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European Urology Today Official newsletter of the European Association of Urology

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Vol. 29 No.2 - March/May 2017

Reports of the Annual EAU Congress:

The potentials of Office Urology

New Chair Research Foundation

Souvenir Sessions, Special Sessions of the Sections, Urology beyond Europe, statistics, awards and personal experiences

EAU supports broader role and network

Prioritise prospective studies and real-world data

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Prof. H. Haas

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Prof. A. Bjartell

EAU17: Multidisciplinary links lead to synergies Opinion leaders call for a collaborative and stronger urology By Joel Vega With reports from L. Keizer, E. De Groot and T. Parkhill A forward-looking, collaborative specialty such as urology will withstand the challenges in medicine and healthcare if it remains committed to innovation, promotes evidence-based medicine and returns the focus of healthcare to patients’ needs. This was the recurring message from opinion leaders at the 32nd Annual EAU Congress in London from 24 to 28 March. The second annual EAU Congress held in the United Kingdom since 2002, London welcomed around 12,700 participants including 10,013 urologists and specialists, 365 urology nurses, and more than 2,200 exhibitors and press members. With participants coming from at least 123 countries, EAU Secretary General Prof. Chris Chapple (GB) noted the expanding reach of urology whilst acknowledging that challenges remain, such as the advance of new technologies, Europe’s ageing population, rising healthcare costs and work pressures encountered by medical professionals. “An event like the Annual Congress provides proof that we are responsive and ready to meet these challenges. This is the opportunity for us not only to learn from each other but also to identify innovative solutions and ideas,” Chapple said during the Opening Ceremony.

Core challenges As in previous years, the EAU held joint meetings with 13 international, regional and national urology associations during the Urology Beyond Europe sessions to examine common issues and share best practices in a range of topics ranging from onco-urology, stones to andrology, amongst many others. Special sessions were also held on Day 1 with the Prostate Cancer Prevention Group, the 4th European School of Oncology (ESO) Prostate Cancer Observatory and the EAU Patient Information Project. “There is a general acceptance that there is over-treatment and that the question of screening has exacerbated that,” commented Prof. Jack Cuzick (GB) at the end of the Prostate Cancer Prevention Group session. Meanwhile, the Prostate Cancer Observatory took an expanded view of developments in prostate cancer and discussed key developments such as the use of PSMA-PET, current genomic studies and the reassessment of Gleason 4 which has an impact on risk classification and clinical decision-making.

The Patient Information Project yielded insights particularly from the perspective of patients, their families and specialized nursing. “Involving patients can spark collaborations with patients in healthcare design,” said Chapple. Andrew Winterbottom (GB), representing patient advocacies “Meetings like this are vitally important since it is at and director of Fight Bladder Cancer UK Charity, these occasions that knowledge and professional links emphasized “good and speedy communication.” are developed, and at these events ideas take seed “We believe in evidence-based medicine, but we and take hold,” said guest and keynote speaker Prof. also believe in medicine-based support,” he said. Sir Bruce Keogh, NHS England’s Medical Director and Commissioner of the Commission for Health From legal battles to cutting-edge surgery Improvement (CHI) during the opening where a The start of the Scientific Programme on Day 2 opened 20-plus-member marching band gave a festive start with Plenary Session 1 with a newly introduced format to the five-day congress. titled “Sleepless Nights,” a reference to the legal pitfalls and endless worry a doctor may have when his clinical decisions are tested or questioned in legal battles. With renowned expert mitigation lawyer Bertie Leigh (GB) acting as cross-examiner, Professors Alex Bex (NL), Karim Bensalah (FR) and Vsevolod Matveev (RU) faced intense questioning with regards their surgical or medical treatment decisions on a range of renal tumour cases.

Tim O'Brien (GB) chairing Plenary session 1 with the newly introduced format "Sleepless Nights"

“A challenge for urology is to carry the quality of European urology to the developing countries,” according to Prof. Paul Abrams (GB), this year’s recipient of the Willy Gregoir Medal, the EAU’s top honour (See related articles and photo gallery on pages 6-8). New appointments were also confirmed during the General Assembly with Prof. Jens Sønksen (DK) elected as the new EAU Adjunct Secretary General for Clinical Practice and Prof. Anders Bjartell (SE) as chairman of the EAU Research Foundation (See interview on page 25).

March/May 2017

“Doctors must make records of the advice they give to patients. They are diligent in recording the results of their investigations, but when it comes to recording their advice, they write nothing. If it’s not written down, it won’t stand up in court,” said Leigh during the session which prompted, at some points during the intense grilling, laughter and applause from the well-filled auditorium. With seven Plenary Sessions spread over four days, and with daily simultaneous sessions, the breadth of key urology issues were examined such as controversial andrology issues, optimal care in bladder cancer, benign prostatic enlargement, PCa management, functional urology and current developments in stones treatment. The EAU Section Office held 10 simultaneous sessions with the EAU Section of Uro-Technology (ESUT) collaborating with the EAU Robotic Urology Section (ERUS) and the EAU Section of Urolithiasis (EULIS) to present a day-long series of Live Surgery and pre-recorded surgical procedures which demonstrated new techniques in minimally invasive surgery, image-guided operations, and technically complex manoeuvres in stone, renal and prostate treatments. Live broadcasts were transmitted from Guy’s Hospital in London to the eURO Auditorium at London ExCeL, and with direct commentary from the surgeons, the audience asked about specific surgical moves to shed insights on complications and optimal results (See related article on page 5).

London welcomed around 12,700 participants, exhibitors and press members

The EAU also gave its consensus view on testosterone therapy (TTH), Magnetic Resonance Imaging and focal therapy which preceded Plenary Session 3. Prof. Vincenzo Mirone (IT) presented the consensus on testosterone supplements and said TTH may increase the effect of PDE5 inhibitor monotherapy in men with late-onset male hypogonadism. On male fertility, he said: “TTH should not be used by hypogonadal (infertile) men who have an active wish to conceive children or undergo infertility treatment.” On MRI, Dr. Jochen Walz (FR) gave the EAU view: “It is essential that MRI is done by dedicated experts and with high-quality images.” Regarding MRI before first biopsy, Walz said there is no consensus that MRI is the gold standard, although MRI is standard for repeat biopsy. He stressed that quality, expertise and training are of crucial importance. In focal therapy, Dr. Henk Van Der Poel (NL) said: “Focal therapy of any sort appears promising but remains investigational, with uncertainties surrounding outcome definitions, follow-up and re-treatment criteria.”

"...Professors Alex Bex (NL), Karim Bensalah (FR) and Vsevolod Matveev (RU) faced intense questioning with regards their surgical or medical treatment decisions on a range of renal tumour cases" At Plenary Session 5 (PCa management), the Breaking News segment tackled reporting on adverse events in clinical trials involving sexually active men with benign prostatic hyperplasia (BPH). Experts said reporting is inaccurate and may lead to incorrect estimates of the treatment impact on sexual function. “Spontaneous adverse event reporting including sexually related AEs in clinical trials is imprecise, arbitrary and may lead to under or overestimation of the treatment impact on sexual function,’’ said Prof. Claus Roehrborn who led a study which looked into the impact of dutasteride/tamsulosin combination

therapy on sexual function domains in sexually active men with BPH. Eighteen Thematic Sessions were held on Days 3 and 4 with a wide selection of issues ranging from personalised therapy in PCa, challenging expert practices, viruses and urological infections, lymph node surgery, rare uro-genital disease, kidney transplants, paediatric urology to urinary tract reconstruction, to name a few. At Thematic Session 2 ´Expert Challenges Expert,´ open salvage prostatectomy was pitted against the robot-assisted variant with Prof. Axel Heidenreich (FR) clashing with Prof. Declan Murphy (AU), the former defending the open approach. “Radical salvage prostatectomy depends on patient selection, and functional outcomes depend on the type of radiation therapy and the surgeon´s expertise,” Heidenreich said, to which Murphy responded that ultimately it is “experience that matters and not the surgical approach.” Souvenir Session highlights Day 5 or the last day concluded with Plenary Session 7 focusing on all aspects of urinary stone disease, from epidemiology and pathogenesis to the whole range of interventions. A mix of state-of-the-art lectures, debates and case discussions examined causes of stone disease, surgical approaches, stones and cardiovascular disease, percutaneous nephrolithomy, small asymptomatic renal stones and complex cases. The Souvenir Session, meanwhile, presented some highlights and most noteworthy developments in prostate disease, urological cancers, systemic therapy in GU cancer, basic science, andrology, imaging, urolithiasis, paediatric, imaging and functional urology. Among the selected key messages are: • Prostate cancer-Early detection and screening: Prof. Chris Bangma (NL) spoke on active surveillance (AS) and detection and said that in screening the population, the window is around 55 years of age and for individual detection he recommended using the volume-based ERSPC Risk Calculator; • Prostate cancer-Localised and advanced disease: Prof. Peter Albers (DE) said that in low-risk disease, delaying treatment as long as possible is recommended while in high-risk disease, there is 87% survival with multimodal treatment; and

In the e-Posters Area in the North Hall the winners their work

• Basic science: Prof. Zoran Culig (AT) discussed key issues in personalised medicine such as targets, models, timing and patient selection. In personalised therapies, he noted the findings in anti-cytokine, radiation and anti-ERG therapies. Regarding the role of miR-373 in metastases, Culig said besides ERG inhibitors, IL-6 and miRNA AGOMIRS are being developed and multiple targets are available. European Urology Today

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EAU17: Souvenir Session Highlights in urothelial cancer Prof. Morgan Rouprêt Academic Dept of Urology of La Pitié-Salpétrière Sorbonne University Paris (FR) morgan.roupret@ aphp.fr This article provides a subjective selection of presentations on urothelial cancer which were discussed during plenary, thematic, and poster sessions at EAU17, and dealt with current discussions on bladder and upper-tract urothelial cancer. In a debate during a plenary session, the following question was asked: Do we need a follow-up in low-grade non-muscle invasive bladder cancer (NMIBC) after 12 months? Current EAU recommendations on the length of follow-up for low-grade NMIBC are mainly based on retrospective data. No randomized studies have investigated the possibility of safely reducing the frequency of follow-up cystoscopies. Mostafid advocated that no further surveillance after one year in recurrence-free low-risk NMIBC was cost-effective. In addition, he claimed that a delay in treating recurrence was not detrimental, as the risk of progression in patients with low-risk NMIBC was very low for the first one to five years.

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

High-risk NMIBC is another issue, in particular, T1 tumours. Babjuk emphasised that there was a less than 30% risk of concomitant CIS with T1 tumours. In addition, the risk of a tumour persisting after initial trans-urethral resection of the bladder (TURB) ranges between 33 and 55%, and the risk of tumour under-staging after the initial resection occurred in about 25% of cases described in the literature. Kamat made a striking parallel between disease-specific survival when predicted by MSKCC nomograms. High-grade T1 bladder cancer had the same outcome as cT3b prostate cancer, Gleason scores of 5+5, 12/12 positive cores, and PSA 75 ng/ml! Palou et al. reported on the retrospective analysis of 2,541 cases of T1G3 NMIBC that were initially treated with BCG, of which 934 underwent re-TURB. The authors analysed tumour stage at re-TUR and the risk of recurrence, progression, and cancer-specific mortality. Palou et al. found, in this contemporary series, that progression rate was 25%, which is far lower than previously reported in historical series, with a CSM rate of 13%; thus underlying the necessity, once again, that high-quality TURB should be delivered to these patients. Regarding immunotherapy and bladder cancer, Kamat reported that BCG was the first type of cancer

immunotherapy, with barely 1.2 million doses of BCG given globally and annually to manage bladder cancer. The next big development will be our ability to predict the response to BCG according to molecular markers, as published in the CYPRIT assay, where a panel of cytokines was used. There is also concern about the quality of BCG itself as it seems that the type of strain matters. Witjes mentioned that recent literature favours a stronger immune response and better recurrence-free survival with the Connaught strain. Device-assisted instillation of thermo-chemotherapy is a serious option to consider after previous failure of intravesical regimens and/or if there is a shortage of BCG. Witjes reported on a recent randomized controlled trial that included 190 patients with intermediate- or high-risk NMIBC. Their results demonstrated a recurrence-free survival rate of 81.8% after thermo-chemotherapy compared to 64.8% after BCG (p = 0.02), with progression of < 2% in both groups. In addition, urologists need to be aware of new trials that combine BCG and systemic immunotherapy in NMIBC to treat high-grade tumours or patients that are unresponsive to BCG. The molecular landscape and substratification of muscle-invasive bladdercancer (MIBC) tumours, as a predictor for a response to systemic chemotherapy, has been discussed extensively. Currently, five molecular subtypes/ classifications have been proposed, which could be too many. In comparison, there is only one molecular stratification available for breast cancer. The evolution of technology and knowledge is certainly a good thing, but we need to make a translation from bench to bedside. The Consultant Outcome Publication, from the UK National Health Service, makes it mandatory to submit surgeon-level data on radical cystectomy practices. Khadouri et al. reported on data collected over a two-year period (i.e., 2014−2016). Their central case volumes were defined as follows: low (< 30), medium (30−60), or high (> 60). The surgery case volumes were similarly grouped into low (< 8), medium (8−30), or high (> 30). The median number of radical cystectomies during the two-year period was 16 per surgeon and 31 per centre. Surprisingly, only 45% of cases were performed for MIBC. An ileal conduit was proposed for 85% of cases. More sophisticated surgical approaches (i.e., robotic/laparoscopy) were proposed in high-volume centres. The possibility of offering radical cystectomy (RC) safely in a metastatic setting has been discussed by Zaffuto et al. These authors reported that the risk of in-hospital mortality in highly-selected individuals with non-regional lymph-node metastasis with RC

was similar to that of patients with non-metastatic BCa. Based on the existing data, RC in a metastatic setting should be limited to patients with non-regional lymph-node metastasis with no distant-organ disease. Catto has extensively explained the concept of "enhanced recovery after radical cystectomy" (ERAS) and how he translated this procedure into his own practice in Sheffield. The process was detailed in the following steps: Seven preoperative (e.g., oral mechanical bowel preparation), seven peroperative (e.g., minimally invasive approach), and seven post-operative steps (e.g., nasogastric intubation). Reporting on 451 cases, he found a dramatic reduction in length of hospital stay (25 down to five days) and blood loss (1,500 down to 500 mL). The ERAS initiative, in this instance, showed that it was possible to objectively decrease perioperative morbidity in RC by re-visiting all the perioperative details. Last, but not least, several studies on upper-tract cancer have emphasised that flexible ureteroscopy plus a biopsy can increase the risk of intra-vesical recurrence. In view of these data, a study is needed that would include two arms to compare intravesical chemotherapy immediately after ureteroscopy with no instillation in order to assess their impacts on bladder recurrence.

32nd Annual EAU Congress 2

European Urology Today

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EAU17: Souvenir Session Highlights in urolithiasis and endourology Prof. Thomas Knoll Klinikum SindelfingenBöblingen Urologische Klinik Sindelfingen Sindelfingen (DE) t.knoll@klinikverbundsuedwest.de

The diagnosis and treatment of urolithiasis was one of the major topics at EAU17 and was discussed in a plenary session, five poster sessions and in several European School of Urology (ESU) courses. Treatment of stones is part of the daily routine for most urologists and account for up to a third of cases in a urological department. It is therefore disappointing that the underlying pathomechanisms are still not fully understood. I was very pleased to see an increasing number of abstracts on basic research and metabolic factors. Chung et al. demonstrated that urolithiasis is an independent risk factor for bone fractures, underlining that calcium handling is a process that cannot be evaluated (isolated) for the kidney. Wendt-Nordahl and colleagues have presented excellent EM images that showed calcium oxalate stones coated with calcium phosphate crystals. Many calcium oxalate stones form on so-called Randall plaques (composed of calcium phosphate), and this might give new insights in the formation of stones.

"I was very pleased to see an increasing number of abstracts on basic research and metabolic factors" Another exciting study came from Jiang et al. who established a lentiviral transfection in an animal model of hyperoxaluria. The transfected siRNA reduced crystallization which opens the door for a completely new therapeutic approach. The patient in pain was a topic in Tuesday’s plenary session. We are aware that many, if not most ureteral stones, may pass spontaneously; thus, we expect to have better predictive tools for correct patient selection. Leukocytosis is common, but was not associated with passage as Shah et al. have shown. In a series conducted by Darrad et al., younger patients were at higher risk for adverse effects under surveillance for asymptomatic renal calculi. URS era In this era of ureteroscopy (URS), many stones are approached without prior stenting. However, a significant portion of the stones cannot be reached. Takashi et al. described ureteral wall thickness as a predictive factor for ureteral stone impaction. Such knowledge will aid decision-making of primary URS vs. pre-stenting. The relaxation of the ureter can be improved for elective procedure by pre-medication of an alpha blocker (Koo et al.). The application of micro –URS (in fact instruments from micro-PNL) may facilitate the treatment of distal stones as shown by Caballero-Romeu. Interestingly, Stojkova et al. have removed ureteral stents one day prior the planned URS and demonstrated that 62% of the patients lost their stone and did not require the intervention.

significant, showing why these patients should be closely monitored. Shock wave can break stones only when they hit the stone surface. The mobility of the kidney and correct focusing are, therefore, key factors. Gatkin et al. have reduced the breathing movement by high-flow oxygen via a nasal probe, which led to a 30% reduction of required shock waves. Al-Dessoukey confirmed findings that slow shock-wave rates do better in breaking stones compared to faster frequencies, though there is some controversy regarding the optimal rate. Brushite stones, composed of an apatite salt formed with higher pH values, and tend to recur frequently. Several centers have described an increasing incidence of this usually rare stone composition. Skuginna et al. have shown that SWL treatment may lead to an increase of urine pH and may therefore promote brushite stone formation, a hypothesis that has been brought up as well by other groups.

EAU17 section: EAU17: Multidisciplinary links lead to synergies . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Highlights in urothelial cancer. . . . . . . . . . . . 2 Highlights in urolithiasis and endourology. . . 3 ESUT Live Surgery Session . . . . . . . . . . . . . . . 4 ESUI in London. . . . . . . . . . . . . . . . . . . . . . . . 5 Overview of prizes and awards EAU17 London. . . . . . . . . . . . . . . . . . . . . . . 6-8 EAU17 in London: A local perspective. . . . . . . 9 Giving EAU17 local and historical flavour . . . . 9

The papilla or not the papilla? The perfect percutaneous puncture is thought to access the kidney via a transpapillary access, as shown by imminent experts in percutaneous nephrolithotomy (PNL), Peter Alken and Arthur Smith. Liatsikos has demonstrated a live case of an infundibular, nearly pelvic puncture of the kidney without complications and proposes in an abstract by Kallidonis that this concept is safe as the traditional approach-- a concept that has yet to stand further evaluation. SWL vs. URS for proximal stones? SWL has been the procedure of choice for this location for decades, mainly due to retropulsion of the stone by ureteroscopic lithotripsy and the lack of flexible scopes. Drake has presented a systematic review by the EAU Guideline on this topic. The review demonstrated higher stone-free rates for URS at four weeks but no difference at three months. The overall complication rate was low but SWL had higher re-treatment rates. Finally, Zanetti et al. presented data from a huge series of URS and PNL live surgery demonstrations that were compared to routine cases, an abstract which is highly expected to

Recognising the potentials of Office Urology. . 10 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 11 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . 12-15 EBU certifies Istanbul Faculty of Medicine. . . 16 European Commission approves eUROGEN. . 16 EAU Guidelines 2017 Publications. . . . . . . . . 18 ESU section: European Urology Forum. . . . . . . . . . . . . . . 20 Highlights of the Masterclass on Lasers in urology. . . . . . . . . . . . . . . . . . . . . . . . . . . 21 ESU Course in Macedonia. . . . . . . . . . . . . . . 22 ESU Hands-on Training on Laparoscopy and Endourology . . . . . . . . . . . . . . . . . . . . . 22 ESTU: International Transplant Fellowship Programme . . . . . . . . . . . . . . . . . . . . . . . . . 24 ERUS: A paradigm shift in surgical training . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 help with ongoing ethical discussions. They have shown safety for both procedures, with slightly higher OR time and re-treatment rates for the URS live cases and no differences for the PNL procedures.

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EAU-RF: Bjartell: “Prioritise prospective studies and real-world data”. . . . . . . . . . . . 27 Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 28

The stones are rolling!

New-style ESU course debuts at ESOU17. . . . 29

32nd Annual EAU Congress

EAU Patient Information: Harnessing patients’ input. . . . . . . . . . . . . . 29 Ten questions: Jens Sønksen. . . . . . . . . . . . . 30 Obituary Jaakko Elo . . . . . . . . . . . . . . . . . . . 30

The evolution of flexible URS, mainly digitalization, has significantly improved image quality. Nowadays, it might be possible to diagnose stone composition intraoperatively, as Estrade et al. have shown with a good atlas correlating endoscopic with microscopic images. However, Dragos et al. have shown that the maneuverability of fiber optic scopes is still superior to digital scopes, proving why they should be kept in stock. The holmium laser became the other working horse in endourology. New technology allows for the modification of many parameters, such as pulse length, frequency and energy. The modulation of the pulse shape, so called Moses effect, might further improve the efficacy of laser lithotripsy, as shown by Elhilali, at least by reduction of retropulsion. Shock Wave Lithotripsy (SWL) remains important in stone treatment and is, according to guideline recommendations, even applied in anticoagulated patients. However, Schregel et al. have shown in a clinical series that the frequency of hematoma is

ESFFU: Diagnostic markers for BPO . . . . . . . 26

USANZ Trainee Week 2016 . . . . . . . . . . . . . . 31 YUO section: EUSP Clinical Visit. . . . . . . . . . . . . . . . . . . . . Surgical training at Aalst, Belgium. . . . . . . . European Urology Scholarship Programme . . . . . . . . . . . . . . . . . . . . . . . . . YOU Board Meetings in Amsterdam and London . . . . . . . . . . . . . . . . . . . . . . . . . Urowebinar for residents. . . . . . . . . . . . . . . Young Academic Urologists Meeting in London. . . . . . . . . . . . . . . . . . . . . . . . . . . YUORDay17 during EAU17 London. . . . . . . . .

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EAU-JUA Academic Exchange Programme. . . 35

Abstract submission opens 1 July 2017

www.eau18.org

EAUN section: EAUN17 in London. . . . . . . . . . . . . . . . . . . . . 38 34th World Congress of Endourology . . . . . . 39

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ESUT Live Surgery Session New techniques in percutaneous, endourological and robotic assisted procedures Dr. Jan-Thorsten Klein Universitätsklinikum Ulm Dept. of Urology & Paediatric Urology Baden Württemberg (DE) jan-thorsten.klein@ uniklinik-ulm.de On Saturday, 25 March, the eURO Auditorium at London’s ExCeL congress complex became the platform for the EAU17’s day-long Live Surgery, annually organised by the EAU Section of UroTechnology (ESUT) in collaboration with the EAU Robotic Urology Section (ERUS) and the EAU Section of Urolithiasis (EULIS). “Technology at its best,” was the slogan for the well-attended session which saw the participation of internationally renowned experts from various fields. The programme primarily featured live transmissions of surgeries from Guy`s Hospital and as pre-recorded cases, and all broadcasted in high definition, 3D quality. The ESUT experts either served as participating surgeons or moderators in the auditorium. To ensure an interactive session as in previous sessions, delegates can directly communicate or address their questions to further clarify and discuss the different aspects of the procedure. Moreover, the organisers took extra efforts to fulfil the requirements and rules of the EAU Ethics on Live Surgery events, and this was shown with the representation of 10 patient advocates observing the live surgeries at Guy´s Hospital, and who were briefed on their role in cases when they have ethical concerns regarding the surgical procedures or deviations thereof from good clinical practices. And to enable all delegates to follow the live surgeries, the session was also posted on-line. ESUT Chairman Prof. Evangelos Liatsikos (GR) opened the session by welcoming all delegates, surgeons and moderators and giving a formal briefing on the day’s schedule. In accordance with ethical standards, the cases in last year’s Live Surgery were discussed by Dr. Michael Straub (DE). His report was also made available via webcast. Minimally invasive techniques Part 1 of the session opened with a procedure done by Prof. Jens-Uwe Stolzenburg (DE) showing a nervesparing extraperitoneal radical prostatectomy, followed by Prof. Alexander Haese (DE) who demonstrated how robotic neurosafe helps intraoperative decision-making in a nerve-sparing procedure during a robotic radical prostatectomy. Lower tract urologic surgery, with focus on urothelial bladder cancer, followed with Prof. Peter Wiklund (SE) performing a robotic radical cystectomy using the DaVinci Si- System and Prof. Jens Rassweiler showing the transurethral bladder tumour resection in combination with photodynamic diagnosis (PDD) technology.

Prof. Peter Tenke (HU) and Dr. Patricia Zondervan (NL) did an excellent job in coordinating the live surgeries. Their expert moderation showed that the main goal of demonstrating the interesting and crucial surgical steps of the various procedures at the right time was fulfilled. By 12:20, Part 1 of the Live Surgery ended and the second part immediately followed. For more flexibility, the session featured pre-recorded cases in a semi-live setting with the surgeons showing and explaining the pre-recorded procedures. This format gave sufficient time to prepare the patients in the ORs that were scheduled for the succeeding surgeries. It also guaranteed that no patient was kept under narcosis for an unnecessary amount of time. Moreover, the strict time schedule was exactly followed. The first case of the pre-recorded series was presented by Dr. Alberto Breda which showed a procedure for upper tract urothelial cell carcinoma (UCC) and its treatment. To complement the procedure, a FURS on a UCC of the upper tract including narrow band imaging (NBI) was shown by Dr. Marianne Brehmer (SE) and Prof. Olivier Traxer (FR).

screen by Prof. Thorsten Bach, DE (bipolar enucleation), Dr. Cesare Scoffone, IT (50W Holmium prostate encleation) and Dr. Joerg Rassler and Dr. Jörg-Uwe Kempter, DE (plasma enucleation). Another possible use of NBI technology was clearly The modern treatment aspects of lower tract transitional cell carcinoma (TCC) following oncological stressed by Prof. Bernard Malavaud (FR) performing a pre-recorded case of NBI-assisted principles were shown by Prof. Alexander Karl (DE) resection of bladder tumour. The last case of the with an en-bloc resection of a bladder tumour with third session was a pre-recorded video of ICGHD-PDD (high definition photodynamic diagnosis). The convincing technique of bipolar enucleation of the guided laparoscopic partial nephrectomy by Prof. Francesco Porpiglia (IT). prostate was shown by Dr. Thomas Herrmann (DE). Meanwhile, Prof. Estevão Augusto Rodrigues-De Lima By mid-afternoon, moderators Dr. Thorsten Bach, (PT) showed the pre-recorded video on Dr. Ahmet Muslumanoglu (TR), Prof. Palle Osther electromagnetic-guided percutaneous puncture (DK), Ass. Prof. Athanasios Papatsoris Marousi technique. (GR), Prof. Kemal Sarica (TR) and Prof. Olivier Traxer (FR) took over to lead the fourth session which begun on time. Focussing mainly on endourologic procedures, the session featured two live sessions of retrograde intrarenal stone surgery performed by Prof. Christian Seitz (AT) and Dr. Leye Ajayi (GB).

Multiple live cases were shown in the eURO Auditorium focussing on the latest techniques in laparoscopic, endoscopic and robotic surgery

When all other previous surgeries were completed, the patients were prepared for the next live cases. Prof. Alex Mottrie (BE) showed a robotic partial nephrectomy using the newest generation of DaVinci Robots – the Xi system. The advantages of high definition (4K) monitor technique combined with 3D Systems in laparoscopy were shown by Prof. Antonio Alcaraz (ES) performing a 3D-4K laparoscopic partial nephrectomy. The second session ended with Prof. Liatsikos performing a prone percutaneous nephrolithotripsy. Once again the moderators (Prof. Erdem Canda (TR), Prof. Thomas Knoll (DE), Prof. Francesco Montorsi (IT), Ass. Prof. Andreas Skolarikos (GR) and Dr. Domenico Veneziano, IT) and the audience gave many comments and questions concerning the surgeries, which made the session very interactive.

Semi-Live content gave the surgeons the opportunity to focus on the crucial steps of their procedure

Following the first segment on lower tract surgery, the stone surgeons took over and showed the new concept of Minimally Invasive Percutaneous (MIP) technique, followed by supine Endoscopic Combined Intrarenal Surgery (ECIRS). The morning sessions were well-attended and moderators Mr. Christopher Anderson (GB), Dr. Alberto Breda (ES), Dr. Rafael Sanchez-Salas (FR),

The live event attracted a large number of delegates following the surgeries on the big screens in 3D HD Quality

The second session ended at 14:05, followed immediately by the third session, moderated by Prof. Alexander Bachmann (CH), Prof. Prokar Dasgupta (GB), Dr. Fernando Gomez Sancha (ES), Prof. Ali Serdar Gözen (DE), Prof. Péter Nyirádi (HU) and Prof. Burak Turna (TR), for another one-and-ahalf-hour of high-quality live and pre-recorded cases. The technique of robotic neobladder reconstruction was shown by Prof. John Kelly (GB), followed by a Holmium-Laser prostate enucleation. New developments such as the single-use flexible ureteroscopy for a lithotripsy were shown aside from the pre-recorded procedures. Focussing on prostate enucleation techniques, pre-recorded cases of this topic were displayed on

To cap the Live Surgery, eight more pre-recorded semi-live cases were shown covering robotic renal transplantation (Prof. Michael Stoeckle, DE), flexible URS using a digital dual channel scope (Dr. Michael Straub, DE), Holmium prostate vaporisation (Dr. Tim Larner, GB), ejaculation preserving low energy thulium enucleation of the prostate (Dr. Jean Baptiste Roche, FR), aqua-ablation (Mr. Neil Barber, GB),

Thulium prostate enucleation (Prof. Giovanni Muto, IT), the Uro-Lift procedure under local anaesthesia (Prof. Thomas McNicholas, GB) and how to remove a ureteral stent with the single-use stent removal system Isiris (Dr. Joyce Baard, NL). Just before 6 p.m. the full-day event which showed the latest developments in endourology, robotics, laparoscopy and stone surgery ended successfully as one of the major congress highlights which attracted thousands of delegates. There were no major complications after the surgeries and the patients recovered well. Thanks to the ESUT, expert moderator panels, support by industry and the local organisers at the congress venue and at Guy´s Hospital, this event showed once more the best of European surgical urology.

The surgeons had the perfect opportunity to explain their instruments and techniques live

JUA-EAU Resident Programme Japanese resident impressed by variety of topics I am a young urologist from north-eastern Japan and was selected to join the JUA-EAU Resident Programme 2017. After a two-year junior residency, I have been practising urology for five years and was certified last year by the board of the Japanese Urological Association. It was my first time to attend the annual meeting of the EAU, which was held in London. I was surprised by the variety of topics taken up during the sessions. There were abundant tips, which will help our daily practice, particulartly in surgical management. Due to the limited time, I could only wish that I could have attended all the attractive sessions. Thankfully, I was also invited to the Resident Dinner which took place on the second congress day. It was a great pleasure to meet residents, coming from across Europe, who are very reliable, ambitious and hopeful. I also joined a tourist excursion to the University of Cambridge and I was impressed by the university’s magnificent and historical environment, and with that experience I felt more respect to European researchers who devote continuous efforts to shed more light on the pages of history.

