler is a mentor to fellows on minimally invasive therapies. European Urological Scholarship Programme Office


European Urology Today

The department has three endourological rooms equipped with fluoroscopy C-arm and Roboflex, a comprehensive device for flexible ureterorenoscopic stone treatment, as well as two operating theaters, where major surgery is performed. Each operating theater is equipped with modern and advanced system for minimal invasive surgery, including Da Vinci and miniaturised laparoscopic instruments (LESS, SMART) to treat diseases of the prostate, bladder and kidney, as well as female incontinence surgery. The centre is recognised as a certified prostate centre, where almost 4000 patients were operated since 1999 either laparoscopically or using Da Vinci system. Other treatment modalities for prostate cancer are also performed in this centre. The most interesting part for every fellow is the training room, where each scholar or resident could train on dry laparoscopic training box, perform basic E-BLUS activities, or use a perfusion training model for dynamic simulation of intra-abdominal environment, with the possibility of performing vascular clip application, suturing of animal models or simulation of pyeloplasty, partial nephrectomy and vesico-urethral anastomosis. Nevertheless, a virtual laparoscopic training model is available and used to improve a fellow’s dexterity, depth perception and speed, with different simulation programmes such as when clipping a renal vascular pedicle. The training room is also equipped with six computers, where fellows could watch everyday procedures, step by

step, with tips and tricks explained by Dr. Ali Gözen, who was not just our teacher but also a friend and dedicated mentor. During my three-month fellowship, I could also train on flexible URS simulator with pelvic model for flexible cystoscopy and ureteroscopy. The purpose of my visit (from 1 February to 1 May this year) was to train on minimal invasive surgery, especially laparoscopy, as well as receiving basic knowledge on flexible ureterorenoscopy and PCNL. Training activities During the three months, I was highly involved in everyday practice and procedures performed in the OP room and endoscopy unit. After the first week, I assisted as second or first assistant in various surgical procedures, both open and laparoscopic. Below are the various and the number of procedures I participated in: Laparoscopic and robotic-assisted surgery • Robotic assisted radical prostatectomy (trans and extraperitoneal approach): 37 • Robotic assisted vaso-vasostomy: 1 • Laparoscopic partial nephrectomy (retroperitoneal approach): 6 • Laparoscopic radical nephrectomy (retroperitoneal approach): 2 • Laparoscopic adrenalectomy (retroperitoneal approach): 1 • Laparoscopic nephroureterectomy (retroperitoneal approach): 1

Some pics of my involvement in everyday practice and procedures performed in the OP room and endoscopy unit

• Laparoscopic hernia repair: 2 • Laparoscopic adenomectomy: 1 • Laparoscopic pyeloplasty (retroperitoneal approach, SMART technique): 1 • Laparoscopic and Robotic assisted sacrocolpopexy: 1 Open surgery • Radical nephrectomy: 1 • Radical cystectomy with continent, orthotopic diversion (Neoblase): 1 • Radical cystectomy with incontinent diversion (ureterocutoneostomy): 1 • Plastica tunicae vaginalis testis: 2 • Radical orchiectomy: 2 • Retroperitoneal tumour extirpation: 2 • Ureterocystoneostomy: 1 I also trained every day in the Laparoscopy Room for several hours on laparoscopic and flexible URS models, which significantly improved my endoscopic abilities and dexterity. Also, I was actively involved in preparing a scientific paper which will be published in peer-reviewed journal, with the topic “Laparoscopic partial nephrectomy: Is Retroperitoneal Approach more relevant than transperitoneal?” A starting point This fellowship was an important part of my residency and a starting point for my future activities and further education. I would strongly recommend this centre to any urologist or resident-on-training since a large number of cases are performed in the centre and there is the opportunity for active involvement in everyday practice. I hope I will have the opportunity to get a one-year scholarship to continue my practical and scientific work in this centre as an EUSP scholar. I owe special thanks to Prof. Jens Rassweiler and Dr. Ali Serdar Gözen who were not just mentors but also friends, and the EUSP board for granting me this wonderful opportunity which significantly boosted my career. June/July 2018

New ESU e-courses Frontline content-based on 2018 EAU Guidelines By Erika De Groot The European School of Urology (ESU) introduces two new e-courses: “EAU Guidelines on Thromboprophylaxis” and “EAU Guidelines on Men’s Health”. These premiere online courses are based on the recommendations of the latest EAU Guidelines, which include developments from recent major studies integrated into the content. EAU Guidelines on Thromboprophylaxis e-course Better perioperative management of antithrombotic agents, reduced risk of venous thromboembolism and post-operative major bleeding are some of the numerous benefits of thromboprophylaxis. It is an established standard of inpatient care complementary to surgical procedures such as robot-assisted radical prostatectomy, laparoscopic radical nephrectomy, and open radical cystectomy. What is the optimal duration of pharmacological prophylaxis? EAU Guidelines say four weeks. What are the recommendations regarding patients receiving antithrombotic agents perioperatively? EAU Guidelines say discontinue antithrombotic therapy during period around surgery; or delay the surgery of patients with a temporary and significantly high risk of thrombosis until risk decreases. If delay is not possible, maintain antithrombotic therapy or bridge through surgery may be advisable. Participants can expect these and other relevant recommendations from this new e-course. The course questions were developed, reviewed and revised by the Guidelines’ Panel Chairs and Dr. Nikolaos Grivas (GR) in cooperation with the Young Academic Urologists (YAU) and with the support of EAU’s e-learning specialists. EAU Guidelines on Men’s Health e-course For a comprehensive overview on relevant andrology updates, the new e-course on men’s health covers the latest EAU Guidelines on non-neurogenic Lower Urinary Tract Symptoms (LUTS), infertility, sexual dysfunction, and hypogonadism. The course questions were developed, reviewed and revised by the Guidelines’ Panel Chairs and Assoc.

Prof. Sabine Brookman-May (DE) in cooperation with the Young Academic Urologists (YAU) Men´s Health Group and with the support of EAU’s e-learning specialists. Course components The e-courses are divided into Learning Modules. These modules consist of multiple-choice questions. To choose the best answer per question, participants must navigate to corresponding chapters in the Guidelines. The first module of the thromboprophylaxis e-course is an introduction to post-surgery thromboprophylaxis, followed by the second module which focuses on thromboprophylaxis for specific surgical procedures. The final module is centred on the perioperative management of antithrombotic agents in urology. The four modules in the men’s health e-course cover non-neurogenic Lower Urinary Tract Symptoms (LUTS), infertility, sexual dysfunction, and hypogonadism. Participants will be able to review the most recent EAU Guidelines on men’s health, learn about recommended diagnostic procedures and treatment based on individual patient cases, and test their knowledge. The e-courses are available in English. The thromboprophylaxis e-course will take approximately 60 to 90 minutes while the e-course on men’s health will take approximately 90 to 120 minutes to finish. Participants are required to answer the questions for the final assessments. A passing grade of 80% and above will guarantee an accreditation of one European CME credit (ECMEC®) per e-course. Participants can stop anytime if needed. They can log-in again to pick up where they left off and proceed with the remaining questions. More learning opportunities Participants can further enhance their know-how and accumulate more CME credits with other ESU e-courses. Topics range from non-muscle-invasive bladder cancer to metastatic prostate cancer and more. For a complete overview of the ESU e-courses, please visit http://uroweb.org/education/onlineeducation/e-courses/.

European School of Urology ESU courses, masterclasses and meetings 2018 - 2019

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Augustus 31-5 Sept 16th European Urology Residents Education Programme (EUREP), Prague (CZ)

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Welcome Learning Unit 1 consists of 1 question which you can answer by navigating to the corresponding chapters of the Thromboprophylaxis guideline. All the questions must be answered to submit the test and to display the results page with the score. After completing all the answers, the good & wrongly answered questions can be reviewed with feedback from the corresponding guideline-section. You also have the option to reset the Learning Unit and start over. Good luck and enjoy learning!

Check out the 2 new e-courses now!


• Every month a new topic • Up to date in 30 minutes • Great interaction with Polls and Q&A uroweb.org/webinars

June/July 2018

September ESU-ERUS courses at the 15th Meeting of the EAU Robotic Urology Section (ERUS), Marseille (FR) E-BLUS at the Boot Camp of the Turkish Urology Association, Istanbul (TR) Hands-on training skills programme on Laparoscopy and Endourology, Caceres (ES) 2nd EAU Update on Prostate Cancer (PCa18), Milan (IT) ESU course on Urolithiasis at the Eastern Siberia international meeting of the Russian Society of Urology, Krasnoyarsk (RU) E-BLUS training and exams at the 18th International Annual Conference UROALEX, Alexandria (EG) ESU-ESFFU Masterclass on Functional urology at the European Lower Urinary Tract Symptoms meeting (ELUTS18), Milan (IT) ESU course on Immunotherapy, new perspectives in bladder cancer at EAU 13th South Eastern European Meeting (SEEM), Belgrade (RS) E-BLUS at the German Urology Congress (DGU), Dresden (DE) ESU course on Update in urology at the national congress of the Armenian Urological Society, Yerevan (AM) October ESU course on Clinical and histopathological basics and main research questions in prostate cancer at the 25th Meeting of the EAU Section of Urological Research (ESUR), Athens (GR) E-BLUS at the Jordan Urology Association Annual Congress, Amman (JO) ESU course on Recent developments and broadening indications in treatment of urolithiasis at the national congress of the Hellenic Urological Association, Athens (GR) ESU course on Urodynamics in daily practice: How to perform and how to interpret at the national congress of the Czech Urological Society, Ostrava (CZ) E-BLUS at the Tunisian Urological Association Annual Congress, Tunis (TN) E-BLUS at the Turkish Urology Association Annual Congress, Kyrinea (CY) ESU course on Update on prostate and bladder cancer at the national congress of the Turkish Association of Urology, Bafra (CY) 5th Confederación Americana de Urologia Residents Education Programme (CAUREP), Punta Cana (DO) November E-BLUS at the Learn with the best, Level I Laparoscopy course, Lisbon (PT) ESU courses on Daily practice in the management of metastatic prostate cancer and Immunotherapy for urological tumours at the 10th European Multidisciplinary Congress in Urological Cancers (EMUC), Amsterdam (NL) ESU course on Urinary tract infections and erectile dysfunction at the national congress of the Russian Society of Urology, Yekaterinburg (RU) 1st ESU-ESTU Masterclass on Kidney transplant, Madrid (ES) ESU Urology Bootcamp, Lisbon (PT) ESU course on Paediatric urology at the national congress of the Iraqi Urological Association, Baghdad (IQ) 5th ESU-ESUT Masterclass on Lasers in urology, Barcelona (ES) December ESU course on Paediatric urology at the national congress of the Egyptian Association of Urology, Cairo (EG) E-BLUs at the Egyptian Urology Association Annual congress, Cairo (EG) ESU course at the national congress of the Georgian Association of Urology, Tbilisi (GE) 3rd ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer, Paris (FR) January 2019 ESU course on Daily practice in prostate cancer at the occasion of the 16th meeting of the EAU Section of Oncological Urology (ESOU), Prague (CZ)

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February 2019 UROBESTT, Berlin (DE) Hands-on training skills programme on Laparoscopy and Endourology, Caceres (ES) 2nd ESU-ESOU Masterclass on Non muscle invasive bladder cancer, Prague (CZ)


March 2019 34th Annual EAU Congress, Barcelona (ES)


April 2019 ESU course at the national congress of the Urological Association of Serbia, Belgrade (RS)


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July E-BLUS training and exam at the Urofair, Singapore (SG) ART in Flexible programme – step 2, Berlin (DE)

May 2019 4th ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction, Heilbronn (DE)


June 2019 ESU – Weill Cornell Masterclass in General urology, Salzburg (AT)

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September 2019 17th European Urology Residents Education Programme (EUREP), Prague (CZ) ESU-ERUS courses at the 17th Meeting of the EAU Robotic Urology Section (ERUS), Lisbon (PT)


European Urology Today


Historic agreement with UAA An outstanding opportunity Cooperation and joined membership

Van Poppel in Budapest as EUSP visiting professor

The EAU and the Urological Association of Asia (UAA) signed an historic agreement in Kyoto last April, ensuring cooperation between the associations and allowing UAA members to become EAU members.

For many decades the Department of Urology at Semmelweis University in Budapest is committed to invite highly skilled urology experts to contribute in expanding knowledge and develop the surgical technique skills of young urologists.

The agreement was signed on April 14th on behalf of both Associations by Secretary Generals Prof. Chris Chapple and Dr. Allen Chiu at the 16th Urological Association of Asia Congress.

The signing of the agreement is the culmination of several years of negotiations between the EAU and the UAA. This marks the first time that the EAU has an agreement with another international urological association, after many previous successful arrangements with individual national societies. The UAA is the EAU’s equivalent in Asia. It was founded in Japan in 1990 and currently consists of 25 member associations from the Middle East to East Asia. It aims to promote urology in Asia, to narrow the gap in standard care and urological training, and to ultimately improve the care of patients across the continent. It holds an Annual Congress as well as various seminars and workshops.

Membership and cooperation agreement with Urological Association of Asia signed last April

Continued from page 1

Following another round of discussion, the meeting closed with the session on post-operative management of surgical patients with James Catto (UK) giving a concise lecture on Enhanced Recovery After Surgery (ERAS) following radical cystectomy. Sexual and urinary rehabilitation were also taken up with a concluding breakout case discussion on managing complications.

in the next few months with novel agents replacing or complementing current therapies, and clinical work needing re-alignment to reflect these changes. Turino in Italy will host the next meeting in 2019. For additional reports on BCa18, visit the meeting website: www.bca18.org

Necchi and Palou gave the concluding remarks with both emphasising the challenge that the newer prospects in bladder cancer management will unfold

8-9 June 2018 Munich, Germany


In May 2018 the Department had the opportunity to welcome Prof. Hendrik Van Poppel, EAU Adjunct Secretary General, from University Hospitals of the KU Leuven, Belgium. Through the EUSP Visiting Professor Programme Prof. Hendrik Van Poppel visited from 6 to 9 May the Semmelweis University, Department of Urology and Centre for Urooncology. Prof. Van Poppel carried out several operations and held presentations to the staff of the Department as well as to German-speaking medical students. During the scientific programme he held presentations about surgical treatment of high-risk prostate cancer and also about new treatment options of oligo-metastatic prostate cancer. During the three-day visit, Prof. Van Poppel also performed an exemplary radical cystectomy with extended lymphadenectomy and also a radical prostatectomy. With his expertise and first-rate routine, he not only performed two instructive surgeries but also had a huge influence on the next-generation specialists.

Prof. Van Poppel also interacted with the urology residents of Semmelweis University. During lunch breaks and dinner with the faculty, he answered questions and encouraged the younger generations to challenge him with different topics in urology. He also contributed to the undergraduate medical education by giving a fascinating lecture on prostate cancer. Finally, Prof. Péter Nyirády, Head of Urologic Department of Semmelweis University expressed his appreciation and acknowledgment to Prof. Van Poppel for the comprehensive discussions and technical demonstrations. We look forward to similar activities and expressed our thanks and support to the EUSP for offering this outstanding programme. A. Horváth, A. Hüttl

What they say: The Faculty Thomas Powles on neoadjuvant and adjuvant therapies: “The European community remains split over the role of adjuvant versus neoadjuvant therapy. There is a lack of clarity on which regime we should give and on the number of cycles, and we’re not sure what to do with node-positive patients. There are questions that we need to answer as a group and guidelines meetings like this help us form opinion. The reality is that still only a small proportion of patients are getting neoadjuvant therapy, and that seems to be the main guideline that we use. In my view we have to have an honest debate, and we had that debate today.” Joaquim Bellmunt on treatment breakthroughs: “Breakthroughs, yes, that’s for sure. All these new data on new mutations such as RCC2…that correlate with outcomes, and these might help us to, maybe, select patients in a more appropriate way.”