I am very grateful to the JUA and the EAU for inviting me to EAU17. I will certainly return to join another EAU congress! Dr. Shingo Kimura Iwate Prefecure Hospital of Isawa, Ichinoseki, Iwate (JP)

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ESUI in London How to get the most out of prostate cancer imaging training, including supervised reading of 3,000 mammograms, before a doctor is allowed to practise. And what about urological ultrasound and prostate? Why does prostate ultrasound fail to take off?

Ass. Prof. Georg Salomon Martini Klinik am UKE Prostate Cancer Clinic University Hospital Hamburg Eppendorf Hamburg (DE) gsalomon@uke. uni-hamburg.de “How to get the most out of prostate cancer imaging” defeated the sunny weather in London! There was high interest in the annual meeting of the EAU Section of Urological Imaging (ESUI) in cooperation with the EAU Section of Urological Research (ESUR) and the European Society of Nuclear Medicine (EANM), which attracted more than 450 participants. ESUI Chairman Dr. Jochen Walz opened the session and announced Dr. Georg Salomon from the Martini Clinic in Hamburg as the new and incoming chairman of ESUI. For the last eight years, Dr. Walz has helped ESUI achieve its goals and has to be congratulated for his significant input in ESUI and urological imaging.

Prof. Fiona Gilbert, Head of Radiology at the University of Cambridge (UK)

“Monkeys can catch the big cancers but it´s training and quality to catch the small cancers” said Prof. Fiona Gilbert, Head of Radiology at the University of Cambridge. Gilbert gave a brilliant talk on “Lessons learned in implementing national screening Afghanistan where she described 1 France programmes,” how quality is 530 Albania 9 Georgia 25 crucial in implementing an effective screening Algeria 119 Germany 648 programme can quality be 5 Argentina for breast cancer. How 75 Ghana Armenia Gilbert posed the question, 14 Greece achieved? saying that a197 Aruba in London gets exactly the 1 same Guadeloupe patient quality as in 2 Australia 103 Guatemala Aberdeen? The answer, she stressed, is quality. There1 Austria 158 Honduras 2 are 101 screening centres across14theHong UK for breast 39 Azerbaijan Kong cancer, double 83 Bahraincomplemented by (independent) 7 Hungary Belarus of mammograms. 17 Iceland 15 readings Belgium Bolivia

286 3

India Indonesia

41 46

Burma Canada Chile China Colombia Costa Rica Croatia Cyprus Czech Republic Denmark Dominican Republic Ecuador Egypt El Salvador Estonia

2 107 22 332 64 7 24 9 125 171 4 7 146 1 30

Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kosovo Kuwait Kyrgyzstan Latvia Lebanon Libya Lithuania Luxembourg

Moreover, a rigorous training has to be implemented Bosnia and Herzegovina 11 Iran 18 for a high-quality standard which a Brazil 84 requires Iraq 23 six-month years of radiological76 Bulgaria fellowship after five 57 Ireland

81 645 1 213 43 21 3 30 23 1 31 73 1 64 3

Urology Beyond Europe at a glance

Whereas the standardization in mpMRI with the PIRADS classification should be done in every patient who gets an mpMRI, the idea of a less time consuming mpMRI protocol with only a biparametric approach was presented by Prof. Peter Pinto. The use of just DWI might reduce the examination time to 15 minutes without quality loss. Nevertheless, this procedure still has to be confirmed in further studies. Prof. Jens Rassweiler thanks Jochen Walz for his excellent support, effort and dedication during the 8 years he served as chair of he EAU Section of Urological Imaging

“Monkeys can catch the big cancers: It´s training and quality to catch the small cancers,” - Prof. Gilbert The following question was raised: Why, with all the innovative ultrasound techniques, publication is low with only a handful of patients compared to the mpMRI studies with thousands of patients? Some of the major problems with innovative ultrasound like Shearwave elastography or contrast-enhanced ultrasound are: 1) The lack of widespread of the method; 2) The learning curve of the methods; and 3) The training of the urologists doing ultrasound. To resolve these challenges, extensive training in urological ultrasound for younger doctors is necessary, besides employing an “easy-to- use” ultrasound without an extensive learning curve. Like what occurred in the development of mammography, standardisation in education will be one of the ESUI’s goals. In addition, multiparametric ultrasound combining B-mode, Shearwave and CEUS could offer an easy and cost-effective option to mpMRI, and a prospective study will soon begin as mentioned by Prof. Wijkstra.

Imaging has not only changed the diagnosis of prostate cancer but also has a high impact on therapy planning and can further improve surgical techniques as discussed by Markus Graefen in his overview lecture. Vision Award This year, the ESUI Vision Award, with sponsorship from Invivo Corporation, was granted to Mahmoud Abdel-Gawad and colleagues for their study entitled “A Prospective Comparative Study of Color Doppler Ultrasound with Twinkling and Non-contrast Computerized Tomography for the Evaluation of Acute Renal Colic”. As shown in the ESUI meeting, urological imaging will increasingly occupy a crucial or important role in therapy planning, monitoring and intra-operative decision-making. Later this year, ESUI will participate at the annual EMUC event in Barcelona with a very interesting programme. Abstract submission and registration for this event on 16 November 2017 in Barcelona is open! More information: www.esui17.org

Malaysia 26 South Africa 44 Malta 9 South Korea 99 Martinique 1 Spain 542 Mexico 99 Sri Lanka 18 Moldova 10 Sudan 7 Monaco 2 Sweden 127 Montenegro 5 Switzerland 230 Morocco 68 Syria 5 Mozambique 1 Taiwan 72 Namibia 2 Tajikistan 2 New Zealand 8 Tanzania 1 Nicaragua 1 Thailand 86 Nigeria 5 The Netherlands 361 Norway 111 Trinidad and Tobago 1 Prof. Bedeir Ali-El-Dein receives the ESUI Vision Award 2017 78 Oman 9 Tunisia from Dr. Jochen Walz behalf of Dr. M. Abdel-Gawad Pakistan 115 onTurkey 243 Palestina 4 Ukraine 43 Panama 8 United Arab Emirates 72 Peru 25 United Kingdom 1176 Philippines 53 United States of America 252 Poland 208 Uruguay 1 Portugal 180 Uzbekistan 12 Qatar 10 Venezuela 2 Reunion 1 Vietnam 10 Romania 194 Yemen 1 Russia 242 Zambia 4 San Marino 1 Zimbabwe 1 Saudi Arabia 137 Total 10339 Serbia 91 Singapore 49 Slovakia 51

32nd Annual EAU Congress

32nd Annual EAU Congress Delegates per country

The red colour corresponds to the number of delegates per country (the more intense the colour, the larger the representation)

2017 EAU EAU/EAUN 2017 - Delegates perRegistrations continent

per category

Unknown EAU members Africa Asia Non EAU members Europe Residents EAU member North America Oceania / Australianon EAU member Residents

3,591 4,479 1,688 255

Total delegates EAU Congress

March/May 2017

10,013

Nurses EAUN member Nurses non EAUN member Total delegates EAUN Meeting

213 10 486 152 1797 365 7164 488

Exhibitors 2,202 Press 82

111

Total delegates EAU Congress/EAUN Meeting

10,378

Total participants

12,662

European Urology Today

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Overview of prizes and awards a EAU Willy Gregoir Medal 2017

EAU Frans Debruyne Life Time Achievement Award 2017

P. Abrams, Bristol, United Kingdom - Handed out by C.R. Chapple

P-A. Abrahamsson, Malmö, Sweden - Handed out by C.R. Chapple

EAU Crystal Matula Award 2017

EAU Hans Marberger Award 2017

C. Gratzke, Munich, Germany Supported by LABORIE - From left to right: C. Gratzke, B. Ellacot (LABORIE) and C.R. Chapple

Opening Ceremony Friday, 24 March

R. Autorino, Cleveland, United States of America Supported by KARL STORZ GMBH & CO.KG - From left to right: E. Dourver (KARL STORZ GMBH & CO.KG), R. Autorino and C.R. Chapple

EAU Innovators in Urology Award 2017

EAU Prostate Cancer Research Award 2017

R. Turner-Warwick, Exeter, United Kingdom - Handed out by C.R. Chapple

M. Shiota, Fukuoka, Japan Supported by the FRITZ H. SCHRÖDER FOUNDATION - From left to right: F.H. Schröder (FRITZ H. SCHRÖDER FOUNDATION), M. Shiota and C.R. Chapple

New EAU Honorary Members

S. Egawa, Tokyo, Japan - Handed out by C.R. Chapple

T. Hanuš, Prague, Czech Republic - Handed out by C.R. Chapple

V. Pansadoro, Rome, Italy - Handed out by C.R. Chapple

Prize for the Best Paper published on Fundamental Research in the Urological Literature

E. Solsona, Valencia, Spain - Handed out by C.R. Chapple

P. Walsh, Baltimore, United States of America - Handed out by C.R. Chapple

Prize for the Best Paper published on Clinical Research in the Urological Literature

I. Ahmad, E. Mui, L. Galbraith, R. Patel, E. Hong Tan, M. Salji, A. Rust, P. Repiscak, A. Hedley, E. Markert, C. Loveridge, L. Van Der Weyden, J. Edwards, O. Sansom, D. Adams, H. Leung (Glasgow, Cambridge, United Kingdom) For the paper: ‘‘Sleeping Beauty screen reveals Pparg activation in metastatic prostate cancer’ PNAS Early Edition (www.pnas.org/cgi/doi/10.1073/ pnas.1601571113) - Handed out by C.R. Chapple

C. Bernemann, T. Schnoeller, M. Luedeke, K. Steinestel, M. Boegemann, A. Schrader, J. Steinestel (Muenster, Ulm, Germany) For the paper: ‘‘Expression of AR-V7 in circulating tumour cells does not preclude response to next generation androgen deprivation therapy in patients with castration resistant prostate cancer’ European Urology - EURURO-6925; http://dx.doi.org/10.1016/j.eururo.2016.07.021 - Handed out by C.R. Chapple

Award Gallery Friday, 24 March Prize for the Best Scientific Paper published in European Urology

Prize for the Best Scientific Paper published on Fundamental Research in European Urology

E. Baco, E. Rud, L. Magne Eri , G. Moen, L. Vlatkovic, A. Svindland, H. Eggesbø, O. Ukimura (Oslo, Bergen, Norway; Los Angeles, United States of America) For the paper: ‘A randomized controlled trial to assess and compare the outcomes of two-core prostate biopsy guided by fused magnetic resonance and transrectal ultrasound images and traditional 12-core systematic biopsy’ European Urology, Volume 69 Issue 1, January 2016, Pages 149-156. Supported by ELSEVIER - From left to right: S. Boer Iwema (ELSEVIER), E. Baco and J. Catto

A. Ross, M. Johnson, K. Yousefi, E. Davicioni, G. Netto, L. Marchionni, H. Fedor, S. Glavaris, V. Choeurng, C. Buerki, N. Erho, L. Lam, E. Humphreys, S. Faraj, S. Bezerra, M. Han, A. Partin, B. Trock, E. Schaeffer (Baltimore, Birmingham, New York, Chicago, United States of America; Vancouver, Ottawa, Canada; São Paulo, Brazil) For the paper: ‘‘Tissue-based genomics augments post-prostatectomy risk stratification in a natural history cohort of intermediate- and high-risk men’ European Urology, Volume 69 Issue 1, January 2016, Pages 157-165. Supported by ELSEVIER - From left to right: S. Boer Iwema (ELSEVIER), A. Ross and J. Catto

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at the 32nd Annual EAU Congress Prize for the Best Scientific Paper published on Clinical Research in European Urology

Prize for the Best Scientific Paper published on Robotic Surgery in European Urology K. Ghani, D. Miller, S. Linsell, A. Brachulis, B. Lane, R. Sarle, D. Dalela, M. Menon, B. Comstock, T. Lendvay, J. Montiea, J. Peabody for the Michigan Urological Surgery Improvement Collaborative (Ann Arbor, Grand Rapids, Detroit, Seattle, United States of America) For the paper: ‘Measuring to improve: peer and crowd-sourced assessments of technical skill with robot-assisted radical prostatectomy’ European Urology, Volume 69 Issue 4, April 2016, Pages 547-550. Supported by the VATTIKUTI FOUNDATION - From left to right: M. Bhandari (VATTIKUTI FOUNDATION), K. Ghani and J. Catto

J. Weinreb, J. Barentsz, P. Choyk, F. Cornu, M. Haider, K. Macur, D. Margolis, M. Schnall, F. Shtern, C. Tempany, H. Thoeny, S. Verma (Nijmegen, The Netherlands; Bethesda, Baltimore, New York, Philadelphia , Boston, Cincinnati, United States of America; Paris, France; Toronto, Canada; Bern, Switzerland) For the paper: : ‘PI-RADS prostate imaging – reporting and data system: 2015, Version 2’ European Urology, Volume 69 Issue 1, January 2016, Pages 16-40. Supported by ELSEVIER - From left to right: S. Boer Iwema (ELSEVIER), J. Weinreb and J. Catto

First Prize for the Best Abstract (Oncology) R. Seiler, H. Ashab, N. Erho, B. Van Rhijn, B. Winters, J. Douglas, K. Van Kessel, E. Fransen Van De Putte, M. Sommerlad, Q. Wang, V. Choeurng, E. Gibb, B. Palmer-Aronsten, L. Lam, C. Buerki, E. Davicioni, G. Sjödahl, J. Kardos, K. Hoadley, S. Lerner, D. McConkey, W. Choi, W. Kim, B. Kiss, G. Thalmann, T. Todenhöfer, S. Crabb, S. North, E. Zwarthoff, J. Boormans, J. Wright, M. Dall'era, M. Van Der Heijden, P. Black (Vancouver, Albertra, Canada; Amsterdam, Rotterdam, The Netherlands; Seattle, Chapel Hill, Houston, Sacramento, United States of America; Hampshire, United Kingdom; Malmö, Sweden; Bern, Switzerland) For the abstract: ‘901: Muscle invasive bladder cancer: A single sample patient assay to predict molecular subtypes and benefit of neoadjuvant chemotherapy’ - Handed out by A. Stenzl

Second Prize for the Best Abstract (Oncology) J. Bedke, S. Flechsig, J. Hennenlotter, A. Wulf-Goldenberg, A. Jandrig, M. Schostak, M. Becker, I. Fichtner, R. Zeisig, J. Hoffmann, C. Schmees, A. Stenzl (Tuebingen, Berlin, Magdeburg, Reutlingen, Germany) For the abstract: ‘842: Impact of intratumoral heterogeneity of renal cancer on drug response and development of resistance in patient derived xenografts’ - Handed out by A. Stenzl

Award Gallery Friday, 24 March

First Prize for the Best Abstract (Non-Oncology) T. Dekkers, A. Prejbisz, L. Schultze Kool, J. Groenewoud, M. Velema, W. Spiering, S. Kołodziejczyk-Kruk, M. Arntz, J. Kadziela, J. Langenhuijsen, M. Kerstens, A. Van Den Meiracker, B. Van Den Born, F. Sweep, A. Hermus, A. Januszewicz, A. Lighthart-Naber, P. Makai, G-J. Van Der Wilt, J. Lenders, J. Deinum, SPARTACUS (Nijmegen, Utrecht, Groningen, Rotterdam, Amsterdam, The Netherlands; Warsaw, Poland) For the abstract: ‘317: Adrenal vein sampling vs. CT scan to determine treatment in primary aldosteronism: An outcome-based randomised diagnostic trial’ - Handed out by A. Stenzl

Third Prize for the Best Abstract (Oncology) N. Fossati, A. Briganti, G. Gandaglia, N. Suardi, M. Colicchia, J. Karnes, F. Haidl, D. Porres, D. Pfister, A. Heidenreich, A. Herlemann, C. Gratzke, C. Stief, A. Battaglia, W. Everaerts, S. Joniau, H. Van Poppel, A. Aksenov, D. Osmonov, K. Juenemann, A. Abreu, F. Almeida, C. Fay, I. Gill, A. Mottrie, F. Montorsi (Milan, Italy; Rochester, Phoenix, Los Angeles, United States of America; Cologne, Munich, Kiel, Germany; Leuven, Aalst, Melle, Belgium) For the abstract: ‘869: 11C-Choline versus 68ga-PSMA PET/CT scan for the detection of nodal recurrence from prostate cancer: Results from a large, multi-institutional salvage lymph node dissection series’ - Handed out by A. Stenzl

Second Prize for the Best Abstract (Non-Oncology) M. Ilg, M. Mateus, W. Stebbeds, B. Ameyaw, A. Raheem, M. Spilotros, M. Capece, A. Parnham, G. Garaffa, N. Christopher, A. Muneer, S. Cellek, D. Ralph (Chelmsford, Bedfordshire, London, United Kingdom) For the abstract: ‘1112: Development and validation of a phenotypic high-throughput, cell-based assay for anti-myofibroblast activity in Peyronie’s disease’ - Handed out by A. Stenzl

The European Urology Platinum Awards 2017

Award Gallery Sunday, 26 March

P. Albertsen, Farmington, Connecticut, United States of America (no photo available)

A. Bex, Amsterdam, The Netherlands - Handed out by J. Catto

J. N’Dow, Aberdeen, United Kingdom - Handed out by J. Catto

D. Sjoberg, New York, United States of America - Handed out by J. Catto

First Video Prize J-L. Bonnal, A. Marien, A. Rock, K. El Maadarani, C. Francois, A. Delebarre, D. Berssard, B. Mauroy, P. Gosset, T. Blaire (Lomme, Lille, France) For the video: ‘V49: Trimodal (18) F-choline-PET/mpMRI/TRUS targeted prostate biopsies: First clinical experience’ - From left to right: C. Stief, M. Emberton, J-L. Bonnal and A. Messas

Second Video Prize G. Simone, L. Misuraca, D. Hatcher, M. Ferriero, F. Minisola, G. Tuderti, S. Guaglianone, A. De Castro Abreu, M. Aron, M. Desai, I. Gill, M. Gallucci (Rome, Italy; Los Angeles, United States of America) For the video: ‘V48: Robot assisted radical nephrectomy and inferior vena cava thrombectomy: Surgical technique, perioperative and oncologic outcomes’ - From left to right: C. Stief, M. Emberton, G. Simone and A. Messas

Video Award Session Sunday, 26 March

Third Video Prize

F. Porpiglia, R. Bertolo, E. Checcucci, M. Manfredi, S. De Cillis, R. Aimar, S. Geuna, C. Fiori (Turin, Italy) For the video: ‘V47: Application of chitosan membranes on the neurovascular bundles after robot-assisted radical prostatectomy: Preliminary results of a phase II study’ - From left to right: C. Stief, M. Emberton, F. Porpiglia and A. Messas

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Overview of prizes and awards at the 32nd Annual EAU Congress ESUI Vision Award 2017

Section Awards

M. Abdel-Gawad, Al Ain, United Arab Emirates For the abstract: ‘A prospective comparative study of color Doppler ultrasound with twinkling and noncontrast computerized tomography for the evaluation of acute renal colic’ Supported by INVIVO CORPORATION - Handed out by J. Walz to B. Ali-El-Dein who accepted the prize on behalf of M. Abdel-Gawad

Saturday, 25 March ESTU - René Küss Prize 2017 Best Booth Award 2017

X. Tillou, Caen, France For the abstract: ‘De novo functional renal graft carcinomas: Are they a different entity?’ (no photo available)

Campbell Team Challenge Quiz

EUSP Best Scholar Award 2017

The winner of the Campbell Team Challenge Quiz is A.K. Czech (Kraków, Poland) - From left to right: J. Gómez Rivas, A. Czech and M. Waterschoot

F. Castiglione, Cologno Monzese, Italy For the project: ‘Stem cell and stromal vascular fraction treatment for penile tunica albuginea and urethral fibrosis: Understanding the mechanism of action’ - From left to right: M. Sedelaar, F. Castiglione, V. Mirone and S. Joniau

Steba Biotech - From left to right: B. Gaillac, C. Chapple, S. Spaniol, J. Rewcastle, S. De Lima Neto, A. Scherz

First Prize for the Best Abstract by a resident

Second Prize for the Best Abstract by a resident

D. Thurtle, G. Treece, T. Barrett, V. Gnanapragasam, Academic Urology Group (Cambridge, United Kingdom) For the abstract: ’63: Novel three-dimensional bone ‘mapping’ software can help assess progression of osseous prostate cancer metastases from routine CT’ - Handed out by S. Sarikaya

M. Haahr, C. Jensen, J. Sørensen, S. Sheikh, L. Lund (Odense, Denmark) For the abstract: ‘368: Safety and potential effect of a single intracavernous injection of autologous adipose-derived regenerative cells in patients with erectile dysfunction following radical prostatectomy: 12-month follow-up’ - Handed out by S. Sarikaya

Third Prize for the Best Abstract by a resident

Residents Day Saturday, 25 March

T. Seisen, G. Sonpavde, N. Kachroo, S. Lipsitz, J. Leow, M. Menon, P. Gild, N. Von Landenberg, M. Rouprêt, A. Kibel, M. Sun, S. Pal, J. Bellmunt, T. Choueiri, Q-D. Trinh (Boston, Birmingham, Detroit, Duarte, United States of America; Paris, France) For the abstract: ’173: Comparative effectiveness of selective adjuvant versus systematic neoadjuvant chemotherapy-based strategy for muscle-invasive urothelial carcinoma of the bladder’ - Handed out by S. Sarikaya

Resident’s Corner Awards - Awards for the two Best Scientific Papers published in European Urology by residents Y. Messai, S. Gad, M. Zaeem Noman, G. Le Teuff, S. Couve, B. Janji, S. Kammerer, N. Rioux-Leclerc, M. Hasmim, S. Ferlicot, V. Baud, A. Mejean, D. Mole, S. Richard, A. Eggermont, L. Albiges, F. Mami-Chouaib, B. Escudier, S. Chouaib (Villejuif, Rennes, Paris, Le Kremlin-Bicêtre, France; Luxembourg City, Luxembourg; Oxford, UK) For the paper: ‘Renal cell carcinoma programmed death-ligand 1, a new direct target of hypoxia-inducible factor-2 alpha, is regulated by von Hippel–Lindau gene mutation status’ (no photo available)

T. Arends, O. Nativ, M. Maffezzini, O. De Cobelli, G. Canepa, F. Verweij, B. Moskovitz, A. Van Der Heijden, J. Witjes (Nijmegen, The Netherlands; Haifa, Israel; Genoa, Milan, Italy) For the paper: ‘Results of a randomised controlled trial comparing intravesical chemohyperthermia with mitomycin c versus bacillus calmetteguérin for adjuvant treatment of patients with intermediate- and high-risk non–muscle-invasive bladder cancer’ - From left to right: J. Catto, T. Arends and S. Sarikaya

First Prize for the Best EAUN Poster Presentation

Prize for the Best EAUN Nursing Research Project

M. Schmidt, J. Midtgaard, A-M. Ragle, J. Avlastenok, J. Sønksen, P. Østergren (Copenhagen, Herlev, Denmark) For the poster: ‘Transition from hospital-based supervised exercise to unsupervised exercise in the community: Experiences from men with prostate cancer’ - Handed out by S. Terzoni

R.N. Knudsen, E. Grainger, M. Svejstrup, B. Jensen, H. Kruse Larsen, J. Bjerggaard Jensen (Aarhus, Denmark) For the project: ‘A quality assurance project: Nephrostomy catheters and bandages’ Supported by WELLSPECT HEALTHCARE - Handed out by M. Aberg Hakansson (WELLSPECT)

Second Prize for the Best EAUN Poster Presentation

Prize for the Best EAUN Nursing Research Project

D. Newman, C. O’Connor, L. Clark (Coeur D’Alene, Idaho, Milwaukee, Philadelphia, United States of America) For the poster: ‘Is re-use of intermittent urethral catheters safe and preferred? Real world data from the United States’ - Handed out by S. Terzoni

E. Van Muilekom, S. Horenblas, S. Ottenhof, J. Kieffer (Amsterdam, The Netherlands) For the project: ‘Quality of life in penile cancer patients: a survey of patient reported outcomes’ Supported by WELLSPECT HEALTHCARE - From left to right: J. Bloos, E. Offringa, who accepted the prize on behalf of E. Van Muilekom, and M. Aberg Hakansson (WELLSPECT)

Third Prize for the Best EAUN Poster Presentation J. Avlastenok, K. Rud, H. Køppen, F. Føns, P. Østergren (Herlev, Denmark) For the poster: ‘A descriptive study of experienced burden by spouses living with men undergoing androgen deprivation therapy for prostate cancer’ - Handed out by S. Terzoni to M. Schmidt who accepted the prize on behalf of J. Avlastenok

EAUN Meeting Monday, 27 March

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EAU17 in London: A local perspective Scientific Programme impresses with wide scope and in-depth discussions Mr. Veeru Kasivisvanathan NIHR Doctoral Fellow and SpR in Urology University College London (Hospital) London (GB) veeru.kasi@ucl.ac.uk From the 24 to 28 March 2017, London was the location of the 32nd Annual European Association of Urology Congress (EAU17). This was my first EAU congress in my home city, the city that I was born, grew up and studied in. In the months building up to the congress, I met this prospect with mixed feelings.

Thames in the East/Central London area. Of the many congress venues that I have been to, ExCeL is certainly one of the most pleasant. Its accessibility, size and facilities were excellent. One could spend some time in the main scientific congress rooms and quite easily pop out into the central food and drink areas for refreshment in between sessions. Some of the pre-arranged board and investigator meetings took place in a dedicated area in the South Gallery and for those wanting to organise impromptu meetings there was, as usual, the lent Meeting’s corner, open to all attendees. These arrangements provided an excellent opportunity to network and exchange ideas with colleagues and friends from all over the world. The technology hall did not disappoint and in its midst, it was easy to forget for a moment that one was still in London. As a local trainee, I am proud to say that there was a strong UK attendance and participation from trainees and consultants alike at the congress,

Part of the EAU congress experience allows one to take in the latest urological research whilst soaking up new cultures and cities which is something that I usually very much enjoy. Though thankfully one of the great things about London is that no matter how long someone has lived there, it continues to surprise with new discoveries. Having the congress in London did save me many hours spent on hotel comparison websites, Google search and booking flights! Rather than worrying about travel arrangements, being in my home city gave me a greater chance to focus on the congress itself.

UK Trainees give a strong account of themselves presenting the MIMC Study in 4,000 patients with renal colic from 71 centres.

The scientific sessions were complemented well with social media, with more than 22 million impressions and 13,700 tweets on Twitter and with the EAU summarising and providing key session highlights videos on their website throughout the conference. Social media has really become a key way of keeping in touch with what is going on in research even if you cannot attend a session or the conference (Figure 3).

and it is fantastic to see such good engagement from our urologists.

Overall, EAU17 was a fantastic experience and I look forward to seeing what Copenhagen has to offer for the 33rd Annual EAU Congress in 2018!

Key studies From a scientific point of view, we were lucky enough to have the world’s leading experts presenting their work in one place (Figure 1). We heard presentations on key studies such as PROTECT, PROMIS, the ERSPC and PLCO and were even lucky enough to hear a ‘rare’ lecture from Patrick Walsh. The unique aspect was that the clinicians involved in the studies were in the same room at the same time, and it was great to be present during the discussions among them, something that one cannot have from reading the papers. The other thing that impressed me was the vast array of sessions.

The days preceding the congress were marred with tragic events with the terrorist attack near the Parliament. In addition, the ongoing Brexit negotiations have been met with uncertainty with regards the UK’s relationship with Europe. But London stood strong in the face of adversity, with EAU17 gathering more than 12,000 delegates from over 120 countries and more than 1,200 scientific presentations! The congress itself was based at the ExCeL centre in the Docklands which is located next to the River

From a UK point-of-view, the residents represented strongly, presenting the trainee-led MIMIC Study in renal colic from the British Urology Researchers in Surgical Training (BURST) research collaborative, a multi-institutional effort in over 4,000 patients from 71 sites (Figure 2). This truly demonstrated the power of collaborative research.

The EAU Congress was full of leading experts presenting key studies

At times there are three important sessions all on the same topic running simultaneously which showed the scale and draw of the EAU Congress. This allowed everyone to participate in something that would interest them and often it was a difficult choice which sessions to go to. Special mention must go to the Live Surgery sessions coordinated locally at Guy’s Hospital Twitter featuring strongly at EAU allowing attendees to catch up on the key messages from sessions that that could not which took a lot of work to organise, but went very smoothly and were a great educational experience. attend

Giving EAU17 local and historical flavour EAU History Office examines history of urology in the British Isles By Loek Keizer Many of the biggest names in the history of British Urology echoed through the ExCeL London Congress venue, as their contributions to the field were presented and analysed from a historic perspective. Sir Henry Thompson, Sir Peter Freyer and Terrence Millin were extensively eulogised, as were more recently departed pioneers like John Blandy and John Fitzpatrick. Thanks to many contributions from historicallyminded BAUS members, the History Office’s annual thematic session during EAU17 was expanded into a three-hour “Special Session” on Saturday morning. In addition to presenting some highlights from local (insofar as the British Empire can be considered “local”) urology, the session also gave time to two contributors to this year’s gift for congress delegates: the new publication Urology Under the Swastika. Truly international While intending to serve as an overview of British urology, British history being what it is made the morning session more international than one might initially expect. The profiles of the 19th and early 20th century urological surgeons created a veritable atlas of the once global British Empire.

As war broke out in Europe in 1914, Freyer rejoined the IMS, having remained fluent in Hindustani from his earlier stretch with the service. Freyer was knighted in 1917, and in 1920, he was elected the first president of the section of urology of the Royal Society of Medicine. This cemented his reputation as “the first leader of British Urology”. Freyer passed away in 1921, and was buried in Clifden, Ireland. Mr. Dinneen showed a picture of Freyer’s gravestone, which is due to be restored in 2021 for the centenary of his death. Freyer’s was just one of the biographies presented at the session, which had serious international connections with several of the profiled urologists being born on the Indian subcontinent, serving within the Empire or, in the case of Thompson, treating 19th century global high society. Britain and European Refugees The second part of the session focused on the publication Urology Under the Swastika, the end of a “seventeen-year process” for its editors Prof. Dirk

Mr. Michael Dinneen (GB) presented a detailed biography of Sir Peter Freyer (1851-1921), beginning with his childhood and education in Ireland shortly after the Great Famine. Freyer signed up for the Indian Medical Service (IMS), serving in India for many years before joining the staff at St. Peter’s Hospital for the Stone in London in 1897. He pioneered The EAU History Office, together with BAUS prepared an his eponymous technique for total enucleation of the exhibition on British Urology, including some rare items like prostate, popularising its implementation. the Cruise Endoscope and the Millin Resectoscope

Schultheiss (DE) and Dr. Friedrich Moll (DE). Schultheiss gave an introduction to the topic, as well as an overview of the book’s major findings. He introduced one of its contributors, medical historian Prof. Paul Weindling (GB), who proceeded to explain the role Britain had in accepting medical professionals (including urologists) who escaped the emergence of National Socialism on the continent. Between 1930 and 1945, 6,000 medical professionals (of which 4,258 were physicians) entered the United Kingdom, the largest single group coming from Poland. Other sizeable groups were Germans, Austrians (including Sigmund Freud and his family and staff in 1938) and Czechoslovakians. Many entered Britain as a first step to emigrating to the United States or beyond, but several “concessionary schemes” were introduced to re-qualify physicians, nurses and dentists. These immigrants were able to find employment after the establishment of the National Health Service shortly after the Second World War, as there was a demand for qualified specialists.

Prof. Weindling, medical historian specialised in the Third Reich spoke about the fate of Jewish urologists and their journey from continental Europe to Britain

Dr. Friedrich Moll (Cologne, DE) took a critical look at the historiography surrounding Albarrán, identifying three distinct groups who contributed to his current reputation as “medical genius” (as the Fernández Arias biography refers to him as): disciples, contemporary colleagues and officials of professional societies. An examination of the various necrologies and biologies throughout the ages revealed that: “the culture of remembrance and commemoration and our collective memory cannot be free from values and is guided by our own interests. The basis often will not be questioned.”

Posters and other activities In addition to the three-hour special session, the History Office offered (aspiring) historians a chance to present their research in a poster session. Presentations Dr. Luis Fariña-Pérez (Vigo, ES) examined newly unearthed correspondence between Albarrán and the were divided more or less equally between Spanishlanguage topics and those on British urological history. contemporary Spanish Prime Minister Maura. Two talks on Joaquin Albarrán (1860-1912) represented Latin America’s contribution to the poster session. Partly as a result of the EAU’s own 2014 publication of an English translation of Albarrán’s most recent and comprehensive biography by Dr. Marlene Fernández Arias.

In addition to the scientific sessions, the History Office together with BAUS curated an exhibition of unique instruments and objects of historical significance, and it presented two new books: the aforementioned Urology Under the Swastika and the 24th volume of De Historia Urologiae Europaeae.

32nd Annual EAU Congress March/May 2017

European Urology Today

9


Recognising the potentials of Office Urology EAU supports broader role and network for European office urologists Prof. Dr. Helmut Haas Chair ESUO Heppenheim (DE)

hf.haas-hp@ t-online.de One in six out-patients with urologic disease require a more specialised care than what general practitioners can offer. These patients have needs that are best managed by office urologists, an area in urology that has exhibited growth and potential over the years. A more direct contact with a specialised doctor obviously has more benefits for urology patients who prefer the accessibility of office urologists. Office urology deserves proper acknowledgement and support since it offers services that are distinct from clinical or hospital-based urology. Unlike general practitioners (GPs), office urologists have acquired specific skills and insights on many urological conditions. The crucial factor for office urologists to consider in managing these patients is the extent of the patient’s disease, since disease extent and progression obviously require specialised hospital equipment and multidisciplinary care. Moreover, after diagnostics they have to decide if the patient needs further treatment in their office, or should be sent back to the GP with a letter of recommendation.

that office urology will not fall out or be excluded from mainstream urology (Read Sidebar Story “Office Urology in Germany”). Office Urology in Europe Our knowledge of office urology in Europe is based on two surveys conducted by the European Board of Urology (EBU) Manpower Committee published in 20001 and 20072. Aside from these surveys, there is no recent literature and the Committee has terminated its work some months ago. In 2000, the more detailed survey described noteworthy numbers (> 20%) of office urologists (office-only) in France (75%), Germany (72%), Austria (40%), Greece (33%), Hungary (28.5%) and Czech Republic (22%). In these countries office urology has to be regarded as a direct consequence of medical professional developments specific to that country. Estimates of around 10% and lower were recorded in Poland (11%), Portugal (11%), Italy (10%), Finland (10%), Norway (8.5%), Sweden (8%), Croatia (6%), and Spain (5%).

Online-based training of office urologists Since office urologists often work on their own and do not have substitutes in case of absence compared to the urologists working for hospitals and other healthcare institutions, many office urologists do not have the opportunity to join congresses and CME-accredited meetings that require significant leave time from their duties. It can prove to be very difficult for them to attend meetings, particularly those that are organised for several days.

In 2007, the EBU survey described the practice of office urology in Lithuania, Bulgaria, Romania and Estonia. The same report also noted that in Switzerland, Greece, Lithuania, United Kingdom, Netherlands, Bulgaria, Even in Germany where office urology has deeper roots, it has been mistakenly perceived as a “step child” Georgia, Romania, Turkey and Czech Republic, national societies planned to encourage or develop office urology. in the urological family, a misconception that fails to 3 recognise office urology’s distinct role and potentials. 3 Despite staying in the side lines, there is an estimated Number of office urologists (abs.) Number of office urologists (abs.) in countries with a proportion of > 20% in countries with a proportion of > 20% 6,000 office urologists in Europe, and although often or more than 100 office urologists (It). or more than 100 office urologists (It). Estimation from ..(Year: (Year:1998) 1998) Estimation from seen as a niche discipline, office urology is ‘well and Austria 149 Austria 149 France 750 France 750 alive’ in the region. Germany 2404 1)

1)

Germany

Majority of office urologists are concentrated in Central Europe with countries such as Germany and France accounting for the biggest numbers. Austria, Greece, Hungary, Czech Republic, and Switzerland represent smaller, but substantial numbers of office urologists. Positioned between GPs and urological surgery departments, office urology has taken over specific urological tasks which do not require in-patient treatment, enabling the office urologist, when needed, to work closely with Urology Departments and provide value-added healthcare to patients with urological conditions. Office urologists can respond, for instance, to a patient’s preference to be treated near or at home. In some cases the care plan by office urologists could deliver a cost-effective and patient-centred level of care even in ‘surgical’ cases such as when initiating investigations and management at an earlier stage and before referral to a hospital-cased colleague [Kiely, EBU Manpower Survey,2000).

Greece Greece Hungary Hungary Czech Czech Republic Republic Italy Italy others others

2404 231 231 100 100 7373 190 190 447 447 4154 4154

digitale-europakarte.de digitale-europakarte.de

Central Europe is the “home” (red)(red) of office Central Europe is the “home” of office urology urology

These figures figures were and thethe number of office urologists in Germany, These wererecorded recorded18 18years yearsago, ago, and number of office urologists in Germany, for example, has increased (3,054 including 650 more office urologists). The same trend for example, has increased (3,054 including 650 more office urologists). The same trend could be expected in other countries, particularly those which in 1998 reported the could be expected in other countries, particularly those which in 1998 reported the emergence of office urology. In any case, we can make a rough estimate of around 5,000 to emergence of office urology. In any case, we can make a rough estimate of around 5,000 to 6,000 office urologists working in Europe today. 6,000 office urologists working in Europe today.

1. 1)E.A. The European Board of Urology survey ofand E.A. Kiely: Kiely: The European Board of Urology survey of current urological manpower, training 1) E.A. Kiely: European Board of Urology of current urological manpower, training and practice in The Europe. BJU International (2000), survey 85, 8 -13. current urological manpower, training and practice in Europe.Today, BJU International 2) practice EuropeaninUrology Sept. 2007. (2000), 85, 8 -13. 2) European Urology Today, Sept. 2007. Europe. BJU International (2000), 85, 8 -13. [SUBHEAD, BOLD] Creating an EAU Section for Urologists in Office [SUBHEAD, BOLD] Creating an EAU Section for Urologists 2. European Urology Today, Sept. 2007. in Office

With the lack of information regarding office urologists and their activities in Europe, there is a need tolack obtain updated information about office urologyand in the region. A questionnaireWith the of information regarding office urologists their activities in Europe, there is to be facilitated in collaboration allurology nationalin societies, plus Aa questionnairepresentation abased needsurvey to obtain updated information aboutwith office the region. at national societies’ meetings about office urology will a commendable and based survey to be facilitated in collaboration with allcertainly nationalbe societies, plus a presentation necessary initiative. at national societies’ meetings about office urology will certainly be a commendable and

Creating an EAU Section for Urologists in Office necessary initiative. Thus, to create a European network of office urologists the first priority of the new Section is With the ofthatinformation office to establish a lack task force will investigate theregarding current situation of office urology in Europe. Thus, to create a European network of office urologists the first priority of the new Section is Collecting information on office urologists in Germany, France, Italy, Austria, Czech Republic, urologists and their activities Europe, there is aagood to establish task force that will investigate thein current situation office give urology in Europe. and Hungaryawhere substantial numbers of office urologists are basedofshould Collecting information on office urologists in Germany, France, Italy, Czech Republic, insight. to obtain updated information about Austria, need and Hungary where substantial numbers of office urologists are basedoffice should give a good insight. The following also crucialA to the success of a fully functioning, active Section that urology inaspects theareregion. questionnaire-based survey responds to the needs of office urologists: following aspects arein alsocollaboration crucial to the success with of a fullyall functioning, active Section that toThebe facilitated national responds to the needs of office urologists: • Identifying core issues that affect the practice of office urology; societies, plus a presentation at national societies’ • Actively collaborating with other EAU Sections; Knowledge and through publications its dissemination; •• Identifying coreskills-sharing issues that affect the practice ofand office urology; meetings about office urology will be a meetings Offering skills and training courses Annualcertainly EAU Congress, regional •• Actively collaborating with other during EAU Sections; and webinars; • Knowledge and skills-sharing through publications and its dissemination; and necessary initiative. In general, drug therapy and diagnostics are considered commendable • Offering skills and training courses during Annual EAU Congress, regional meetings and webinars; the main tasks in office urology, whereas in a hospital Thus, to create a European network of office urologists the predominant activities cover surgery and related the first priority of the new Section is to establish a task activities. The difference in focus between urologists working in a hospital and office urologists can therefore force that will investigate the current situation of office urology in Europe. Collecting information on office profoundly affect how they view the management of urologists in Germany, France, Italy, Austria, Czech urological diseases. Although there are specific areas Republic, and Hungary where substantial numbers of where hospital-based urologists are expected to office urologists are based should give a good insight. actively intervene or are more suited to take a more dominant role. With this mind, office urologists do need The following aspects are also crucial to the success of proper support in education and training. a fully functioning, active Section that responds to the needs of office urologists: As previously mentioned, there might be existing • Identifying core issues that affect the practice of biases, with office urologists often unfairly viewed as office urology; performing “minor urology” compared with hospital• Actively collaborating with other EAU Sections; based urologists who are seen as representing • Knowledge and skills-sharing through publications mainstream or ‘real urology’. This prejudice is further and its dissemination; reinforced by the fact the office urologists are not • Offering skills and training courses during Annual engaged or involved in scientific research, and are EAU Congress, regional meetings and webinars; basically on their own. Lacking a representative profile in scientific groups, office urologists are not engaged by • Defining a career structure on how to become an office urologist, including residency programmes, scientific associations but usually are members of CME opportunities, etc.; and professional groups which mainly tackle economic • Ensuring the sound financial state of the section. concerns. Thus, there is a persuasive rationale for the creation of an EAU Section for “Urologists in Office” (ESUO) which should not only focus on promoting office urologists under a scientific society’s direction, but also ensure EAU Section for Urologists in Office (ESUO)

10

European Urology Today

Focused efforts should be exerted to recruit members to this planned EAU Section considering the number of office urologists. Other activities that can later be added to the previously mentioned goals would include organising meetings specifically for office urologists and the logistical support for countries that are still developing office urology.

Editorial Note: Office urologists who want to collaborate with the section or need more information, contact Ms. Angela Terberg at esuo@uroweb.org or Prof. Helmut Haas at hf.haas-hp@t-online.de

Thus, distance learning or e-learning can offer alternatives to the skills training and further education of office urologists. Among the long list of topics

Office urology is marginal in Belgium, Denmark, and in the United Kingdom with estimates of around 1% to 2%. In these countries, it can be presumed that the slow growth of office urology could be due to individual career choices and development or professional retirement. In Ireland, Luxembourg and the Netherlands there is no office urology practice similar to those observed in the aforementioned countries.

relevant to the training of office urologists are diagnostics in genital infections, diagnostics and treatment in sexually transmitted diseases (STDs), urodynamics in office urology, urinary incontinence, spermatology, andrologic aspects in cancer patients, palliative medicine, andrology, chronic prostatitis, decision making in prostate cancer, stone treatment, urinary tract infections, antibiotics in urology and pain therapy, to name a few.

Office Urology in Germany German model provides insights on developing a dynamic office urology network Office urology in Germany has a long tradition with its roots in surgeons in hospitals who treated patients in an outpatient setting and, on the other hand, its contacts with dermatology, whose practitioners treated syphilis and gonorrhoea but had difficulty in managing urethral strictures. Data from December 2015 showed there were 3,056 office urologists in Germany, and another 2,443 with hospital affiliations. Patients are often referred to urologic office by general practitioners, although patients can have direct access to urologists if they choose. Patients prefer to go directly to a specialist who they believe are more knowledgeable in managing specific conditions such as prostate cancer or stone disease. Moreover, the ever-growing knowledge in medicine, and the strict adherence to current guidelines are proving to be difficult tasks for GPs. Variations of Office Urology in Germany There are variations in the practice of office urology in Germany, which falls in two categories, namely, urologists are working in their own office or those who are based in a medical centre. Their tasks are often defined by the following: • Without doing operations (office-only); • Having the opportunity of doing out-patient operations in office or in a surgical centre, but without treating in-patients; and • Having the opportunity of in-patient treatment as per contract with a hospital.

while severe urological diseases are treated in hospitals. The data also show that patients in urologic offices (and these are the 20% of those who consulted a GP regarding a urologic condition) can be further categorised in five groups, namely: 1) Those referred to hospital (5%): For in-patient treatment. 2) Small operations and instrumentations, new drugs in tumour-treatment, chemotherapy (10%) May cost-effectively be done in urologic office, otherwise in a hospital; 3) Moderate disease (12%): complicated UTI (fever), drug therapy of tumours (ADT, instillation therapy). Urologic experience is necessary; 4) Minor disease (39%): rec. uncomplicated infections, conservatively treated BPH, small stones, follow-up of tumours, (micro-) haematuria. Therapy may be done by a GP, diagnostics demand urologic equipment (e.g. cystoscopy); 5) No urologic disease (33%): screening, differential diagnostics (e.g. flank pain), fear of disease. Screening may be done by GP, but differential diagnostics and exclusion of disease are demanding and need special equipment. % 100

Hospitalized 5 10

Small operations Instrumentations

12

Moderate disease, e.g. Complicated UTI (fever) Tumour therapy

90 80 70

Follow up tumours

60

39

50

C l i n i c

Minor disease, e.g. Rec. uncomplicated infections Conservatively treated BPH Small stones Follow-up of tumours

40

Germany has a well-developed system of office urology. In this system, more than 80% of the patients with urological complaints are treated by general practitioners, 5% (1% of all) are treated in a hospital, and 15% are treated by an office urologist. Referral to an office urologist can prove to be more cost effective since the specialised management leads to timely intervention and effective treatment. In Germany, there is the “Berufsverband der Deutschen Urologen (BDU)”, a national professional organisation which is more focused on economic issues and working conditions. A substantial number of office urologists are BDU members, rather than the mainstream urology group DGU. Moreover, in recent years, the BDU has been organising meetings that cover both clinical and non-clinical (work-related issues) topics. This development indicates that a responsive group such as the BDU proved to be attractive to office urologists which are normally side-lined by the more dominant and mainstream associations. Referral systems and disease characteristics Nevertheless, the vast majority of patients in Germany with urologic concerns are initially seen by GPs. Based on the data collected, every fifth of these patients is referred to an office urologist. In turn, the office urologist refers about 4% to 5% of these patients to hospitals for in-patient care. This procedure and figures reflect that disease extent (from mild to moderate and severe) influences the way patients are referred and managed. Thus, GPs often treat mild diseases; office urologists manage moderate conditions,

30

34

No disease or irrelevant results, e.g. Screening Fear of disease

20 10

Extent of disease (own office)

G e n e r a l P r a c t i t i o n e r

0

2) and 3) are originally fields for office urologists, and in 2) they will save costs for the insurance systems. But also in 4) and 5) their equipment (ultrasound, X-ray, endoscopy, laboratory) is necessary for diagnostics.

Diagnostic and Therapeutic Methods in Urologic Office in Germany In brackets: Only performed by some office urologists or transferred to other specialists or urologic hospital Diagnostics Therapy urinalysis

drug therapy

erythrocytes’ morphology

for urinary tract infections

urine cultures and antibiotic susceptibility testing

for tuberculosis

(urine cytology)

for STD

smear diagnostics for STD

analgesic therapy

blood tests

spasmolytic therapy

(PSA)

for BPH

ultrasonography

chemical litholysis

abdominal

hormone substitution

transrectal

for ED

Duplex sonography radiography

local therapy with oestrogens drug therapy of tumours

urography

prostate cancer

voiding cysturethrogramme

renal cell carcinoma

urethrography

instillation therapy for BC

ascending urography

therapy with bisphosphonates

prostate biopsy

ureteral stents

urethrocystoscopy

catheter and cystostomy

bladder biopsies

(percutaneous nephrostomy)

ureteral stent management outpatient operations uroflowmetry

psychotherapy

(urodynamic studies)

pelvic floor muscle training

March/May 2017


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. 50

Case study No. 51 A 77 year old man presented as an emergency with severe right inguinal pain of sudden onset radiating caudally and voiding difficulties. Due to the pain the patient was unable to lie still. The history consisted of 35 pack-years of cigarette smoking and moderate alcohol consumption but was otherwise unremarkable. Current medication included clopidogrel and tamsulosin. Body mass index was 32 and on physical examination a mass was palpable in the middle lower abdomen. Urinalysis showed micro haematuria but no sign of infection. Ultrasound showed a fluid-filled non-echogenic structure in the middle lower abdomen and mild dilatation of both renal pelvicalyceal systems, more pronounced on the right side. A plain abdominal x-ray showed calcifications in the lower pelvis (fig 1). A transurethral catheter was inserted but drained only 30 mL of urine and did not alleviate the pain.

A 49-year-old man was investigated for lower urinary tract symptoms and urethral bleeding and was diagnosed with an exophytic carcinoma of the bulbar urethra, verified by biopsy showing high-grade urothelial carcinoma. There was no relevant history at all. Complete staging including cystoscopy and MR urography did not give any evidence of other neoplastic lesions in the urinary tract. The patient had been advised to undergo radical urethrocystectomy with a urinary diversion. As he was quite averse to losing his urinary bladder he presented for a second opinion. Case provided by Oliver Hakenberg, Department of Urology, Rostock University, Germany. Email: oliver.hakenberg@med.uni-rostock.de Readers are encouraged to provide interesting and challenging cases for discussion.

Discussion points: 1. Should radical urethrocystectomy be advised? 2. Are treatment alternatives possible and reasonable?

Three basic therapeutic approaches need to be discussed Comments by Prof. Georgios Gakis Tuebingen (DE)

chemotherapy followed by surgery (2) and, third, a genital-preserving approach with primary radiochemotherapy (3).

(6). However, the risk of performing consolidation surgery after irradiation in case of failure of primary chemoradiotherapy also needs to be discussed with the patient.

The available data on chemoradiotherapy for proximal tumours is scarce. Yet, in a larger radiotherapy series, 1. Gakis G, Morgan TM, Efstathiou JA, Keegan primary chemoradiotherapy for proximal tumours has KA, Mischinger J, Todenhoefer T, et al. This case of a 49-year-old man with a large been shown to provide a high chance of complete Prognostic factors and outcomes in primary high-grade urothelial carcinoma of the bulbar response (≈80%) (3). Of note, consolidation surgery urethral cancer: results from the international urethra represents the classic clinical challenge in in case of residual disease was shown to further collaboration on primary urethral carcinoma. the decision-making process of an optimal improve survival outcomes for patients treated World journal of urology. 2016;34(1):97-103. primarily with chemotherapy (4). Yet, radical 2. Gakis G, Morgan TM, Daneshmand S, Keegan therapeutic approach for proximal urethral cystourethrectomy with adjuvant chemotherapy is still KA, Todenhofer T, Mischinger J, et al. Impact malignancies. Given the rarity of the disease, all available data are of retrospective nature. Patients an option in the given case (5). Given the high risk of of perioperative chemotherapy on survival in with proximal tumours present with clinical micrometastatic disease, a primary surgical approach patients with advanced primary urethral symptoms often associated with advanced clinical would also allow for locoregional lymph-node cancer: results of the international stages (1). Therefore, the risk of micrometastatic dissection. Conversely, neoadjuvant chemotherapy collaboration on primary urethral carcinoma. was shown to provide improved survival rates in Annals of oncology : official journal of the disease has to be taken into account. In the presence of negative findings on clinical staging, clinically advanced stages (cT3-4 and/or cN+) European Society for Medical Oncology. compared to surgery with adjuvant chemotherapy (2). 2015;26(8):1754-9. three basic therapeutic approaches need to be discussed: first, upfront radical cystourethrectomy As the patient seeks a genital-preserving modality, 3. Kent M, Zinman L, Girshovich L, Sands J, with adjuvant chemotherapy if locally advanced chemoradiotherapy represents a reasonable Vanni A. Combined chemoradiation as primary treatment for invasive male urethral pathological stage (≥ pT3 and/or pN+) is confirmed alternative to surgery and has also been recommended for locally advanced proximal tumours cancer. The Journal of urology. on final histology (2); second, neoadjuvant 2015;193(2):532-7. 4. Dayyani F, Pettaway CA, Kamat AM, Munsell MF, Sircar K, Pagliaro LC. Retrospective Case Study No. 50 continued there was no lymph node enlargement and we analysis of survival outcomes and the role of did not perform any lymphadenectomy. cisplatin-based chemotherapy in patients This man was very averse to having his urinary Further treatment was complicated by perineal bladder removed with resultant diversion. hematoma/seroma formation with infection Thus, we resected the urethra completely with which required two further surgical bladder neck closure and performed a procedures finally resulting in secondary Mitrofanoff procedure for self-catheterisation. perineal wound closure and uneventful Histology was reported as urethral squamous recovery after that. No adjuvant treatment but cell carcinoma pT2G2 with negative surgical close follow-up is planned. margins. Clinically and on CT-based staging

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

Discussion points: 1. What are likely differential diagnoses? 2. What further diagnostic management is helpful? Case provided by Prof. Malte Böhm and Dr.Hans Peter Stockamp, Dill-Kliniken, Dillenburg, Germany Email: malte.boehm@microdissect.de Readers are encouraged to provide interesting and challenging cases for discussion.

with urethral carcinomas referred to medical oncologists. Urologic oncology. 2013;31(7):1171-7. 5. Hakenberg OW, Franke HJ, Froehner M, Wirth MP. The treatment of primary urethral carcinoma--the dilemmas of a rare condition: experience with partial urethrectomy and adjuvant chemotherapy. Onkologie. 2001;24(1):48-52. 6. Gakis G, Witjes JA, Comperat E, Cowan NC, De Santis M, Lebret T, et al. EAU guidelines on primary urethral carcinoma. European urology. 2013;64(5):823-30.

NGage®: ANNOUNCEMENT

Reach for the original. NGage Nitinol Stone Extractor

• EBU Online Written Examination: 17 November 2017 •

EBU In-Service Assessment: 1 & 2 March 2018

EBU Oral Examination: 2 June 2018

MEDICAL

© COOK 01/2017 URO-D32084-EN-F

March/May 2017

European Urology Today

11


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

Oliver.Hakenberg@ med.uni-rostock.de

Maintenance chemotherapy for advanced urothelial carcinoma TCC of the urothelial tract treated with platinum-based regimens is associated with a 40-60% objective response rate although duration of response is limited and prognosis after progression is poor. Several regimens have been tested following progression and vinflunine was approved in this setting in 2009. It is an antineoplastic agent in the vinca alkaloid class that inhibits microtubule dynamics. Optimising its use could improve disease outcomes. An approach might be to introduce maintenance therapy after first-line treatment in patients who achieve disease control, as has been done in other tumours. Vinflunine is a potentially suitable agent for maintenance therapy because its toxicity profile is favourable and with manageable cumulative effects. This paper reports a randomised, controlled, open-label, phase 2 trial done by the Spanish Oncology Genitourinary group done in patients previously treated with cisplatin and gemcitabine and who had achieved a radiological response or stable disease on RECIST criteria. Patients were randomised on a 1:1 ratio to best supportive care plus or minus Vinflunine until disease progression. The primary endpoint was median PFS longer than 5.3 months in the treatment groups with comparison between the groups as secondary endpoint.

This study would appear to support the development of vinflunine maintenance therapy for patients with advanced transitional-cell carcinoma of the urothelial tract Between January 2012 and January 2015, 88 patients with a median age of 63.7 years (42.1-83.9 years) were enrolled. Baseline characteristics were generally well balanced except liver metastasis, which were less frequent in the Vinflunine group. After a median follow-up of 15∙6 months (IQR 8·5–26·0) in all patients and 27·6 months (21·5–40·5) in patients alive at data cut-off, 29 (66%) of 44 patients in the vinflunine group had progressive disease and 24 (55%) had died, compared with 36 (84%) and 32 (74%), respectively, of 43 patients in the best supportive care group. Median progression-free survival was 6∙5 months (95% CI 2∙0–11∙1) in the vinflunine group and 4∙2 months (2∙1–6∙3) in the best supportive care group (HR 0∙59, 95% CI 0∙37–0∙96, log-rank p = 0∙031). In a post-hoc multivariate analysis that included all the stratification factors, only vinflunine treatment and the presence of liver metastases were significantly associated with progression-free survival.

compared with using the drug as second-line treatment on relapse, and should include combinations with monoclonal antibodies or checkpoint inhibitors. However, this is a novel approach and opens a new therapeutic opportunity for patients with advanced TCC

Source: Maintenance therapy with vinflunine plus best supportive care versus best supportive care alone in patients with advanced urothelial carcinoma with a response after first-line chemotherapy (MAJA; SOGUG 2011/02): a multicentre, randomised, controlled, open label, phase 2 trial. Garcia-Donas J, Font A, Perez-Valderrama B , et al. Lancet Oncol. 2017; http://dx.doi.org/10.1016/S14702045(17)30242-5.

More new treatments for metastatic RCC? Despite the multiple advances in the treatment of metastatic renal cell carcinoma (mRCC), the vast majority of patients remain incurable. Current first-line treatments are designed to abrogate signalling through either the VEGF receptor or mTOR. Following VEGF-directed therapy, several new options have been recently approved including the VEGF/AXL/ MET inhibitor cabazantinib, the PD-1 inhibitor nivolumab and the multikinase inhibitor lenvatinib; but improvement to progression free survival is limited to 4-5-7.5 months. As a consequence there remains interest in the role of sphingosine-1-phosphate (S1P) in mediating resistance to VEGF tyrosine kinase inhibitors. Antagonism of S1P in preclinical models appears to overcome this resistance. In this phase 2 study, the authors assessed the activity of sonepcizumab, a first-in-class inhibitor of S1P. Patients with clear cell mRCC who had received at least one prior VEGF-directed therapy and remained performance status 0-2 with adequate haematological, hepatic and renal function were recruited. The study was an open-label, single arm phase II evaluating PFS. Initially using a 15mg/kg iv weekly regimen; but after 17 patients this was amended to 24 mk/kg following favourable pharmacodynamics observed in a concurrent phase 1 study.

The favourable safety profile of sonepcizumab suggests that the agent could be explored in combination with currently approved agents for mRCC 40 patients were enrolled in five centres between May 2013 and December 2014 with a median of three prior therapies. Because 12 of the 22 patients enrolled at the 24 mg/kg dose did not demonstrate the study endpoint of PFS at two months, the study was terminated in September 2015. At that point the PFS for all 40 patients was evaluated and found to be 2.2 months with the median OS of 21.7 months. There were no drug related serious adverse events and the main complications were fatigue, weight gain, constipation and nausea.

Median overall survival was 16·7 months (95% CI 3·1–30·3) in the vinflunine group and 13·2 months (6·1–20·3) in the best supportive care group. These data, however, are immature, and require longer follow-up. As expected there were more adverse events in the vinflunine group. The most common grade 3 or 4 adverse events were neutropenia (eight [18%] of 44 in the vinflunine group vs none of 42 in the best supportive care group), asthenia or fatigue (seven [16%] vs one [2%]), and constipation (six [14%] vs none). 18 serious adverse events were reported in the vinflunine group and 14 in the best supportive care group. One patient in the vinflunine group died from pneumonia that was deemed to be treatment related.

The discordance between PFS and OS in this study mirrors what was observed in the randomized phase 3 study of nivolumab, which demonstrated no difference in PFS compared with everolimus. A similar discordance was noted with the use of novel immunotherapeutic agents across tumour types, with PD-1 and PD-L1 inhibitors demonstrating modest response rates and PFS but substantial improvements in OS in patients with lung and bladder cancer. Latent immune responses that follow evidence of radiographic disease progression are believed to explain this phenomenon. This study may have therefore underestimated response because progression on a CT scan at four weeks was the common reason for failing and that may be too early to assess efficacy.

This study would appear to support the development of vinflunine maintenance therapy for patients with advanced transitional-cell carcinoma of the urothelial tract. Further studies are warranted to better establish the role of vinflunine as maintenance therapy as

The favourable safety profile of sonepcizumab suggests that the agent could be explored in combination with currently approved agents for mRCC. Hepatotoxicity and colitis have limited previous attempts to combine sunitinib and pazopanib with

Key articles

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nivolumab; it is possible that sonepcizumab may be a better immunomodulator with which to pair with these VEGF-directed therapies. Furthermore, given non-overlapping mechanisms of action, sonepcizumab possibly could complement currently available PD-1 and PD-L1 inhibitors.

Source: A phase 2 study of the sphingosine-1phosphate antibody Sonepcizumab in patients with metastatic renal cell carcinoma. Pal SK, Drabkin HA, Reeves JA, et al.

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

Cancer. 2017;123:576-82.

Faecal carriage of extended spectrum β-lactamase producing Escherichia coli and Klebsiella pneumoniae three years after UTI The authors of this study performed a prospective cohort analysis of the duration of and risk factors for prolonged faecal carriage of ESBL-producing Escherichia coli or Klebsiella pneumoniae in patients with community-acquired urinary tract infection caused by these bacteria.

The ESBL point prevalence of faecal carriage were 61% at 4 months, 56% at seven months, 48% at 10 months, 39% at 13 months, 19% after two years, and 15% after three years or more. From 2009 to 2011, 101 Norwegian patients were recruited. Stool swabs and questionnaires were collected every three months for one year and at the end of the study in 2012. Information on antibiotic prescriptions was collected from the Norwegian Prescription Database. Stool samples were cultured directly on ChromID ESBL agar as well as in an enrichment broth, and culture positive isolates were examined by blaCTX-M multiplex PCR. Isolates without blaCTX-M were investigated for alternative ESBL-determinants with a commercial microarray system. Time –to-faecal clearance of ESBL producing Enterobacteriaceae was also analysed using Kaplan-Meier estimates. Uni- and multivariate logistic regression was used to compare groups according to previously described risk factors. The ESBL point prevalence of faecal carriage were 61% at 4 months, 56% at seven months, 48% at 10 months, 39% at 13 months, 19% after two years, and 15% after three years or more. Investigators found no correlation between duration of carriage, comorbidity, antibiotic use or travel to ESBL high-prevalence countries. Prolonged carriage was associated with E. coli isolates of phylogroup B2 or D. Importantly, comparative MLST and MLVA analyses of individual paired urine and faecal E. coli isolates revealed that ESBL production commonly occurred in diverse strains within the same host. When investigating cross-transmission of ESBL producing bacteria in health care institutions, this notion should be taken into account.