Shahrokh Shariat on variant histologies in bladder cancer: “We’re recognising the challenge in variant histologies, the difficulty in identifying and diagnosing these variants histologies, and their misinterpretation that is quite significant. Variant histologies are hard to identify but they’re necessary to be looked up and the pathologist needs to report them whether they’re present or not, and what types. Variant histology matters and it will impact our decision-making, counselling and interpretation.” Asish Kamat on the urologist’s role in MDT: “There is a need for us to be involved in immuno-oncology. Once we have identified the need, we have to make sure that we do it right. That’s why educational efforts and courses are important. We have to learn the side effect profile of new drugs.”

What they say: The Participants

Voting during the breakout case discussions

Ilaria Lucca, Urologist, Lausanne (CH): “My main goal is to have a discussion on clinical practices and know what the experts are doing in their clinics. Everyone knows the guidelines but there’s also the actual clinical practice. In this congress there is a clear and open discussion on practical cases besides the guideline theory. It turned out to be exactly what I expected with open discussions. I like the idea that there is no right answer which allows the participants to express their concerns about the guidelines, be critical or present a different view of treatment. The main message for me is that there are no general agreements in some topics, while others need to be further investigated. We need more evidence-based data since bladder cancer is a heterogeneous disease with some types progressing in a different way. We don’t know exactly what is happening in the biological level— we need to know more. Stefan Hautmann, Urologist, Kiel (DE): “This meeting has an excellent format with many experts and great speakers. The interaction is very effective since the voting keeps the audience alert. There are good studies and data to discuss and everyone is encouraged to contribute. With update lectures in the big room and the

discussions in smaller groups, this give us the chance to discuss directly with the lecturer. My take-home message is that we need the multi-disciplinary approach to obtain excellent diagnoses. Disease pathology, for example, is very important. We must find good diagnoses, and we have treatment options such as surgery, chemoimmunotherapy, and the radiation therapy. Then, there is the patient who must make a decision with the multidisciplinary team. You need a team of doctors to decide since a single doctor is not enough for such a malignant disease.” Hesham Abdel Aziz, Urologist, Cairo (EG): “My aim to have the most updated information, research outcomes and clinical practices in European and international urology. Bladder cancer is one of the most common diseases back home and there are new developments in immunotherapy which I would like to learn. My expectations are more than met since this is a very informative meeting. The key message I picked up is that proper assessment, staging and management may give the patient a good chance of cure. Immunotherapy, in my view, will also play a key role in managing metastatic bladder cancer, and refining endoscopic and surgical techniques is important. Also, doctors need to be knowledgeable on rare and variant bladder cancer types to inform their decision-making.”

From left, Prof. A. Necchi and Dr. J. Palou at the concluding session


European Urology Today

June/July 2018

Newly restructured ELUTS18 to get to the core of urology LUTS meeting features contributions from ESFFU, ESGURS and ESU By Loek Keizer The treatment of lower urinary tract symptoms (LUTS) is something that every urologist deals with in daily practice, in the opinion of Prof. Francisco Cruz (Porto, PT). Cruz is chairman of the EAU Section of Female and Functional Urology (ESFFU) and co-chairman of ELUTS18. After a successful launch in 2017, the second edition of the LUTSfocused meeting will be coming to Milan on 20-22 September, 2018. ELUTS18 now features a parallel scientific programme: one based on LUTS and primarily organized by the ESFFU, and one based on reconstructive surgery, primarily organised by the EAU Section of Genitourinary Reconstructive Surgeons (ESGURS) under Dr. Rados Djinovic (Belgrade, RS). Additionally, the ESU Masterclass on Functional Urology is structured around the ELUTS18 scientific programme, so that participants can also join regular sessions in between their masterclass curriculum. EAU Secretary General Prof. Chris Chapple (Sheffield, GB) and Dr. John Heesakkers (Nijmegen, NL) complete the ELUTS18 Organising Committee. Structuring the lectures Speaking about the LUTS programme, Prof. Cruz highlighted the new structure of the talks, which are more case-based than usual. “Instead of simply having lectures that cover the different LUTS topics, Prof. Francisco Cruz we’ve made a more structured programme. We start with a case in daily practice, and immediately involve the audience by asking for their suggested treatment approach.” Cruz is referring to the voting rounds that occur regularly in these sessions. The audience is asked for their preferred approach, given the case’s facts and

new developments. “The audience will for instance be asked to advise single or combination treatment. The first speaker will elaborate on the audience’s answers. The next steps lead to more audience interaction. The patient in this case might also have erectile problems, which leads to a talk on how to solve this in LUTS patients, and so forth.”

Register now for a reduced fee! Deadline: 20 September 2018

conventional lecture. We also want to gauge if the lessons of the first part of the programme have been learned by the audience. That’s why we have more clinical cases in the afternoons.” Hot Topics in LUTS When asked about the big topics at ELUTS18, as well as the significance of the meeting in general, Prof. Cruz reflected: “Functional urology is of course our daily practice. Even if we’re more focused on oncology, we have to cover patients with OAB symptoms, or LUTS in elderly men, for example as a result of prostate cancer or its treatment. Male LUTS might also be something we deal with as a part of active surveillance.”

“This is asking for a little more effort from the session moderator, as he or she has to tie every individual talk together and guide the audience through the session-long case discussion. The discussion has to be steered so that it flows into the next step of the “Stress urinary incontinence in females is a hot procedure, and the next presentation.” topic due to use of artificial meshes. There is no firm evidence that they cause serious harm, but our “We think this is a more attractive way to present the patients are being misinformed by incorrect lectures, that is to say in the sequence of the information that flies around. If we are talking problems that the urologist might encounter. The about 3% of patients developing a problem with audience might be reminded of the patients that they artificial mesh use after five years, is it a serious saw before coming to ELUTS18.” problem? We need to discuss this, and (beginning) urologists need to be informed on possible options Faculty rotation and their consequences for their patients.” For ELUTS18, one of the main areas for improvement for the Organising Committee was to Prof. Cruz is also looking forward to ELUTS18’s last achieve more audience interaction than last year, session, which will address the future of functional through voting and more moments for discussion. urology. “I think that, as urologists, we need to call Another innovation comes on the afternoon of the to attention that functional urology is always there, meeting’s first day. During the real-life case whether we are practising functional urology alone discussions presented in that part of the meeting, or as a component of wider urology. We cannot the audience and faculty are split into three groups, ignore that, following radical prostatectomy, 30% of covering urodynamics, neuro-urology and sacral the patients will have incontinency, independent of neuromodulation. The groups and faculty will whether the procedure is open, laparoscopic or rotate, allowing every participant to follow each robotic.” topic, with all the didactic advantages of a small group. “We need to draw attention to the fact that functional urology is the basis of daily practice. As “The faculty of this part of the programme is the urologists, we cannot only check PSA levels and do best and most experienced in the field,” Cruz some biopsies. We see patients, and patients have explains. “The smaller groups will create a more more ailments than this. This is what we have to get intimate atmosphere, one that is closer to that of across to the audience.” an educational course or masterclass than a

ESU-ESFFU Masterclass This year, the ESU-ESFFU Masterclass is more closely integrated into ELUTS18, as a true joint meeting. Cruz explains the reasoning for this change, compared to ELUTS17: “If ELUTS18 features good talks on LUTS, we thought it was a shame to have two days of masterclass that run parallel to the ELUTS programme, with 30 people who would also be interested in the rest of the meeting.” “Last year, these participants did not join the regular programme at all, which is a shame, particularly as there is also an overlap in topics like OAB and incontinence. In some cases even the speakers overlapped and the concept of the lectures was very similar. So we decided to combine the two and increase participation.” The masterclass will take place on the Friday before the regular ELUTS18 programme, as well as on the afternoon of the Saturday. Masterclass participants are encouraged to join the ELUTS18 sessions on the Saturday morning. Topics covered by the masterclass on functional urology include: male and female anatomy, neuroanatomy, bladder pain syndrome, sexual dysfunction, urinary diversion and a lot of (submitted) case discussions.

Register for the ESU Masterclass! Deadline: 5 August 2018

Abstract submission for the ESGURS reconstructive programme Deadline: 16 July 2018 For the complete Scientific Programme visit www.eluts18.org

Join us! ELUTS18 European Lower Urinary Tract Symptoms meeting

20-22 September 2018 Milan, Italy


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

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



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



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



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

urologyweek.org June/July 2018

#urologyweek European Urology Today


PCa18: Meeting the challenges in PCa management New imaging tools help resolve treatment dilemmas in locally advanced PCa By Joel Vega Treatment dilemmas in managing locally advanced prostate cancer (PCa) is one of the most problematic cases in PCa management, but thanks to new screening and diagnostic imaging tools specialists today are better equipped to meet some of these challenges head-on. At the upcoming and second edition of the EAU Update on Prostate Cancer (PCa18) to be held in Milan on 14 and 15 September, cancer experts are presenting a compact and comprehensive interactive course to inform specialists of the best practices and most optimal therapeutic options for patients with advanced disease.

cases, however, a wellthought out treatment plan can mean appropriate intervention.

Asked what in his view are the biggest challenges for urologists, and the role of focused educational meetings such as PCa18 in dealing with these challenges, Heidenreich said:

Heidenreich said in patients with oligometastatic disease, there are still options that physicians can carefully Prof. Axel Heidenreich look into. “Oligometastatic disease exists and that even patients with low volume lymph node metastases will benefit from salvage surgery or salvage radiation therapy,” he said.

“Some of the biggest challenges are in the areas of low-risk disease such as ideal patient selection, ideal treatment which can either be active surveillance, active or focal therapy. Another area of discussion is biochemical relapse after local therapy, such as the role of salvage surgery; and finally, the issue of metastatic hormone-naive PCa, what options to choose— ADT versus ADT plus abiraterone versus ADT plus docetaxel,” he added.

Key developments In a session on local treatment for PCa, expert speaker Participants to PCa18 can also look forward to a and faculty member Prof. Axel Heidenreich (DE) will comprehensive update on key developments and speak on salvage local treatment to highlight issues the role of best practices in decision-making. In that pose a tough challenge to many doctors. salvage local treatment, Heidenreich said the emergence of sophisticated imaging such as One of the key issues that Heidenreich, director of the PSMA-PET/CT has made a clear impact on how Urology Clinic at the Universitätsklinikum in Cologne doctors select the patients suited for local (DE), will examine is the aim of curative local therapy treatment. in organ confined and locally advanced PCa following primary radiation therapy. “The key developments took place in the selection process of patients: every patient should undergo a “Too few patients are subjected to a second local multi-parametric MRI of the prostate and a therapy with curative intent because of the fear of too PSMA-PET/CT scan in order to identify the extent of many that radical salvage prostatectomy is associated locally relapsing disease and to rule out lymph with many complications. However, more than 90% node or even systemic metastases,” he explained. only receive palliative androgen deprivation therapy,” Heidenreich pointed out. “Another message is that Furthermore, Heidenreich said that in patients with this type of surgery should be done at reference biochemical relapse following radical centres only.” prostatectomy, “… PSMA-PET/CT is a key development with the possibility to identifying patients with oligometastatic lymph node disease For the complete Scientific amenable to local surgery/radiation.”

He also reiterated that often many urologists and prostate cancer experts struggle in the management of the primary tumour. “Treatment of the primary in the setting of locally advanced PCA, metastatic hormone-naive and castration PCA is often overlooked, as it is the case with the multimodality management of oligometastatic disease.”

2nd EAU Update on Prostate Cancer 14 -15 September 2018 Milan, Italy

As a compact, in-depth update meeting with many opportunities for participants to directly confer with experts and learn new insights in managing difficult cases, Heidenreich said a dedicated update meeting such as PCa18 has added value in bringing together experts for a critical assessment. “One of the gains from this meeting is that we can learn more about the benefits of multimodality treatment and interdisciplinary approaches, enabling specialists to consider options that can provide a more optimal treatment,” he said. PCa18 is part of the EAU’s new onco-urology series which aims to provide essential updates. For more details on the Scientific Programme, learning goals and registration, visit the meeting website at www.pca18.org

Join us at #PCA18

EAU onco-urology series


Programme visit www.pca18.org

With expertise and a high success rate for these type of operations making a crucial difference, due caution is not necessarily a handicap in certain cases. In other

This option is crucial since it underscores the vital role that modern imaging plays in identifying the most suitable patients, enabling doctors to intervene at an opportune time.

ERUS18 to offer wide range of education in robotic surgery Hands-on Training, ESU courses and live surgery complete annual meeting By Loek Keizer “ERUS18 aims to offer participants a wide range of content that will fulfil their educational needs,” according to Dr. Justin Collins (Melle, BE). “This ranges from updates on surgical improvements in the most common robotic surgical procedures to fantastic opportunities to meet and discuss issues with world leading experts. This year it will also be very interesting to hear the updates on the new robotic platforms that are coming to the market.” The 15th edition of the annual EAU Robotic Urology Section meeting is coming to Marseille on 5-7 September, 2018. September 5th features the Junior ERUS-Young Academic Urologists’ meeting as well as a choice of four courses by the European School of Urology. Wednesday also features the Technology Forum, where companies can showcase the latest robotic surgery platforms. The regular scientific programme starts on September 6th and features both live and semi-live surgery, case discussions and state-of-the-art lectures on all the latest in robotic urology. Dr. Collins has been part of the ERUS scientific working group for the last four years, as well as its educational group for the past two. In Marseille, Dr. Collins will be presenting on Enhanced Recovery After Surgery (ERAS) protocols in robotics and moderating a plenary session on this topic. He will present updates from the scientific working group and also speak on theatre team efficiency models as part of the Junior ERUS programme.

published in European Urology in 2016 (see: ‘Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View’ Eur Urol. 2016 Oct;70(4):649-660). For the last four years, Dr. Collins was a urologist and research co-ordinator at Karolinska Institute in Stockholm, Sweden. In April 2018, he began a new job as Medical Director at Orsi Academy: “My specialty interests are developing robotic training curricula and Dr. Justin Collins (Melle, BE) research in e-learning and eHealth. With the opening of the new Orsi Academy building we will have many exciting opportunities to both improve training and develop research in MedTech.” Junior ERUS & Hands-on Training As has become tradition at ERUS meetings, a whole day is set aside for a special programme that is designed to appeal to younger urologists. Lectures are geared to their interests and concerns, and the ESU courses also take place on this day. Dr. Collins sees clear value for young urologists: “I believe that the Junior ERUS-YAU day is a great opportunity for younger ERUS members to meet more experienced surgeons and to learn from them. At the same time, ERUS18 allows more senior members to actively engage with these juniors, to listen to their ideas and concerns, so I see great value in this special day for everyone involved.”

“I have been involved in developing a pamphlet that will be available at ERUS18 on enhanced recovery guidelines with a focus on robotics,” Dr. Collins explains. “We plan to do a summary of these and give On the ESU courses on offer at ERUS18: “These include them to all delegates at this meeting. These will include guidance on RAPN, RARP and RARC.” nerve-sparing and locally-advanced RARP technique, RAPN and RARC. The ESU courses are run by experts from around the world and always get excellent The ERUS scientific working group published a consensus view on an enhanced recovery for RARC, feedback, so they come highly recommended.” 24

European Urology Today

Throughout ERUS18, slots are available for hands-on training. “These courses are aimed at novice and experienced surgeons practising or looking to hone their technical skills. The training uses VR simulators and focuses mainly on basic robotic skills training, although there are increasingly good options for full procedure training in VR simulation, so there is also an introduction into standardised surgical steps in robot-assisted procedures.”

opportunity to learn surgical tips and tricks from highly experienced surgeons.” Asked about the continued use of live surgery at educational events, Collins remained optimistic: “I believe that live surgery, appropriately done, is of huge educational value. It is in our DNA that we learn more when we feel engaged with something. Live surgery is simply more engaging than pre-recorded surgery.”