Source: Fecal carriage of extended spectrum β-lactamase producing Escherichia coli and Klebsiella pneumoniae after urinary tract infection - A three year prospective cohort study. Jørgensen SB, Søraas A, Sundsfjord A, Liestøl K, Leegaard TM, Jenum PA. PLoS ONE. 2017; 12(3):e0173510. DOI: 10.1371/journal. pone.0173510

Too old for radical prostatectomy? Although radical prostatectomy is an effective treatment for clinically localised prostate cancer it is recognised that a life expectancy of at least 10 years is required before patients benefit from attempt to cure. This has led clinicians to be reluctant to offer curative

therapies to men over 80 years of age. However, assumptions about life expectancy in this group have been challenged with data suggesting the life expectancy of the fittest octogenarians was 12.15 years as far back as 2010. As life expectancy increases across the world it is important to understand the consequences of operating upon such men. This paper used the SEER-Medicare database to assess the long-term survival rates of patients aged 80 years or older that were treated with radical prostatectomy. The group studied were men diagnosed with prostate cancer between 1991 and 2009 who had both Part A and Part B claims data available and excluding those diagnosed on autopsy or with other pre-existing malignancies plus those with T4 disease or distant metastasis. Focusing exclusively on patients treated with radical prostatectomy within six months of diagnosis, 234 men over the age of 80 years with T1-3 disease were included. Just 14 men were 86 or more. Kapla-Meier analyses examined 10-year survival patterns. Multivariable Cox regression analyses focused on the combined effect of age and/or Charlson Comorbidity Index (CCI) after adjusting for different confounders.

The authors suggest that men with a CCI of zero and aged 80-81 years represent a group in whom radical prostatectomy might be considered The 10-year overall survival (OS) and cancer specific mortality (CSM) rates in the overall population were 51 and 9.9%. In individuals aged 80-81 years old (n = 125), the 10-year OS was 62.4 vs. 39.6% in older patients (p < 0.001). 110 men had a CCI of 0 and the majority of men had clinical stage T2 disease prostate cancer and harbored G7-10 disease. Moreover, combination of age 80-81 with CCI = 0 yielded 10-year OS of 67.9 vs. 28.5% in older and sicker patients (p < 0.001). Age 80-81, absence of comorbidities and the combination of age 80-81 with CCI = 0, represented independent predictors of lower overall mortality (all p < 0.01). The authors suggest that men with a CCI of zero and aged 80-81 years represent a group in whom radical prostatectomy might be considered. However, it is clear that these 234 men represent a highly irregular group amongst the approximately 1.2 million radical prostatectomies performed over the same period in USA. What drove clinicians to operate on this group of individuals is not clear from the database but it is likely that exceptional circumstances applied and although you might meet such an individual, the chance is slim and nearly certainly less than 1 in 5,000.

Source: Long-term survival of patients aged 80 years or older treated with radical prostatectomy for prostate cancer. Dell’Oglio P, Zaffuto E, Boehm K et al. EJSO. 2017; http://dx.doi.org/10.1016/j.ejso.2017.02.018.

Discrepancy between preoperative urine culture results and bacteriology of urologic prosthetic device infections Although pre-operative negative urine culture results and treatment of urinary tract infections are generally advised before artificial urinary sphincter (AUS) and penile prosthesis (PP) surgery to prevent device infection, limited evidence exists to support this practice. The aim of the present study was to evaluate the relation between pre-operative urine culture results and the bacteriology of prosthetic device infections.

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March/May 2017


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

tebj@medisin.uio.no Men undergoing AUS and/or PP placement at a tertiary referral centre from 2007 through 2015 were analysed. A total of 713 devices were implanted in 681 patients (337 AUSs in 314 patients and 376 PPs in 367 patients), of whom 259 (36%) did not have preoperative urine culture and were excluded. The remaining 454 patients received standard broadspectrum peri-operative antibiotics. Two patient groups were identified based on pre-operative urine cultures: group 1 had negative urine culture results and group 2 had untreated asymptomatic positive urine culture results identified post-operatively. Device infection was diagnosed clinically and cultures obtained from the explanted device and tissue spaces were compared with pre-operative urine culture results.

… pre-operative urine culture results appeared to show little correlation with the bacteriology of prosthetic device infections

Women with rUTIs had lower FSFI scores (p <  0.001) and a greater proportion of pathological FSFI (78.9% vs. 21.4%; p <  0.001) and SDS scores (77.8% vs. 21.4%; p <  0.001) than controls. Of rUTIs patients, 88 (60%), 77 (52.2%), and 75 (51.1%) reported pathological scores for FSFI-pain, lubrication and arousal, respectively; moreover, 64% had concomitant pathological FSFI and SDS scores. Age, IPSS severity, rUTIs, a history of ≥ 6 UTIs/year and a history of constipation were independent predictors of pathologic FSFI and SDS (all p ≤ 0.05). It is concluded that up to 80% of women with rUTIs showed pathologic FSFI and SDS scores, with 60% reporting scores suggestive of distressful FSD. Having ≥ 6 UTIs/year and a history of constipation independently predicted distressful FSD.

Source: Six out of ten women with recurrent urinary tract infections complain of distressful sexual dysfunction - A case-control study. Boeri L, Capogrosso P, Ventimiglia E, Scano R, Graziottin A, Dehò F, Montanari E, Montorsi F, Salonia A. Sci Rep. 2017 Mar 15; 7:44380. DOI: 10.1038/srep44380

Belatacept increases acute rejections compared to tacrolimus

Belatacept has been introduced as a novel immunosuppressive drug with different pharmacodynamics; it inhibits the CD28-CD80/86 co-stimulatory pathway and allows for calcineurininhibitor free immunosuppression in kidney Although multivariate analysis showed that patients undergoing AUS placement had a 4.5-fold greater risk transplantation. However, belatacept is associated with a higher acute rejection rate than ciclosporin but of positive urine culture results (114 of 250, 45%) compared with those undergoing PP placement (36 of no biomarker for belatacept-resistant rejection has been validated. In this randomized controlled trial, 204, 18%; p < .001), infection rates between device the acute rejection-rate between belatacept- and types were similar (eight of 250 for AUSs [3%] and 7 tacrolimus-treated patients was compared and of 204 for PPs [3%]; p = .89). At a median follow-up immunological biomarkers for acute rejection were of 15 months, device infection occurred in 15 of 454 devices (3%) implanted and no differences in infection investigated. rates were noted between urine culture groups (10 of Forty kidney-transplant recipients were randomized 337 in group 1 [3.3%] and 5 of 117 in group 2 [4.3%]; 1:1 to belatacept or tacrolimus combined with p = .28). basiliximab, mycophenolate mofetil and Remarkably, only one of 15 device infections (7%) had prednisolone. The one-year incidence of biopsyproven acute rejection was monitored. Potential the same organism present at pre-operative urine biomarkers, namely CD8CD28, CD4CD57PD1 and culture. CD8CD28 EMRA T cells were measured pre- and post-transplantation and correlated with rejection It is concluded that despite the finding that episodes. Pharmacodynamic monitoring of patients with AUS placement had a 4.5 times belatacept was performed by measuring free CD86 higher rate of positive urine culture results than on monocytes. patients with PP placement, pre-operative urine culture results appeared to show little correlation with the bacteriology of prosthetic device …there seems to be a significantly infections.

Source: Preoperative urine culture results correlate poorly with bacteriology of urologic prosthetic device infections. Kavoussi NL, Siegel JA, Viers BR, Pagliara TJ, Hofer MD, Cordon BH, Shakir N, Scott JM, Morey AF. J Sex Med. 2017 Jan; 14(1):163-168. DOI: 10.1016/j. jsxm.2016.10.017

Women with recurrent Urinary Tract Infections complain of distressful sexual dysfunction Uncomplicated recurrent urinary tract infections (rUTIs) are common among reproductive-aged women. In this study, the authors aimed to assess the prevalence and predictors of sexual dysfunction (FSD) in a cohort of women with rUTIs and compare their psychometric scores to those of matched controls.

…up to 80% of women with rUTIs showed pathologic FSFI and SDS scores, with 60% reporting scores suggestive of distressful FSD Data from 147 rUTIs women and 150 healthy controls were analysed. Participants completed the International Prostatic Symptoms Score (IPSS), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (SDS). Descriptive statistics and logistic regression models tested prevalence and predictors of distressful FSD. Key articles

March/May 2017

Increased alloreactivity in diabetic renal transplant recipients Many renal transplant patients suffer from preexisting diabetes mellitus and some patients develop diabetes after transplantation. It has been previously reported that post-transplantation diabetes mellitus (PTDM) has been associated with inferior patient and allograft outcomes. This study looked at infection control and alloreactivity. The authors studied 449 kidney transplant recipients between 2005 and 2013. 50 (11.1%) of those were diagnosed with PTDM and 60 (13.4%) had preexisting diabetes. Samples were collected pretransplantation, at +1, +2, +3 months posttransplantation and CMV-specific and alloreactive T-cells were quantified by interferon-γ Elispot assay. Lymphocyte subpopulations were quantified by flow cytometry.

The study results suggested higher rates of infection in renal transplant recipients with pre-existing diabetes or new-onset post-transplant diabetes that may be attributed to impaired overall immunity Upon multivariate analysis age, obesity and the use of tacrolimus increased the risk of new onset PTDM (p < 0.05). Transplant recipients with pre-existing diabetes or PTDM showed higher rates of sepsis (p < 0.01). Total CD3+ and CD4+ T-cell counts were significantly lower after transplantation in recipients with PTDM or pre-existing diabetes (p < 0.05). No differences were observed for CMV-specific T-cells between any group (p > 0.05). Recipients who developed PTDM showed increased frequencies of alloreactive T-cells posttransplantation (p < 0.05). The study results suggested higher rates of infection in renal transplant recipients with pre-existing diabetes or new-onset post-transplant diabetes that may be attributed to impaired overall immunity. Higher frequencies of alloreactive T-cells contribute to inferior long-term outcomes. Since in this series acute rejection, but not pre-existing diabetes/PTDM, was associated with inferior allograft survival and function, maintaining adequate immunosuppression to prevent rejection seems very important in recipients with pre-existing or new-onset diabetes.

Source: Diabetic kidney transplant recipients: impaired infection control and increased alloreactivity. Schachtner T, Stein M, Reinke P.

Clin Transplant. 2017, doi: 10.1111/ctr.12986. [Epub ahead higher risk of acute rejections of print] with belatacept versus tacrolimus treatment but a biomarker could not hTERT polymporphism be identified increases the risk of delayed There were significantly more rejections in graft function belatacept-treated than in tacrolimus-treated patients: 55% vs. 10% (p < 0.007). Three graft losses due to rejection occurred in the belatacept group. Although four of five belatacept-treated patients with > 35 CD8/CD28-EMRA T cells/μL rejected, the median pre-transplant values of the biomarkers did not differ between belatacept-treated rejectors and nonrejectors. In univariable Cox regression analysis and the studied cell subsets were not associated with rejections. CD86 molecules on circulating monocytes in belatacept-treated patients were saturated at all time points.

There are several known factors increasing the risk of delayed graft function and impaired long-term allograft function, e.g. post-transplant complications accelerate transplanted organ aging, and thus contribute to decreases in estimated glomerular filtration rate (eGFR). The influence of genetic alterations is emerging as another important factor. There are several genes and genetic loci affecting telomere length, including hTERT gene and BICD1 gene, as well as polymorphisms within chromosome 18 which were assessed in this study.

Thus, there seems to be a significantly higher risk of acute rejections with belatacept versus tacrolimus treatment, but a biomarker could not be identified. Also, the belatecept-related rejections were more severe. The CD28-CD80/86 co-stimulatory pathway appeared to be sufficiently blocked by belatacept but did not predict rejection.

It seems that both the donor's and the recipient's rs2735940 hTERT gene polymorphism is an important factor for delayed graft function

Source: A randomized controlled clinical trial comparing belatacept with tacrolimus after de novo kidney transplantation. de Graav G, Baan CC, Clahsen-van Groningen MC, Kraaijeveld R, Dieterich M, Verschoor W, von der Thusen JH, Roelen DL, Cadogan M, van de Wetering J, van Rosmalen J, Weimar W, Hesselink DA.

The study examined 74 pairs of Polish Caucasian kidney allograft cadaveric donors (60% male, mean age 45 years) and recipients (50.0% male, mean age 48 years), transplantation was performed between 2001 and 2012. All samples were genotyped in duplicate using real-time PCR.

Transplantation. 2017, doi: 10.1097/ TP.0000000000001755. [Epub ahead of print]

It was shown that the rs2735940 hTERT CX-TT donor-recipient genotype pair was associated with

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com almost five times higher odds for delayed graft function (OR = 4.82; 95% CI: 1.32-18; p < 0.02) while rs2735940 hTERT, rs2630578 BICD1, and rs7235755 chromosome 18 polymorphisms combined pairs were not associated with acute rejection. It seems that both the donor's and the recipient's rs2735940 hTERT gene polymorphism is an important factor for delayed graft function. Thus, although this field is just developing, assessment of donor-recipient genotype pairs may provide more information for the prediction of early kidney transplantation outcomes.

Source: Joint assessment of donor and recipient hTERT gene polymorphism provides additional information for early kidney transplantation outcomes. Kłoda K, Mierzecki A, Domanski L, Borowiecka E, Safranow K, Ciechanowicz A, Ciechanowski K. Med Sci Monit. 2017, 14;23:1812-1818.

Partial nephrectomy: What really matters to maximise preservation of renal function? Preservation of renal function is the main goal of a partial nephrectomy once oncological outcomes are successfully delivered. Many factors are involved in the attempt to achieve the best of this functional outcome including time of warm ischaemia, extirpative approach and haemostatic/reconstructive technique. After many years with debates regarding the best technique to reduce ischaemia time or even to avoid it (superselective clamp or off-clamp), some recent evidences are switching the focus on the importance of sparing, as much as possible, the healthy renal tissue. On this regard, some centres have routinely adopted the simple enucleation of tumour by developing the plane through the pseudocapsule: good surgical and functional outcomes have been shown because no rim of healthy tissue is needed for resection and fewer vessels are likely to be encountered. However, recent reports have shown a higher rate of positive surgical margins, even though this factor did not translate into an associated increased risk of local tumour recurrence (1-2). More recently, a team from the Glickman Institute of the Cleveland Clinic-USA retrospectively reviewed their large series of robotic partial nephrectomy to identify factors associated with the preservation of estimated glomerular filtration rate (eGFR-P) (3). They calculated this latter value as the percentage of post-operative eGFR between three and 12 months (i.e. when supposedly the eGFR has recovered and stabilised) with respect to pre-operative recorded values. They included in their study nearly 650 patients who underwent robotic partial nephrectomy in the span of 10 years (2006-2016), whose full records of the variables in observations were available.

…the present study is another evidence highlighting the importance of performing a precise procedure rather than just a quick one Univariate and multivariate analysis were conducted by testing effects of demographics (age, gender, body mass index and race), comorbidities (hypertension or diabetes), pre-operative clinical factors (basal eGFR), tumour characteristics (RENAL score and tumour size) and surgical outcomes (warm ischaemia time, excisional volume loss-EVL- and complications). EVL was measured by taking off the estimated volume of tumour from the calculated volume of the specimen.

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Dr. Francesco Sanguedolce Section editor London (UK)

fsangue@ hotmail.com The EVL was found to be the only surgical variable associated to the eGFR-P at three to 12 months at both univariate and multivariate analysis; accordingly, the authors concluded that precision in resecting the renal tumour with a (alleged) rim of 5 mm is more important than a shorter ischaemia time, especially when fastness may increase risk of a) larger dissection of healthy tissue, b) bleeding, requiring more haemostatic stitches or even c) positive surgical margins. Zargar et al (4) showed previously similar results by assessing residual renal function with MAG-3 renal scans; though these latter outcomes were methodologically more robust in emphasising the importance of the preservation of healthy tissue by including the effect of the renorraphy, the present study is another evidence highlighting the importance of performing a precise procedure rather than just a quick one.

Sources: 1) Tumor enucleation specimens of small renal tumors more frequently have a positive surgical margin than partial nephrectomy specimens, but this is not associated with local tumor recurrence. Wang L, Hughes I, Snarskis C, Alvarez H, Feng J, Gupta GN, Picken MM. Virchows Arch. 2017 Jan;470(1):55-61. doi: 10.1007/ s00428-016-2031-9. Epub 2016 Oct 24.

2) A prospective, multicenter evaluation of predictive factors for positive surgical margins after nephron-sparing surgery for renal cell carcinoma: the RECORd1 Italian Project. Schiavina R, Serni S, Mari A, Antonelli A, Bertolo R, Bianchi G, Brunocilla E, Borghesi M, Carini M, Longo N, Martorana G, Mirone V, Morgia G, Porpiglia F, Rocco B, Rovereto B, Simeone C, Sodano M, Terrone C, Ficarra V, Minervini A. Clin Genitourin Cancer. 2015 Apr;13(2):165-70. doi: 10.1016/j.clgc.2014.08.008. Epub 2014 Sep 23.

In the span of six years, 1,256 ureteroscopies were performed and sepsis occurred in 2.8% of the cases (n = 36). In a first multivariate logistic regression analysis, the authors found that sepsis was associated with pre-operative stent placement, female gender and higher Charlson comorbidity index; in particular stented patients were associated with almost a five-time odds (OR 4.78, 95%CI: 1.95-11.76; p = 0.001) of developing sepsis with respect to non-stented patients.

Interestingly, the SLR technique allowed a shorter WIT (19.6 min …the principle of performing as vs. 17.3 min; p = 0.04) without soon as possible a ureteroscopy exposing patients to higher rate of in a stented patient should in general find agreement, considering complications that stented patients may suffer Some studies have recently argued that the two-layer suture principle is not necessarily needed to be significant stent-related symptoms applied all the time: in order to avoid loss of while waiting for surgery functioning renal parenchyma, some authors have To better investigate the factors associated with pre-operative stent and events (i.e. sepsis) they analysed the impact of the stent dwelling time prior to surgery.

4) Ipsilateral renal function preservation after robot-assisted partial nephrectomy (RAPN): an objective analysis using mercaptoacetyltriglycine (MAG3) renal scan data and volumetric assessment. Zargar H, Akca O, Autorino R, et al. BJU Int 2015;115:787–95.

Risk of sepsis after ureteroscopy for urinary stones: The impact of pre-operative stenting Some authors have described the utility of stenting patients before a ureteroscopy especially in the case of high-stone burden and when a ureteral access sheath is necessary for placement However, stenting a patient who is deemed to have a subsequent endoscopic procedure for removal of urinary stone may not be free of consequences. Bacterial colonisation of a foreign body introduced in the urinary tract may expose patients to a risk of post-operative urinary infection due to the manipulation during endoscopy. An Israeli group has recently reviewed their large cohort of ureteroscopy patients to identify predictive factors for the development of post-operative sepsis. Condition of urosepsis was defined according to the International Sepsis Definitions Conference of 2001, which combines presence of documented or presumed urinary tract infection with clinical and/or laboratorial variables. Key articles

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proposed either the suturing of the resection bed or of the renal cortex in a single-layer renorrhaphy.

The latest evidence on this regard comes from a paper published by the Mayo Clinic in Florida whose authors retrospectively reviewed data from Interestingly, they noted that the longer the dwelling a cohort of RAPN patients who received either time with stent was, the higher the rate of sepsis: conventional renorrhaphy (CR) in two layers or more in details, patients receiving ureteroscopy within single layer renorrhaphy (SLR) by closing the cortex 30 days after stent insertion had 1.1% of sepsis rate, defect. which was comparable to non-pre-operatively stented patients, whilst 6.2% of sepsis rate was observed in There were in total 64 CR and 27 SLR with complete patients with stents dwelling for more than one data; groups were compared in terms of age, sex, month (p = 0.048). BMI, ASA score, pre-operative renal function, RENAL nephrometry score, tumour size and no significant differences were observed. More in detail, mean Finally, they also analysed whether the reasons of pre-operative stenting played any role in the RENAL score was 8.5 vs. 8 (p = 0.16) and tumour size post-operative development of sepsis. They was 3.4 cm vs. 3.3 cm (p = 0.61), respectively for CR categorised reasons for stenting as “sepsis” and not and SLR patients. sepsis,” the latter presumably including pain and elective stent insertion for large stone burden. Interestingly, the SLR technique allowed a shorter WIT (19.6 min vs. 17.3 min; p = 0.04) without Regardless of the fact that pre-operative septic patients received antibiotic treatment before surgery, exposing patients to higher rate of complications. insertion of stent because of infection was almost five In particular, the authors reported comparable times (OR 4, 95%CI: 1.79-8.92; p = 0.001) more likely number of complications with > Grade 2 according associated with the development of a post-operative to Clavien classification; moreover, mean drain time sepsis; in the same multivariate analysis, female and hospital stay were almost identical. gender and stent dwelling time were also associated with the events. However, these results are undermined by several biases including the selection bias as surgeons at Accordingly, the authors recommended performing the presence of large defects of the collecting ureteroscopy for active stone removal < 1 month from system (defined as > 1 cm) systematically applied stent insertion, especially if stenting indication was the suture of the resection bed/closure of due to sepsis. collecting system.

3) Excisional Precision Matters: Understanding the Influence of Excisional Volume Loss on Renal Function After Partial Nephrectomy. Dagenais J, Maurice MJ, Mouracade P, Kara O, Malkoc E, Kaouk JH. However, the threshold of 30 days may not be Eur Urol. 2017 Mar 1. pii: S0302-2838(17)30093-3. doi: 10.1016/j.eururo.2017.02.004. [Epub ahead of print]

One of the key steps of the procedure is to keep the WIT as much low as possible to prevent loss of nephrons; however, other factors may play a role including the sutures applied for the renorrhaphy. The sliding clip technique has undoubtedly contributed to reduce the ischaemia time and guaranteeing efficacy and safety at the same time with a lower risk of complications, including bleeding and urinary leakage.

universally/necessarily applicable: as the same authors recognised, septic patients may require longer time before recovering from events and deemed suitable for surgery. Moreover, pre-operative stented patients may account for a significant proportion of patients in waiting lists (47.8 % in this series) and may add significant pressure on urological services from the managerial point of view.

Overall, their results cannot be generalised; however, SLR can be safely applied especially in patients whose WIT is exceeding > 20 mins and there are not large defects of collecting system.

Source: Has sliding-clip renorrhaphy eliminated the need for collecting system repair during robot-assisted partial nephrectomy? Williams R, Snowden C, Frank RD, Thiel DD. J Endourol. 2016 Dec 13. [Epub ahead of print]

Nevertheless, the principle of performing as soon as possible a ureteroscopy in a stented patient should in general find agreement, considering that stented patients may suffer significant stent-related symptoms while waiting for surgery.

Source: Ureteric stent dwelling time: a risk factor for post-ureteroscopy sepsis. Nevo A, Mano R, Baniel J, Lifshitz DA. BJU Int. 2017 Feb 1. doi: 10.1111/bju.13796. [Epub ahead of print]

Evolution of technique during partial nephrectomy: Is double layer renorrhaphy always necessary? Many refinements of technique have been introduced in the very last few years to improve outcomes when performing partial nephrectomies for the treatment of T1 renal masses. Almost all of them have been tested and applied with robotic-assisted partial nephrectomy (RAPN) in an attempt to achieve as much frequently as possible the so-called trifecta outcomes, which variably involve warm ischaemia time (WIT), surgical margins and complications.

Patient-reported outcomes after localised treatment for prostate cancer: Results from two prospective trials Patients with localised prostate cancer are facing multiple treatment options. Whereas the oncologic outcomes are well assessed and are quite similar between recommended options, scarce data have been published regarding patient-reported outcomes and quality-of-life after initial treatment. However, patients with localised prostate cancer often have a long-term life expectancy, and the effects of different treatment options on quality-of-life should be an important consideration in the decision-making process.

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk studies already published few years ago on qualityof-life after primary treatment does not accurately provide the functional outcomes after these new technologies. In the two present studies published in the recent issue of the Journal of American Medical Association, the authors compared the impact of surgery, radiation therapy, and active surveillance on quality of life (QoL), using patient-reported outcomes. The purpose was to analyse QoL changes from baseline pretreatment assessment to mid-term follow-up according to the initial treatment. Several methodology differences may be highlighted in these two studies; nevertheless the aim and the endpoint were quite similar. In the study from Chen and colleagues, active surveillance has been used as a control group. The quality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline and three, 12, and 24 months after treatment. The questionnaire contains four domains—sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems. All surveys were conducted by telephone. Of 1141 enrolled men, 27.5% were on active surveillance, 41.1% underwent radical prostatectomy, 21.8% chose external beam radiotherapy, and 9.6% underwent brachytherapy. Interestingly, and differently to the recent published phase III ProtecT trial, among included patients undergoing radiation therapy, 94.8% received intensity-modulated radiotherapy, 70.7% had image guidance. Robotic surgery was performed in 86.6% of patients treated by surgery. In the study from Barocas and colleagues, patientreported function was obtained by the 26-item Expanded Prostate Cancer Index Composite (EPIC), a validated instrument for measuring disease-specific function. The main assessment was performed 36 months after enrolment. Patient-reported outcomes were collected via mail survey. Of the 2550 men, 59.7% underwent radical prostatectomy, 23.5% radiation therapy, and 16.8% active surveillance. Both studies were observational, prospective, without randomisation at inclusion. Thus, to adjust for potentially important differences in baseline characteristics across cohorts, propensity weighting (Chen et al.) or multivariable modelling approaches (Barocas et al.) were used to reduce confounding. In addition to analyses of the overall cohort, stratified subgroup analyses based on patients’ baseline QOL level in each domain were also performed to assess if treatments differentially affected men who had different levels of baseline QOL.

In spite of its prospective manner, both studies were observational which explains the not negligible imbalances in baseline patient characteristics, and the difficulties for group comparisons even with propensity weighting or various multivariable modelling approaches.

What were the main conclusions of both articles? Each treatment modality affected at least one domain, and modified the baseline pre-treatment QoL. The most affected domain was probably the sexual function. For example, in the study from Chen and colleagues, 57.1% of men with normal baseline sexual The recent ProtecT trial provides meaningful function reported poor function at 24 months after comparisons between surveillance, surgery and prostatectomy, 27.2% after radiotherapy, 34.2% after radiotherapy, but used old treatments such as brachytherapy, and 25.2% after active surveillance. three-dimensional radiotherapy, open radical The impact of surveillance on QoL was also prostatectomy, which could not reflect the actual emphasised in the article from Barocas and adverse effects of the current treatments. Recent colleagues. However, the time between domain refinements and advances in technology have also led scores decrease and the intensity of this worsening to reduced treatment-related morbidity (minimally were different between treatment arms. invasive surgery, Intensity-modulated radiotherapy) Each treatment modality led to different patterns of while sustaining or improving oncologic control. Thus, QoL changes.

EAU EU-ACME Office

European Urology Today

March/May 2017


To summarise all detailed findings, radical prostatectomy was associated with worse sexual dysfunction and urinary incontinence compared with active surveillance; brachytherapy with worse short-term urinary obstruction and irritation; and external beam radiotherapy with worse short-term bowel symptoms. Conversely, compared with active surveillance, urinary obstruction and irritation scores increased after radiotherapy, and decreased after radical prostatectomy in both studies. Adjusted urinary irritative function scores were slightly better for men with surgery than being monitored at the threshold of clinical significance at one year. Bowel function scores were also higher at Month 6 in men who underwent radical prostatectomy than those who underwent radiotherapy. A continuous improvement was seen over time, whatever the initial treatment. Thus, in the study of Chen et al., by 24 months, mean scores between treatment groups versus active surveillance were not significantly different in most domains. The patient counselling should also integrate the continuous and late improvement of QoL and domain scores after the first initial 12 months of follow-up. None of the treatment groups experienced a clinically significant decline in physical functioning, emotional well-being, or fatigue scores. No differences in health-related quality of life or disease-specific survival. Thus, both studies demonstrated that in spite of the frequency and severity of adverse effects of contemporary treatments, the global quality of life was preserved regardless of treatment. Several limitations have to be emphasised: The use of active surveillance as control group may be questioned. Whereas the QoL scores did not change until 12 months, the differences seen then can be explained by the proportion of patients with cancer progression over time (at control biopsy) and who needed treatment after this initial monitoring period. The choice of the radical deferred treatment will directly impact the QoL scores at 24 months in this control group and will mitigate the differences between active surveillance and immediate radical treatments. In the study from Barocas and colleagues, a participant was categorised as undergoing active surveillance if no treatment was administered within one year of diagnosis. Thus, the distinction between treatment delays, watchful waiting, or real active surveillance could not be clearly done, that introduced interpretation biases. Moreover, a not negligible proportion of patients did answer the baseline assessment after the treatment initiation. The interpretation of QoL score changes remains challenging with doubts with regards to the real clinical relevance of score differences. The minimal clinically important difference representing the magnitude of change that is clinically meaningful to patients remains very debatable and may be discussed in both studies.

localized prostate cancer. Chen et al. JAMA. 2017;317(11):1141-1150. doi:10.1001/jama.2017.1652

Association between radiation therapy, surgery, or observation for localized prostate cancer and patient-reported outcomes after 3 years. Barocas et al. JAMA. 2017;317(11):1126-1140. doi:10.1001/jama.2017.1704

Bariatric surgery by itself may resolve pelvic floor disorders Obesity is correlated with pelvic floor disorders, stress urinary incontinence, overactive bladder, sexual dysfunction and resistance to therapy. Pelvic floor impairment related to obesity may be explained by mechanical and structural changes, weak sphincteric mechanisms, detrusor overactivity. Each symptom may be treated separately; however, obesity-induced pelvic floor disorders could be potentially reversible by weight loss. The impact of life-style interventions on urinary symptoms improvement is difficult to evaluate given the low adherence rate and the doubt regarding long-term efficacy. Bariatric surgery offers the advantages to lead to a rapid and often sustainable weight loss in motivated women. In this prospective trial, the authors have assessed the impact of rapid weight loss provided by bariatric surgery on lower urinary tract symptoms, sexual dysfunction, and organ prolapse. Overall, 150 obese women were included and evaluated pre-operatively and at three to six months by validated questionnaires (ICIQ, BFLUTS, PFDI-20, PISQ-12). Bariatric surgery consisted in 93% of sleeve gastrectomy and 7% only of by-pass surgery. Mean percentage of weight loss after surgery was 22% (mean BMI decrease: 9 kg/m2). At baseline, 37% of women suffered from urinary incontinence (UI), mainly by stress UI (59%) or mixed UI (30%). Surgically-induced weight loss was associated with statistically significant improvement in incontinence rate, storage phase symptoms, organ prolapse symptoms, and sexual function. About half of pre-operatively incontinent women reported complete resolution after bariatric surgery. Only two patients developed de novo urinary incontinence after surgery. Overall, nocturia, urinary frequency, urgency, and bladder pain were improved post-operatively.

Additional specific treatments such as behavioural treatment, pelvic floor muscle training, antimuscarinics drug have not been evaluated in the present study...

At baseline, 29% of women reported organ prolapseIn spite of its prospective manner, both studies were related symptoms. After surgery, 70% experienced observational which explains the not negligible significant improvement, and 32% a complete imbalances in baseline patient characteristics, and the resolution of their symptoms. The overall difficulties for group comparisons even with improvement was mainly attributable to a significant propensity weighting or various multivariable reduction in pelvic heaviness\dullness feeling, as well modelling approaches. And baseline domain scores, as incomplete bladder emptying. and time-since-treatment were the independent variables with clinically significant associations with Among the two-thirds of women sexually active domain scores. Detailed treatment regimens were not before surgery, improvement reported in sexual systematically reported and we know that these function was mainly attributable to sexual desire features (non nerve-sparing surgery, radiation increase, satisfaction during sexual activities, and therapy with concomitant androgen deprivation decrease in negative emotions when having sex. therapy) play a role in functional recovery, mainly regarding sexual function. This prospective study focused on the urinary and pelvic floor symptoms improvements after bariatric Another limitation was that there was no control or surgery in obese women. It demonstrated the positive adjustment for the physician experience and the impact of significant weight loss on all types of quality of care. Regarding missing data, in the urinary incontinence, organ prolapse-related study from Chen and colleagues, at the end of the symptoms, and sexual function. study follow-up, there was no negligible rate of 20-30% of participants across groups and QOL Long-term follow-up remains warranted given that domains. the three to six-month term is not sufficient to conclude on the sustainability of this rapid weight loss In spite of all these limitations, these data should on pelvic floor disorders. Additional specific influence our treatment decision-making and the treatments such as behavioural treatment, pelvic floor patient counselling by anticipating the quality-of-life muscle training, antimuscarinic drugs have not been impact of different therapy options, in terms of evaluated in the present study, and should keep their severity, timing, and recovery. All these findings can place in routine management, as bariatric surgery help patients and physicians choose the most won’t resolve all the multifactorial symptoms appropriate treatment at an individual basis. potentially present in obese women.

Sources: Association between choice of radical Source: Effects of bariatric surgery on female prostatectomy, external beam radiotherapy, pelvic floor disorders. Leshem et al. Urology, 2017, doi/10.1016/j.urology.2017.03.003 brachytherapy, or active surveillance and patient-reported quality of life among men with

Heritability of Lower Urinary Tract Symptoms in men Symptoms of urinary irritation, urgency, frequency and obstruction, known as lower urinary tract symptoms, are common in urological practice. However, little is known about the etiology or pathogenesis of lower urinary tract symptoms, especially the relative contributions of genetic and environmental factors to the development of these symptoms. The authors used a twin study design to examine the relative contributions of genetic and environmental factors to the occurrence of lower urinary tract symptoms in middle-aged men. Twins were members of the Vietnam Era Twin Registry. The investigators used a mail survey to collect data on lower urinary tract symptoms using the I-PSS (International Prostate Symptom Score) instrument. Twin correlations and biometric modeling were used to determine the relative genetic and environmental contributions to variance in I-PSS total score and individual items.

Genetic factors provide a moderate contribution (20% to 40%) to lower urinary tract symptoms in middle-aged men, suggesting that environmental factors may also contribute substantially to lower urinary tract symptoms Participants were 1,002 monozygotic and 580 dizygotic middle-aged male twin pairs (mean age 50.2 years, SD 3.0). Nearly 25% of the sample had an I-PSS greater than 8, indicating at least moderate lower urinary tract symptoms. The heritability of the total I-PSS was 37% (95% CI 32-42). Heritability estimates ranged from 21% for nocturia to 40% for straining, with moderate heritability (34% to 36%) for urinary frequency and urgency. Genetic factors provide a moderate contribution (20% to 40%) to lower urinary tract symptoms in middleaged men, suggesting that environmental factors may also contribute substantially to lower urinary tract symptoms. Future research is needed to define specific genetic and environmental mechanisms that underlie the development of these symptoms and conditions associated with lower urinary tract symptoms.

Source: Heritability of lower urinary tract symptoms in men: A twin study. Afari N, Gasperi M, Forsberg CW, Goldberg J, Buchwald D, Krieger JN J Urol. 2016 Nov;196(5):1486-1492

Are lower urinary tract symptoms in children associated with urinary symptoms in their mothers? The association between parents who suffered daytime incontinence as children and children who are incontinent has been reported. However, the association of lower urinary tract (LUT) dysfunction in children and urinary symptoms in mothers has not been studied.

Mothers with typical symptoms of overactive bladder are more likely to have a child with LUT dysfunction The authors intended to test the hypothesis that the children of mothers with lower urinary tract symptoms (LUTS) are more likely to have urinary symptoms. A cross-sectional multi-centre study was conducted in two cities in Brazil. Children/adolescents of five to 17 years of age and their mothers were interviewed. Children with neurological problems, previously detected urinary tract abnormalities or who refused to sign the informed consent or assent form were excluded. The DVSS questionnaire was used to evaluate the presence of LUTS in the children and the ICIQ-OAB questionnaire was used to evaluate their mothers. Constipation in the children was investigated using the ROME III criteria. A total of 827 mother-child pairs were included, with 414 of the children (50.06%) being male. Mean age

was 9.1 ± 2.9 years for the children and 35.9 ± 6.5 years for the mothers. Urinary symptoms (occurring at least once or twice a week) were present in 315 children (38.1%), incontinence in 114 (13.8%) and urinary urgency in 141 (17%). Of the mothers, 378 (45.7%) had at least one LUTS, with 103 (12.5%) having incontinence and 153 (18.5%) urgency. According to the DVSS, the overall prevalence of LUT dysfunction was 9.1%. The children's DVSS scores were significantly associated with the mothers' ICIQ-OAB scores (p < 0.0010). Mothers with urinary symptoms were 2.5 times more likely to have a child with LUT dysfunction (95%CI: 1.52-4.17; p < 0.001), while mothers with overactive bladder were 2.8 times more likely to have a child with an overactive bladder (95%CI: 1.63-4.86; p < 0.001). In the multivariate analysis, these same characteristics were confirmed as independent predictive factors of the presence of LUT dysfunction in the child. Children of mothers with incontinence and urinary urgency were also more likely to have incontinence and urgency. Mothers with typical symptoms of overactive bladder are more likely to have a child with LUT dysfunction. This correlation is also positive for the isolated symptoms of urinary urgency and incontinence. Independent predictive factors of the presence of LUT dysfunction in children were: being female, enuresis, constipation, and having a mother with LUTS.

Source: Are lower urinary tract symptoms in children associated with urinary symptoms in their mothers? Sampaio AS, Fraga LG, Salomão BA, Oliveira JB, Seixas CL, Veiga ML, Netto JM, Barroso U J Pediatr Urol. 2017 Feb 17. pii: S1477-5131(17)30037-2. doi: 10.1016/j.jpurol.2016.12.017. [Epub ahead of print]

Association between treatment for erectile dysfunction and death or cardiovascular outcomes after myocardial infarction Erectile dysfunction (ED) is associated with an increased risk of cardiovascular disease in healthy men. However, the association between treatment for ED and death or cardiovascular outcomes after a first myocardial infarction (MI) is unknown. In a Swedish nationwide cohort study, all men < 80 years of age without prior MI, or cardiac revascularisation, hospitalised for MI during 2007-2013 were included. Treatment for ED, defined as dispensed phosphodiesterase-5 inhibitors or alprostadil, was related to risk of death, MI, cardiac revascularisation or heart failure.

Treatment for ED after a first MI was associated with a reduced mortality and heart failure hospitalisation A total of 43,145 men with mean age 64 (±10) years were included, of whom 7.1% had ED medication dispensed during a mean 3.3 years (141 739 personyears) of follow--up. Men with, compared with those without treatment for ED, had a 33% lower mortality (adjusted HR 0.67 (95%CI 0.55 to -0.81)), and 40% lower risk of hospitalisation for heart failure (HR 0.60 (95% CI 0.44 to 0.82)). There was no association between treatment with alprostadil and mortality. The adjusted risk of death in men with 1, 2-5 and > 5 dispensed prescriptions of phosphodiesterase-5 inhibitors was reduced by 34% (HR 0.66 (95% CI 0.38 to 1.15), 53% (HR 0.47 (95% CI 0.26 to 0.87) and 81% (HR 0.19 (95% CI 0.08 to 0.45), respectively, when compared with alprostadil treatment. Treatment for ED after a first MI was associated with a reduced mortality and heart failure hospitalisation. Only men treated with phosphodiesterase-5 inhibitors had a reduced risk, which appeared to be dosedependent.

Source: Association between treatment for erectile dysfunction and death or cardiovascular outcomes after myocardial infarction. Andersson DP, Trolle Lagerros Y, Grotta A, Bellocco R, Lehtihet M, Holzmann MJ Heart. 2017 Mar 9. pii: heartjnl-2016-310746. doi: 10.1136/heartjnl-2016-310746. [Epub ahead of print]

Key articles

March/May 2017

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EBU certifies Istanbul Faculty of Medicine IFM’s performance earns third consecutive certification Prof. Dr. Ismet Nane Istanbul University, Faculty of Medicine Dept. of Urology Istanbul (TR)

urology@ istanbul.edu.tr Located within the old city walls, the Istanbul Faculty of Medicine (IFM) has a storied history with roots to the Fatih Darüssifa which dates back to 1470. With over 1,500 hospital beds and more than one million in-patient admissions annually, the IFM integrates clinical, educational, and research activities to retain its place among the country’s top medical schools. The Urology Department was established in 1909 under the General Surgery clinic. In 1944 the Department had a capacity of 40 hospital beds together with Cerrahpasa Faculty of Medicine (CFM), the other Medical Faculty of Istanbul University. After a long period of working together with the CFM of Istanbul University, our department earned in 1967 an independent status within the Istanbul Faculty of Medicine. Prof. Necati Güvenç, who was appointed as the first chairman, introduced the residency training programme in the same year. The Urology Department has a 31-bed adult ward, 10 beds for paediatric patients, and 10 for renal transplant patients. Additionally, a six-bed ambulatory unit serves patients for routine, out-patient procedures. All full breadth of sub-specialty coverage and education is offered, with emphasis on paediatric urology, andrology, renal transplantation, urologic oncology, and urinary stone disease. Sub-specialties such as neuro-urology, female urology, minimally invasive surgery, and reconstructive urology are also led by experienced staff members.

EBU Certified Centres

Last year, the Urology Department admitted over 1,450 patients and performed over 1,100 major surgeries including more than 250 paediatric operations, 210 fertility cases, and 40 renal transplants. Additionally, we see over 43,000 out-patient visits and perform about 3,100 ambulatory procedures annually.

attend case conferences on a weekly basis, and the residents present cases in a formal, organised fashion to facilitate a rational approach to individual patient care. Every resident has the opportunity to present a contemporary article at a journal club meeting, which is held every week and attended by all faculty members and trainees. These meetings aim to improve presentation skills and critical analysis of scientific publications. A morbidity and mortality meeting is held every month and organised by the ward resident. The meeting presents summaries of surgical procedures, out-patient clinic cases, and performance of the department to identify areas where improvements could be made.

Training programme for residents The training programme is nationally accredited for 60 months and is under the supervision of the Programme Director and Training Committee Chair, Prof. Ismet Nane and the Training Committee members Professors Haluk Ander and Faruk Özcan, and Accreditation Faculty, Prof. Taner Koçak. The residents rotate for six months in general surgery, anaesthesiology and nephrology. One to three residents are appointed each year and seven residents With resident rotations, trainees are encouraged to are currently in the programme. attend the relevant subspecialty conferences which are also held on a weekly basis. These are: The programme aims to prepare the residents under the medical education programme created by the • Renal Transplant Conference – Organised in Union Européenne des Médecins Spécialistes (UEMS), conjunction with the department of nephrology the European Board of Urology (EBU), the and medical biology. End-stage renal disease Accreditation Council for General Medical Education patients are evaluated for renal transplantation; (ACGME) and standardised accreditation for Turkey to • Pediatric Urology Conference – Challenging cases create a curriculum for the board of medical are presented and appropriate treatment plans specialists (TUKMOS) in urology. The EBU granted full are developed utilising a consensus of relevant certification to our training programme via the sub-specialists; and Residency Training Programme in Urology (RTPU) for • Urologic-Oncology Conference – Organised in the first time in 2004 and most recently in 2016. conjunction with faculty from the departments of urology, medical oncology, radiation oncology, Education for future academic leaders are also radiology, and pathology. encouraged by the faculty members which are committed to develop a structured programme with Additionally, the National Turkish Association of diverse clinical activities, a focused conference Urology (TAU) and the Pediatric Urology Society schedule, guidance in clinical and laboratory organise monthly conferences on contemporary research activities, and precise supervision for urologic and pediatric topics. Trainees are strongly clinical patient care. encouraged to attend these meetings. Conferences The programme director organises a series of monthly didactic lectures, given by faculty members, which are focused on residents’ education. These state-of-the-art lectures, which are complemented by case discussions, are among the most important educational activities. Trainees are required to

Trainees and faculty are encouraged to take active part in regional, national, and international meetings and educational meetings, including short-term clinical rotations in other institutions. Every resident attends at least two national urological conferences to present academic activities during the course of their training.

Trainees and faculty members

Training Courses The residents are expected to attend, once during their training period, the residency training programme held each year by the Turkish Board of Urology (TBU). Residents in their final year of training attend the European Urology Residents Programme (EUREP) course held in Prague and are encouraged to take the EBU and TBU examinations. Supervision and evaluation All residents keep a log provided by the EBU to document surgical and academic activities and an academic supervisor guides each resident throughout his or her 60-month period of training. The performance of each resident is carefully evaluated annually by the Training Committee members to ensure appropriate growth and establish a rationale for progression through the residency. Residents take the EBU In-Service Assessment annually and the results are evaluated by the Training Committee and resident’s academic supervisor. The standards of our commitment to trainee education are reflected in our third consecutive EBU-RTPU certification under the leadership of Prof. Taner Koçak. Residents are expected to pursue their careers as academics and lecturers in various national and international universities and training hospitals. Our trainees acquire significant advantages for future career development through the discipline and competencies obtained in our department.

European Commission approves eUROGEN Networks to help facilitate healthcare for patients with rare diseases Michelle Battye EAU EU Policy Coordinator Sheffield (UK)

michelle.battye@ uroweb.org After an extensive assessment, eUROGEN, the European Reference Network (ERN) for rare and complex urogenital diseases and conditions, was officially launched during the 3rd conference on European Reference Networks held in Vilnius, Lithuania 9 to 10 March this year. Vytenis Andriukaitis, the European Commissioner for Health and Food Safety, officially awarded certificates to the 24 ERNs Coordinators. They represented almost a thousand multidisciplinary medical teams in more than 300 hospitals, located in 25 EU Member States and Norway. ERN aims to improve diagnosis and treatment and help provide affordable, high-quality and cost-effective healthcare. “I am particularly pleased to launch the European Reference Networks on European Rare Disease Day. As a medical doctor, I too have often been a witness to tragic stories of patients with rare or complex diseases who were left in the dark, sometimes unable to find an accurate diagnosis and receive treatment,” said Andriukaitis. He added: “I have also seen my colleagues struggling to help because they lack information and opportunities to network. These Networks will connect the considerable EU knowledge and expertise that is currently scattered amongst countries, making this initiative a tangible illustration of the added value of EU-collaboration. I am 16

European Urology Today

very confident that ERNs can light the way for rare disease patients, leading them to potentially life-saving and life-changing breakthroughs.” Prof. Chris Chapple, Secretary General of the EAU and also Coordinator of eUROGEN, led a delegation of the network’s clinicians and patient representatives. eUROGEN comprises 29 healthcare providers from 11 Member States. Chapple gave a rousing speech at the event. “I am honoured to be at this meeting celebrating the birth of this new form of cooperation between healthcare providers at a European level,” said Chapple. “In the case of rare or complex urogenital diseases, we can achieve quicker diagnosis and better treatment outcomes for patients by working together at an EU level using an evidence-based approach, and by doing so effectively advance our knowledge of every condition we are treating. This has the full support of the European Association of Urology (EAU) and we will be able to harness the scientific, clinical and educational excellence of the EAU and its membership of over 16,000 members to achieve this.” What are ERNs? ERNs are clinical networks bringing together healthcare providers across Europe to tackle complex

All twenty-four ERN coordinators gathered in Vilnius last March

or rare medical conditions that require highly specialised treatment and a concentration of knowledge and resources. Between 6,000 and 8,000 rare diseases affect an estimated 30 million people in the EU and, frequently, a lack of specialist knowledge for specific rare diseases means patients can miss out on diagnosis and treatment options in their own country. By consolidating knowledge and expertise scattered across countries, ERNs give healthcare providers access to a much larger pool of expertise. This will result in better chances for patients to receive an accurate diagnosis and advice on the best treatment for their specific condition. It is expected that ERNs will lead to improvements in service delivery, working systems, patient pathways, clinical tools, and the earlier adoption of scientific evidence. They will also act as focal points for medical training and clinical research. How will eUROGEN operate? To review a patient’s diagnosis and treatment, eUROGEN will consult, exchange information and share knowledge with other members of the network. A dedicated IT platform and tele-medicine tools will be used for this purpose. ERNs are not directly

accessible to individual patients. However, with the patient’s consent, and in accordance with the rules of their national health system, a patient’s case can be referred to the relevant ERN member in their country by their healthcare provider. ERNs work as an accreditation system, with participating healthcare providers being awarded a protected logo which certifies them as centres of clinical excellence in a particular clinical domain. To achieve this status, providers will have documented their competence, experience, and level of activity, as well as demonstrated evidence of good clinical care and outcomes through a rigorous assessment process. The objectives of eUROGEN are as follows: • Improve care for patients with rare or lowprevalence complex diseases or conditions; • Concentrate expertise where capacity and knowledge are rare; • Provide access to the most appropriate diagnosis and treatment of certain conditions; • Allow expertise -not the patient- to travel across borders; and • Act as focal point for medical training and research. March/May 2017


PCa17: Focus on critical insights and best practices

PCa17 EAU Update on Prostate Cancer

15-16 September 2017 Vienna, Austria

www.pca17.org

New EAU onco-urology series Register before 15 June for the early fee!

Management of prostate cancer remains a challenge particularly with the rapid changes in drug development, surgical approaches and new evidence-based medical strategies. To provide an incisive, expert-led meeting, the European Association of Urology (EAU) has launched PCa17, the first of a new and specialised uro-oncology series, which will be held in Vienna from 15 to 16 September. Organised with the full support of the EAU’s frontline educational and specialist offices, the meeting distinguishes itself by focusing on educational goals, training and expert-led interactive sessions. “PCa17 will provide a new didactic concept and participants will be fully updated on all aspects of diagnosis and treatment of prostate cancer. They will be able to follow and understand the actual EAU Guidelines on prostate cancer, and at the same time be informed on upcoming developments which challenge the guidelines,” said Prof. Jens Rassweiler, chairman of the EAU Section Office. Rassweiler co-chairs PCa17 together with Professors Manfred Wirth, EAU Executive member and Joan Palou of the European School of Urology (ESU). “Participants will benefit by learning new insights in the diagnosis and surgical management of prostate cancer,” added Palou. “Quite often there are a lot of lectures on prostate cancer, but in this meeting we will go through practical clinical cases, a much better way to learn.” Rassweiler said medical technology has seen advances in recent years that have re-defined the diagnosis and treatment of PCa. “We need to define the optimal treatment option (i.e. active surveillance, focal therapy, radical therapy, radiotherapy) for each individual patient,” he said whilst noting that specialists have to take into account the benefits that can be gained from new approaches.

“The emphasis is not only on new approaches and technologies, but more importantly how real-life case scenarios require approaches that may even show the limits of these new technologies.” “There is a continuous improvement concerning imaging of prostate cancer, mainly in multiparametric magnetic resonance tomography (mp-MRT); however, transrectal ultrasound technology has also improved (i.e. by including elastography or color-coded Duplex),” Rassweiler explained. “Parallel to these technologies, computerized systems enable the use of fusion technology to overlay the MR-image on real-time TRUS-screen. Moreover, the first robot-assisted devices have been introduced to facilitate biopsy of the prostate. This will have an impact on the detection rate of prostate cancer and might be even used as a tool for focal therapy of prostate cancer.” Palou noted that many hospitals in Europe have yet to fully implement a multi-disciplinary strategy or form multi-disciplinary teams (MDTs) when treating prostate cancer, which he considers a missed opportunity since MDTs can provide crucial support and enable doctors to offer optimal care.

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March/May 2017

“It’s important to have a multi-modality approach. We have to work with radiotherapists, radiologist and oncologists since a multidisciplinary approach is a very important step in PCa treatment,” Palou said. “A lot of centres are still not working in this manner. Having a multi-modal approach has to be clearly conveyed. This is important.” The ESU is also introducing pre- and post-meeting testing for PCa17. To quantify the knowledge attained during the meeting, delegates will receive a questionnaire before and after the meeting, which will cover the contents taken up during the meeting. To keep track of answers, PCa17 will also feature personal voting. The meeting’s Scientific Programme features breakout case discussions where the faculty will form four groups to discuss in detail treatment strategies using cases encountered in clinical practice. Practical insights will be gained from in-depth discussions of topics such as how to perform fusion and systematic biopsy, using imaging tools and patient selection for active surveillance, among others. “The emphasis is not only on new approaches and technologies, but more importantly how real-life case scenarios require approaches that may even show the limits of these new technologies,” said Wirth. On Day 1, for example, expert radio-oncologists will shed insights on radiotherapy, informing urologists regarding best practices, their benefits and the limits of radiotherapy. “Individual patients have distinct needs and what we previously think to fit all patients does not necessarily apply to everyone,” added Wirth who will lecture on the role of biomarkers and genomics. The series will in the future also include renal, bladder and other malignant urological diseases, with the core objective to provide a dynamic platform for education and knowledge-sharing. An exhaustive assessment of both standard and new treatment approaches will also be offered, characterised by a practical approach in discussing clinical cases and a close interaction with the faculty. With its emphasis on both practical and educational aspects, the compact programme complements the EAU’s existing line-up of CME-accredited and specialised meetings, and especially tailored to the needs of doctors who can only take a few days off from their clinical duties. For all relevant information including the full scientific programme and registration details, visit: www.pca17.org

First, single-topic update on onco-urology series In-depth and interactive break-out sessions Pre & post-educational assessments Expert mentorship and CME accreditation

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The 2018 Guidelines print Attention now moves swiftly to the preparation of the 2018 Guidelines. The focus this year will continue to be on ensuring all Guidelines are based on detailed and evidenced literature searches and standardising the phrasing of recommendations.

The 2017 Guidelines print The EAU Annual Congress in March marked the publication of the 2017 EAU Guidelines compilations; both pocket and extended versions (see below). Both publications were given out at the EAU Congress in London to an enthusiastic audience resulting in long queues of 45 minutes or more.

Please note that to access individual Guidelines and their translations as PDFs, you must log in as an EAU member. Non-members are only able to view the documents on the website.

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Platinum Award Winners We are pleased to announce that our Guidelines Board Chairman, Prof. James N’Dow and the Vice-Chairman of the Renal Cell Cancer Guidelines Panel, Prof. Axel Bex, have been honoured with the European Urology Platinum Award in recognition of their continuing support and dedication to the Platinum Journal both as reviewers and authors.

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Pocket App The Guidelines Office has launched a new and improved app for the pocket guidelines. It is available free to download for all EAU members in the iTunes App Store and Google Play Store. Search for “eau guidelines” in your app store.

The Guidelines and Social Media The EAU GO can be found on Facebook and Twitter (#eauguidelines). Look out for our weekly tweets from the Guidelines Panels. From its official start in January 2015, the hashtag #eauguidelines has disseminated over 8,000 tweets, with upwards of 9 million impressions, leading to a 40% increase in the number of followers of the EAU Twitter account. In addition the Social Media Group, chaired by Prof. Maria Ribal, has had its first paper published in the BJUI on the EAU’s success with using Twitter as a medium to disseminate and evaluate adherence to its guidelines.

Background information from the Guidelines, including systematic review protocols and literature search strategies, can be viewed online on the Uroweb pages under ‘Individual Guidelines’. Some of this information is already available, but these pages will continue to grow in the upcoming months.

Euro

016 Box 30 Arnhem 03 AA rlands the he Ne 80 389 06 (0)26 9 0674 T +31 (0)26 38 g F +31 eb.or @urowg lines guide uroweb.or www. idelines gu #eau

EAU Guidelines 2017 Publications

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2017 edition

2017 n editio

2017 Guidelines cover

Prof. Axel Bex receiving his award from Prof. James Catto, Editor-in-Chief of European Urology

Prof. James N’Dow receiving his award from Prof. James Catto, Editor-in-Chief of European Urology

WEEK 2017 25-29 SEPTEMBER

Cutting-edge Science at Europe’s largest Urology Congress

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

Step Up! Join the Campaign for public awareness of urological conditions

33rd Annual EAU Congress www.eau18.org

European Prostate Cancer Awareness Day 27 September 2017

urologyweek.org 18

European Urology Today

#urologyweek March/May 2017


ELUTS17: A new meeting dedicated to lower urinary tract symptoms ESFFU, ESGURS, ESU and EUGA join forces Lower urinary tract symptoms and functional urology are receiving less attention from traditional industry partners, and so it is vital that the European Association of Urology fills this void with a dedicated meeting, according to Prof. Francisco Cruz (Porto, PT) Chairman of the ELUTS17 Organising Committee. Prof. Cruz is also the chairman of the EAU Section of Female and Functional Urology, ESFFU.

Prof. Cruz

“At the moment, functional urology lags behind other topics within our field, topics like uro-oncology. The purpose of our meeting is two-fold: firstly to draw urologists’ attention to functional urology, particularly as LUTS are extremely common in the ageing European population.”

“Secondly, we want to convince younger urologists who have not yet specialised in a particular area that functional urology is attractive and can provide an interesting and competitive future for them. The European Lower Urinary Tract Symptoms Meeting will be taking place on 13-14 October, in Germany’s capital, Berlin. It will be taking place in conjunction with the 10th ESU-ESFFU Masterclass on Female and Functional Reconstructive Urology, a seven-module course held on 12-13 October. Together with PCa17 in Vienna, ELUTS17 marks the beginning of a new direction for EAU Meetings: topic-oriented and with a strong educational component. Importance of functional urology and LUTS Lower urinary tract symptoms may not be an immediate, acute killer for the patients that suffer them, but they can be a (first) indicator of larger problems and have a large impact on the quality of life of the sufferer. Therefore, a continuing familiarity of urologists with LUTS and functional urology is vital for patient welfare. Prof. Cruz: “Of course we don’t expect patients to die because they have urgency or frequency incontinence, but they will be extremely bothered. Their sleep patterns will be affected and daily activities will be much more difficult. Eventually LUTS can cause co-morbidity, for example if elderly patients have to get out of bed multiple times during the night. They are vulnerable for falls and fractures, especially the femur.” “Another point is that the treatment of LUTS must be understood in conjunction with all the treatments of co-morbidities that these patients usually have. There are serious concerns about the use of antimuscarinic drugs and common medications with antimuscarinic effect over long periods of time.” “A third point: many functional changes in the lower urinary tract can be a consequence of oncological treatment, so as urologists we can make a bridge between the two. Urologists deal with oncological problems and cannot simply abandon patients with, for example, urinary incontinence following radical prostatectomy.” If urologists are no longer the prime carers for LUTS patients, the closest specialty to deal with these symptoms are gynaecologists. “Some countries have specialists in between both fields, uro-gynaecologists. We understand the importance of gynaecologists and their experience in the treatment of LUTS, hence our collaboration with EUGA, the European Urogynaecological Association for this meeting. This brings gynaecologists to the EAU, allows us to exchange information and experience and ultimately lets us improve the quality of the meeting.” Essential educational value This year, ELUTS17 is combined with the 10th ESU-ESFFU Masterclass on Female and Functional Reconstructive Urology. The masterclass has been successfully held since 2008. While successful in its own right, Prof. Cruz hopes that by combining it with a larger meeting like ELUTS17 the masterclass will be introduced to a larger public and lead to more applications in future.

March/May 2017

Register before 12 July for the early fee!

The masterclass aims to provide high-level training on a very interactive basis that will not only update but also equip urologists with specialised skills to meet future challenges. The management of functional disorders in the female, such as lower urinary tract diseases and those in the pelvic floor and related organs are among the subjects covered in this compact, 7-module course. Male incontinence and diversion surgery will also be covered. The masterclass will be held on 12-13 October, and will require a separate registration. Attendance is free, but due to the limited space available the course directors will make a selection of the attendants. More information is available on www.eluts17.org Prof. Cruz: “In addition to this dedicated, intense masterclass, the scientific programme of ELUTS17 will also have a strong educational component. Delegates can expect to receive a questionnaire pre- and post-meeting in order to gauge their knowledge. Each speaker is also expected to prepare a few short multiple choice questions related to their talk for a pre- and post-session quiz.”

“Many functional changes in the lower urinary tract can be a consequence of oncological treatment, so as urologists we can make a bridge between the two.” Hottest topics The ELUTS17 scientific programme takes place over the course of two days, and features state-of-theart lectures, in-depth sessions with multiple discussants, semi-live surgery sessions and a lot of specific, practical and clinically applicable advice for delegates. Prof. Cruz on some of the more pressing topics that delegates can look forward to: “First, we must examine LUTS and in particular storage LUTS. These symptoms are difficult to treat, and occur widely, particularly in elderly people. The cause of these symptoms is not always clear, but for the patient they are extremely bothersome. Correct management of these symptoms is essential in my opinion.” “These kinds of storage LUTS will affect women, but not exclusively. This gender ‘problem’ is the result of most regulatory trials by industry dealing in the past with women only. It has almost become assumed that this was exclusively a women's problem while men suffer from BPH and bladder outlet obstruction. So it’s important to know that these symptoms can exist in both genders and should be recognised by treating urologists.” Nocturia is the most prevalent LUTS, and it too is associated with mortality. The aforementioned risk of falling during nightly voiding is one aspect, but nocturia can often be an indicator of bigger problems: “Nocturia is multifactorial, and heart disease, sleep apnoea, and diabetes, all might contribute to nocturia. Here education is again very important for young urologists, and those dedicated to functional urology: nocturia is not the same as a sign of prostate problems. It’s in fact a symptom that can be caused by a huge number of different conditions. Urologists are in the ‘front line’ when these patients look for help, so urologists need to be well aware of the related conditions that patients may be suffering from.”

ELUTS17 European Lower Urinary Tract Symptoms meeting

12-14 October 2017 Berlin, Germany

www.eluts17.org

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

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

European Urology Today

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European Urology Forum Davos ‘Challengers’ commend insightful discussions Participants in the Challenge the Experts segment of the annual European Urology Forum held annually in Davos commended the excellent critiques and discussions, and expressed enthusiasm regarding the dynamic interaction among the challengers, expert panel and the audience. Below are the comments and feedback from the five participants: Dr. Achilles Ploumidis Athens Medical Center, Dept. of Urology, Athens (GR) The European Urology Forum in Davos is one of the wellestablished congresses with a high-quality scientific programme. This year was the 26th edition and as expected the highlight of the forum was the “Challenge the Experts.” In this segment five young, promising urologists with an academic profile prepare three (chosen out of an initial five) 20-minute state-of-the-art lectures that are presented over three days to the audience and a panel of five expert professors. After each lecture the tension starts to mount as the expert panel confronts the challengers with provocative questions. To participate in this prestigious but demanding programme is a great honour and once-in-a-lifetime experience. The opportunity to exchange experiences led to new friendships and brought the urological community even closer. All in all, the Challenge the Experts Forum is a unique experience.