“The main aim of these 90 minutes courses is to improve the participants’ control-skills and hand-eye-coordination. Training includes Endowrist manipulation, camera control and the use of the additional robotic arm. There is also skills training in needle placement, in driving and suturing and knot tying. All delegates receive constructive feedback with objective benchmarking of their console performance.”

Collins stresses that live surgery should only be included in a scientific meeting if all requirements are met to ensure patient safety. Both the adherence to the EAU Live Surgery Guidelines and patient selection are very important. “Highly complex or so-called redo surgery is often not the best learning experience.”

Live surgery at ERUS18 A clear highlight of the scientific programme at ERUS18 according to Dr. Collins is the live surgery. “I think it’s always very educational. It’s a great

Robotic Live Surgery

“Surgeons performing live surgery should be operating within their comfort zone at all times, in my opinion. Although it is not always possible at international conferences, live surgery should ideally be performed in a home institution with the surgeon’s own patients and staff, which will likely improve the overall quality of the care that the patient receives.”

ERUS18 15th Meeting of the EAU Robotic Urology Section Optimising clinical pathways with robotic surgery

5-7 September 2018, Marseille, France

In conjunction with: • Junior ERUS-YAU Meeting • European School of Urology (ESU) Courses • ESU/ERUS Hands-on Training in Robotic Surgery

Register now for the late fee! Deadline: 27 August 2018

June/July 2018

Madrid hosts EULIS-URS Workshop Successful interactive course will have a sequel in Romania Dr. Ramón Cansino Hospital Universitario La Paz Madrid (ES)

for a renal pelvic stone using a single use flexible ureteroscopic lithotripsy performed by Dr. R. Cansino (ES) and a for a flexible URS for a lower pole stone performed by Dr. O. Traxer (FR).

urocansino@ yahoo.es

“'EULIS standardised workshop on URS' provided key insights on the management of upper urinary stones with both rigid and flexible ureteroscopy.”

Under the collaboration of the EAU Section of Urolithiasis (EULIS) and the Urology Department of Hospital La Paz in Madrid, the first EULIS workshop took place on 10 to 12 May this year in Spain. The two-day meeting was a well-organised and highly interactive course which gathered around 50 urologists (58 registration plus faculty experts) from different countries and leading experts in the field of stone disease. Day 1 included an introduction to ureteroscopic instrumentation and lithotripsy devices by the local course chairman (and EULIS URS working group member) Dr. R. Cansino (ES), followed by a lecture on radiation exposure and safety in ureteroscopy given by Dr. J.A. Mainez (ES) whose presentation prompted many questions from the participants concerning the safety measures and radiation limits in our commonly used endourologic procedures for stone removal. Day 2 was highly intensive with three live surgeries (performed by three renowned experts) broadcasted successfully from the OR of Hospital La Paz, and where the first semi-rigid ureteroscopy procedures was performed by Dr. E. Pérez-Castro (ES). Procedures included a semi-rigid URS for an impacted proximal ureteral stone performed by Dr. M. Straub (DE), a retrograde intrarenal surgery EAU Section of Urolithiasis (EULIS)

Additionally, interactive discussions following these live surgery cases provided important tips and tricks on stone surgery. Expert comments were given by EULIS board members K. Sarica (TR), Dr. J.A. Galan Llopis (ES) and Dr. P. Geavlete (RO).State-of-the-art lectures were also presented on Day 2 including the latest developments on URS stone management, complications management, post-operative imaging, assessment of stone-free status and the learning curve in URS, a topic enthusiastically received by many of the participants.

Prof. Kemal Sarica Chairman EULIS Istanbul (TR)

saricakemal@ gmail.com can take the form of one-hour hands-on training courses. Modular progression is recommended, with ureteroscopy training occurring before percutaneous surgery due to its relative complexity.

Fellowship programmes are imperative and recommended for transition towards independent practice. On Day 3, the last half-day of the meeting, featured a concluding session with a lecture on complex clinical scenarios presented by Dr. P. Geavlete (RO), followed by clinical case discussions and unedited videos on stone disease presented by the expert speakers. All participants were enthusiastic and for readers who would want to check some of the presentations and photos, you can visit the webpage (https://eulisursworkshop.org/). With this successful event, EULIS is planning another workshop on PCNL this coming November (2018) in Romania.

The EULIS Workshop programme also included a three-hour Hands-on Training course using various simulators to look into the many aspects of endourologic stone surgery such as navigation by both rigid and flexible ureteroscopes, basket handling and laser use. The course was carefully supervised by mentors such as Dr. K. Ahmed (UK) who was very helpful in assisting the trainers. EULIS has developed an evidence-based programme for ureteroscopy training. Training for urolithiasis procedures should occur in a stepwise fashion, beginning with e-learning for theoretical training. This theoretical segment should, at its core, cover procedural related knowledge. Successfully passing these online modules is necessary before the trainee can proceed to the simulated hands-on training. Simulation training

Olexander Fedorowytsch Vozianov Dedicated clinician and mentor 1938 - 2018

Last May 7th I lost a dear friend, Professor Olexander F. Vozianov. He passed away in his hometown Kiev in Ukraine, and with him we lose one of the giants in urology, a committed clinician who never really retired from clinical practice. He cared deeply for his patients, his students and his profession as a whole. His commitment to urology was absolute and far reaching, and clearly not limited to his beloved home country alone. His many publications, some of which were published quite recently, support his strong desire to help shape urology and contribute to urological care worldwide. Olexander Vozianov’s publications cover basic urological research, as well as applied science, both oncology and non-oncology. He also published widely on the consequences of radiation exposure following the Chernobyl accident, demonstrating his insights into the particular challenges the medical profession face in a world dependent on nuclear energy. He authored over 600 scientific publications,

June/July 2018

colleagues. He was a mentor and a role model for his students, many of them now leading professors in Ukraine. including 55 monographs, and he held a number of patents, mostly related to the development of diagnostic and surgical innovations. Olexander was the recipient of numerous awards and honours, and he was widely recognised for his achievements, most notably in prostate and bladder cancer research, far beyond the Ukraine. Any list of his credentials will be incomplete, but to name a few: Prof. Vozianov became a full professor in 1980 and full member of the National Academy of Sciences of Ukraine in 1991. In 1993 he became a full Member of the Academy of Medical Sciences of Ukraine and received the “State Prize of Ukraine” twice (in 1983 and 2001). Olexander was awarded “Honoured Scientist of Ukraine” in 1983; received the special “Excellence Award” from the President of Ukraine in 1996 and received the Highest Ukrainian award, “Hero of Ukraine” in 2000.

He was director of the Urology Institute Academy of Medical Sciences of Ukraine from 1987 to 2011, president of the National Academy of Medical Sciences of Ukraine (1993-2011) and presided over the Ukrainian Association of Urology from 1987 to 2011. Under his leadership, the Academy of Medical Science developed into an internationally renowned scientific institution. He was the recipient of the Order of Merit “Commodore of Italian Republic” (1999), and the “American Order of Excellence” (2001). As a long-standing, prominent member of the European Association of Urology, he was awarded the EAU Honorary Membership in 2009, recognising his outstanding achievements in urology. His legacy will be remembered as he fully dedicated his life to teaching and promoting excellence in urological care, inspiring many students and

A wonderful friend known for his kindness and amazing insights, Olexander will be greatly missed. We extend our deepest sympathies and condolence to his family, many friends and colleagues. Prof. P.A. Abrahamsson Past EAU Secretary General

European Urology Today


Uropathologists to use blood (liquid) biopsy as routine tool Analysing circulating tumour cells: A powerful tool in diagnosing urothelial cancer Circulating tumour cells (CTCS) Identification and enumeration CTCs are tumour cells shed from the primary tumour or metastatic deposits into the blood. Immunomagnetic isolation is the most established method to isolate CTCs. It is based on magnetic beads attached to antibodies directed at specific cell surface antigens. The interaction of the antibody-coated magnetic beads and the CTCs separates them from the other cells. In UC, the most commonly used antigen is the epithelial r.montironi@univpm.it cell adhesion molecule (EpCAM). This is expressed by most UC cells. Once isolated, the cells are stained with Collaborating authors: A. Lopez-Beltran (Lisbon, PT); fluorophore-labelled antibodies directed against L. Cheng (Indianapolis, USA); A. Zizzi, A. Cimadamore, cytokeratin (CK), CD45, and DAPI nuclear stain. Cells A. Galosi, R. Berardi, M. Scarpelli (Ancona, IT) that are positive for EpCAM, CK, and DAPI, but negative for CD45, are considered as CTCs (Figure 2). Prof. Rodolfo Montironi Chairman, EAU Section of Uropathology (ESUP) Polytechnic University of the Marche Region Ancona (IT)

remodelling, transcription regulation, and cell differentiation. Single cell sequencing can also be used to differentiate cancer cells from normal blood cells and, at the same time, to obtain the expression profiles of tumour cells. The molecular profiles derived from single cell sequencing of CTCs can give precise information to predict recurrence and progression, elucidate new drivers of resistance and progression, as well as offering utility in directing targeted therapy. Serum circulating cell-free tumour DNA ctDNA is fragmented DNA between 180 and 200 base pairs in length, < 1.0% of the total cell-free DNA. Apoptosis is the main source. In addition, DNA may

Urothelial cancer (UC) of the urinary bladder, ureter and renal pelvis is the second most frequent malignancy in the genitourinary organs. It is the sixth most common malignancy in men. Routine screening tests for early detection of the disease have not been validated. Diagnosis of UC is generally made when disease-related symptoms appear. When UC is clinically suspected, there are no serum biomarkers to help clinicians reach a diagnosis. Invasive diagnostic approaches, including cystoscopy, are generally needed. Urinary cytology is a noninvasive technique with a high sensitivity rate for high-grade UC (84%) with a specificity rate ranging from 84% to 100%. However, it shows low sensitivity for low-grade neoplasms (i.e., 16%). Tissue biopsy is the standard diagnostic procedure. It can also provide material for genotyping, thus assisting not only in the diagnosis but also in the selection of targeted therapies. However, it falls short in those cases with inadequate sampling, in particular from heterogeneous tumours. Traditional tissue biopsy has limitations in its capability of prognosis over the course of neoplastic disease, and also with respect to tumour clonal evolution and metastasis over time from the initial biopsy1-3. Liquid biopsy (LB), based on the circulating tumour cells (CTCs) and cell-free nucleic acids (i.e., circulating tumour DNA (ctDNA), also known as cell-free tumour DNA; circulating RNA; and exosomes) from blood and urine, has received great attention because of its potential to monitor the disease status in patients with urogenital cancers, including UC (Figure 1). Genomic profiles of liquid biopsy have been shown to match very closely those of the corresponding

advanced UC and analysed the material by using a 70-gene NGS panel7. Clinically significant ctDNA was detected in 86% of the patients. Within these fragments, they detected somatic mutations in genes important for therapeutic targets, such as TP53, FGFR2/3, BRACA1/2, ARID1A, KRAS (Figure 4), and NF1, as well as copy number alterations for ERBB2. Gootenberg et al. combined the Cas13a enzyme with isothermal amplification to establish a CRISPR (clustered regularly interspaced short palindromic repeats)-based diagnostic system (called SHERLOCK system: specific high-sensitivity enzymatic reporter unlocking)8. This approach enabled the user to detect DNA or RNA with attomolar sensitivity and single-base mismatch specificity. These investigators detected low frequency/rare ctDNA mutations in cancer, in particular, single-strand ctDNA at attomolar concentrations diluted in a background of genomic DNA. The system also found single nucleotide polymorphism–containing alleles at levels as low as 0.1% of background DNA. As detection techniques continue to improve, the utility of ctDNA analysis for UC diagnosis and prognosis could be translated into routine clinical care.

Figure 2: Identification and enumeration of circulating tumour cells

Several studies have shown that the quantification of CTCs has a considerable clinical utility in UC patients, predicting progression-free survival and overall survival, including response to therapy. It is not the scope of this article to mention all such studies. As an example of these, Naoe et al. reported the detection of CTCs in almost 60% of metastatic UC. There was no detection in cases that had not metastasised4. Several subsequent small studies confirmed these findings, CTCs being detected in approximately 50% of patients with metastatic disease, and reported correlations between the number of CTCs present and prognosis, tumour stage, and the number of metastatic sites. Contrasting reports regarding the utility of the application of CTC detection and quantitation in UC

enter the bloodstream via secretion from viable tumour cells as either free DNA extruded directly from the cell, in cell-derived vesicles (exosomes), or as a result of tumour cell death through necrosis. Macrophages seem to have a role in the release of ctDNA into the circulation via phagocytosis of necrotic cells. ctDNA derives from all tumour sites, as opposed to the single site that is biopsied in a traditional tumour biopsy (Figure 3). This means that ctDNA analysis has the potential to monitor more accurately a patient’s disease burden and progression, including characterisation of intra-tumour and inter-tumour heterogeneity. ctDNA analysis can also be used to monitor tumours over time in response to targeted therapies, to monitor the development of resistance, and to detect residual disease.

"Several studies have shown that the quantification of CTCs has a considerable clinical utility in UC patients, predicting progressionfree survival and overall survival, including response to therapy." Cancer staging system: From TNM to TNMB Conventional cancer stage follows the TNM notation system, which includes T (local tumour extent), N (lymph node invasion), and M (detectable metastasis). Based on the development of new genomic technologies able to improve evaluation of risk for cancer progression and/or metastatic disease, Yang et

Figure 3. Steps in the isolation of cell tumour DNA in the blood

ctDNA workflow Plasma 55% Buffy Coat <1% (leukocytes and platelets) Eritrocytes 45%

Blood samples (10-12 mL) can be collected in EDTA tubes (processing within 2-3 hrs) or Cell stabilization tubes (transportation and storage up to 72 hrs)

Sample arrives in lab and spun to isolate the plasma (5-6 mL)

Plasma is stored at -80°C

Figure 1: Clinical significance of circulating tumour cells in urothelial carcinoma

tumours in a non-invasive manner. This article focuses on circulating tumour cells (CTCs) and cell-free nucleic acids (i.e., ctDNA, circulating RNA, and exosomes) (Table 1) from patients with UC, highlighting their current and future application in clinical practice. Table 1: Blood (Liquid) biopsy • Circulating tumour cells (CTCs) • Identification and enumeration • Molecular characterisation • Serum circulating cell-free tumour DNA • Circulating miRNA • Exosomes

EAU Section of Uropathology (ESUP)


European Urology Today

have also been observed. Guzzo et al. detected CTCs in low numbers in a small percentage (21%) of patients prior to radical cystectomy. The quantification of CTCs was not a robust predictor of extravesical or node-positive disease5. Molecular characterisation of CTCs Clinical research has moved towards the study of molecular biomarkers in isolated CTCs by using high-throughput genomic, transcriptomic, or proteomic techniques. Studies on the application of single cell sequencing in the CTCs examined the sequence information from individual cells with optimised next-generation sequencing (NGS) technologies, thus providing a higher resolution of cellular differences as well as better understanding of the function of an individual cell, in the context of its microenvironment. Yang et al. conducted single cell sequencing on 59 cells, including UC stem cells, UC non-stem cells, bladder epithelial stem cells, and bladder epithelial non-stem cells, from three patients with UC6. 21 key gene mutations were identified in UC stem cells in the following five functional pathways: cell cycle regulation, self-renewal, chromatin

Real Time-PCR Amplification and gene mutation analysis of ctDNA (See Figure 4)

ctDNA is extracted from plasma using commercial kits and system to concentrate DNA up to 3 times

Figure 3: Steps in the isolation of cell tumour DNA in the blood

Figure 4. Detection of somatic mutations (KRAS)

The major challenge for ctDNA diagnostics is to identify and track rare mutated DNA fragments from thousands of wild-type DNA copies. This difficulty can be solved either by using NGS at very high-read depths or by applying mutation-specific PCR approaches, such as Real time (allele-specific) PCR or digital PCR. NGS-based assays uses either targeted gene specific panels or larger, whole exome- or genome-based arrays, similar to NGS techniques utilised on traditional solid tumour biopsy specimens.

al. have proposed a modified staging system by adding a liquid biopsy ‘B’ to capture the prognostic and therapeutic implications gained from ctDNA evaluation: TNMB. According to the authors: “Paralleling the ‘M’ category, initial categorisation may be defined as the absence (‘B0’) or presence (‘B1’) of detectable ctDNA”3.