"The faculty gave excellent critiques, and many of their comments will help me shape my future research."

Dr. Prasanna Sooriakumaran University College Hospitals London, Dept. of Oncology, London (GB) I was privileged to be a Challenger at the European Urology Forum in Davos this year. I wanted to use the opportunity to get feedback on my own research. Hence, all my presentations revolved around my own work. The faculty gave excellent critiques, and many of their comments will help me shape my future research. Besides the immense intellectual benefit, the congress was also a lot of fun. I got to know the other Challengers and learn from their experience, and the spirit of camaraderie was great. I am fortunate to have been invited to speak at many national and international conferences, but the European Urology Forum was one of my favourites and I will treasure my experience of this congress.

Rafael! With these friendships, I believe we could work together and carry out joint scientific collaborations. Dr. Marij Dinkelman Erasmus MC, Dept. of Urology, Rotterdam (NL) The concept of the European Urology Forum immediately sparked my enthusiasm because it raised the opportunity to lecture on three topics of my choice in andrology, challenge an expert panel and interact with an audience of urologists. The cherry on the cake was to compete with four peers with impressive track records in their fields of expertise with the snowy Davos mountains as setting.

have and you start thinking about the actual event, your presentations, questions, arguments, etc... The solution is to go back to the basics-- read, study and clarify every single point to be discussed during the lectures. It is stressful but definitively delighting.

You work hard and then the day comes: you arrive at beautiful Davos and the actual challenge starts… During the event, all participants get full support at all times. The organisation is perfect and you have opinion leaders exchanging ideas with you in a very familiar fashion. Amazing. Most importantly, you exchange ideas with your fellow challengers. Everyone is supportive and the difficulty is gone since the ambience is cordial. That being said, one is inspired to improve the succeeding presentations, reading until late night as if in a training. From this routine, one thing happens: you actually challenge yourself. After I gave the last lecture, the snow looks a It was challenging to balance the educational value with my opposing views on the common opinions that bit different than in the first day… and you realise you have another great day of fulfilment: A goal is microTESE is always superior to conventional TESE, Dr. A. Erdem Canda accomplished. Davos was certainly a unique, rich and and the adequacy of current methods to assess Professor of Urology, Ankara positive experience! patient and partner satisfaction following penile Yildirim Beyazit University, curvature surgery. I shared my thoughts on future Ankara (TR) research directions in the development of diagnostic The European Urology Forum’s seminal plasma biomarkers and alternative hormonal Challenge the Experts in Davos treatment to testosterone replacement therapy. It was was a great experience, and I a privilege to participate and an honour to win First would like to thank the organizing Prize (also a first for a female contestant). committee for inviting me to this wonderful meeting. I had the chance of giving three talks during this Dr. Rafael Sanchez Salas meeting which have improved my presentation skills. L’Institut Mutualiste Montsouris, After each presentation, I received advice and Paris (FR) suggestions from the expert panel of professors which Two days of happiness and an helped me to further improve my next talk. awesome experience. The day you Additionally, I had the opportunity of presenting my receive the invitation to own surgical interests and experience to the audience participate as a Challenger in and expert panel. Lastly, and maybe the most Davos makes one, indeed, very The five challengers after the forum with Prof. Palou in the important, I formed wonderful friendships with the happy. Somehow, it comes as a prize for your effort middle other challengers- Marij, Achilles, Prasanna and and work. Then you realize the responsibility you

EAU Education Online presents;

EAU Guidelines E-Courses How well do you know EAU Guidelines? The online e-courses feature questions formulated by experts in the field, reviewed by the EAU Guidelines Office and the Young Urologists Office.

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

Renal Cell Carcinoma (RCC)

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

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

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

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

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European Urology Today

Surgery in Motion School is a collaboration of

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

uroweb.org/education

March/May 2017


Highlights of the ESU Masterclass on Lasers in urology Comprehensive masterclass in Barcelona provides key skills and insights Dr. Angelo Territo Urology Dept Fundació Puigvert Barcelona (ES)

Dr. Alberto Breda Urology Dept Fundació Puigvert Barcelona (ES)

abreda@fundaciopuigvert.es Co-Authors: Ass. Prof. Evangelos Liatsikos, Dr. Joan Palou The third edition of the ESU Masterclass on Lasers in Urology took place on November 3 to 4, 2016 at Fundaciò Puigvert in Barcelona (Spain) in collaboration with the EAU Section of Uro-Technology (ESUT). Organised by Alberto Breda, Evangelos Liatsikos and Joan Palou, the two-day course aims to provide a detailed description of all applications of laser technology in urology, including the management of benign prostatic obstruction (BPH), bladder and upper tract urothelial tumours (UTUC), urinary tract strictures as well as stone disease. Pre-recorded operations were shown and, for the first time, live surgery was performed to provide participants with a realistic insight of clinical laser practice. The programme’s first day examined the use of contemporary laser systems such as the Holmium laser, the 532-nm lasers, KTP-80W, HPS-120W and XPS-180, Diode laser and the Thulium: YttriumAluminium-Garnet. Lectures were given by experts such as Oliver Traxer, Fernando Gomez Sancha, Luca Carmignani, Evangelos Liatsikos and Thomas Knoll who described the various techniques and procedural details. Live surgery sessions included a flexible ureteroscopy (Olympus) with laser lithotripsy (Rocamed) of a lower pole < 2 cm kidney stone performed by Prof. Traxer and a mini – PCNL (Karl

Storz) with laser lithotripsy (Lumenis) performed by Prof. Knoll.

"Pre-recorded operations were shown and, for the first time, live surgery was performed.." In the afternoon, Prof. Traxer gave a comprehensive lecture on the conservative management of upper tract urinary cancer (UTUC). The emerging use of confocal laser endomicroscopy (Cellvizio® system, Cook Medical) was presented during a live surgery performed by Dr. Alberto Breda. He emphasised the advantages of conservative management of UTUC with Holmium laser ablation (Cook), and the usefulness of Dr. Breda moderating discussion on “Lasers for BPH” with Dr. Scoffone, Dr. Fernando Gomez Sancha, Dr. Carmignani, Dr. Ponce de Leon the CLE in distinguishing low versus high-grade UTUC. A pre-recorded UTUC surgery (Olympus) with laser ablation performed by Prof. Marianne Brehmer was also shown. The attention shifted to the bladder cancer laser treatment and various pre-recorded cases including an excellent demonstration of en-bloc technique by Prof. Thomas Herrmann, as well as a live en-bloc laser resection (Revolix, Lisa Laser) of a 2 cm bladder tumour by Dr. Breda were shown. The second day course was dedicated to the laser treatment of BPH. The first two hours consisted of lectures on the different enucleation/vaporisation techniques presented by Dr. Gomez Sancha. Dr. Cesare Scoffone, Dr. Luca Carmignani and Prof. Evangelos Liatsikos led a round-table case discussion. Drs. Scoffone and Fernando Gomez Sancha later performed live surgical procedures, including a HoLEP (Boston Scientific) and 180 W vapo-enucleation with the green light laser (AMS), respectively. On both days, tips and tricks were given to optimise the efficacy of laser treatment and to manage commonly encountered complications. From left: Prof. Evangelos Liatsikos, Dr. Alberto Breda, Dr. Armando de Gracia, Dr. Cesare Scoffone, Dr. Joan Palou

In this masterclass, Fundaciò Puigvert hosted 44 participants, from all over Europe, who learned the basic concepts of the various laser treatments and how to identify the ideal patient for each approach. With expert lectures and interactive discussions, the course provided two full days for participants to exchange opinions and experiences. This year’s Lasers ESU Masterclass will again take place in Barcelona at Fundaciò Puigvert from 23 to 24 November 2017. We hope to see you for another comprehensive masterclass! Special thanks to our sponsors BK Ultrasound, Boston Scientific, Cook Medical, Karl Storz, Lisa Laser, Lumenis, Olympus, Rocamed, Quanta Systems.

Dr. Fernando Gomez Sancha performing BPH vapoenucleation

Participants of the Masterclass: Dr Giocchino Leto, Dr Angelo Territo, Dr. Giuseppe Mastrocinque

Teaching activities 2017 European School of Urology June 3 3

8 16 16 16-17 20 30

October ESU course on Current topics in andrology at the national congress of the Slovenian Association of urology, Bled (SI) ESU course on The management of small renal masses: From active surveillance to partial nephrectomy at the time of the Uro-oncology section meeting of the Hellenic Urological Association, Kavala (GR) ESU course on Current topics in andrology at the national congress of the Slovak Urological Society, Trenčianské Teplice (SK) ESU course on Renal and penile cancer at the national congress of the Romanian Association of Urology, Bucharest (RO) ESU course on Urolithiasis at the national congress of the Ukrainian Urological Association, Kiev (UA) 1st ESU-ESUT Masterclass on Urolithiasis, Patras (GR) ESU course on Urethral reconstruction at the national congress of the Polish Urological Association, Katowice (PL) ESU course on Update in diagnosis and treatment of prostatic diseases and Chronic pelvic pain at the national congress of the Kyrgyzstan urology and andrology Association, Cholpon Ata (KG)

July 9-15

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March/May 2017

12-13 13 17

ESU course on The management of small renal masses at the national congress of the Tunisian Urological Society, Hammamet (TN) 10th ESU-ESFFU Masterclass on Female and functional reconstructive urology at the European Lower Urinary Tract Symptoms meeting (ELUTS17), Berlin (DE) ESU course on Update on Uro-oncology at the national congress of the Turkish Association of Urology, Girne (CY) 4th Confederación Americana de Urologia Residents Education Programme (CAUREP), Santa Cruz (BO)

November 6 10 16-19 23-24

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

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

September 1-6 25

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15th European Urology Residents Education Programme (EUREP), Prague (CZ) ESU-ERUS courses at the 15th Meeting of the EAU Robotic Urology Section (ERUS), Bruges (BE) ESU course on Recent developments in diagnosis and treatment of stone disease at the Urological Section of Serbian Medical Society, Belgrade (RS)

2 6 7-8 8

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

European Urology Today

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ESU Course in Macedonia Insights and best practices in uro-oncology Ass. Prof. Sotis Stavridis Clinical Center Skopje Dept. of Urology Skopje (MK)

stavridiss@ gmail.com After 15 years, the European School of Urology (ESU) returned to Macedonia to participate in the 2nd Congress of the Macedonian Association of Urology which took place in Skopje from 8 to 9 April at the Macedonian Academy of Sciences and Arts. There were more than 150 participants and lecturers from several countries in the region, Europe and overseas. Besides general urology, the main topics included uro-pathology, uro-oncology and transplantation. The sessions featured several lectures which offered updates on contemporary diagnostic and therapeutic modalities in prostate, kidney and bladder cancers, surgical approaches, as well as treatment for both benign and malignant diseases. The meeting was endorsed by regional urological associations whose members contributed to the meeting with lectures and poster presentations and actively joined in plenary discussions.

The scientific programme of the congress focused on state-of-the-art lectures and debates participated in by distinguished and locally renowned faculty. The programme provided the opportunity for participants to update their knowledge and refine their clinical practice and surgical skills. Moreover, the participants were given an overview of the latest developments in modern urology.

"At the end of the course several quality interactive cases were discussed with the local faculty, Drs. Ristovski, Stankov, Saidi and the author"

Over 150 colleagues joined the congress in Skopje

A half-day ESU Course in which new treatments and techniques in uro-oncology were presented, including lectures on the advances in minimally invasive treatments of prostate, bladder and kidney carcinomas. The international ESU faculty composed of Prof. Axel Bex (NL), Dr. O. Rodriguez Faba (ES) and Assoc. Prof. Alexander Govorov (RU) gave interesting lectures on the abovementioned topics. At the end of the course several quality interactive cases were discussed with the local faculty, Drs. Ristovski, Stankov, Saidi and the author. Finally, the participants, the local and ESU faculty were unanimous in one thing; the ESU Course during our national congress was a success!

In the breaks there was time to meet up and exchange with the other participants

Dr. Oliver Stankov, MAU President, welcoming the participants to the 2nd MAU Congress

ESU Hands-on Training on Laparoscopy and Endourology Cáceres comprehensive training impresses young surgeons Participants to this year’s edition of the European School of Urology’s (ESU) Hands-on Training Course on Laparoscopy and Endourology expressed satisfaction and high approval for the four-day annual training which took place from 31 January to 3 February in Cáceres, Spain.

skills were vastly improved. I am very satisfied and would not hesitate to join again.

The programme is well-known for its full training scheme and its goal to provide participants a practical platform wherein they have the opportunity to hone and master surgical skills with the aid of modern equipment, expert mentors and an excellent support staff.

Dr. Konstantinos Zougkas: Thank you very much for this opportunity to participate in the ESU Hands-on Training Course on Laparoscopy and Endourology. I truly enjoyed the whole experience. We had good facilities and the professionalism of the local staff was impressive. It was also wonderful to meet colleagues from other European countries. I definitely recommended this meeting to those who are interested to improve their skills in laparoscopy and endourology.

Below are some of the comments and short testimonials from participants in this year’s training programme: Dr. Rauno Okas: The ESU Hands-on Training Course on Laparoscopy and Endourology which took place from 31 January to 3 February 2017 in Caceres, Spain was just fantastic. The course was well organised and very practical. Twenty participants from different European countries were grouped into pairs. Each pair learned and practised together various laparoscopy and endourology procedures for two days.

Dr. Ramiro García Ruiz: The course was wonderful and helped me improve my skills using a wide range of instruments (human and electronic).

The trainees were grouped in pairs

Laparoscopic superextended lymph node dissection

Learning laparoscopy started with the use of training sets to get familiar with basic manoeuvers. We then proceeded to practise vesicourethral anastomosis and later operated on anesthetized pigs. We performed kidney resections, nephrectomies, pyeloplasties and radical prostatectomies.

Dr. Carlos Carrillo: Thank you for the opportunity to participate in the ESU Hands-on Training Course in Cáceres. It has really been an interesting practical course where we performed many laparoscopic and endourological procedures using simulators and animal models. The chance to meet colleagues from other European countries and share impressions and work experience has been really satisfactory. I would recommend this course and would even join again given the chance.

"This was an unparalleled opportunity to develop skills with fantastic resources" Similarly, endourology training started with the use of training sets for semi-rigid ureteroscopy and later advanced to pig models. Each pair could practise puncturing the kidney (for PCNL or nephrostomy). The second day of endourology was dedicated to practising the handling of flexible ureterorenoscopes and stone dusting in kidneys. Although pig anatomy differs from human anatomy, this course was very helpful in improving our technical skills in various urological procedures.

Dr. Miguel Angel Rodriguez Cabello: The course was excellent and I look forward to a similar opportunity in the future. Dr. Mateo Hevia: There were great facilities, accommodation, tutors, trainees and a high-quality course which improved our laparoscopic and endourological skills. Thank you ESU.

A great opportunity to meet people with different background

Dr. Grzegorz Fojecki: I enjoyed the course which exceeded all my expectations. The good facilities of the surgical centre, high-level of training and the chance to interact with colleagues from across Europe in a relaxed atmosphere make this course memorable. Thank you very much. Dr. Wojciech Polom: Thank you for this excellent course which helped me improved my endourological and laparoscopic skills.

Rauno Okas and colleague practising one of the basic manoeuvers

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European Urology Today

C-arm X-ray

Pieter Uvin and colleague training with an animal model

Dr. Ahmet Keles: Thanks for this excellent ESU course! We improved our lap-endo skills and shared knowledge with colleagues from other European countries.

Dr. Pieter Uvin: The ESU course is certainly one of the best educational experiences I have had. The practical training in real surgery was so good that my surgical

Dr. Aideen Madden: This was an unparalleled opportunity to develop skills with fantastic resources. I really enjoyed this course, and loved the opportunity to meet people with different backgrounds! March/May 2017


www.esuurolithiasis17.org

www.esusalzburg17.org

1st ESU-ESUT Masterclass on Urolithiasis

ESU - Weill Cornell Masterclass in General urology

16-17 June 2017, Patras, Greece An application has been made to the EACCME速 for CME accreditation of this event

9-15 July 2017, Salzburg, Austria An application has been made to the EACCME速 for CME accreditation of this event

www.esulasers17.org

www.esufocaltherapy17.org

4th ESU-ESUT Masterclass on Lasers in urology

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

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

March/May 2017

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

European Urology Today

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International Transplant Fellowship Programme Offering a global transplant fellowship Prof. Enrique LledóGarcía Chairman, ESTU Madrid (ES)

elledo.hgugm@ salud.madrid.org

Prof. Jens Rassweiler Chairman, EAU Section Office Heilbronn (DE)

jens.rassweiler@ slk-kliniken.de Co-Authors: Prof. Giselle Guerra, Prof. Gaetano Ciancio Transplantation is an evolving field throughout the world. Both medical and surgical advances have paved the way to significant improvements in donor and recipient selection/care, OR and peri-operative management, and long-term post-transplant patient follow-up. Throughout Europe, the transplant practice involves urologists performing kidney transplants and follow-up of these patients, which they perform independent of specialised nephrologists. However, there are limited fellowships in both medicine and surgery solely focusing on transplant care and none which involve a multidisciplinary approach. This limitation on kidney transplant fellowships throughout Europe has EAU Section of Transplantation Urology (ESTU)

warranted a significant need for expansion and an opportunity to establish an elite group of physicians trained from two different systems, both European and American that will lead to better patient care. The Miami Transplant Institute (MTI) is one of the leading transplant centres in the United States. It is a unique place where both academia through the University of Miami collaborates with one of the largest public health systems in the country, the Jackson Memorial Hospital. Since the 1970s, it has been in the forefront of both surgical and medical endeavours where new surgical skill sets and clinical research have led to some of the current standard practices of medical care in kidney transplant recipients. The MTI has currently performed more than 570 transplants in 2016 of which 350 were kidney/kidney pancreas surgeries. This volume has enabled the MTI to have the third largest transplant programme and become the No. 7 in kidney transplants in the US. Besides volume, quality forms the core essence for improving patient and allograft survival; and thus many committees at this transplant centre are actively working on redefining opportunities to excel on. At the MTI, the kidney transplant programme has exceled in one-year and three-year graft survivals especially in the paediatric programme where survival is at 100%. With the collaboration of the European Association of Urology-ESTU, MTI and several European Kidney Transplant Urological - excellence centres, there will be a chance to develop a unique international training programme. The goal with the international Kidney Transplant fellowship will be to develop a wellformulated comprehensive educational training that will enhance growth of quality across current existing European transplant programmes with emphasis on both surgical and non-surgical aspects. The curriculum will focus on the following: different surgical modalities for donor and recipient kidney surgeries; organ preservation; integration of various immunological testing and thus risk stratification of

patients prior to transplant to formulate proper immunosuppressive protocols/monitoring (especially with highly sensitised patients); post-transplant follow-up management for both short and long term care; various use of immunosuppressive regimens; importance of identifying non-surgical complications and management that includes chronic rejection, polyomavirus, infections and malignancy; and integration and importance of a multidisciplinary approach to promote best quality practice. There will exist plenty of opportunities for global communication not only to enhance clinical practice but allow for ongoing research endeavours.

Profs. E. Lledo-Garcia, J. Rassweiler, G. Guerra (Transplant Institute, Miami) and G. Ciancio (Transplant Institute, Miami)

The fellowship will provide potential urologist and nephrologist candidates in Europe a rotating six-month programme at a recognised European urologicalnephrological centre of excellence in renal transplantation followed by 12 months at the Miami Transplant Institute at Jackson Memorial Hospital in Miami, Florida. Thus, the fellowship will last for a minimum duration of 18 months. It will require the selected urological and transplant nephrology fellows to participate at the transplant hospital (OR, ICU, and floor care) as well as in the outpatient setting in clinics and all multidisciplinary meetings including: selection/ wait-list meetings for kidney, kidney pancreas and living donors, MTI high risk committee meetings, journal clubs and morbidity and mortality reviews.

transplant programme in Europe with career endeavours excelling in transplant as noted in their CV.

In addition, educational opportunities will be offered at the Histoimmunological (HLA) lab and the Organ Procurement Organization (OPO). We also aim to provide opportunities for active participation in the various current research projects at the MTI.

An outstanding support coming from EAU Section Board Chairman, Prof. Jens Rassweiler, EAU Executive Committee and EAU-EUSP Chairman Prof. Vincenzo Mirone has been essential in developing this process, with the first application proposal, hopefully, coming in by 2017-2018.

The basic requirements of the international transplant fellowship will be for the participants to be nationally board-certified in Urology or Nephrology respective of their career paths, have obtained their European Board of Urology (EBU) or the European Board of Nephrology degrees, have at least passed their US Medical Licensing Exam (USMLE) for Steps 1 and 2, and have had a two-year minimum clinical experience at a renal

We will have a selection board formed by both kidney transplant urologists and nephrologists from the respective European Urological Association and European Nephrological Societies along with the Miami Transplant Institute. We will proceed with selection of candidates, six to eight months before the start of the fellowship. Every six months, fellow evaluations will take place and at the end of the fellowship an attainable degree will be given- the International Degree on Renal Transplant Fellowship. ESTU-EAU Fellowship on Kidney Transplant certificate could be awarded on behalf of the EAU-EUSP.

The degree will be evaluated across European centres to work as transplant physician and in the US in order to define possible credits which are useful as an additional merit to apply for full fellowship in US centres. Ultimately, this is the start of how a global transplant fellowship should run, which is unlike any other in the world.

A chance to join the ...

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

2018 Canadian Tour The European Association of Urology (EAU) and the Canadian Urological Association (CUA) are pleased to announce the 2018 Canadian tour! The CUA/EAU International Exchange Programme will send Canadian faculty to Europe and European faculty to Canada. The programme aims to promote international exchange of urological medical skills, expertise and knowledge. For 2018 the CUA/EAU International Exchange Programme will provide grants to enable three Junior EAU Members to participate in the Canadian Tour. The tour should take place from 10-26 June 2018 starting with visits to different urological centres in Canada, culminating with participation at the 73rd CUA Annual Meeting in Halifax, NS, from 23-26 June 2018. Eligibility criteria • Less than 42 years of age • Minimum academic rank of assistant professor • Letter from the departmental chairman of the applicant’s commitment to academic medicine • Membership of the EAU • Availability to travel around 2.5 to 3 weeks at the earlier mentioned time

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

Canadian Urological Association (CUA)

March/May 2017


A paradigm shift in surgical training ERUS-certified curriculum for robot-assisted radical prostatectomy Prof. Alexandre Mottrie Dept. of Urology OLV Hospital Aalst (BE)

Unit C consists of one intensive week of robotic surgery simulation in three different settings, namely virtual skill simulator, dry-lab activity and wet-lab surgery on dedicated animal models, in order to guide the trainee from the simplest task to the most advanced simulation setting in the committed environment of ORSI Academy.

alex.mottrie@ olvz-aalst.be

For instance, cadaveric canine model can effectively simulate robot-assisted radical prostatectomy [Figure 1] and living porcine model provides an extremely realistic experience of pelvic and upper urinary tract surgery.

Dr. Alessandro Larcher ORSI Academy Melle (BE)

alelarcher@ gmail.com Robot-assisted surgery prompted several innovations that radically changed the training process. First, skills simulator allows for training activity in a virtual environment. This key factor changes the context where surgical training takes place, moving from operative theatres to dedicated educational platforms. Notably, such a shift from a “real” to an “ideal” setting can reduce the risk of sub-optimal clinical outcomes due to the learning process. Moreover, surgical skill simulators provide computer-generated performance evaluations that are, by definition, free of human observer bias, offering an objective metrics that can be used to plan further training steps. It is also important to remember that when a robot-assisted surgery programme is implemented, virtually all cases can be recorded and reviewed, with a non-negligible impact on surgeon self-assessment and daily practice review. Finally, training activity in the operative theatre is also significantly affected, since dual-console systems designed for instant switch of the leading role between trainer and trainee favour modular training programmes. With all these exciting changes, the EAU Robotic Urology Section (ERUS) developed a standardised training pathway for those surgeons who embrace a robotic programme: the ERUS Certified Curriculum [http://uroweb.org/section/erus/robotic-curriculum/].

After the simulation-based training, the participant will start the modular console training activity which represents the core of the entire programme [Unit D]. Using a modular pattern2, the participant will perform only a specific step of a case with a progressive transition from low to high technical complexity, under the supervision of a dedicated mentor. Specifically, 10 different steps of robotassisted radical prostatectomy were identified [Figure 2]. The number of repetition for each individual step required to complete the programme varies based on the specific complexity of the step, ranging from five to 20. Pre-clinical and clinical settings for the curriculum The pre-clinical phase of the curriculum takes place at ORSI Academy. ORSI Academy achieved the status of Network for accredited skills centres in Europe [https://nascenet.org/accredited-centres] certified Figure 2: Robot-assisted radical prostatectomy step-by-step modular training training centre in 2016. The facility is equipped with five robotic operating theatres, with dual-console system and skills simulator operated by a dedicated References team of trainers, engineers, veterinarians and 1. Volpe A, Ahmed K, Dasgupta P, Ficarra V, Novara G, Van 2. Stolzenburg J-U, Rabenalt R, Do M, Horn LC, Liatsikos EN. data-managers. Using such resources, the training der Poel H, et al. Pilot Validation Study of the European Modular Training for Residents with no Prior Experience centre can offer any kind of training programme, Association of Urology Robotic Training Curriculum. with Open Pelvic Surgery in Endoscopic Extraperitoneal ranging from basic virtual reality manoeuvres, cutting European Urology 2015;68:292–9. doi:10.1016/j. Radical Prostatectomy. European Urology 2006;49:491– and knot-tying exercises on synthetic models and eururo.2014.10.025. 500. doi:10.1016/j.eururo.2005.10.022. simulation of a full case on a living animal under general anaesthesia. Notably, factors like the experience of the trainer, the surgical volume of the centre and the technology available are important determinants of such learning process, and for this reason the modular console training phase of the curriculum requires a special environment. Several centres in Europe meet the criteria for ERUS Certified Robotic Training Centre eligibility [http://uroweb.org/section/erus/ erus-robotic-certified-host-centers/] and offer dedicated fellowship, which represent the ideal organisation of training activity. The modular training phase is completed when the participant achieves the ability to perform independently a full robot-assisted radical prostatectomy case, and the video of an index case will be the subject of the final examination [Unit E and F].

www.esou18.org

ESOU18 15th Meeting of the EAU Section of Oncological Urology 19-21 January 2018 Amsterdam, The Netherlands An application has been made to the EACCME® for CME accreditation of this event

Although the original curriculum was specifically tailored for Figure 1: Robot-assisted radical prostatectomy in a canine cadaveric model radical prostatectomy, ERUS is currently working to expand the availability of standardised training programmes, Structure of the curriculum including other urological procedures, into innovative Originally described in the PILOT study1, the curriculum is designed to train a novice surgeon curriculum formats. A robot-assisted partial from the very beginning to the completion of a full nephrectomy and robot-assisted radical cystectomy case robot-assisted radical prostatectomy. The curriculum will be operational soon, with the goal to programme has a defined structure and begins with constantly improve education in the field of robotic the baseline assessment of the participant using the surgery. *. objective scores generated by a skill simulator [Unit A]. These figures will be used as a reference to * This project has been funded with support from the monitor the participant’s improvement. Unit B European Commission. This publication reflects the integrates the introduction to the programme with views only of the author, and the Commission cannot the EAU Basic Robotic Urology Skills theoretical be held responsible for any use which may be made course [http://uroweb.org/education/onlineof the information contained therein. education/surgical-education/robotics/] and the table-assisting activity. EAU Robotic Urology Section (ERUS)

March/May 2017

European Urology Today

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Diagnostic markers for BPO Myth or reality? Prof. Fiona Burkhard Dept of Urology University Hospital Berne (CH)

fiona.burkhard@ insel.ch

Dr. Ali Hashemi Gheinani Urology Research Laboratory Dept Clinical Research University of Berne Berne (CH) ali.hashemi@dkf. unibe.ch Co-Author: Katia Monastyrskaya (CH) By 85 years of age, approximately 90% of men will have benign prostatic hyperplasia (BPH) and benign prostatic obstruction (BPO) with lower urinary tract symptoms (LUTS) including urgency, frequency, nocturia and urinary retention. Concomitant with increased aging of the population, the incidence of BPO is steadily growing, and now poses a common and recurrent problem in urological practice. Obstruction leads to bladder hypertrophy with an increasing bladder wall thickness, which corresponds to the severity of obstruction1. At the same time significant characteristic changes in the expression profile of smooth muscle contractile and signalling proteins, modification of extracellular matrix proteins, and an increase in bladder innervation can be observed2,3. Functionally, BPO is associated with reduced bladder compliance, alterations in sensitivity, detrusor overactivity (DO) or detrusor underactivity (UA). Although relief of obstruction is a traditional form of therapy for this disorder, many storage and voiding symptoms, including urgency and incomplete bladder emptying, persist after surgery, indicating that timing of the surgical intervention may be critical for the complete recovery of bladder function. As bladder outlet obstruction progresses from inflammation to hypertrophy to fibrosis4, early identification of structural changes can guide therapeutic decisions that might prevent further damage of the bladder and optimize the timing of treatment. Reliable markers of bladder function are urgently needed in order not to surpass the “point of no return”, leading to bladder decompensation/failure. Profound gene expression changes caused by BPO lead to organ remodelling Changes in gene expression are caused by a dysregulation of cell signalling. Studies of individual cellular signalling pathways conducted in animal models5-7 have identified some regulated genes, typical for partial outlet obstruction-induced bladder remodelling. The main intracellular signalling pathways, relevant to bladder hypertrophy, fibrosis and decompensation include Ca2+ signalling / calcineurin / NFAT, TGF-β, hypoxia, and extracellular matrix remodelling. TGF-β is a key player in wound healing and fibrosis, and its levels are increased in the majority of fibrotic diseases8,9. In the obstructed bladder progressive accumulation of ECM and smooth muscle hypertrophy induced by TGF-β leads to impaired contractility and micturition disorders during the final decompensated / fibrotic stage10. As obstruction progresses, hypoxia develops in the detrusor smooth muscle, concomitant with a decrease of intercontraction intervals11. Gene expression changes occurring during BPO-induced bladder hypertrophy and fibrosis resemble the pressureoverloaded heart12. This is not surprising, as both the bladder and the heart are hollow muscular organs afflicted by pressure overload injury, to which they respond with hypertrophy and fibrotic remodelling leading to the loss of contractility13,14. There are striking parallels in the cellular and molecular mechanisms, particularly regarding the role of miRNAs, important epigenetic regulators of stress signalling pathways. EAU Section of Female and Functional Urology

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MicroRNAs (miRNAs), small non-coding singlestranded RNAs, are quickly gaining recognition for their role in many biological processes and disease states. MiRNAs are important modulators of gene expression, and dysregulation of their synthesis contributes in many human diseases15,16. A number of regulatory miRNAs have been implicated in bladder pathologies17-21 and function22. Increasing evidence indicates that miRNAs may play a role in the regulation of urothelial permeability23 and bladder contractility24,25. Using miRNA as biomarkers has diagnostic potential, and new therapeutic options modulating miRNA levels by introducing miRNA replacements and miRNA antagonists may significantly impact clinical practice in the future.

evaluation of miRNA inhibitors of fibrosis will provide a novel therapeutic tool to assist full restoration of organ function following relief of obstruction, which will be beneficial for many elderly patients with BPO.

Next generation sequencing identifies molecular biomarkers and hubs of signalling in BPO Our lab has pioneered the miRNA research in bladder dysfunction21, and the regulatory impact of miRNAs on cell signalling in disease remains our focus. Recently, we completed the quantitative transcriptome and miRNA profiling of different urodynamically-defined states of BPO26. Using comprehensive next-generation sequencing (NGS)-derived transcriptome data, we performed an integrated analysis of miRNA and mRNA paired expression profiling in the bladder biopsies of human patients (Figure 1). MiRNAs and mRNAs expression profiles revealed a progressive increase in the number of altered mRNA and miRNAs from BPO with detrusor overactivity (DO) to BPO without DO (BO) to detrusor underactivity (UA), with the most significant changes of miRNAs and mRNA expression detected in UA. Overall, the gene expression profiles correlated well with the functional characteristics of the bladder, identified by urodynamics (Figure 1). Three-mRNA (NRXN3, BMP7 and UPK1A) and three-miRNA (miR-103a-3p, miR-10a-5p and miR-199a-3p) signatures were identified based on ROC curve analysis of NGS data and validated by QPCR in an independent patient population. These signatures are sufficient to discriminate DO, BO and UA groups26. Gene expression changes at mRNA and miRNA level are indicative of activation of cell signalling pathways, leading to the morphological and functional changes in the bladder. For BPO pathways, characteristic for hypertrophy and cell differentiation were most significant. DO was characterised by an activation of neurotransmitters and other nervous system signalling. From DO to BO and UA we observed a progressive increase in the number of activated pathways. Overall, 22 common pathways were detected. These included cytokine and immune response pathways, growth factor signalling (TGF-β, HGF and IGF-1), activation of GPCRs (endothelin and cholecytokinin/gastrin pathways), NO signalling and hypertrophy-relevant PI3K/AKT signalling pathways. The main transcription factors were activator protein AP-1 (JUN-FOS) and NFkB. Common and unique miRNAs and their mRNA targets characteristic of BPO and specific for urodynamicallydefined states of the disease have been identified. Several pro-fibrotic miRNAs are up-regulated including miR-192 in BO and UA, and miRNAs miR-34c, miR-146a/b and miR-21 in all groups. Notably, muscle specific miRNAs including miR-1, miR-133 and miR-143/145 were downregulated, in parallel with a decrease in detrusor contractility. Among the miRNA targets important molecules, acting as hubs of signalling can be identified and their numbers increase from DO to BO and UA. These results suggest an increasing regulatory role of miRNAs during progression from detrusor overactivity to underactive bladder (Figure 2). Future directions: urinary biomarkers for noninvasive diagnosis of bladder dysfunction and miRNA-based tools for gene expression regulation Circulating miRNAs have been detected in the extracellular space and body fluids and are hailed as disease biomarkers. Urine is a useful source of circulating RNAs as it is easy to collect noninvasively in large amounts, and urinary circulating miRNAs could be explored in the context of BPO and used as diagnostic and/or prognostic markers. Reliably relating the levels of circulating urinary miRNA, including the signature miRNAs identified in our recent study to the symptoms of BPO will lay the foundation for new diagnostic options. Selective pharmacological interference with pathways activated during the progression from hypertrophy to decompensation/underactivity will allow prevention of bladder failure. Development and

The references of this article are available from the EUT Editorial Office by sending an e-mail to: EUT@ uroweb.org with reference to the article “Diagnostic markers for BPO” by Prof. F. Burkhard, March/May issue 2017.

mRNA

Urodynamic states correspond to specific pathways miRNA Figure 1: Gene expression changes correlate with DO, BO and UA. 2634 significantly regulated mRNA and 343 significantly regulated miRNA were detected. Controls and DO are clustered together, whereas BO and UA samples show more similarity to each other. Each group has specific biological functions altered, leading to the changes in bladder contractility. C = controls, DO = BPO with detrusor overactivity, BO = BPO without detrusor overactivity, UA = BPO with underactivity.

number of miRNA-regulated pathways UA BO DOUA BO DO

number of miRNA-regulated pathways

DO < BO < UA DO < BO < UA BO DO BO

UA UA

DO

miRNAs miRNAs

BO BODO

UA UA

DO

regulated pathways regulated pathways

Impact of abundant miRNAs is low in DO and high in UA Impact of abundant miRNAs is low in DO and high in UA

Figure 2: Regulatory role of miRNAs in DO, BO and UA 2a: Number of miRNA-regulated pathways and biological functions increases from DO to BO and is the highest in UA. 2b: Targets of 9 abundant DO miRNAs contribute to only 2 significant pathways, whereas 23 BO miRNAs control 45 pathways and 30 UA miRNAs regulate 143 pathways.

March/May 2017


“Prioritise prospective studies and real-world data” An interview with new EAU Research Foundation Chairman, Prof. Anders Bjartell By Loek Keizer The EAU Research Foundation is uniquely placed to conduct and coordinate important prospective trials in the coming years, its new chairman has told European Urology Today. Prof. Anders Bjartell (Malmö, SE) took over chairmanship of the EAU Research Foundation at EAU17 in London. Prof. Peter Mulders (Nijmegen, NL) chaired the Research Foundation for two four-year terms before him. Prof. Bjartell is an esteemed and experienced researcher and urologist, having previously worked with the EAU in different positions. (see insert) On this occasion, we spoke to Bjartell about his views on the Foundation’s work, his ambitions and the field of clinical trials in general. Strengths of the EAU RF “Of course I’ve been familiar with the EAU RF for quite some time now,” Prof. Bjartell begins. “I’ve been following their work, and the Foundation has become more and more active in recent years, but I believe there’s a lot more to do.” “Things have changed a lot in the last decade. On the whole, we’ve generated a lot of retrospective studies. Now what we need is to examine real-world data. How do drugs, biomarkers, and new genetic tests work? We also need to initiate prospective studies because these will be increasingly important in the near future. To focus on prospective studies and real-world data, that should be our focus as researchers and for the EAU RF.” The EAU RF has some unique qualities that give it an advantage when establishing new trials, most of that is due to the position and reputation of the EAU itself. Bjartell: “I think the EAU is a strong and established name in the world of urology. We not only have such a large membership to rely on, but also a Scientific Committee and a world-class Guidelines Office, with all of its panels. These different parts of the EAU are vital partners for the future work of the Research Foundation. As a research foundation, we can lean on all of this expertise when we set up new studies.” “The EAU is also a strong partner in relation to other bodies. We have a good relationship with the EORTC, which we absolutely need to get close to and collaborate with in new studies, as well as with Cancer Research UK, and beyond Europe with the AUA. Patient organisations should also be considered very important stakeholders. In designing new trials and studies, I think it’s important to discuss with patient organisations what is relevant, to get their opinion about how the studies are designed and what we can achieve by initiating new studies.” “On its own, the EAU RF already has a great team. As part of the EAU, we have a chance to bring together highly-skilled and experienced people. As part of an international body, this gives us the opportunity to initiate multicentre studies.” Ambitions The EAU RF faces some important challenges in the coming years. Prof. Bjartell points to the emerging of new biomarkers and improving cooperation as major challenges for the Foundation. “New biomarkers are emerging, we need to identify even more. Crucially, it’s important to see how they work in real life. We need to critically evaluate biomarkers and new methods, treatments, and imaging modalities. There is so much still to be evaluated in prospective studies. It’s also important to collaborate with drug companies and other parties by providing new tests, biomarker tests and also imaging modalities. Together we can design the studies we really need to perform and take another step forward in helping patients.” When asked if this marks a break from the previous policies of the Research Foundation, Bjartell praised his predecessor: “Prof. Mulders has done a wonderful job in initiating a number of new studies and mobilising many experts in different fields and we now have a solid platform for research. But because EAU Research Foundation

March/May 2017

many, then they will have a unique database. There’s so much more to be gained by further examining that database, allowing you to generate new studies from that.”

“If we initiate our own studies from the Research Foundation, we may also choose to get the industry involved, for a variety of reasons. That will of course be a win-win for both of us.”

Prof. Anders Bjartell: A career in research Anders Bjartell has worked with or within the EAU for several years. He was Associate Editor for European Urology from 2005 to 2012, and he is a former chairman and board member of the EAU Section of Urological Research (ESUR). Bjartell is currently Senior Consultant in Urology at Skåne University Hospital (1998-) and Professor in Urology (2006-) and assistant Dean (2012-2017) at the Medical Faculty of Lund University.

He leads a research group in translational prostate cancer research with long-term experience in prostate cancer biomarkers. His research also encompasses clinical projects on robotic surgery, imaging, and drug development. He has participated in several EUsponsored prostate cancer projects, and he has published more than 235 peer-reviewed original articles.

Bjartell is also a national principal investigator for several trials of new drugs in castration-resistant prostate cancer and Head of the clinical trial unit at the Urology Department at Skåne University Hospital.

Reflecting on his new position, Prof. Bjartell stated: “I’m extremely grateful to get this big opportunity to chair the Research Foundation. With my background in all different kind of research, and experience, I hope I can contribute and do something worthwhile in the coming years.”

Prof. Anders Bjartell

things are changing, sometimes very quickly, we need to identify which studies are most urgent today. Those will probably not be the same as we could identify only five years ago.” “This will be a challenge, but personally I think the most urgent studies will have to look prospectively. Involving patient organisations in future studies is also essential. These will be my priorities in the coming years.” Suggestions and submissions for new trials will be most welcome and always be considered at the EAU RF. “There are so many topics within urology that deserve our attention. All initiatives are welcome but of course we have to be selective and we cannot accept every proposal. It is also important for us to give feedback to those who propose the studies, and not just decline. We need to discuss the relevance of the study, the impact on patients, and its scientific soundness. Maybe the proposal only needs some modification before it goes ahead.” Trends in research Looking at the landscape of urological research in general, Prof. Bjartell sees some trends that will become more prevalent in coming years. Big data will determine the course of registries and trials more and more. “As the number of registries increases, we need to know how to handle big data like genetic information and biomarkers in new tools and next generation sequencing. How should we manage this data, and how should we diagnose, monitor and treat patients in the future?”

European Urological Scholarship Programme (EUSP) Do not forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme, before the next deadline of 1 September 2017! For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website http://www.uroweb.org/education/scholarship/

Apply for your EAU membership online!

Beyond diagnostics and treatment, patient monitoring can be improved as well: “be it through active monitoring, surveillance, and different options for post-treatment monitoring. There are so many steps between diagnosis and the final end-stage of the disease, and we need to take this into consideration when we devise new studies.” Fellowships and investigator-led research The EAU RF collaborates with the European Urology Scholarship Programme to offer researchers the opportunity to visit centres across Europe. These scholarships go beyond urology, also designed to involve basic scientists. Prof. Bjartell has personally divided his time between a career as a urologist involved with patients and a basic scientist involved with drug evaluations and clinical studies. Bjartell: “It’s important for us to focus on new genetic tests, new ways to improve diagnostics, and the experts on these topics are basic researchers. We need to get close to them from the clinical side, and the basic and translational researchers also need clinicians to implement their findings in practice. The Research Foundation can create a bridge between basic and translational research on the one hand and clinics and clinical researchers on the other.” On the role of industry in initiating trials, as opposed to those initiated by independent researchers: “Both are important. For instance, if a medical company recently performed a multicentre study, as there are

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! European Association of Urology

European Urology Today

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

paul.meria@ sls.aphp.fr

Urodynamics: A Quick Pocket Guide Urodynamics is a widely used investigation intended for assessing bladder and urinary sphincter pressures and behaviour. It represents a recommended part of the evaluation of patients presenting with incontinence and/or lower urinary tract symptoms, either before medical treatment or before surgical management. Editor G. Vignoli wrote this practical pocketbook to provide the reader with an appropriate description of urodynamic techniques, focusing on various aspects of test’s accuracy and patient’s evaluation.

Time and Life Management for Medical Students and Residents

This well-illustrated textbook is a concise synopsis of urodynamics, very helpful for practitioners anxious to improve their knowledge with practical information. Many figures illustrate each chapter and the author provides the reader with a listing of additional resources.

The bases of active surveillance were described in a dedicated chapter, covering all aspects of strategies currently enhanced by MRI use. Technical aspects of radical treatments were described in the succeeding chapters, with focus on retropubic and robotic prostatectomies.

Many students undertake to do medical studies and, consequently, go to residency. Most of them are unaware of the consequences of such studies on their personal life and development, only to discover the weight of their tasks. A high level of organisation is required to succeed in such studies, besides other work priorities.

The first part was dedicated to “the eagle’s perspective,” and provides the reader with a “macroscopic” view. After a chapter dedicated to the importance of defining new goals, the author focused on the multiple “roles” assigned to the trainee.

: G. Vignoli : 9783319337609 : Available : 2017 : Springer : 1st : 203 : 94 (92 colour) : Softcover : €89.99 : http://www.springer.com

Book reviews

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This richly illustrated textbook was intended for all practitioners involved in the management of urologic malignancies, and the practical information makes this book very useful. : S.H. Kim and J.Y. Cho : 9783662452172 : Available : 2017 : Springer : 1st : 260 : 168 (86 colour) : Hardcover : €109.99 : www.springer.com

Endoscopic Diagnosis and Treatment in Urethral Pathology: Handbook of Endourology Radiation therapy and its various techniques were addressed, including single and concomitant treatments, and physical therapies such as cryotherapy and high intensity focused ultrasound (HIFU). Palliative treatments were described in next chapters, including an overview of hormonal manipulations. Second-line therapies, targeted therapies and immunotherapy were considered in dedicated chapters. The authors also wrote on current EAU guidelines on prostate cancer management.

The management of prostatic diseases remains one of the most important fields of our specialty. Symptomatic benign prostatic hyperplasia (BPH) usually requires medical treatments, but complications and/or medical treatment failure can lead to interventional therapies.

This outstanding textbook offers useful information for urologists and oncologists who are looking for updates on prostate cancer. Editors : M. Bolla and H. Van Poppel ISBN : 9783319427690 e-Book : Available Published : 2017 Publisher : Springer Edition : 2nd Pages : 422 Illustrations : 76 (64 colour) The book also addressed goals and the actions needed Binding : hardcover to achieve them, and many of the recommendations Price : €99.99 were given including what to prioritise and what to Website : www.springer.com avoid. In the succeeding chapters the author wrote on “disasters” or crisis management and anxiety. He also highlighted the importance of having an experienced Oncologic Imaging Urology colleague who can play the role of “mentor.” The final chapter focused on the need of analysing errors and Imaging techniques are widely used in the how to benefit from the lessons learned. Some management of patients referred for urologic recommended videos, readings and software were tumours. Currently, all patients need an exhaustive mentioned in the concluding section of this excellent imaging assessment, either for diagnosis or during textbook. This book is recommended to all students follow-up after treatment. Editors S. H. Kim and J. Y. and residents since it provides practical information Cho, with the help of 20 Korean experts in radiology, useful for their studies. oncology, nuclear medicine, pathology, aimed to gather practical information, focusing on imaging Editor : M. Sabel techniques in onco-urology. ISBN : 9783132412798 e-Book : Available Publisher : Thieme Publishers Publication : 2016 Pages : 76 Illustrations : 24 Binding : Softcover Price : €24.99 Website : www.thieme.com http://ebookstore.thieme.com

Management of Prostate Cancer: A Multidisciplinary Approach Editor ISBN e-Book Published Publisher Edition Pages Illustrations Binding Price Website

Additional figures were included, with emphasis on operative views and pathological aspects of the tumours. Interventional techniques for diagnosis and treatment were also described, such as imageguided biopsy and focal therapies. Some aspects of post-therapeutic imaging for patients’ follow-up were addressed when relevant.

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

Editor M. Sabel, a famous German neurosurgeon, wrote this pocketbook on the basis of 20 years of residents’ education. His experience in residents’ training programmes is worth sharing and this work compiled insights and advice which can help young doctors.

A short introductory chapter described basic principles of urodynamics and those of micturition cycle. Clinical aspects of lower urinary tract symptoms, enuresis, incontinence and nocturia were addressed in a dedicated chapter, while clinical examination is examined in another chapter. The indications of urodynamic testing were described and the authors focused on test selection based on clinical aspects. Non-invasive and invasive urodynamic tests were considered in the succeeding chapters; all aspects of uroflowmetry were described including paediatric values and conventional invasive tests such as cystometry, and pressure-flow studies were addressed with special focus on paediatric aspects. Urethral profilometry and electromyography of pelvic floor muscles were also described and followed by a description of video-urodynamics. The conclusive chapter dealt with upper urinary tract assessment, including imaging techniques and pressure-flow studies.

all aspects of multiparametric MRI and nuclear medicine investigations.

Prostate cancer is currently the most frequent cancer in European men. Diagnosis and treatment options have dramatically evolved during the past decade and most of our clinical strategies have changed accordingly. Editors M. Bolla and H. Van Poppel with the help of about 50 worldwide experts aimed to revise the first edition of this textbook and present an exhaustive review intended for practitioners involved in prostate cancer management. The opening chapters were dedicated to basic aspects and included various topics such as epidemiology, chemoprevention, screening, biomarkers and genomics of prostate cancer. Prostate cancer imaging was addressed in the succeeding chapters, including

Recent advances in endourology contributed to dramatically change many therapeutic concepts in the field of BPH and, currently, various options can be proposed as an alternative to the conventional transurethral resection of the prostate (TURP). P.A. Geavlete and co-workers, all of them members of a well-known Romanian institution, aimed to write a textbook dedicated to endoscopic procedures in BPH and related diseases. The first chapter presented endoscopic aspects of prostate anatomy and described various useful landmarks. TURP was exhaustively described in the following chapter and the authors provided the reader with many tips and tricks, either in usual practice or in the event of complications. The succeeding chapters were dedicated to all current alternatives to TURP and the authors described bipolar resection, electro-vaporisation, endoscopic incision, laser techniques, microwave thermotherapy, radiofrequency, balloon dilation and stents placement. Based on the preceding chapters, a synthesis algorithm was proposed for BPH management. Two additional chapters addressed endoscopic management of prostatic abscesses and prostatic stones. This textbook is very practical and well-illustrated. Urologists will find relevant information and we hope the next edition will be supplemented by videos.

Their work addressed all imaging aspects of various tumours of the genitourinary tract. Six chapters were dedicated to kidney tumours, urothelial and prostate tumours, tumours of the genitalia, adrenal and retroperitoneal tumours. In each chapter the authors described all imaging aspects of benign and malignant tumours, and focused on the most accurate imaging technique. Tumour classifications were presented and the authors summarised current therapeutic options based on tumour characteristics.

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

: P.A. Geavlete : 9780128024065 : Available : 2016 : Elsevier, Academic Press : 1st : 222 : 29 : Hardcover : €109.99 : www.elsevier.com March/May 2017


New-style ESU course debuts at ESOU17

ESOU 17

20-22 January 2017 Barcelona, Spain

14th ESOU Meeting offers complete update on onco-urology By Loek Keizer The 14th Meeting of the EAU Section of Oncological Urology (ESOU17) was held in Barcelona on 20-22 January and attracted close to 1,000 oncologic urologists and other genitourinary cancer specialists. It is one of the European Association of Urology’s most popular annual section meetings and usually the first to take place every year. The meeting was organised by a committee led by ESOU Chairman Prof. Maurizio Brausi (Modena, IT), Prof. Paolo Gontero (Turin, IT) and Prof. Joan Palou (Barcelona, ES). Prof. Gontero characterises the meeting: “ESOU17 is uniquely geared to the needs of the urologist who deals with oncology as part of his or her daily clinical practice. As research and basic science is moving into practice, it is essential for us as urologists, to remain updated on novelties pertaining to clinical oncology and on developing topics like genomics.” Scientific programme Major topics at ESOU17 included prostate cancer (diagnosis, pathology, active surveillance, locally advanced, advanced and metastatic); renal cancer (localised, locally advanced and metastatic); urothelial and bladder cancer (muscle invasive and non-muscle invasive); and testis and penile cancer. The meeting featured a broad spectrum of top international speakers with many different backgrounds, including experts specialised in basic science and imaging who offered their own viewpoints. On prostate cancer, Prof. Brausi summarised some of the newest developments discussed at ESOU17: “In terms of diagnosis, we learned about new markers that facilitate the distinction between insignificant, significant and aggressive disease, and the state-ofart multiparametric MRI with fusion biopsy. We saw an examination of the new classification of renal anatomical structure as utilised for nephron-sparing surgery. One of the several debates held in Barcelona

pitted standard therapy for high-risk, non-muscleinvasive TCC of the bladder against sequential BCG (Bacillus Calmette-Guerin) + EMDA MMC (electrically stimulated Mitomycin-C). And as a meeting intended for urologists, ESOU17 also devoted a lot of time to the latest updates on the role of surgery for metastatic PCa.”

The detailed, three-hour cystectomy ESU Course was a welcome addition to the scientific programme of ESOU17

Innovating in education For the first time at an ESOU meeting, the European School of Urology offered a major, three-hour oncology-related course. The workshop-style cystectomy course was directed by ESU Chairman Joan Palou and co-presented by Prof. Noel Clarke (Manchester, GB) Dr. Jose Maria Gaya Sopena (Barcelona, ES) and Prof. George Thalmann (Bern, CH), all surgeons with many hundreds of cystectomies under their belts. The course was freely available to all the delegates of ESOU17, and close to 300 took the opportunity to take part. The course went through all steps of the cystectomy, from pre-op nutrition, bowel preparation, desired location of the stoma, through surgical complications and post-operative troubles like fever, leakage and antibiotics use. This ESU Course was embedded in the ESOU programme, and it was adjusted accordingly to suit the larger audience. Often, ESU Courses serve a smaller group for easier interaction. Prof. Palou: “Since cystectomy is quite a difficult procedure with a significant chance of morbidity, we thought it would be interesting to offer a nice, long and detailed course. This allowed us to talk about all of the details of the surgery, from patient prep to interoperative problems and post-op complications.”

The programme was highly detailed and showed the whole procedure step by step. Issues were discussed that every professional will face in daily practice, things that arise that aren’t necessarily covered by journals, or textbooks or even plenary sessions. “The course proved to be extremely popular, because as urologist we like to operate. When you really get into surgical details, delegates tend to take interest!” Topics that provoked discussion in the audience were antibiotic treatment, the use of stents (which, where and for how long), and the need for bowel prep. Palou: “A lot of people are doing bowel prep but it has been demonstrated that it is not necessary. We also talked extensively on renal function as we need to better prepare specific patients who have hydronephrosis or otherwise altered renal function.” Rather than discussing the merits of the EAU Guidelines or different treatment options, this cystectomy course was much about practical details, management of complications and personal experiences and preferences of some of the most experienced surgeons in the field. Palou: “Of course there have been randomised trials on various topics related to cystectomy, like catheter use, but not on every detail of the procedure. This

leaves room for ‘eminence-based medicine’, the expertise of the faculty and their own personal choices.” As the course progressed, the audience was continually polled on how they would approach certain situations, and which experiences they had in the course of their own operations. Questions and interruptions started coming regularly as the panel discussed pre-operative procedures. At the Annual EAU Congress or Regional Meetings, the audience of an ESU course might include a lot of residents or young urologists, but at ESOU17 the audience was largely made up of experienced urologists, some of whom are already working in high-volume centres. “This was almost like a pilot course for us, and a very successful one. Offering a course to a big audience might be useful for popular section meetings like ESOU. Even with 300 people in the audience there was interaction and we managed to keep them engaged till the end.” The next ESOU meeting has already been announced: ESOU18 will be taking place in Amsterdam on 19-21 January 2018. A preliminary scientific programme will be announced soon.

EAU Patient Information: Harnessing patients’ input PI activities get a boost with new projects and meetings Dr. Seluk Sarikaya Co-Chair EAU PI Gulhane Research and Training Hospital Ankara (TR)

Other topics discussed were renal and ureteral stone disease which is common in many Turkish populations. The speakers explained in layman’s terms topics such as stone composition, basic preventive methods, role of diet and standard treatment. Patients were also informed about medical instruments and were shown informative demonstrations of urological procedures.

drselcuksarikaya@ hotmail.com

Basic information on renal masses and benign prostatic hyperplasia, their causes, symptoms, diagnosis and treatment were described using visual slides. The importance of being properly informed With patient information (PI) becoming one of the most discussed topics, the EAU’s Patient Information about kidney cancers was also explained to raise awareness. Early diagnoses of malignant diseases Working Group projects have been boosted recently with the publication of informative leaflets (translated were emphasised and the message was conveyed that more successful interventions and results can be from English into other languages) and animated expected if early diagnoses are made. The patients videos, and the holding of patient information also had the time to express what they know about meetings. benign prostatic hyperplasia and its symptoms and got the chance to ask questions regarding treatment Recently, a patient information meeting was options. successfully held in the south eastern Turkish city of Silopi which turned out to be very interesting for many patients who participated. Many of the patients Dynamic discussions in andrology In the second part, prostate cancer (PCa) and asked a lots of questions regarding their treatment andrological diseases were discussed. Topics such as and concerns, showing that there is a need for these type of meetings to enable us to inform people about symptoms and the role of new technology in therapies were explained. Many of the patients urology and urological diseases. Moreover, the meeting offered a great chance for patients to receive showed keen interest on recent issues in PCa diagnosis and treatment and have had many reliable information directly from experts. Nine topics were discussed in the meeting including general and functional urology, andrology, urooncology and stone disease. In the first part, we provided a brief introduction about urology with questions such as ‘What is Urology?‘, for patients to have a clear idea about the scope of urology and some of its sub-specialties. Information was also given about the number of urology centres in Turkey, their locations and how to reach them.

Patient Information

March/May 2017

Andrew Winterbottom speaking on patient information and support

questions regarding robotic surgery. Other topics were nocturia, over-active bladder (OAB) symptoms, urinary incontinence and sexual problems. Female patients paid close attention during the discussion on urinary incontinence and OAB, topics where they usually have problems during consultations with doctors due to shame or embarrassment. In the last and most exciting part, main sexual problems were discussed and many of the patients were really interested regarding the latest developments in diagnosis and treatment for erectile dysfunction, premature ejaculation and infertility. The meeting was deemed a success and similar meetings will be planned in other cities in Turkey. We consider it important to hold these meetings in other European countries with the support of the EAU to effectively convey to patient groups basic issues about urological conditions. Strengthening PI through direct contacts The Patient Information group also initiated direct meetings with its partners with the first meeting held in London during EAU17, and organised and led by Prof. Thorsten Bach, Chairman of the Patient Information Project. During this meeting, EAU Secretary General Prof. Chris Chapple spoke about the EAU’s perspective on patient information. Other speakers were Andrew Winterbottom who talked about the importance of information and patient support, Corinne Tillier who discussed the nursing perspective, Carlos Llorente who spoke on behalf of the Spanish Association, and Giulio Patruno who discussed the use of patient information in clinical practice. The Patient Information meetings is now intended to be part of the regular programme of the EAU annual congresses, which can provide an effective way to share knowledge and directly engage patients’ representatives. We anticipate PI projects to further expand to achieve our goals not only to strengthen ties with patient advocates, but also to harness or use their input in improving healthcare. We invite patient

EAU Patient information website

groups to join our future activities and engage with us either directly or through social media and online channels. The Patient Information website is found at patients.uroweb.org

Prof. Thorsten Bach chairing the first PI Meeting together with partner groups in London

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• What do you think is the biggest challenge in urology? Identifying the right treatment for the right patient at the right time. We need to collaborate with other specialists to find the best treatment. Training of young doctors is also important. Finally, we encounter demographic changes, an ageing population and higher healthcare costs. • If you were not a urologist, what would you be? My father had a paint shop when I was a child and he was quite successful in this business. I always envisioned myself following his example and starting my own independent business. • What is your most important piece of advice for doctors just starting out? Find your field of interest. Be driven by enthusiasm, be curious and passionate and take responsibilities to develop yourself. Above all, keep the patient’s interests at the forefront. • What is the most rewarding aspect of being a doctor? Performing cutting-edge research to advance the tools which enable us to reduce the suffering of patients. Also, passing on the knowledge to the next generation of doctors. • What is your advice to other physicians on how to avoid burnout? Always reserve time each day to relax. I go biking or walking in the forest with my dog. One cannot work 24 hours per day. • If you could change something in the healthcare system, what would it be? More focus on the patients and less on the administrative parts (modern management). In the area of medicine and clinical care doctors should take the lead. • What´s the last wonderful book you have read? “Mindfulness—A Practical Guide to Awakening” by Joseph Goldstein. The book is about experiencing the present. This has helped me be more aware of the present and try to slow down. • What do you most often wish you could say to patients, but didn’t? I wish I could have more time with my patients to give them room to understand their disease. Patient understanding is the key to take responsibility of their health and promote lifestyle changes if needed. • What’s the last thing that surprised you? My daughter’s engagement. I woke up one day and realized she is not just my little girl anymore but a grown woman.

TEN QUESTIONS Interview by Joel Vega Photography by Jan Willem de Venster

Age: 57 Sub-Specialty: Andrology City: Herlev (DK) Current Posts: EAU Adjunct Secretary General for Clinical Practice; Chair Professor of Urology, University of Copenhagen; Chairman, Urological Research Centre, Herlev and Gentofte University Hospital, Denmark

• What’s your favourite hour in a day and why? Early morning when I walk my dog and reflect on the day to come.

JENS SØNKSEN

Jaakko Elo Eminent Urologist and Historian of Urology

1925-2017

On behalf of the History Office of the EAU, we want to present our condolences after the passing away of our member Jaakko Elo. He was a very active member of our group and we will always remember his valuable contributions to our work. Prof. Philip Van Kerrebroeck, Chairman (Maastricht, NL) I remember Jaakko Elo as a real bosom friend and a very generous person. Suffice it mentioning this particular fact: he knew that my wife collects postal stamps. After having known this, he gave to my wife the most precious gift of all: the containers of his personal collection of Finnish stamps. This is the most illustrative proof of Jaakko's kindness and exceptional friendship! Prof. Sergio Musitelli (Milan, IT)

Eminent Finnish Urologist Prof. Dr. Jaakko Elo passed away on Saturday, 28 January 2017. He was 91 years old and is survived by his wife and three children. Jaakko Elo was born on 25 July 1925 in Kojkemäki, Finland. His father was a construction engineer and his mother was a nurse. During the Winter War of 1939-1940, Elo volunteered as an orderly of From 1966 to 1988 Elo served as urological surgeon the Civil Defence Staff and served as Second and deputy head of the surgical section of Aurora Lieutenant during the Second World War from 1942 till 1944. Hospital in Helsinki and had a private practice in Mehiläinen Hospital in the same city from 1966 to 2002. Elo lectured at Helsinki University from 1983 to Medical Career 1992, being the first lecturer of paediatric urology in Elo studied medicine at Helsinki University. In Finland. 1948, he received a scholarship to study at Cambridge university. He researched the virulence and pathogenic capacities of Escherichia coli in He founded the “Journal Urologia Fennica” in 1986 the 1950’s and human blood group antigens in and was the first editor. From 1986 to 1988 he was mushrooms. chairman of the Finnish Urological Association. He published 30 articles in Finnish and international publications. He qualified as a medical doctor in 1953 and became Doctor of Medicine in 1960. He qualified as a surgeon in 1961 and specialised in paediatric Elo was honorary member of the Finnish and urology as the first medical doctor in Finland. Scandinavian Urological Associations and was With a French State stipend he studied at Hôpital nominated Professor Honoris Causa by the President of Finland in 2011. Necker in Paris in 1966.