Circulating miRNA A number of RNA classes, including miRNA, mRNA, and long non-codingRNA (lncRNA) have been considered as potential biomarkers for UC. There are several investigations demonstrating the 12 Limited data indicates that circulating mRNA and application of serum ctDNA in patients with UC. lncRNA are promising new non-invasive Nagy et al. collected samples from patients with diagnostic biomarkers. June/July 2018

miRNAs are single stranded noncoding RNA approximately 18–24 nucleotides long. miRNAs may be detected as free circulating miRNA, bound to ribonucleoprotein complexes, or in extracellular vesicles, such as exosomes. miRNA-array and real-time PCR-based technologies are the preferred techniques to study miRNA. They inhibit the function of target mRNAs and regulate gene expression post-transcriptionally. They can influence several cell processes, such as cell cycle control, apoptosis, and proliferation. Therefore, miRNA profiling of cancers provides highly valuable clinical information.

"Analysis of exosomal mRNA for cancer diagnosis and prognosis is considered to be advantageous over the isolation of ctDNA, mainly in those patients with a limited amount of detectable ctDNA." The composition of miRNAs in the bloodstream correlates with that of the solid tumours from which they originate. Studies have shown that specific miRNAs have a major role in carcinogenesis as tumour suppressor or oncogenic molecules. They could be used as diagnostic, prognostic, or even therapeutic biomarkers in UC patients. Exosomes Exosomes, small (30-100 nm) cellular membrane vesicles, are a subset of extracellular vesicles released into the extracellular environment. They are carriers of RNAs, DNA, and proteins, and are at elevated levels in patients with cancer. Exosomes may be isolated through ultracentrifugation, visualised by transmission electron microscopy, or selected based on the presence of specific protein markers such as CD63, CD9, and CD81. They can modulate the activity of the cells with the recipient cells, i.e., the cells they fuse with. Analysis of exosomal mRNA for cancer diagnosis and prognosis

Figure 4: Detection of somatic mutations (KRAS)

is considered to be advantageous over the isolation of ctDNA, mainly in those patients with a limited amount of detectable ctDNA. Although a promising source of cancer biomarkers, the use for cancer diagnostics and prognosis of biomarkers derived from exosomes has been slow to be included into clinical practice. This is partly due to the complexity of biological samples and the lack of accurate and inexpensive isolation and detection methods. Conclusions In patients with UC, the tumours release CTCs originating from primary and/or metastatic deposits as well as ctDNA into the bloodstream. The characterisation of the former, a non-invasive approach, allows monitoring of molecular changes of UC. The latter, i.e., ctDNA, a very minor fraction of the circulating DNA, contains tumour-specific genomic sequences that are unique biomarkers. Analysis of CTCs and their ctDNA from blood is a powerful method for early diagnosis, early detection of recurrence, and prediction of response to therapy in a non-invasive way. The molecular patterns derived from CTCs and ctDNA can be complemented with those derived from RNA and exosome analyses.

Biomarkers for Diagnosis, Surveillance, and TreatmentResponse Prediction. Crit Rev Oncog. 2017;22:389-401. 3. Yang M, Forbes ME, Bitting RL, et al. Incorporating blood-based liquid biopsy information into cancer staging: time for a TNMB system? Ann Oncol. 2018;29:311-323. 4. Naoe M, Ogawa Y, Morita J, et al. Detection of circulating urothelial cancer cells in the blood using the CellSearch System. Cancer. 2007;109:1439-45. 5. Guzzo TJ, McNeil BK, Bivalacqua TJ, et al. The presence of circulating tumour cells does not predict extravesical disease in bladder cancer patients prior to radical

European Urology Focus gives you breadth and depth. We cover the entire spectrum of urology - from oncology to benign disease - and publish themed issues on hot topics. Submit your paper today: ees.elsevier.com/eufocus

cystectomy. Urol Oncol. 2012;30:44-8. 6. Yang Z, Li C, Fan Z, et al. Single-cell sequencing reveals variants in ARID1A, GPRC5A and MLL2 driving self-renewal of human bladder cancer stem cells. Eur Urol. 2017;71:8-12. 7. Nagy RJ, Agarwal N, Gupta S, et al. Circulating cell-free DNA profiling of patients with advanced urothelial carcinoma of the bladder. J Clin Oncol. 2016;34:(suppl; abstr 4528). 8. Gootenberg JS, Abudayyeh OO, Lee JW, et al. Nucleic acid detection with CRISPR-Cas13a/C2c2. Science. 2017;356:438-42.


References 1. Massari F, Di Nunno V, Comito F, et al. Circulating tumour cells in genitourinary tumours. Ther Adv Urol. 2017;10:65-77. 2. Yang Y, Miller CR, Lopez-Beltran A, et al. Liquid Biopsies in the Management of Bladder Cancer: Next-Generation


A chance to join the ...

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

2019 American Tour To date 13 American and 13 European tours have been organised and each of those proved extremely successful. Therefore the European Association of Urology (EAU) and the American Urological Association are pleased to announce the 2019 American tour! The AUA/EAU International Exchange Programme will send American faculty to Europe and European faculty to the United States. The programme aims to promote international exchange of urological medical skills, expertise and knowledge. This upcoming 2019 American Tour will provide grants which will enable 3 EAU members to travel to and attend the AUA congress in Chicago, IL (3-6 May 2019) and to participate in an extended ten days travel programme, taking them to several urology centres in the United States.

Eligibility criteria • Less than 42 years of age • Minimum academic rank of assistant professor • Letter from the departmental chairman of the applicant’s commitment to academic medicine • Membership of the EAU Information and application forms For all further information and programme application forms please visit www.uroweb.org, and select 'our partners' at the bottom of the page, AUA-EAU International Academic Exchange Programme or contact the EAU Central Office, a.terberg@uroweb.org. We look forward to receiving your application before 1 November 2018. EAU Central Office, Attn. Secretariat, P.O. Box 30016, 6803 AA Arnhem, The Netherlands

June/July 2018

European Urology Today


EMUC18: Identifying optimal management in MIBC Standard therapies still have a role despite novel strategies in managing MIBC Managing muscle invasive bladder cancer (MIBC) has undergone rapid changes in recent years with the use of genetic profiling and immunotherapies, but experts say current treatment strategies considered as standard procedures for several years now still have a place in the optimal management of aggressive bladder cancer.

He added there are still challenges that GU specialists have to contend with such as the wider use of molecular characterisation of aggressive GU disease. “The major challenge is to generate widely applicable and reproducible methods of molecular characterisation of GU malignancies, in order to promote the concept of personalised medicine in this field,” he said.

“Metastatic MIBC remains a chronic disease and novel and old therapies should all be used in the best possible way and not replace each other. In this context, it is important to acknowledge the clinical and biological diversity of this disease and seek ways of selecting patients for one or the other therapy,” said medical oncologist Aristotelis Bamias, Professor of Therapeutics Oncology at the National and Kapodistrian University of Athens and Alexandra Hospital and coordinator of the Genito-Urinary Faculty of the European Society of Medical Oncology (ESMO). Prof. Bamias, a resource speaker at the upcoming 10th European Multidisciplinary Congress on Urological Cancers (EMUC18) to be held in Amsterdam from 8 to 11 November, will speak on the topic “Metastatic MIBC: When should immunotherapy be used?” during the first day session that will examine the role of immunotherapy in genito-urinary (GU) cancers.

Register now for the early fee! Deadline: 13 August 2018 He noted that recent research studies have renewed the interest for immunotherapy as a potential management option for selected patients. “The treatment paradigm in metastatic MIBC is rapidly changing. There is no doubt that immunotherapy represents a novel, dynamic trend. On the other hand, MIBC is an excellent model for Multi-Disciplinary Team (MDT) approach. I will try to give my opinion on the role of immunotherapy in this disease in a way that will underline how important it is to adopt these developments in our MDT management of our patients,” Bamias said.

Prof. Bamias emphasised that developments in personalised medicine, however, require and can certainly benefit from effective collaborative work among basic and clinical researchers. “Progress in cancer treatment is the result of interaction between basic and clinical research. The latter is essential for drug development and emergence of novel therapies. Clinical doctors, therefore, have a central role in the conduct of properly designed studies, which currently represent the only way for a new, effective therapy to get approval for use in everyday practice,” he explained. He underscored the importance of inter-disciplinary cooperation: “The only guarantee that such studies will be possible in a timely manner is the close collaboration between urologists, oncologists but also many other disciplines which are involved in the diagnosis and management of cancer.” Synergies in MDT work Now on its 10th edition, EMUC has drawn from the collaborative efforts of ESMO, the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU), to link up

various specialists and healthcare professionals not only for a critical assessment of optimal therapies, but also to provide a consensus on controversial issues and identify potential treatment options. Prof. Bamias noted ESMO’s efforts to contribute to multidisciplinary exchanges. “First, formal MDT activities should be established, when they are not in place. Second, educational activities involving and addressed to different oncology professionals, such as EMUC, at national and international level, should be encouraged. Finally, specialised postgraduate education in GU Cancer can improve clinical practice, as underlined in an article which appeared in the 5th Issue of ESMO Perspectives.” Close interaction between the disciplines is key to bring about changes in cancer management. “Such education requires close interaction between the two disciplines. Bringing specialists together will underline the significant contributions made by the different disciplines in the optimisation of the management of our patients and will eventually increase adherence to clinical guidelines, which are

very similar between the Societies representing the two disciplines,” he said.

More information on registration and the scientific programme go to www.emuc18.org Prof. Bamias is optimistic that the various medical disciplines will find a way to benefit from the synergies of their research and clinical activities. He also said multidisciplinary teams are commonly acknowledged as the gold standard of care for patients with cancer. “This is implemented by law or national directives in many European countries. And rightly so. The management of any type of cancer cannot be, in the vast majority of cases, ideal if only one discipline is involved.” “I believe that this collaboration has improved in recent years and certainly, educational activities, such as EMUC, where the products of this fruitful collaboration are presented, represent powerful means to improve this interaction,” he added.

8-11 November 2018, Amsterdam, The Netherlands

Implementing multidisciplinary strategies in genito-urinary cancers

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


ESUI18: Critically assessing modern imaging techniques Amsterdam meeting will thresh out benefits and limits of new technologies The role and impact of new imaging technologies will take centre-stage in Amsterdam where the EAU Section of Urological Imaging (ESUI) will hold its 7th annual meeting (ESUI18), gathering specialists and expert opinion leaders for a critical assessment of the practical clinical use and anticipated effects of new techniques on current diagnostic and treatment strategies. To be held on 8 November, and preceding the 10th European Multidisciplinary Congress on Urological Cancers (EMUC18), ESUI18 will anchor its day-long Scientific Programme on the over-arching theme “Getting it right: Indications for modern urological imaging.”

Register now for the early fee! Deadline: 13 August 2018 With the emergence of precision imaging, oncourology specialists face the question as to which situations current imaging methods are most effective. Additionally, new methods of imaging require standardised reporting processes to enable physicians to deliver optimal patient care.

Prof. George Salomon, ESUI Chairman

“The 7th ESUI meeting will address these issues in detail and critically assess the role, performance and limits of emerging technologies in relation to image-guided approaches. Moreover, the meeting will provide detailed clinical knowledge regarding the application and use of these technologies,” said Salomon.

‘Must-know’ issues The meeting’s agenda is a checklist of key and ‘must know’ issues covering not only essential topics in urological imaging but also their links to other areas of 28

European Urology Today

urology. Six core topics will be taken up starting with the role of biopsies in prostate cancer, with the initial session titled “From finger-guided to imaging targeted biopsy.” Pros and cons of the PRECISION study will be discussed alongside issues such as transperineal biopsies, quality mpMRI and antibiotic prophylaxis in the setting of transrectal biopsies and sepsis.

Back to the future As finale to the compact and comprehensive programme the closing segment “Back to the future part II: A must-know session,” will present insights on the anticipated impact of emerging technologies.

A top item in this session is a lecture on multiparametric MRI for the detection and staging of bladder cancer, focusing on the development of The next session “Is innovative ultrasound sensitive enough?,” will feature four lectures which will take up VI-RADS 1.0. Which tracers are essential in PSMA PET CT is the central point in another lecture, while the the clinical implications of radiomics- C-TRUS Anna, query on whether radio-guided surgery will become micro-ultrasound, an update on elastography/ shearwave, and the features of contrast enhanced standard of care will be taken up in a follow-up ultrasound– CUDI. A follow-up session provides an exciting look into imminent technologies. Aptly titled “Back to the future part I: What to expect in the next decade?”, resource speakers will discuss issues such as whether so-called intelligent machines will be more precise in image reading compared to their human counterparts, key points regarding image-related toxicities, how to speed up MR time, and the mpUS study and its potential challenge to MRI. The halfway session will focus on mpMRI, tackling topics in reading, reporting and biopsy-related issues such as comparing PIRADS and Likert scoring, lessons from fusion biopsies, future trends in PIRADS v3.0, and the differences in MR fusion systems.

For the complete Scientific Programme visit www.esui18.org

lecture. Finally, the topics “3-D Modelling in prostate and kidney,” and “Will radiomics change MRI reading?” will round up the concluding session. Salomon said the annual ESUI meeting aims to provide a complete update to both members and participating specialists. He expressed his appreciation to the speakers, faculty and organising committee members for their thorough preparations. “Examining these issues will close the gap between preliminary experiences in selected centres, and the early and broad application of these technologies in daily practice,” he said.

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

Getting it right: Indications for modern urological imaging

Punctuating the sessions are six best abstract oral presentations with the best presentation awarded on the same day. Immediately following the abstract presentations is the session titled “What´s up with that?” a thorough examination of technologies such as dual energy analysis, fluorescence diagnostics in cystoscopy, contrast enhanced ultrasound for the kidney, and mpCystoscopy for bladder cancer. As in previous sessions, a Q&A segment will follow the lectures. June/July 2018

Technology strikes big-time in Copenhagen A showcase of best practices and new techniques at ESUT-led Live Surgery Dr. Jan-Thorsten Klein Universitätsklinikum Ulm Dept. of Urology & Pediatric Urology Ulm (DE) jan-thorsten.klein@ uniklinik-ulm.de During this year‘s Annual EAU Congress in Copenhagen, the EAU Section of Uro-technology (ESUT) in collaboration with the EAU Robotic Urology Section (ERUS) and the EAU Section of Urolithiasis (EULIS), organised a day-long live surgery session with the theme “Technology Strikes Back“. Moderators of the Live Surgery sessions at EAU18

Following the annual ESUT tradition of organising a live surgery day, more than a dozen live surgeries were presented via direct transmission from Herlev Hospital, with additional pre-recorded videos that all showed a wide range of up-to-date surgical techniques in laparoscopic and robotic prostatectomy, percutaneous and transurethral stone surgery techniques, robotic radical cystectomy, and laparoscopic and robotic kidney surgeries, just to name a few. The complex programme that involved surgeons from various countries was organised in four parts, with the educational content consisting of practical insights and some of the most cutting-edge techniques in urological surgery. The transmissions were streamed in 3D technology, with the audience in the fully booked eURO Auditorium no longer requiring the use of 3D glasses. As required by the rules for live surgeries, the surgeons consulted their patients 24 hours before the surgery and patient advocates were present at the

ureteroscopic lithotripsy by Kim Andreassen (DK) and a robotic (partial) nephrectomy by Stefan Siemer (DE) were broadcasted from Herlev. Siemer encountered a tumour thrombosis of various small venous branches during his operation, providing the possibility to comment on this special situation. Another topic that was discussed was how to do the clamping technique and the pre-operative strategy to anticipate potential problems during the surgery. Questions from the audience also included resection techniques and the option when to shift to a radical nephrectomy in the aforementioned situation. The decision on this case was left to the lead surgeon. Another robot-assisted radical prostatectomy showing the preperitoneal approach was demonstrated by Alexandre De La Taille (FR). And the pre-recorded video on Holmium enucleation of the prostate by Gunnar Wendt-Nordahl ended the first part of the session.

bipolar or alternative laser energy by Jens Rassler (DE) and Mark Cynk (GB). How to go for the adenoma with the robot was shown by Alex Mottrie (BE). A switch to the upper tract with Bjarne Kromann-Andersen (DK) demonstrating a robotassisted radical nephro-ureterectomy. How to deal with kidney tumours using simple laparoscopy but with the help of 3D vision was perfectly shown by Antonio Alcaraz who performed a laparoscopic partial nephrectomy. Two kidney stone treatments using flexi URS were demonstrated by Christian Seitz (AU) and Olivier Traxer (FR), which made clear that there is an outstanding level of experience in present-day endoscopic stone treatment. By 4 p.m. the moderators changed for the last time and the patients were prepared for the last part of this exciting session. A set of semi-live cases showed how a perfect TUR-B should be carried out with the aid of PDD, as demonstrated by Lukas Lusuardi (AT), or an NBI as shown by Bernard Malavaud (FR) for a better detection of flat papillary tumour tissue. The

Moderator explains the finer points of a procedure

by Giorgio Bozzini (IT). Switching to the lower tract, various surgical techniques showed that the type of energy source used for the treatment of BPS is of lesser influence. Laser treatment like the greenlight laser, demonstrated by Fernando Gomez Sancha (ES), or the Thulium-Laser which confirmed that this technology is one of the most frequently used energy sources nowadays, was shown by Giorgio Carmignani (IT) and Panagiotis Kallidonis (GR). Although sometimes one has to focus on the laser settings as noted by by Jean Baptiste Roche (FR). Not only light can do the job but also the power of a high-pressure water beam produced by the Aquabeam-machine will do a perfect cavity in the prostate. This was demonstrated by Thorsten Bach (DE). How to treat localised prostate cancer using mini-invasive ablative procedures was impressively displayed with the HIFU procedure by Roman Ganzer (DE). After the preparation of the patients was completed, the OR coordinator gave the go-ahead sign for the last transmissions. Two more flexi URS once again demonstrated the clear advantage of this endoscopic procedure in modern stone management as shown by Guido Kamphuis (NL) and Leye Ajayi (GB).

Session coordinators A. Breda and A. Gross facilitate direct interaction with the audience

operation theatre for every single case. In the eURO Auditorium four sets of moderators commented on the surgeries and questioned the participating surgeons for further details. The audience was also encouraged to ask questions on the various surgical techniques and the rationale of the surgical steps, including insights on the pre-operative planning and surgical strategy. To guarantee an efficient flow of the programme, two coordinators, Alberto Breda (ES) and Andreas Gross (DE) were present at the eURO Auditorium. Expert techniques The first part showed a “lightning fast“ 3D nerve-sparing laparoscopic prostatectomy performed by Jens Stolzenburg (DE), focussing on the correct layers that one has to penetrate during the nerve-sparing process. The prostatectomy was followed by a mini-percutaneous nephrolithotripsy in prone position performed by Udo Nagele (AT). Nagele demonstrated the laser effects on the stones and showed how to retrieve bigger stone fragments. To complete the first session, a flexi ureteroscopic lithotripsy by Guido Giusti (IT), a single-use

EAU Section of Uro-Technology (ESUT)

June/July 2018

technique of en-bloc resection of bladder tumours was shown as well, demonstrating the oncological surgery principles of: En bloc, no touch, early clamping.

And last but not the least, a 4K transperitoneal laparoscopic nephrectomy was conducted by J. Jepsen (DK),which showed that modern technology and surgical techniques are thriving, characterising the high standard of care in modern European surgery. Thanks to the organisers, surgeons and moderators for this wonderful, well-attended and unique 3D surgical event!

Focussing on TCC, the effect of the Thulium Laser on the upper tract urothelial cancer was illustrated

Definitely, technology has struck back in Copenhagen!

3-D High-definition screens ensure clear transmission of details in surgical procedures

Without pausing programme, the moderators changed and the new panel opened the second part of the session covering a variety of pre-recorded videos. Meanwhile, the next set of patients at the Herlev Hospital were prepared for the following cases. The pre-recorded semi-live cases included new techniques and technology showing confocal and endomicroscopical technology in upper tract tumours by Alberto Breda (ES), and a step-by-step demonstration on how to perform a robotic intracorporeal neobladder using the Wiklund technique by Peter Wiklund (SE) himself. Former ESUT chairman Jens Rassweiler (DE) demonstrated a 4K laparoscopic extraperitoneal partial nephrectomy followed by a 15-minute skin-to-stone-free prone percutaneous nephrolithotripsy by current ESUT chair Evangelos Liatsikos (GR). These live cases were completed by the tag team composed of Cesare Scoffone (IT) and Palle Osther (DK), who performed a supine ECIRS and a demonstration of the Moses Technology in Holmium Laser Stone treatment by Kurshid Ghani (US). After another change of the moderating panel, the third session begun. Semi-live videos commented by the authors clearly showed how to enucleate the prostate adenoma transurethrally using either

Interactive and dynamic, the audience participates by directly asking the surgeons and moderators

European Urology Today


Young Urologists/Residents Corner Surgery in the 3rd millennium: The future is female A new window of opportunity as prejudice on gender roles lessens Dr. Leonardo Tortolero Blanco Hospital Imed Levante Benidorm Scientific Activities Manager Spanish YUOR workgroup YUO Board Member Alicante (ES) leotor85@gmail.com Urology has historically been a male-dominated surgical specialty, and although the number of female urologists is growing worldwide, they still represent a minority particularly in leadership and academic positions. The first edition of the congress Surgery in the 3rd millennium: The future is female was held in Ospedale San Rafaelle Turro in Milan on 12-13th April 2018. Directed by Prof. Franco Gaboardi, the format of the congress included live laparoscopic, robotic and endourological surgeries performed exclusively by women. Although there is growing evidence that female urologists are being represented in all urological specialties, it is equally true that women are often under-represented in live-surgery meetings which are not focused on female or functional urology. The procedures performed during the two-day congress were outstanding and educational with special emphasis on surgical tips and tricks. The discussions also reflected a dynamic interaction with the audience. During the first day, we assisted in a 3D laparoscopic partial nephrectomy performed by Prof.

Some participating surgeons and faculty members

Dr. Maria J. Ribal and Dr. Mireia Musquera, both from Barcelona. Dr. Silvia Secco (IT) performed a RoboticAssisted Radical Prostatectomy (RALP), demonstrating the retzius-sparing technique. During the afternoon session Dr. Loredana A. Romano (IT) performed a ProACT implant for urinary incontinence after radical prostatectomy therapy, while Dr. Piera Bellinzoni of the Ospedale San Raffaelle Turro showed some tricks for percutaneous nephrolithotomy (PNL). The second featured 3D laparoscopic radical prostatectomy with bilateral pelvic lymphadenectomy performed by Dr. Virginia Varca (IT) and RALP with retzius-sparing technique performed by Dr. Karen Frances (BE).

"Directed by Prof. Franco Gaboardi, the format of the congress included live laparoscopic, robotic and endourological surgeries performed exclusively by women." Beside the surgeries we organised several talks regarding topics such as the role of women in medicine and science, which was presented by Dr. Sveva Avveduto. The only presentation performed by a male urologist was on pelvic pain and decompression surgery of the pudendal nerve, given by Prof. Tibet Erdogru (TR). Also noteworthy was the participation via Skype of well-known prostate cancer expert Dr. Stacy Loeb (USA) who gave a very interesting presentation regarding active surveillance in prostate cancer.

Speakers, moderators and participants at the congress “The Future is Female”

The atmosphere during the meetings was cordial and pleasant, and the participants shared their impressions with the surgeons and speakers during a typical Italian dinner organised at the end of the congress. In my view, this congress contradicted the prevailing gender stereotypes and opened another door of opportunity for female urologists to show their surgical skills in different areas. Besides being educational with diverse topics from a scientific point of view, this meeting provided inspiration to female medical students, young residents and urologists. The next edition in 2019 is widely anticipated and promises another exciting programme.

Congress programme

Urological volunteering in Cameroon Urologists are invited to take part in the urological campaign Dr. Luis Miguel Quintana Franco Hospital Universitario La Paz Dept. of Urology Madrid (ES) luismi. quintanafranco@ gmail.com

“The meaning of life is to find your gift. The purpose of life is to give it away”. This may be the first time you read these words from Sir William Shakespeare, but I’m sure the idea of volunteering has at one time crossed your mind. In this article, which is a departure from topics such as fusionguided biopsies or robotic procedures, I will share my experience as a volunteer in Africa. When I started my residency, a colleague introduced me to IDIWAKA, a non-profit organisation (NPO) of doctors. They collaborate with other NPOs in hospitals from north-western Cameroon, run by the Servants of Mary, a religious congregation. IDIWAKA and the Servants of Mary are doing an excellent job attending to many patients and developing different projects, both medical and educational. To date, numerous campaigns have been carried out in ophthalmology, paediatrics, thyroid surgery— all of them with great success. 30

European Urology Today

I wanted to help them out and they proposed that I develop a urological campaign. I really liked the idea, so I packed my bag to see that part of the world with my own eyes. I stayed in the Hospital Notre Dame de la Sante (Basengla, Dschang), run by the most joyful nuns I have ever met. They are supported by two local doctors and a great nursing crew. The hospital is equipped with two operating rooms, a delivery room and around 60 beds for patients. I attended to patients at the office, helped the doctors from the gynaecology campaign that was running at the time, and supported the local staff deal with urological issues they often encounter. By the end of my volunteer work, I realised two things: first is that few experiences are as enriching as this one; second, that there is still much work to be done.

Discussing procedures with the staff

"IDIWAKA and the Servants of Mary are doing an excellent job attending to many patients and developing different projects, both medical and educational." That is why with this article, I invite you to take part in this project: to develop a model for a urological campaign which is sustainable and reproducible, and with the final aim of enabling local hospitals to attend to urological cases with solvency and independence. And because you don’t need a randomised control trial to know that it can make a real difference. Operating with the support of the great nursing team at Notre Dame de la Sante June/July 2018

Young Urologists/Residents Corner Lake-side ’Ultrabalaton’ promotes prostate awareness Semmelweis University’s Urology Department joins fun race Dr. András Hüttl Semmelweis University, Urology Department Budapest (HU)

andrashuttl@ gmail.com

Lake Balaton lies in western Hungary and is the largest lake in central Europe. It is famous for it’s spectacular scenery and history and is also a popular destination among Hungarians. Every year a marathon event, called ’Ultrabalaton’ is organised around the lake, with the whopping distance of 221 kilometers. The race can be either completed alone or by teams as a relay run with a maximum number of 12 runners. The run needs to be completed in 32 hours.

The Urology Department of Semmelweis University took part in the race this year on May 12 as part of its prostate cancer awareness programme. The team included 12 enthusiastic runners of the clinic, with the chair of the department, Prof. Péter Nyirády, trained urologists, residents and nurses. The preparation for the race consisted of individual training and organised group runs in the park next to the hospital building in Budapest. The determination and the hard work that the preparation required drew the attention of the less athletic members of the hospital staff and as a result, some of them started to exercise regularly as well. The Urology Department, as one of the largest urologic oncology centres in Hungary, has an obligation to raise awareness for urologic cancers. The clinic regularly organises prostate cancer screening and promotes events that focus on prevention. The running team wore the t-shirt with the logo of the 10000 Steps Movement. This movement, organised by the National Cancer League, also exerts efforts to raise awereness for prostate cancer and highlights the need of physical activity to help reduce the risks for this disease.

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

paul.meria@ sls.aphp.fr

Robotic Urology Robotic surgery has developed in the last 25 past years and provides surgeons with high level technology. Currently, urologists are in the forefront in robotic use and many procedures they perform are robot-assisted. Nevertheless, robot-assisted surgery requires special training and excellent knowledge in technology. Nearly 1,000,000 robot-assisted procedures are performed every year worldwide, and many of these procedures have become the “gold standard”, which implies that a step back is not realistic. The third edition of this textbook updated those published in 2007 and 2013 and was edited by Hubert John and Peter Wiklund, in collaboration with a panel of worldwide experts. The first part was dedicated to general aspects of robotics, including an update of new robotic platforms. In this chapter the authors focused on technical aspects, evolutions and developments. Special anaesthesiological considerations were addressed, including the various aspects of the anaesthesiologist’s work during robot-assisted procedures. The recommendations of the EAU Robotic Section regarding education and training were also included in a special chapter. The other sections of the textbook were dedicated to technical aspects of various procedures, listed by system organ class. Kidney and adrenal surgery were presented after a consideration of anatomical aspects with the authors highlighting radical and partial nephrectomies, and the special aspects of warm ischemia. Surgical anatomy of pelvic organs was exhaustively described before the authors tackled Book reviews

June/July 2018

bladder and prostate procedures. All aspects of radical cystectomy and urinary diversion were described, followed by the technical aspects of radical prostatectomy (described in a step-by-step manner), and its technical variants. Reconstructive surgery was addressed in another section, focusing on upper and lower urinary tract procedures, such as pyeloplasty, organ prolapse, or ureteral reimplantation. The last part was dedicated to the complications of robotic procedures and their management. This exhaustive textbook highlights robotic techniques currently performed by urologists and provides the reader with a useful overview of such techniques. Some videos should be of interest. Editors ISBN e-Book Published Publisher Edition Pages Illustrations Binding Price Website

: H. John and P. Wiklund : 978-3-319-65864-3 : Available : 2018 : Springer International Publishing : Third : 580 : 18 b/w illustrations, 387 illustrations in colour : Hardcover : € 137.79 : www.springer.com

The Management of Small Renal Masses Currently, most renal tumours are detected at an early stage due to the availability of modern imaging techniques. Consequently, small masses account for the majority of the tumours, which is dramatically changing the management of such tumours. On the other hand, the natural history of renal tumours is well-known and guides practitioners in their clinical approach. Editors K. Ahmed, N. Raison, B. Challacombe, A. Mottrie and P. Dasgupta, in collaboration with worldwide experts, aimed to write a comprehensive review addressing the entire spectrum of small renal tumours. After a short description of renal physiology and anatomy, the

Out of the 579 competing teams, the Urology Clinic finished at 217th place with a time of 21 hours and 10 minutes (average pace 5:44 min/km). With each team member pushing themselves to the limit and running their best split times during the race, the clinic is proud of its runners. As primary prevention has not been the strong side of Hungarian health

care in the past, the Urology Department of Semmelweis University hopes that this event marks the start of a new era in raising awareness of prostate cancer prevention in Hungary. We are also looking forward to see the participation of both national and international urologists in our campaign next year.

The enthusiatic running team of the Semmelweis University Urology Department

authors focused on prognostic factors of small renal tumours. All pathological subtypes were described before they addressed predictive factors and mathematical models. Diagnostic modalities and renal biopsies were considered followed by a segment on active surveillance. In that chapter, the natural history of small renal tumours was described, and the role and modalities of active surveillance were examined. The subsequent chapters were dedicated to various treatments currently available. Percutaneous techniques of ablation, either radiofrequency or cryotherapy, were reviewed, focusing on patient’s selection and technical aspects. Partial nephrectomy was exhaustively described, including all common procedures. Open, laparoscopic and robot-assisted operations were also addressed and the authors also examined new developments in minimally invasive procedures such as LESS and NOTES. The succeeding chapters were dedicated to training, management of challenging situations, complications, and future developments. This textbook provides expert information on devices and represents a very useful tool for urologists involved in renal cancer management. We hope some videos can be accessed online. Editors ISBN e-Book Published Publisher Edition Pages Illustrations Binding Price Website

: K. Ahmed, N. Raison, B. Challacombe, A. Mottrie and P. Dasgupta : 978-3-319-65656-4 : Available : 2018 : Springer International Publishing : First : 178 : 23 b/w illustrations, 34 illustrations in colour : Hardcover : € 95.39 : www.springer.com

Clinical Applications of Urologic Catheters, Devices and Products The daily practice of urology requires many tools and urologists must be aware of their characteristics and functions. Most chronic genitourinary diseases are managed with various devices, some of which are intended especially for men or women. Practical information about indications, characteristics, complications of such devices are not always well known and can be unavailable. In this unique textbook, editors Diane Newman, Eric Rovner and Alan Wein collected information on external catheters, stents, devices for skin care and many others, all of them used on a daily basis.

The first chapter was dedicated to indwelling catheters. After presenting clinical indications, the authors described the characteristics of such devices, including suprapubic and urethral catheters. Tips and tricks for better use were presented in detail and placement was explained, including procedures recommended for difficult cases. Complications were addressed and their management and prevention were described. A concluding table summarised the best practical advice and a short paragraph presented information for patient’s education. Catheters for intermittent use were described in the following part, focusing on special device features and their technical use. The next section outlined penile sheaths, and external catheters collecting systems were discussed including ancillary devices. Various troubleshooting tips of male problems were presented in a special table. Most commonly used absorbent products for incontinence were also described and the authors focused on their use. Ureteral stents and nephrostomy tubes were exhaustively described in detail before the authors presented a compendium of all urologic devices. Skin care was considered in the last part, focusing on incontinence-associated skin diseases and their management. All chapters were followed by a special paragraph, describing various advices, which is intended for patient’s education. This outstanding textbook fills a lack and provides the reader with handy practical information. Urologists, whatever their interests, will find in this well-resourced work everything they need to know about urologic devices used in daily practice. Authors ISBN e-Book Published Publisher Edition Pages Illustrations Binding Price Website

: D. Newman, E. Rovner, A. Wein : 978-3-319-14820-5 : available : 2018 : Springer International Publishing : First : 242 : 11 b/w illustrations, 236 illustrations in colour : Hardcover : € 95.39 : www.springer.com European Urology Today


US researcher wins Diokno prize in urology Van Batavia’s study investigates link between brain and bladder problems By Joel Vega Dr. Jason Van Batavia, of Children’s Hospital of Philadelphia (CHOP), was selected as the Grand Prize Winner of the Diokno-Lapides Essay Contest for his breakthrough research on urodynamics and neurology. The study identified pathways in the brain associated with voiding function and dysfunction. Van Batavia received the prize at a special event during the recent American Urological Association 2018 Annual Meeting held in San Francisco. The annual award recognises, since 1984, pioneering basic, clinical or translation research in neurourology, urodynamics or voiding dysfunction and is considered one of the most prestigious urology prizes. “Dr. Van Batavia has established himself as a pioneer in the field of paediatric urology, utilising a combination of his clinical background and neurological research techniques to provide a deeper understanding into what causes urological dysfunction,” said Dr. Douglas A. Canning, chief of Urology at CHOP. Van Batavia’s research focuses on the connection between the brain and bladder function. Approximately 40% of CHOP’s urology patients report having lower urinary tract symptoms, including frequent trips to the bathroom or urine leakage during the day or night. Despite the frequency of these issues, Van Batavia said that there have not been many advancements in the field, which motivated him to conduct his research. The EUT interviewed Dr. Van Batavia on his findings and their significance. Below is an excerpt of the interview: Question: What are the key findings in your awardwinning research on urological (bladder) dysfunction, and what are the implications of these on current bladder dysfunction therapies?

Q: Since the study focused on paediatric cases, using animal models, how can the outcomes or findings be linked or translated into adult populations or with the general condition of bladder dysfunction? Our study was in animal models – the mouse – but the findings are not limited to just paediatrics. We are hoping to shed light on the central nervous system (brain and brainstem) control of voiding in physiologic conditions which should be similar in children and adults. If we can better understand how voiding/micturition is controlled normally than we can begin to understand how or why it goes awry in pathologic states of voiding dysfunction. Importantly, voiding/bladder/lower urinary tract dysfunction (there are many names in the literature, probably the best term as per the ICCS and ICS is lower urinary tract dysfunction) are not just a paediatric problem. Yes, these conditions are common in children and are estimated to account for ~40% of all paediatric urology outpatient referrals and lead to decreased quality of life, social humiliation and isolation in both children and adults. Population-based studies have shown that lower urinary tract symptoms (LUTS), including urinary urgency, frequency, and incontinence, affect 17-22% of school-aged children across different races and ethnicities. While these are high numbers, the prevalence of LUTS and LUT dysfunction is even higher in adults according to studies: >20% of adults ages 20-60, and >40% of adults over the age of 60. Furthermore, children affected with LUTS are at increased risk of developing interstitial cystitis and chronic pelvic pain as adults. Therefore these disorders can persist if not treated in childhood and also can occur later in adults. Q: In your view, what areas in bladder dysfunctions require more attention or further research compared to other topics?

We need to focus on better defining and diagnosing the conditions that underlie LUT Van Batavia: Recent advances in techniques allow for dysfunction in children. Too often, the treating targeting of specific neuronal subpopulations physician will either minimise symptoms or try whereas older technique often involved stimulation or medication(s) empirically without a thorough and ablating brain regions without this specificity. This complete evaluation of the true voiding and bowel likely accounts for the conflicting data in the literature habits. Complete evaluation including voiding/ about the role of Barrington’s nucleus and the bowel elimination diaries +/- measured voids and brainstem in voiding – whether it causes detrusor non-invasive uroflowmetry with EMG and post-void contractions and voiding or inhibits voiding. We used residual measurements can be time consuming optogenetics (a state-of-the-art neuroscience and compliance can be low, thus we need better technique) in mice to target a specific neuronal ways to ensure that patient adherence. population in Barrington’s nucleus (BN) (i.e., the pontine micturition centre) that express corticotropin- We also need better models of bladder hypertrophy releasing hormone (CRH). or bladder wall remodelling. Currently most animal models are limited by poor reproducibility and These neurons with CRH are upregulated following therefore our ability to test or evaluate potential social stress/defeat in mice and these stressed mice therapeutics to minimise or reverse bladder wall show an infrequent voiding pattern with fewer voids remodelling has also been limited. If a but larger volumes per void each day. We know that reproducible and reliable model were to be certain lower urinary tract dysfunction in children and developed then this would have tremendous adults likely have a central nervous system benefit for the field of bladder dysfunction component and the goal of our basic science research research. is to define the CNS pathways that control normal voiding. A better understanding of these pathways Q: What do you think are the main challenges in the and the specific neurons that control voiding (both field of bladder dysfunction/voiding, and do you facilitate and inhibit it) will give us insight into what anticipate research breakthroughs in the near future? may be going wrong in certain LUT dysfunction conditions. As mentioned earlier, the major challengers are the lack of reproducible models of bladder dysfunction Our research showed that stimulating these CRHin animals. Our hope is that state-of-the-art neurons in BN leads to an infrequent voiding techniques in neuroscience, molecular genetics, phenotype with longer time period between voids and bioinformatics will further our understanding and larger bladder capacities and voided volumes of bladder function and dysfunction by allowing during awake cystometry in these mice. This may lead better specificity to study of neuronal to the identification of potential targets for therapy in subpopulations. As these techniques translate to patients with LUT dysfunction in the future, although neuro-urology research, our hope is that the future we are still quite a ways away from translating these will in fact hold breakthroughs in treating bladder findings into clinical benefit. dysfunction – although we are still many years away. Q: What additional studies are needed as follow-up to this current research? What are your plans in the Q: As a urologist and research scientist, what specific coming years? issues in bladder dysfunction management should practising urologists be aware of for them to deliver We have several studies planned and started to optimal care to their patients, particularly children? further define these neurons and identify other neurons in BN that may play a role in voiding. Of first These children often get ostracised, misdiagnosed step is to perform studies of long-term stimulation of and mistreated such that morbidity is prolonged. It CRH-neurons over the course of weeks to months. is important for all practising urologists to Our hope is that this will create a model of LUT recognise that not all children with LUTS are the dysfunction that is similar to infrequent voiders and same. As much as medical treatment for other identical to that seen in mice who undergo social disease processes is personalised, treatment of LUT defeat. dysfunction must be tailored to the specific child 32

European Urology Today

From left, Dr. Michael Chancellor, Dr. Jason Van Batavia and Dr. Ananias Diokno (for whom the award is partially named)

and the specific underlying LUT condition. There are likely at least four LUT conditions that cause the majority of LUT dysfunction in children: dysfunctional voiding, overactive bladder, infrequent voiding/voiding postponement, and primary bladder neck dysfunction. All practising paediatric urologists should read the ICCS standardisation of terminology for lower urinary tract dysfunction and evaluate all children with LUTS in a systematic way. Complete evaluation is important before attempting empiric

medications. The association between bladder and bowel dysfunction has been well established and thus every child should be evaluated for bowel dysfunction (i.e., constipation or encopresis) and treated if present. The key point I would like to make is that not all LUT dysfunction is the same and thus not all LUT dysfunction treatment should be the same. We must listen to the child and family and incorporate voiding history and diaries, evaluation for bowel dysfunction, uroflowmetry and PVR results into making a specific LUT diagnosis which will guide treatment.

Fellowship Programme European Association of Urology Nurses

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 31 August 2018 • Only EAUN members can apply • Host hospitals in Belgium, Denmark, the Netherlands, Sweden, Switzerland and the United Kingdom • A great way of widening your horizon For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

European Association of Urology Nurses

June/July 2018

EAU-JUA Academic Exchange Programme 2018 Japanese tour offers a mix of medicine, science, culture and new friendships Dr. Roderick Van Den Bergh St. Antonius Ziekenhuis Nieuwegein (NL)

roodvdb@ hotmail.com

Prof. Dr. Igor Tsaur University Medical Center Mainz Dept. of Urology and Pediatric Urology Mainz (DE) igor.tsaur@ unimedizin-mainz.de From April 7 to 21 this year, we have been given the opportunity to participate in the international exchange programme between the Japanese Urological Association (JUA) and the European Association of Urology (EAU). This annual project aims to strengthen the relationships between European and Japanese urologists, to exchange knowledge, establish collaborations, get familiar with each other's culture and traditions, and to meet new friends. Young Japanese urologists also visit Europe in a similar exchange project. Other EAU exchange programmes include the Canadian and USA tour as well as the ‘Trainee Week’ in Australia. In the two weeks we spent in Japan, we have enjoyed incredible hospitality. We have countless special memories from these two weeks, having met wonderful people and visited magnificent sites. Below, we give a short overview of our time in Japan and try to give an impression of how we have enjoyed this unique country.

attended scientific lectures and journal club discussions, but also had time to discuss the career of urologists in Japan and work-life balance. In the evening, we were invited to dinner in traditional Japanese restaurants, where we were introduced to cultural and social practices, like never pouring your own glass, but to always keep your table companion’s glasses topped up. Thus, we experienced Japanese politeness and saw first-hand what the region is famous for — the different sake rice wine variants. A guided tour at an old Japanese Mansion and castle ended our tour. Luckily, the cherry-blossom season was not yet over, so we could enjoy this beautiful and festive season. We ended our stay by jogging along the beautiful Shinano River. Tokyo A ‘Shinkansen’ bullet train took us through the snowy mountains from Niigata to Tokyo for our next stop. Tokyo is a huge (13 million inhabitants), efficient, clean city with a vibrant atmosphere, that sometimes even feels European. The sound and bustle on the streets can be overwhelming. Prof. Egawa leads the urology department at Jikei University, which is located right in the heart of the city centre, close to Shimbashi Station. The department is very internationally-oriented, and is often involved in international research and exchange programmes. We were welcomed by Dr. Tanaka and Dr. Koike, and we passed by a stunning Buddhist temple near the hospital. Later in the day, we gave a short presentation on European urology and our career. In the clinic, we were shown the hospital departments and the OR where Prof. Egawa performed an outstanding laparoscopic radical prostatectomy. We had not only many interesting discussions on different surgical techniques and urology in Japan, but also on Japanese traditions and cultural life. We also enjoyed traditional Japanese

Group photo with (sitting, from left to right): Prof. Egawa, Prof. Van Poppel, Prof. Tsaur, Dr. Van Den Bergh, Prof. Fujisawa (President of JUA), Prof. Tomita, and Prof. Yasui

Drs. Iida and Etani guided us around. We also had time to sightsee and we went to the Inuyama protected site, had a special tofu dinner, and visited the Tagata Jinja ‘penis’ shrine which makes every man feel very humble. The last Yakatori dinner pushed our boundaries, as some of the least known parts of different animals were being served on the table. Kyoto Our last Shinkansen ride took us to the old imperial city of Kyoto. The city sits in a beautiful hilly and forested area. We attended the Annual JUA Meeting, held at Kyoto’s International Conference Centre. This year, the JUA Meeting was held jointly with the Annual Urological Association of Asia (UAA) Meeting. The high quality conference included a parallel English session almost all day long, while in some translation was provided. New developments in robotic urology were presented, which also noted the role of the Japanese industrial know-how. The

language barriers. The Japanese are extremely helpful and polite. They work hard and have a special honour in what they are doing. Not only an amazingly beautiful country, Japan has a thousand-year-old sophisticated culture. We hope to return soon. The authors enjoyed many high and, occasionally, ‘lower quality’ discussions between the two of them during the time in Japan. Clinical cases approach and treatment were debated on a daily basis. The EAU Young Academic Urologists Working Group on Prostate Cancer has provided an excellent basis for travelling together. We thank again everyone in Japan who were involved in the exchange programme, and the EAU for giving us this chance to represent European urologists. We hope to see our friends again, either at the EAU-JUA joint sessions during the EAU conference, in Japan, or in some other place around the world.

Niigata Having arrived at Osaka airport early in the morning and feeling tired after more than a 10-hour flight, we recovered by taking a “healthy” Western diet breakfast in a burger restaurant. A short connecting ‘Peach Air’ flight brought us to Niigata, in the northern part of Honshu, Japan’s largest island. Dr. Saito and Dr. Tasaki (and his son) picked us up from the airport and later that evening we were introduced to the urology team led by Prof. Tomita. An ECIRS (Endoscopic Combined IntraRenal Surgery) performed at Nagoya City University

Niigata University Medical & Dental Hospital has a large urology department, where oncology, kidney transplant surgery as well as paediatric urology are three main sub-specialisations. We were impressed to know that the clinical tasks included giving immune suppressive medication to renal transplant recipients by urologists themselves. Our clinical observations included the ward rounds, grand rounds, seeing outpatient clinics, and the OR, where a smooth robot-assisted radical prostatectomy was performed by Prof. Tomita. He presented us his interesting approach of TRUS-assisted identification of bladder neck during robotic procedure. We also

Tour around the hospital at Nagoya City University

June/July 2018

baths, Tokyo cuisine and nightlife, including of course karaoke and sky bars. Tokyo, with its many foreign influences, is a city that truly never sleeps. And Dr. Tanaka has been an excellent guide, bringing us to Shinto and Buddhist shrines, sightseeing spots, and shopping centres. Nagoya The next Shinkansen took us to Nagoya, Japan’s third-largest city, and known for its large-scale industries such as the Toyota car factories. Prof. Yasui and his department at Nagoya City University had organised a scientific symposium where local scientific work was presented, and where we also discussed our own research activities. We toured the ward and outpatient clinic. The OR programme included Endoscopic Combined IntraRenal Surgery for a large staghorn renal stone, MRI-TRUS-fusion guided biopsies, and an elegant extraperitoneal robotassisted radical prostatectomy. Remarkably, some of the urologists provided spinal anaesthesia to patients.

Prof. Tsaur receives the EAU-JUA exchange programme certificate from Prof. Tomita, Prof. Fujisawa, and Prof. Van Poppel

Presidents’ Dinner took place at a breathtaking location— the courtyard Daikakuji, one of the main Shinto temples. We had time to explore the gardens around the conference centre and the famous ‘Kinkaku-ji’ golden temple. Many of our new friends from Niigata, Tokyo, and Nagoya were present at the combined JUA-UAA meeting, and we had time to update them on our tour experience. Profs. Chapple, Van Poppel, and Sønksen represented the EAU executive board and gave lectures in both meetings. Prof. Fritz Schröder also gave an EAU special lecture on prostate cancer prevention and screening. It is difficult to put in words what the trip was actually like, but certainly it has been an unforgettable experience. We have experienced a warm and personal welcome in each of the cities we have visited. There is no better way to get an insiders’ view of Japan and its culture than to visit colleagues and discuss urology, life, and career. The common background in urology truly overcomes any cultural or





8-11 April


Niigata University Medical & Dental Hospital

Prof. Tomita

11-15 April


Jikei University Hospital

Prof. Egawa

15-18 April


Nagoya City University

Prof. Yasui

18-21 April


UAA / JUA meeting 2018


Figure 1 – Travel overview

Prof. Yao, IJU Editor-in-Chief with the authors

Tagata Jinja 'penis' 'shrine

European Urology Today


Apply now!

EAU Prostate Cancer Research Award 2019 For the best paper published on clinical or experimental studies in prostate cancer With the goal to encourage innovative, high-quality research in prostate cancer, the EAU has launched the EAU Prostate Cancer Research Award. Supported by the Fritz H. Schröder Foundation, an expert jury will select the best paper dealing with clinical or experimental studies in prostate cancer. The award will be handed over at the 34th Annual EAU Congress in Barcelona, 15-19 March 2019 during the Opening Ceremony.

• The paper must have been published or accepted for publication in a high-ranking international journal between 1 July 2017 and 30 June 2018, and submitted in English. • Applicants must be a member of the EAU. • The submitting author must be the first author of the paper or, by exception, the corresponding senior last author. • Applicants should only submit one paper. • Deadline for submission by e-mail is 1 November 2018.

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

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

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

How to apply Inquiries and correspondence should be addressed to the EAU Central Office, at m.smink@uroweb.org, with “EAU Prostate Cancer Research Award 2019” in the subject line of your e-mail.

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

Send your nominations today!

EAU Crystal Matula Award 2019 For a young promising European urologist The EAU Crystal Matula Award 2019 is the most prestigious prize given to a young promising European urologist aged 40 or under who has the potential to become one of the future leaders in academic European urology. The award will be presented at the Opening Ceremony of the upcoming 34th Annual EAU Congress in Barcelona from 15-19 March 2019. The list of previous awardees includes many well-known names: S. Silay (2018), C. Gratzke (2017), A. Briganti (2016), M. Rouprêt (2015), S.F. Shariat (2014), P. Boström (2013), P.J. Bastian (2012), S.G. Joniau (2011), J.W.F. Catto (2010), M.J. Ribal (2009), V. Ficarra (2008), M.S. Michel (2007), A. De La Taille (2006), M.P. Matikainen (2005), P.F.A. Mulders (2004), B. Malavaud (2003), M. Kuczyk (2002), B. Djavan (2001), A. Zlotta (2000), G. Thalmann (1999), F. Montorsi (1998), F.C. Hamdy (1996). Nomination Process National Societies can nominate a candidate by supplying the following documents: • Letter of endorsement • Motivation letter

• Complete curriculum vitae • List of publications in the below sequence: 1. Peer reviewed papers (including the impact factors of the journals) • Original articles • Reviews • Case reports 2. Book chapters or editor of books • Overview of grants received from (inter-)national institutions or from the industry • List of received Awards • The deadline for nomination is 1 November 2018. Please note that eligible candidates can also apply for this award by contacting their national urological society directly. The candidate is then expected to supply his/ her national society with a CV and the above mentioned documents, requesting a letter of endorsement. How to apply Please send your nominations to the EAU Central Office at m.smink@uroweb.org and mention “EAU Crystal Matula Award 2019” in the subject line of your e-mail.

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


European Urology Today


June/July 2018

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

• •

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

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

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

Eligibility criteria • Less than 42 years of age • Minimum academic rank of assistant professor • Letter from the departmental chairman of the applicant’s commitment to academic medicine • Membership of the EAU • Availability to travel around two weeks at the earlier mentioned time

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

Application deadline: 1 November 2018

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

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


Apply for your EAU membership online!

ESOU19 16th Meeting of the EAU Section of Oncological Urology 18-20 January 2019 Prague, Czech Republic An application has been made to the EACCME® for CME accreditation of this event

Would you like to receive all the benefits of EAU membership, but have no time for tedious paperwork?

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

June/July 2018

Register for the early fee! Deadline 1 November 2018

European Urology Today


EAU Best Papers published in Urological Literature Awards

Apply now!

To be awarded at the 34th Annual EAU Congress in Barcelona, 15-19 March 2019 The two EAU Prizes for Best Paper published in Urological Literature are tools through which the EAU encourages young and promising urological scientists to continue their work and to communicate their achievements to the European urological community. Two awards of € 5,000 each will be made available for the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers have to be published or accepted for publication between 1 July 2017 and 30 June 2018. The awards will be handed out at the 34th Annual EAU Congress in Barcelona, 15-19 March 2019. Rules and Eligibility • Eligible to apply for the EAU Best Paper published in Urological Literature are urologists, urologists-intraining or urology-related scientists. All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • The paper must be written in English (or translated into English).

• The subject of the paper must be urological or urology related. • The deadline for submission is 1 November 2018. How to apply • Please send your paper by e-mail to m.smink@uroweb.org, indicating clearly the category in the subject line: “EAU Best Paper on Clinical Research” or “EAU Best Paper on Fundamental Research”. • Include a copy of your curriculum vitae. • Supply a list of all authors who have significantly contributed (if relevant). • Mention any financial support by companies, government or health organisations. • A publisher’s letter of acceptance has to be submitted along with your paper. A review committee consisting of members of the EAU Scientific Congress Office will review all submitted papers and select the winner of the two EAU awards for Best Paper published in Urological Literature.

EAU Hans Marberger Award 2019 For the best European paper published on Minimally Invasive Surgery in Urology The EAU Hans Marberger Award will be handed out for the best European paper published on Minimally Invasive Surgery in Urology. The award, annually given since 2004, is named after Prof. Hans Marberger to honour his pioneering achievements and contributions to endourology and the development of urologic minimally invasive surgical procedures. The award will be handed over at the 34th Annual EAU Congress in Barcelona, 15-19 March 2019 during the Opening Ceremony. Rules and Eligibility • All urologists and scientists are invited to send in papers. • The topic of the paper should deal with Minimally Invasive Surgery in Urology. • The paper must have been published or accepted for publication in a European Journal between 1 July 2017 and 30 June 2018.

Apply now!

• All papers must be submitted in English. • All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • Deadline for submission is 1 November 2018. A review committee, consisting of members of the EAU Scientific Congress Office, will select the winning paper. How to apply Please send your paper to the EAU Central Office at m.smink@uroweb.org and mention “EAU Hans Marberger Award 2019” in the subject line of your e-mail.

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


European Urology Today

June/July 2018

Baltic18 features top research in and beyond the region An overview report on the meeting’s fifth edition Dr. Peteris Vaganovs Chairman of the 5th Baltic Meeting in conjunction with the EAU Riga (LV)

androgen deprivation therapy (ADT) in biochemical relapse and possibly delay progression in oligometastatic hormone-resistant PCa. Mežeckis also emphasised that careful examination, including positron emission tomography–computed tomography (PET-CT), is mandatory in detecting all subclinical lesions in the body.

peteris.vaganovs@ gmail.com

In her lecture, Dr. Ruta Austeja Lenkaityte (LT) stated that all eligible patients with intermediate to high-risk PCa should be offered external beam radiotherapy (EBRT) plus brachytherapy boost. High-dose rate brachytherapy (HDR-BT) monotherapy is effective using multiple fractions but further investigation is needed to assess the effectiveness and late toxicities of between oneand two-fraction schemes.

The 5th Baltic Meeting in conjunction with the EAU (Baltic18) took place in historic Riga, Latvia, a serendipitous event as my country will celebrate the centenary of its proclamation of independence this year. I, along with the meeting’s esteemed faculty, welcomed participants for a two-day meeting centred on the latest developments in urology and its subspecialties. Male infertility updates Baltic18 commenced with the EAU Lecture “Where are we in male infertility in 2018?” by EAU Adjunct Secretary General – Clinical Practice Prof. Jens Sønksen (DK), who stated that endocrine disruptors and the testicular dysgenesis syndrome might be a common underlying cause for infertility, cryptorchidism, hypospadias and testis cancer. Moreover, male infertility is associated with a two-fold increased risk for testis cancer: both the cancer and its treatment may adversely affect fertility. Fertility preservation for testis cancer is mandatory. Baltic expert presentations The session “Advances in imaging radiotherapy on prostate cancer” chaired by Dr. Martin Kivi (EE) and Assoc. Prof. Egils Vjaters (LV) highlighted innovative research of experts from the Baltic region.

According to Dr. Marika Kalniņa (LV), 68GA-PSMA PET/ CT imaging is superior to choline-PET and standard imaging procedures for lymph node and bone staging. However, small-sized lesions can still be missed. Nonetheless, 68Ga-PSMA PET-CT shows great promise in improving PCa care.



Dr. M. Kalnina answers questions from the panel

research and the second day of the meeting, Dr. Taavi Põdramägi (EE) was named prize winner. Recipients of the Berlin Chemie Best Poster included Ms. Kristina Stuopelyte (LT), et al. at first place with the poster “Blood-circulating androgen receptor variants as markers for progression and response to treatment in prostate cancer patients”; Mr. Arnas Bakavicius, et al. at second place for “Epigenetic markers to overcome limitations in prostate cancer diagnostics”; and at third place, Dr. Zane Pilsetniece (LT), et al. for “The influence of specific urinary incontinence type on the quality of life of incontinent women”.

Top awards Baltic18 brought together promising talent during the Young Urologists Competition, which was chaired by Dr. Teemu Murtola (FI) and Dr. Juan Luis Vásquez (DK). Four up-and-coming urologists presented their The prizes of the Karl Storz Best Poster were given to Dr. Minija Cerskute, et al. for “Laparoscopic pyeloplasty combined with flexible nephroscopy” at first place; Dr. Jack Donati-Bourne, et al. for “Prostate resection speed in TURP – how determining is this for patients and how appropriate as a measure for assessing trainees?” at second place; and Dr. Martin Kivi, et al. for “Laparoscopic left adrenalectomy. Adrenal ganglioneuroma” at third place.

Dr. Maris Mežeckis (LV) presented the benefits of CyberKnife robotic radiosurgery as a safe and effective treatment for solitary and oligometastatic prostate cancer (PCa) which can postpone the need for Popularity of the Baltic meetings increases every year

PCa state-of-the-art lecture Prof. Nicolas Mottet (FR), Chairman of the EAU Working Group on Prostate Cancer, shared an abridgment of the latest PCa updates based on recommendations in the new 2018 EAU Guidelines

during his state-of-the-lecture. Updates included offering further risk-assessment to asymptomatic men with a normal digital rectal examination (DRE) and a prostate-specific antigen (PSA) level between 2-10 ng/ mL prior to performing a prostate biopsy wherein multiparametric magnetic resonance imaging (mpMRI) is only as an option. However, for repeat biopsy following a negative one, mpMRI is strongly recommended beforehand. ESU activities The European School of Urology (ESU), together with the EAU Section of Uro-Technology (ESUT) organised the two Hands-on Training sessions ESU/ESUT Hands-on Training in laparoscopy and ESU/ESUT Hands-on training in Ureterorenoscopy for Baltic18 complemented by the ESU Course on bladder cancer which was spearheaded by ESU Chairman, Dr. Joan Palou (ES). On behalf of the rest of the Baltic18 faculty, thank you for your support and participation! Mark the 24th and 25th of May 2019 in your calendars for the 6th edition of the Baltic Meeting in picturesque Tallinn, Estonia.

EAU Secretary General, Prof. C. Chapple deliberates with faculty





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

EAU 13th South Eastern European Meeting 21-22 September 2018, Belgrade, Serbia

12 October 2018, Cluj Napoca, Romania

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

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

Call for Abstracts

Register for the early fee!

Deadline 15 July 2018

Deadline 1 August 2018

June/July 2018

25-26 May 2018 Riga, Latvia

European Urology Today


EAUN Fellowship at MSK Insights from the Department of Nursing Research Memorial Sloan Kettering Cancer Center Bente Thoft Jensen, PhD Chair of EAUN Bladder Cancer SIG Group Aarhus (DK) benjense@ skejby.rm.dk The EAUN offers every year a one to two-week fellowship to its members. With the overarching goal to foster the highest standard of urological nursing care throughout Europe, nursing research activities becomes mandatory to improve the level of evidencebased care. This year, the Aarhus University Hospital (represented by Bente Thoft Jensen) received the fellowship award and visited the Office of Nursing Research at Memorial Sloan Kettering Cancer Center (MSK) in New York from 2 to 16 April this year. For years, the Aarhus University Hospital, EAUN and MSK have been cooperating through educational initiatives, research, publications, and contributions to scientific meetings of the EAUN. The scope of this fellowship was to observe and identify possibilities to further engage in research projects between/within our institutions and the EAUN. The goal at MSK is to provide state-of-the-art cancer treatment and care. Moreover, MSK seeks to improve the lives of cancer patients through dynamic partnerships with the patients and their local care providers. Besides providing patients with the best possible cancer care, the Memorial Hospital maintains an extensive research programme that focus on basic laboratory research, and translational research that bridges discoveries made in the laboratory and those made in the clinic. European Association of Urology Nurses

To provide the best care, MSK has reinforced the focus on nursing research and the Director of Nursing Research, Dr. Margaret Barton-Burke, past chair of the ONS, has been leading the Office of Nursing Research since 2016. When Dr. Barton-Burke took office, the number of nursing research activities at MSK have grown tremendously and her research team now consists of five junior and senior researchers and administrative co-workers supported by different service departments including the Department of Clinical Research Administration and support service. A new trend is also seen with several PhD and master students from the states of New Jersey and New York affiliating with the research team.

"Clearly, we face the same kind of challenges in the clinic and organisational spheres despite the differences between our healthcare systems." The two-week programme was carefully set up in cooperation with Dr. Margaret Barton-Burke and her staff. During the planning phase, it was possible to arrange specific meetings in those clinics, which had the highest interest in potential partnership in upcoming research protocols. The actual programme was divided into two tracks; workshop with nurses and nurses leaders engaged within research in clinical practice and conditions for research on administrative and educational level at MSK. Workshop activities During the workshops, at the Rockefeller Institute, I met with the local group of CNSs and NPs from different cancer specialties and discussed the “life of nursing research” in clinical practice. Another interesting topic was how we define and differentiate between developments and research in nursing. What are the educational needs and minimum set of

institutional requirements to make a nursing research programme a success? Clearly, we face the same kind of challenges in the clinic and organisational spheres despite the differences between our healthcare systems. Among the participants in the workshops was CNS Nora Love, well-known for several outstanding lectures at the EAUN meetings, EAUN-speaker Mallory Bowker, Department of Surgery and Nurse Leader Beau Amaya, Outpatient Genitourinary Services, who welcomed further initiatives to improve evidencebased care in urology. Following the research track, I met with the group of experts facilitating sexual health in females care after major cancer surgery. My special thanks to Dr. Jeanne Carter, Head of the Female Sexual Medicine & Women’s Health programs, Gynecology Service, Department of Surgery, and Dr. Shari Goldfarb, MD, Department of Medicine. They both assisted with experiences, discussions and considerations on how we can join forces and possibly improve awareness on sexual aspects in survivorship care in females undergoing major abdominal cancer surgery. NP and PhD student Lisa Mill added to the information regarding barriers in female sexuality issues during the past 20 years, and noted how the public awareness in this field still lacks professional interest.

Director of Nursing Research, Dr. Margaret Barton-Burke and her staff

Nurse Forum at MSK April 2018

Participating in the IRB-meeting was encouraging, particularly the issues on nursing care and patient perspective, which are highly recognised and pivotal in any research protocol at MSK. Moreover, the actual numbers of nursing-based research protocols are significantly increasing along with the growing acknowledgement of the importance of our contribution to research in patient care. Finally, I lectured at the Nurse Forum at MSK to present results of earlier shared research projects. I expressed my appreciation for the continued interest and support of the Office of Nursing Research, MSK to cooperate with the EAUN and Aarhus University Hospital. Special thanks to Dr. Guido Dalbagni, Department of Surgery (MSK), Dr. Jørgen B. Jensen (AUH) and Director of Nursing Research, Dr. Margaret Barton-Burke and her staff who all have been very supportive of this “journey” in the last couples of years.

Apply now for the EAU-SUO Exchange Programme! A two-week scholarship in the USA

The European Association of Urology (EAU) and the Society of Urologic Oncology (SUO) are pleased to announce a new scholar exchange programme. The two associations may send one of their members for a two-week scholarship at a department of choice following the other association’s Annual Meeting. With the 2018 programme, the EAU provides a great opportunity for one selected European onco-urologist to attend a two-week scholarship in the USA! The Scholarship In 2018, the visit will start with attendance of the 19th Annual Meeting of the SUO, held in Phoenix AZ on 28-30 November 2018. Preferably, the applicant will have submitted an abstract to the congress to encourage scientific exchange. The departmental exchange will take place directly following the Annual Meeting.


European Urology Today

All meeting registration fees will be waived and travel and accommodation will be covered by the EAU and SUO.

Don't miss out on this unique opportunity and apply now! Deadline: 1 August 2018 Information and application forms For all further information and application forms please visit www.uroweb.org, and select 'our partners' at the bottom of the page, and select EAU-SUO. Or contact the EAU Central Office, a.terberg@uroweb.org.

June/July 2018

Using cannabis in prostate cancer patients Although popular using cannabis oil to ‘cure’ prostate cancer remains unfounded Corinne Tillier Nurse Practitioner Urology Antoni van Leeuwenhoek Hospital Amsterdam (NL)

Cannabinoid receptor type 1 (CB1) is mainly found in the brain, and also in the lungs, the reproductive organs, etc. Cannabinoid receptor type 2 (CB2) is usually located in the immune system and in the bones. THC mainly works on CB1 receptors, CBD on CB2 receptors.



c.tillier@eaun.org -

In our hospital’s daily practice we notice the popular use of cannabis oil in prostate cancer (PCa) patients. As a nursing specialist for urology, I have even met patients who are so convinced of the curative benefits of cannabis oil in treating prostate cancer that they replace standard treatment with the use of cannabis oil. These patients include those who have localized prostate cancer where active surveillance is followed, those with biochemical recurrence after treatment, and patients with metastatic PCa. I have always wondered whether cannabis oil could indeed be a cure for prostate cancer. Unfortunately, I do not see in practice the desired beneficial effect and the PSA values continue to rise. To find some answers, I did a search in scientific literature. Cannabis, a very easy plant to grow, has been used for centuries for its medicinal properties. The oldest known document about cannabis use originates from the Chinese emperor Shen Nung in 2727 B.C.. It suggested that cannabis has a neuron-protective effect. The Egyptians used cannabis to treat glaucoma and as an anti-inflammatory agent (inflammation of the eyes, fever). Cannabis was even used in obstetrics (mixed with honey) and the mixture was applied in the vagina to “cool” the uterus. In the Old Testament, there is also an account of God instructing Moses to make a holy anointing olive oil-based "Kaneh Bosm.”

It is also important that we inform the patient about the possible interactions of cannabis oil with certain regular medications such as Coumarin (this blood thinner interacts with cannabis oil, leading to an increase of the INR and a greater risk of bleeding!).


There are different types of cannabis oil available, such as CBD and THC oils with different concentrations - which makes it difficult for patients to make a choice.

In vitro studies with THC have shown that cannabinoids affect migration, angiogenesis and apoptosis (programmed cell death) of cancer cells, but each type of cancer appears to respond differently to the effect of exogenous cannabinoids. Many types of cancer cells have a higher concentration of CB1 and CB2 receptors. Use of cannabis in cancer - Pain: Cannabinoids have been used for centuries to lessen pain. Historical texts and old pharmacopoeia noted the use of cannabis for menstrual cramps, pain during childbirth, and headaches. Studies have shown that the cannabinoids have no effect on acute pain and post- operative pain. Two placebo-controlled studies with a cannabis extract showed modest benefits when using cannabinoids in addition to opioids and other adjuvant pain-killers in cancer patients with chronic pain. However, the effect of cannabinoids in chronic neuropathic pain was clearly demonstrated in 29 randomized studies. - Nausea and vomiting: An initial study in 1975 showed a beneficial effect of THC on nausea induced by chemotherapy. Subsequently, two systematic reviews showed benefits of cannabinoids in nausea and vomiting due to chemotherapy, but most studies were observational or uncontrolled.

Conclusions: • There is no proof of cannabis oil as cure for - prostate cancer; • It is important not to be prejudiced or judgmental against patients who use cannabis oil; - • Listening to the patient’s view can be helpful since the patient often confides to the nurse rather than to their physicians; • Avoid persuading patients not to use cannabis oil, but try to convince them of the need to follow a regular treatment combined with cannabis oil; and • Consider adverse interactions between cannabis oil and certain medications and inform your patient about these. References - Abrams, D.I. Integrating cannabis into clinical cancer care. Current Oncology, 23, S8-S14 (2016). - Benzi Kluger, Piera Triolo, Wallace Jones, Joseph Jankovic. The Therapeutic Potential of Cannabinoids for Movement Disorders. Mov Disord. 2015 Mar; 30(3): 313–327. - Bowles, D.W, O’Brien, C.L, Camidge D.R, Jimeno A. The intersection between cannabis and cancer in the U.S. Critical Reviews in Oncology/Hematology, 83, 1-10 (2012) - Bridgeman M.B and Abazia D. T. Medicinal Cannabis: History, Pharmacology, And Implications for the Acute Care Setting. P T. 2017 Mar; 42(3): 180–188. - De Petrocellis L. et al. Non-THC cannabinoids inhibit prostate carcinoma growth in vitro and in vivo:

pro-apoptotic effects and underlying mechanisms. Br J Pharmacol. 2013 Jan; 168(1): 79–102. Guindon, J. Hohmann, A.J. The Endocannabinoid System and Cancer.: Therapeutic Implication. British Journal of Pharmacology. 163, 14447-1463 (2011) Johnson J.R et al. Multicenter, dubbel blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety and tolerability of THC: CBD extract and THC extract in patients with intractable cancerrelated pain. J.Pain Symptom Manage 2010;39:167-79 Machado Rocha F.C. et al. Therapeutic use of Cannabis Sativa on chemotherapy-induced nausea and vomiting among cancer patients: systematic review and meta-analysis. Eur. J. Cancer Care 2008;17:431-43 Olea-Herrero N. et al. Inhibition of human tumour prostate PC-3 cell growth by cannabinoids R(+)Methanandamide and JWH-015: Involvement of CB2. British Journal of Cancer volume 101, pages 940–950 (15 September 2009) Portenoy R.K et al. Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: a randomized, placebo-controlled, graded dose trial. J. Pain 2012;13:438-49 Ramos J.A. et al. The role of cannabinoids in prostate cancer: Basic science perspective and potential clinical applications. Indian J Urol. 2012 Jan-Mar; 28(1): 9–14. Tramer M.R. et al. Cannabinoids for control of chemotherapy induced nausea and vomiting: quantitative systematic review. BMJ 2001;323:16-21

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

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


Cannabis contains more than 400 chemical components 80 of which contain cannabinoid components and 200 non-cannabinoids components. For medical purposes, cannabinoid substances such as THC (Delta-9-tertrahydrocannabinol), CBD (cannabidiol) and non-cannabinoid substances such as terpenoids and flavonoids are relevant. Medicinal cannabis must be distinguished from recreational cannabis which is used to achieve a psychotomimetic state of 'high'. Cannabis strains used for recreational purposes contain a higher THC and lower CBD ratio than cannabis for medicinal use. Usually two cannabis plants are used: cannabis sativa which has a higher THC concentration and cannabis indica which has a higher CBD concentrate. The flavonoids are known for their antioxidant and anti-inflammatory effects. The terpenoids are resins (oil) with a strong odour. In the 1990s, the endocannabinoid system (ESC) of the body was discovered by Raphael Mechoulam, an Israeli professor of medical chemistry. The endocannabinoid system, a central regulatory system, is the body's largest receptor system and is important to maintain the homeostasis of the body. Human beings produce their own cannabinoids (endocannabinoids) according to need and are not stored in the body. Like endorphins, the human body produces endocannabinoids in response to activities such as physical exercise (the high of runners might be due to endocannabinoids, not endorphins!). European Association of Urology Nurses

June/July 2018

- Pre-clinical studies (in vitro = cells in laboratory and in vivo = in mouse model) have shown the antiproliferative, anti-metastatic, anti-angiogenic and pro-apoptotic effects of cannabinoids in various malignancies (lung, glioma, thyroid, lymphoma, skin, pancreas, endometrium, breast and prostate). Even if an identified substance in vitro / in vivo appears to have a beneficial effect on a disease, it is important to realise that only one in 5,000-500,000 substances obtain a registration and becomes available to the patient (after 10-16 years of different study phases). Cannabis has never been clinically studied as a treatment for malignancy. On the Internet, patients can get a lot of information about the curative effect of cannabis oil on prostate cancer but this information extrapolate the results of pre-clinical work to possible effects in people without any factual evidence. I often see patients in the doctor's office showing me a website where it has been proven that cannabis oil can cure prostate cancer, which is obviously their own interpretation. In my view this can be a misleading message even though the website does not explicitly provide false information. The website [See figure below] shows information which is based on a study published in the British Journal of Cancer. This is correct, but the website "neglects" to mention that this is a publication of an in vitro study. The patient might not even know what an in vitro study is and is not aware that there are no studies on humans yet to prove this. A challenge for the caregiver can be that the patient is convinced that we as healthcare practitioners work together with the pharmacists, and that we do not wish to carry out clinical trials (unfortunately I hear that very often). We can hardly persuade patients that this is not true.

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- Stimulation of appetite: Cannabinoids seem to have only a modest effect in cancer patients with cachexia. More promising results were seen in studies in the population without cancer.

Becoming a member is now fast and easy! Go to www.eaun.uroweb.org and click EAUN 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 Association of Urology European Nurses Association of Urology Nurses European Urology Today


EAUN supports urology nursing in China and Hong Kong Four more collaborative training centres for exemplary nursing care opened in 2018 Paula Allchorne, MBA, Dip, RGN (UK) EAUN Chair Elect London (UK)

p.allchorne@ eaun.org The EAUN has built good links with China and Hong Kong over a number of years and this year the EAUN was invited again to collaborate with the Chinese Urological Association of Nursing (CUAN) and Urology Nurses Association of Hong Kong (UNAHK) to run five joint conferences and workshops across Hong Kong. Previous years have covered prostate cancer but this year the requested focus was on bladder cancer. Two board members Paula Allchorne (EAUN Chair Elect and Nurse representative of the Action on Bladder Cancer Charity) and Lawrence Drudge-Coates (EAUN Past Chair) were chosen as expert EAUN speakers to join an experienced CUAN and Hong Kong Team to teach on innovations and exemplary nursing care in this important area. With this aim, the EAUN, CUAN and UNAHK team jointly designed and implemented an educational programme for the urology nurses in Hong Kong, Guangzhou, Hefei, Beijing, and Tianjin over a nine-day period. China, with its geographical size, required a schedule that was intensive with short stops and long hops (journeys) to the five centres to reach the maximum number of nurses in this short timeline.

management of intravesical treatments. The EAUN lectures in Hong Kong and China (Guangzhou, Hefei, Beijing, Tianjin) , were attended by 1048 local delegates, but this year the organisers used cuttingedge technology to reach out to thousands of other nurses who were not able to make the long trips to these cities. This had a large impact, the lectures were podcasted in real time and 56,000 nurses and doctors registered online to watch it live. An amazing number, which would take most lecturers their whole career (or a lifetime) to reach, but China does have a very large population and a large number of urology nurses who are interested in education!

”… the lectures were podcasted in real time and 56,000 nurses and doctors registered online to watch it live.” Paula and Lawrence also ran four workshops (Hong Kong, Guangzhou, Hefei and Tianjin) on the safe administration of intravesical treatments, closed systems and safe handling of any spillage; these were hands-on workshops where 418 nurses attended. They also ran sessions on flexible cystoscopies, handling of the equipment, anatomy and pathology. The sessions were interactive and the delegates

Nurses on the ward in Guangzhou

Opening of Tianjin training centre

feedback was extremely positive, from the podcasts alone there were over 2,400 responses from the participants.

centres further demonstrate the strong connections between Europe, Hong Kong and China and their shared enthusiasm for high-quality education. At the opening, Paula gave five inaugural speeches at each centre on behalf of Susanne Vahr Lauridsen (Chair of the EAUN), highlighting the importance of the global work going on and, in particular, the guidelines that the EAUN have developed for Europe that are now being used internationally.

Besides the lecture tours and workshops, the EAUN/ CUAN/UNAHK collaboration is keen to develop a lasting legacy in China and Hong Kong to facilitate urology nursing and have set up a number of Nursing Education Centres throughout China. This elegant model has been producing great benefit by locally enhancing the care that patients receive. On this trip four training centres were officially opened in Beijing, Hefei, Tianjin and Guangzhou besides those opened in previous years in Hong Kong and Hangzhou. These new

Paula and Lawrence delivered state-of-the-art lectures on the UK experience regarding the diagnostic pathway and bladder cancer management, which included nurse-led diagnostic and follow-up clinics and the European Association of Urology Nurses

Interactive workshop in Tianjin being podcasted

20th International EAUN Meeting

16-18 March 2019, Barcelona

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Small group photo in Beijing

The International Journal of

Urological Nursing

- the official Journal of the BAUN International Journal of

Urological Nursing the journal of the baun

Deadline: 1 December 2018

The schedule for this work has been impressive and the impact of this collaboration reflects well on all the three societies (EAUN, CUAN & UNAHK). Importantly, it shows that the aims and aspirations of the EAUN synchronise well with other National Nursing Societies as they provide nurses with the tools, platform and framework to deliver high standards of care. The EAUN is justly proud of the fact that it produces evidence-based guidelines that are being used globally and it provides standards for training and practice, for European urological nurses, that can be a guide for other countries. The EAUN has grown into an organisation that is keen to work with other countries to nurture nursing excellence in urology to improve the care patients receive worldwide. This trip reached an incredible number of nurses in such a short time and the organisation for next year has already begun.

ISSN 1749-7701

Volume 10 • Issue 2 • July 2016

Editor Rachel Busuttil Leaver Associate Editor Jerome Marley

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The journal welcomes contributions across the whole spectrum of urological nursing skills and knowledge: • General Urology • Clinical audit • Continence care • Clinical governance • Oncology • Nurse-led services • Andrology • Reflective analysis • Stoma care • Education • Paediatric urology • Management • Men’s health • Research

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