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European Urology Today

EAU History Office In 2000, Elo succeeded E. M. Lindtsted as a member of the History Office of the EAU, representing the Nordic countries. He became a very productive and constructive member of this group of urological historians and published many articles in the “de Historia Urologiae Europaeae” series of books. He also organised two fall meetings of the EAU History Office in Helsinki, most recently in 2014. He was also very proud of his son Jorma who is a world-renowned choreographer. We will always remember Jaakko as an excellent urologist, an enthusiastic and ardent specialist in the history of urology, and as a very good friend with a friendly character and a warm heart. We will miss him and present our sincere condolences to his wife and family.

By Dr. Johan Mattelaer (Kortrijk, BE) on behalf of the EAU History Office

We lost a member, a good friend, a talented urologist, and a scientist. I will keep him in my mind and heart. Prof. Imre Romics (Budapest, HU) It saddens me to hear of the passing away of Jaakko. I will remember him as a good friend. We shared many interesting and cheerful moments. I wish his family warm regards from all his friends and urology colleagues from Holland and wish them strength in the coming period to carry this loss. Dr. Erik Felderhof (Hoofddorp, NL) I share with you the regret for the passing away of our friend Jaakko. I will always have the pleasant memory of the many talks in the occasional meetings, Jaakko’s teachings of his writings and the pleasant evening spent with Jaakko and his family in Helsinki in 2014. Best wishes to all who mourn for him. Dr. Luis Farina (Madrid, ES)

March/May 2017


USANZ Trainee Week 2016 A memorable training week Down Under Dr. Anneleen Verbrugghe UZ Leuven Urology Service Leuven (BE)

verbruggheanneleen@ gmail.com

My trip Down Under began when the EAU accepted my application to participate in the USANZ Trainee Week 2016. Each year the Urological Society of Australia and New Zealand organises a mandatory trainee week for approximately 90 second to fifth-year residents. The programme venue changes, with Sydney as venue for 2016.

"With lectures and pro/con discussions on prostate cancer therapies, mostly led by experts and participating residents, our knowledge on this topic was boosted. The discussions also reflected the fact that Australia and Europe face the same challenges in prostate cancer treatment." All the practical arrangements were efficiently coordinated by the wonderful team of USANZ’s Education and Training Managers Deborah Klein and Kirsten Isaacs. The week started on Sunday with

practice exams where five registrars took written and oral exams to prepare them for a definitive exam later that year. The younger registrars (set 2) and the international guests participated as observers, and for the former their participation provides the opportunity to gain an idea how the exams are organised. The oral exams are divided in four different categories (Pathology, Anatomy, Management, Structured Oral and Clinical Investigation), where the registrar is interrogated during each time segment for 20 minutes.

on androgen deprivation therapy), led this intense training session. This prepared us for a full day of urology training. On Monday, the main focus was on radiology, pathology and dermatology, with very practical lectures. The very interactive way of teaching, with internet-guided voting, was also effective. The interactive way of teaching, with internet-guided voting, was very effective

On Tuesday, a sexual health physician and endocrinologist lectured on As meeting kick-off, a Welcome BBQ with a grand sea view was organised, and where we got the opportunity infertility/andrology including the views of other specialties on this topic. Tuesday afternoon to meet-and-greet the faculty and the last-year was scheduled for recreation with a food tour in residents at ‘Drinks and Canapes’. Australians are Sydney, giving us the chance to get to know fellow known for their ‘open minds’ and everybody was residents and learn how training is organised in interested in sharing knowledge and experiences. Australia and New Zealand. Besides Peter-Paul To go with the ‘Healthy body, healthy mind’ spirit, a Willemse from the Netherlands there were eight other group training session was organised on a Monday overseas urology registrars (four from UAA, two from morning at Coogee Beach, located just across the SURG and two from CUA), who all shared their congress venue. An exercise physiologist, who is also experiences. The Australian and New Zealand's residents are expected to take initiative in their own involved in the ‘Man Plan’ (an exercise plan for men training, with more than half of the registrars presenting lectures during the trainee week. When they graduate, a majority of the residents would work in big cities, although vacancies are limited. To gain more experience and boost their career, most residents will apply for fellowships, preferably overseas.

Waiting for the next question in the hilarious Section vs Section quiz

Discussions on therapies With lectures and pro/con discussions on prostate cancer therapies, mostly led by experts and participating residents, our knowledge on this topic was boosted. The discussions also reflected

the fact that Australia and Europe face the same challenges in prostate cancer treatment. In general, the EAU and AUA guidelines are followed. With regards the practical aspects, the USANZ Trainee Week 2016 App kept us updated with notifications on the start of the sessions. There were also ‘thread’ discussions on twitter. Worth mentioning is the hilarious Section vs Section Quiz, where teams from different states competed against each other to answer, as fast as possible, urological trivia questions. The costumes and team names (e.g. masters of the perineum) added a jovial atmosphere and reflected the great sense of humor of the registrars. The farewell dinner on Wednesday evening at Watson Bay with a skyline view was memorable. Not only for the beautiful location, but also for the warm camaraderie, it was indeed an experience to meet enthusiastic people with whom one could discuss urology, urology training and life in general. The memory of this training programme will always stay with me and I will definitely keep in contact with the urological community Down Under. My heartfelt thanks to the EAU and USANZ for this wonderful experience!

Advertorial Changing the Treatment Paradigm: Immunotherapy in Bladder Cancer Management Supported by F.Hoffman-La Roche Ltd Chair: Morgan Rouprêt, MD, PhD; Pitié-Salpêtrière Hospital; Paris, France

Immunotherapies could transform the therapeutic landscape for bladder cancer and offer new hope to patients with this condition. This satellite symposium looked at the role immunotherapy— specifically checkpoint inhibitors—could play in advanced bladder cancer management and how clinicians could help patients fully benefit from these treatments. Cancer immunotherapies are making their mark across many tumour types, including bladder cancer.1 Prof. Rouprêt made reference to this at the beginning of the symposium stating, “It is a very exciting time (in the treatment of this condition).” Clinicians treating patients with advanced bladder cancer have few treatment options and outcomes can be poor.2,3 The advent of cancer immunotherapies will increase the treatments available to clinicians; however, “there is a learning curve” associated with their use. The high volume of emerging data for these novel agents—which have distinct mechanisms of action, patterns of response, and adverse-event (AE) profiles4-6—means that if clinicians are to use these treatments effectively, they must understand how to convert this research into clinical practice. In this respect, clinicians in the United States seem further ahead than their European counterparts, as noted by Andrea Necchi, MD (Fondazione IRCCS Istituto Nazionale dei Tumori; Milan, Italy), who was part of the expert faculty for this event: “We are at the very beginning in Europe; we have a gap compared with the United States.” This satellite symposium titled “Multidisciplinary Perspectives on Managing Bladder Cancer: Hope Is on the Horizon” was held at the ExCel Exhibition Centre in London on Sunday, March 26, 2017 and attended by leading urologists from Europe. The event comprised two presentations and a panel discussion, concerning the most promising checkpoint inhibitors for bladder cancer, delivered by well recognised speakers in the field of urology and medical oncology. Audience participation was welcomed through an “Ask the Expert” session.

Rationale for Cancer Immunotherapy in Bladder Cancer: What Do We Know? (Speaker: Javier Puente, MD, PhD; Complutense University of Madrid; University Hospital Clinico San Carlos; Madrid, Spain) Dr. Puente opened his presentation by providing an overview of the role of the immune system in cancer pathogenesis and explaining why bladder cancer is a good candidate for immunotherapy, based on its high mutation load. He stated how “a better understanding of the role of the immunologic system in tumour control has paved the way for strategies to enhance the immune response against cancer cells.” Checkpoint inhibitors block the interaction between PD-L1 and PD-1 surface proteins, found on tumour and immune cells, respectively, thereby “releasing the brakes” on the immune system and enabling immune cells to attack tumours. As immune checkpoint inhibitors

March/May 2017 1 505202977_Advertorial.indd

specifically target the tumour, they can circumvent traditional resistance mechanisms and achieve more durable responses than conventional treatments through activation of the adaptive immune system which generates immune memory.

Clinical Data for Immunotherapy in Bladder Cancer: What Do the Data Tell Us? (Speaker: Andrea Necchi, MD; Fondazione IRCCS Istituto Nazionale dei Tumori; Milan, Italy)

Progress in treatment options for advanced bladder cancer has been slow over the last 20-30 years; however, this may be about to change as demonstrated by recent trials investigating the therapeutic potential of checkpoint inhibitors. Dr. Necchi explained that the FDA-approved agents atezolizumab and nivolumab as well as pembrolizumab (which is under FDA priority review) are particularly promising immunotherapies and went on to consider efficacy and safety data from key trials for these agents. Dr. Necchi pointed to a slide showing the poor survival curve associated with chemotherapy and explained that median survival was especially poor for frail patients with multiple comorbidities and with poor renal function and performance status. He explained that such patients were in fact representative of approximately half of those seen in clinical practice. In phase 3 trials, one-year survival and response rates associated with checkpoint inhibitors were significantly better than with chemotherapy and AEs were manageable. In summarising the key trial data, Dr. Necchi stated, “So, this overview shows you the revolution which is coming to the clinical setting.”

“There are opportunities for urologists and oncologists to work together to improve the outcomes for patients with bladder cancer.”

Putting Data and Theory Into Practice: What Is the Function of a Multidisciplinary Team? (Chair: Morgan Rouprêt, MD, PhD; Pitié-Salpêtrière Hospital; Paris, France)

Prof. Rouprêt begun this panel discussion by considering the various members of a multidisciplinary team for advanced bladder cancer care: “The clinical and medical oncologists—they will help us with their experience with systemic drugs; the biomedical staff with the oncology nurse specialists and the palliative care specialists; the pathologists, because there are differences between one tumour from another according to the urothelial status of the tumour; the patient advocates; and the radiation oncologists.” Dr. Puente stated that it was important to involve the urologists in the metastatic setting, and medical oncologists in noninvasive disease. He spoke of the heterogeneity in the patient population of patients with bladder cancer and how this necessitated a multidisciplinary approach. He also mentioned that “the improvements we have made in treating bladder cancer have come through working together with the urologists

and the medical oncologists.” Dr. Necchi added: “Multidisciplinary collaboration with the medical oncologist is crucial because the early recognition of the infrequent side effects—which can be deadly—is crucial.” Another point over which the panel strongly agreed concerned the prominent role the patients play in bladder cancer management. Patients could provide valuable contributions to clinical trials; for example, patients could give insights on appropriate endpoints and they could also help guide treatment choices in the clinical setting. Concluding Thoughts As the satellite symposium drew to a close, the panel reiterated their optimism about the use of checkpoint inhibitors for bladder cancer treatment. However, while they acknowledged the potential of these agents, they also highlighted the need for combination treatments in order to further optimise bladder cancer care (Figure 1).7 Combination with genomically targeted agent and immune checkpoint therapy Percent Survival

Report on a Satellite Symposium at EAU Congress 2017

Chemotherapy

Immune checkpoint therapy

Genomically targeted therapy Time

Sharma P, Allison JP. Cell. 2015;161:205-214

Figure 1: Looking toward the future: optimising anti-tumour response in bladder cancer7 The panel speculated over the future use of checkpoint inhibitors in a curative or neoadjuvant setting, rather than just the metastatic setting or as a palliative treatment and on the importance of working with urologists in developing ongoing trials. They also underlined the need for greater understanding in the management of immunotherapy-related AEs and for biomarkers to help in the selection of patients for immunotherapies. You can visit the programme at: www.peervoice.com/mmz References 1. Kim J. Immune checkpoint blockade therapy for bladder cancer treatment. Investig Clin Urol. 2016;57(suppl 1):S98-S105. 2. Ghasemzadeh A, et al. New Strategies in Bladder Cancer: A Second Coming for Immunotherapy. Clin Cancer Res. 2016;22:793-801. 3. Powles T et al. MPDL3280A (anti-PD-L1) treatment leads to clinical activity in metastatic bladder cancer. Nature. 2014;515:558-562. 4. Bidnur S et al. Inhibiting immune checkpoints for the treatment of bladder cancer. Bladder Cancer. 2016;2:15-25. 5. Yuan J, et al. Novel technologies and emerging biomarkers for personalized cancer immunotherapy. J Immunother Cancer. 2016;4:3. 6. Day D, Hansen AR. Immune-related adverse events associated with immune checkpoint inhibitors. BioDrugs. 2016;30:571-584. 7. Sharma P, Allison JP. Immune checkpoint targeting in cancer therapy: toward combination strategies with curative potential. Cell. 2015;161:205-214.

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Young Urologists/Residents Corner EUSP Clinical Visit Gaining skills at Madrid’s University Hospital La Paz Dr. Bilal Gunaydin Istanbul Medeniyet University Goztepe Training and Research Hospital Dept. of Urology Istanbul (TR) bilalgun@ hotmail.com

From 10 December 2016 to 10 March this year, I was fortunate to be the recipient of a Clinical Visit scholarship from the European Urological Scholarship Programme (EUSP). The EUSP host centre was the University Hospital La Paz, a public hospital located in the northern outskirts of Madrid. Since the inauguration of the General Hospital in July 1964, it has now become the well-known hospital complex consisting of 17 buildings and four large hospitals, namely: General Hospital, Maternal Hospital, Hospital Infantil and the Hospital of Traumatology and Rehabilitation. It also offers specialised healthcare not only to local patients from across Spain but also those coming from other countries. High volume center La Paz is a high volume healthcare center. In 2009, the La Paz University Hospital has hosted more than 50,500 patients in its hospitalisation facilities, and had more than 220,000 emergency consultations. Approximately one million outpatient consultations and 42,890 surgical procedures have been performed in its facilities, including complex surgical procedures such as organ transplantations. To meet this volume, La Paz University Hospital employs a team of almost 7,000 professionals on 180,000 square meters of modern facilities.

Urology Department The chief of the Urology Department is Dr. Luis Martinez-Piñeiro Lorenzo, an excellent urologist. Although specialised in uro-oncology and reconstructive urology, he also performs other urologic procedures. Since my interest is in renal transplantation and endourology, La Paz urology clinic was an ideal centre, thanks to the European Urological Scholarship Programme ( EUSP). On my first day, I met Dr. Juan Gomez Rivas and Prof. Fermín R. de Bethencourt, who both briefed me on the daily tasks and routines of the department. Daily morning meetings begin at 8 a.m. with clinical discussion of the hospitalised patients, urgent cases and patients scheduled for surgical operations the next day. After the meeting, I proceeded to the operation room to observe all of the cases. La Paz Urology clinic has three operation rooms, with one room for uro-oncology, an ideal set-up for me since I had the opportunity to see a lot of procedures in endourology, uro-oncology and renal transplantations. My special thanks to Dr. Fermin R de Bethencourt, Dr. Luis Martinez-Piñeiro, Dr. Alfredo Aguilera, Dr. Alonso Dorrego, Dr. Cristina de Castro, Dr. Ramón Cansino, Dr. Jose Ramón Perez-Carral, Dr. Juan Gomez Rivas and Dr. Mario Alvarez Maestro for their experienced mentorship. Madrid has been memorable and I had special dinners with Dr. Mario Alvarez Maestro, Dr. Juan Gomez Rivas and the residents with whom I developed good friendships. Certainly, I will use the experience and insights I learned in Madrid in my own university. My heartfelt thanks to all the staff of the Department of Urology at La Paz University Hospital, my mentor Dr. Selçuk Sılay and the EUSP for giving me this priceless opportunity!

Impressions of my wonderful fellowship in University Hospital La Paz

Surgical training at Aalst, Belgium Turkish surgeon benefits from excellent robot-assisted surgical training There are four DaVinci Robotic Surgery systems available at ORSI Academy, including three Si systems and one Xi. Trainees have the opportunity to work in wet and dry laboratories. Each system has a simulator and in three systems, there is a possibility to work on a dual console. Besides the theoretical and practical knowledge, trainees also work on living animals, cadavers and training boxes for them to fully adapt to the system. At the end of the course, successful participants are issued a certificate from the NASCE-accredited training centre ORSI Academy.

Dr. Fatih Özkaya Erzurum Regional Training and Research Hospital Dept. of Urology Erzurum (TR)

drfatihm@gmail.com Live animal model surgery with dual console at ORSI

The acceptance of robotic surgery as a minimally invasive procedure has increased due to the perceived comfort experienced by patients and physicians. Robot-assisted surgery, used especially in treating urological diseases such as prostate and kidney cancers and uretero-pelvic junction obstruction, is becoming more and more frequent in other surgical fields. There are, however, obstacles to robot-assisted surgery such as expensive equipment (limited to expert centres), certification and a learning curve for surgeons.

O.L.V. Vattikuti Robotic Surgery Institute (ORSI)

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European Urology Today

As a young urologist, I trained hard in a six-week programme with Prof. Dr. Alex Mottrie, professor in the Urology Department of the OLV Hospital in Aalst-Belgium, chairman of the EAU Robotic Urology Section (ERUS) and head of the ORSI Academy. Training programme The programme consists of clinical work in the operating theatres on weekdays but mostly on Tuesday and Thursday. We received intensive hands-on training in ORSI Academy and the hospital and ORSI staff were very helpful. The operations begin at about 8 o’clock and our daily routine tasks end when all cases were finalised.

Pelvic lymph node dissection on a fresh dog cadaver at ORSI

One-on-one mentorship One of the key aims of the programme is for participants to engage one-on-one in the cases, train hard using the simulator for them to hone their skills with a 3D environment. Staff members in Aalst and at the institute are very helpful, and Prof. Mottrie as a mentor provides experienced insights. Besides the case discussions and sharing tips and tricks, he also teaches that learning does not happen only by watching. Although my training programme was limited to a short period, I highly recommend this robotic

training and I would suggest a longer period, for example at least three months. This programme provides not only specialised training, but also practical experience and friends. The training programme has seen increasing numbers of participants, and I am sure that for those who have participated and learned in Aalst, the mentorship they have received has contributed significantly in the improvement of to their surgical skills.

There are three DaVinci robotic surgery systems, (two Si and one Xi systems) used in the Urology Department. Different robotic procedures, mainly radical prostatectomy operations as well as cystectomy, partial cystectomy, partial nephrectomy, radical nephrectomy, pyeloplasty, lymphadenectomy, sacrocolpopexy and ureteral re-implantation are being performed. With a dual console and 3D screens, trainees have the opportunity to monitor, observe and work with the surgeon. For trainees, active participation is important since this will hone their skills and provides practical insights regarding the procedures. Prof. Dr. Alex Mottrie and the training fellows March/May 2017


Young Urologists/Residents Corner European Urology Scholarship Programme Tips and tricks for scholarship application Dr. Selcuk Sarikaya Past Chairman of ESRU Gulhane Research and Training Hospital Dept. of Urology Ankara (TR) drselcuksarikaya@ hotmail.com The European Association of Urology (EAU) provides different types of scholarship programmes for both residents and specialists in every field of urology. Once a resident or specialist decides to apply for a scholarship, they should first determine the appropriate timing and the centre suitable to their application. There are several types of programmes and it is very important to define the necessary duration for a specific education. ReproUnion, clinical/lab scholarship, clinical visit, short visit and visiting professor programmes are the main

There are also several accommodation types and for cheaper options applicants may consider house rents rather than hotels. Airbnb is a suitable option The deadlines are important for applicants and before to rent rooms. City taxes and the other extras are also items to keep in mind. Applicants should also applying for these programmes applicants must be aware that they can get reimbursements after the contact the host centres for the required application scholarship by providing the necessary documents. documents. It is very important to carefully read the It is also helpful for applicants to look for local travel webpage with the list of required papers, and to options and city information or guide to the nearest contact the coordinators in case of further inquiries. Applicants should also be aware of visa requirements. markets, airports, parking areas, trains and bus stations before their travel for them to gain more confidence. Contacting the host centres for the Accommodation and travel costs necessary documents is also essential to avoid or In the application forms, applicants should also reduce travel delays, problems and security checks mention any details or information regarding before arrival. expenditures. To acquire sufficient information regarding expenditures, it is recommended for To optimise benefits from the scholarship, applicants to seek advice from previous participants applicants should prepare their own programme or query their colleagues based in these host related to their needs and then compare their own countries. In some European countries, applicants objectives with the general education programme of should be aware that actual expenditures can be the host centres. If there is a big gap between their higher than the budget provided by EUSP. goals and the offered programme, participants Accommodation and travel expenditures are very important and if the flight tickets are arranged earlier, should discuss this with their programme coordinators and mentors. applicants could save on some expenses. categories. Many centres in Europe are hosting scholars and provide specific training programmes.

Clear goals Having a clear goal or set of needs is important for a scholarship applicant to avoid disappointments and expectations that cannot be fulfilled by the host centres. It is also very important for scholarship participants to be aware of the facilities and their rights or the extent of their participation in medical and surgical interventions. It is recommended that applicants should plan for different types of procedures and treatment methods since a wide range of interventions will vastly improve their medical and professional skills and own experience. Whenever possible they should get involved in at least one study in the host centres to boost their academic careers. A scholarship provides new connections, friends, fresh point of views and new experiences which can lead to future collaborations. Do not miss these opportunities and try to apply for at least one scholarship or skills training which will certainly open doors and enrich your professional career.

Young Urologists Office

Urowebinar for residents

Board Meetings in Amsterdam and London

A new way to expand knowledge

By Dr. Selcuk Sarikaya The Young Urologists Office’s (YUO) Board Meeting held in Amsterdam at the beginning of November last year proved to be not only productive but also discussed topics and issues that affect young urologists. YUO is mainly divided into three specific and active subgroups: the Young Academic Urologists, European Society of Residents in Urology and Non-academics. Assessment of recent activities and plans for these groups topped the meeting agenda. There was also a special testimonial about our recently deceased friend and former ESRU secretary and head of the YUO’s non-academics, Guillermo Martinez Bustamante, who died in a tragic incident. Prof. Michiel Sedelaar gave the welcome remarks and outlined the agenda and the leadership programme that will be launched during the EAU17 congress. The programme is unique in Europe and will cover several topics including medical leadership. After the presentation of Prof. Sedelaar, the author gave a brief talk on the recent ESRU activities, upcoming events, academic programmes and plans. ESRU collaborates with different working groups within the EAU and with urological societies in and beyond Europe. These connections allow ESRU to be more active and involve in international projects. Dr. Silay discussed the YAU’s projects, new organisational scheme, subgroups, eligibility criterias, recent activities and relations. YAU, composed of

ESRU Board Meeting group picture after the board meeting in London

March/May 2017

young academicians and a very well-organised society, enables young urologists to improve their academic skills. Prof. Hein Van Poppel discussed his ideas about subgroup activities and future events. There was a dynamic exchange of creative ideas particularly with the gradual expansion of YUO and its dynamic role within the EAU. Board Meeting in London The latest YUO Board meeting was in London within the EAU 2017 congress. The latest issues were discussed with board members. Prof. Michiel Sedelaar welcomed the board members and talked about the main activities of YUO during the EAU Congress. Selcuk Sarikaya, MD. Chairman of ESRU and Selcuk Silay, MD, Chairman of Young Academic Urologists held a presentation about the latest activities and upcoming projects, especially some projects of the EAU in which ESRU is collaborating, including UroSource, the EAU urological scientific update platform and the Patient Information Project, an EAU platform designed to provide high quality urological information to patients and the general public in several languages (English, Spanish, Dutch, German, Chinese, French and more). Another area that ESRU has explored is the development of surveys on topics considered interesting by the ESRU Board for future training for residents and young urologists, some of which include: A Residency survey, a survey to know the current conditions of urological surgical and academic training in Europe; A survey on Geographical distribution and use of Social Media; A Lifestyle survey aimed at understanding the modifiable lifestyle conditions of residents and young urologists in response to rising rates of burnout and depression reported in urology. Other future surveys and publications derived will be coming soon, e.g. on Andrology training. ESRU board elections During the board meeting in London, elections for some positions of ESRU board were held. Here was elected Juan Gómez Rivas (ES) as new Chairman-elect, also Diederick Duijvesz (NL) as new Secretary and Angelika Cebulla (DE) was elected as new Treasurer. Juan Luis Vásquez (DK) continues as Chairman and Selcuck Sarikaya (TR) as Past Chairman; furthermore Francesco Esperto (IT) remains as Internal Coordinator and Moises Rodríguez Socarrás (ES) as webmaster. From ESRU we are happy to embrace the structure of the new board and look forward to continuing to work together as a family among the different national resident associations and to welcome the new NCOs.

Dr. Leonardo Tortolero @DrTortolero Urologist Scientific activities manager @ResidentesAEU Elche (ES) leotor85@gmail.com

Dr. Juan Gómez Rivas Chairman, Spanish Residents Workgroup ESRU Chair Elect YUO-EAU Board Member Madrid (ES) juangomezr@ gmail.com We are in a new era of communication where distance and time have ceased to be an obstacle to efficiently share information, and new ways of imparting knowledge have emerged among professionals.

and interact using live Internet connection. This programme proved to be highly successful with the three sessions held in 2016 in Madrid and Vigo, connecting nearly 200 urologists and residents per session.

Spanish Residents and the Young Urologist Workgroup or RAEU has initiated the Urowebinar sessions with the participation of residents, young urologists and experts from all over Spain. This initiative aims to provide an ideal platform for interaction among urologists and to learn, share and boost urological knowledge through sessions where experts discuss new topics, and where residents and urologists from all over the country can directly ask

An interesting format has been created where interactive one-hour sessions with connections in 15 headquarters from different Spanish cities. This has been the perfect opportunity for new and talented residents, providing them the opportunity to present clinical cases and, in a dynamic way, apply scientific evidence to daily practice. To get the viewers’ attention, ‘hot’ topics were taken up such as laparoscopic training for residents, lymphadenectomy in testicular cancer and surgical treatment of BPH. Experts from all over Spain included Dr. Martinez Piñeiro, Dr. Mario Alvarez Maestro, Dr. Manuel Ribal and Dr. Lopez Garcia. One of the most important and innovative improvements of this format is the opportunity to get connected at home. It is required to register online days or hours before the Urowebinar session. The high satisfaction rate has inspired us to continue with this successful programme in different places. In the future other Spanish-speaking countries such as those in Latin-America could also join these interesting webinar sessions.

YUO is one of the most active groups within the EAU and will continue with excellent activities in the following time period. Young Academics and ESRU will do their best to contribute to the activities of EAU

and YUO. As always together we are stronger and also we will do our best to be more and more active in the following period. See you all in the upcoming activities! European Urology Today

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Young Urologists/Residents Corner Young Academic Urologists Meeting in London YAU assesses achievements and current projects young urologists and eventually developed into a dynamic scientific community. Over a period of five years, YAU produced scientific papers, online courses, books and book chapters as well as joint projects with EAU sections and the European School of Urology (ESU). With 84 members, YAU represents one of the most dynamic groups and platforms within the EAU. YAU’s profile has grown and its structure has expanded by the inclusion of additional working groups. EAU Adjunct Secretary General for Science, Prof. Francesco Montorsi, who was present in the The session of the Young Academic Urologists at the annual session, also commented on the achievements of the meeting should no be missed The Annual European Association of Urology (EAU) YAU during its initial years. He applauded the work Congress attracts several thousands of urologists and that has been done and encouraged YAU’s further every time that I attend this major annual congress, I development and involvement with the EAU. have this sweet anticipation to experience something treatment changed to surgical treatment in the last 15 new, and each year I am not disappointed. years. Moreover, it raised questions on the optimal The session also presented an update on the work of the non-oncology and oncology groups, which were management of prostate cancer patients in the This year, the Young Academic Urologists (YAUs) presented by Dr. Verze (IT) and Dr. Xylinas (FR), coming years. Their study proposals, on-going meeting held on March 24 was one of the sessions respectively. Aside from publishing several papers, surveys, EAU guidelines and e-learning courses that nobody should miss. The session, chaired by Prof. the non-oncology group was also involved in the involvement were also presented. Michel Sedelaar (Chairman of the Young Urologist development of systematic reviews, in guideline Office) and Dr. Selcuk Silay (Chairman of the YAU), For the first time, awards for the best paper and panels as well as social media activities such as the provided an overview of YAU activities during its first design of patient information material. The oncology abstract were given with Dr. Sanguedolce (ES) years. Silay described YAU’s development, and his groups conducted very interesting studies including a receiving the award for the best paper on behalf of inspiration was reflected in his words when he said recently completed clinical investigation showing the the Endourology group. The best abstract was granted that “…a solitary fantasy can transform a million of to Dr. Borgmann (DE) and the Renal Cancer group. trends on prostate cancer treatment based on risk realities.” distribution over a period of 15 years. This study was Key studies of the year were presented by YAU made possible by collaborative work and provided members (Drs. Marcelissen, Kallidonis and Gandaglia) YAU started as a talent pool for recruiting renowned insights on how the clinical practice of prostate cancer and these articles were discussed by prominent urologists such as Professors De La Taille, Olivier Traxer and Prof. Freddie Hamdy. The different perspectives of the young and experienced urologists on a controversial topic led to interesting, thoughtprovoking conclusions. Dr. Panagiotis Kallidonis Dept. of Urology Lithiasis and Laparoscopy unit University Hospital of Patras Patras (GR) pkallidonis@ yahoo.com

Prof. Alberto Briganti (IT), YAU member and recipient of the 2016 Crystal Matula Award, gave a motivational talk regarding career development as he stressed that focused efforts and determination are crucial in achieving one’s career goals. Dr. Borgmann (DE) received the award for the best abstract on behalf of the Renal Cancer group

Dr. Buffi was recognised as Chair of the Working group for Robotics in Urology

The Challenge the Expert Session presented intriguing debates which tackled advantages and disadvantages

Dr. Sanguedolce (ES) received the award for the best paper on behalf of the Endourology group

of adjuvant therapy for high-risk renal cell carcinoma, adjuvant radiation therapy for prostate cancer and adjuvant chemotherapy for bladder cancer. Three YAU members, Drs. Ouzaid, Ost and Kluth, provided arguments against prominent speakers such as Profs. Bex (NL), Heidenreich (DE) and Seiler (CH). The effort of the YAU to increase collaborations with the EAU sections which are not represented in the YAU was underlined by the very interesting presentations of Dr. Walz (FR), Prof. Junker (DE) and Dr. Lledo-Garcia (ES) who provided insights on the aims, structure and work of Urological Imaging, Urological Research and Transplantation sections of the EAU. Following the sessions, each YAU group brainstormed for a couple of hours to take up plans, collaborations and academic involvements. This session is the basis for the next projects of each group. It should be noted that the meeting this year included for the first time scientific content, which reflects YAU’s emphasis on scientific excellence. It also made clear that the YAU is an integral part of the EAU and represents the ambition and enthusiasm of younger urologists. The session attracted the interest of many participants, filling up the meeting room to its maximum capacity. YAU has made clear their visibility through talent and hard work, and we could only wish them more achievements.

YUORDay17 during EAU17 London Report on the most important event in the ESRU calendar Dr. Moisés Rodríguez Socarrás Webmaster of @ESRUrology Team @ResidentesAEU Vigo (ES) @moisessocarras

Dr. Juan Gómez Rivas Chairman elect ESRU Chair of Spanish Residents & Young Urologist Workgroup YUO-EAU Board Member Madrid (ES) @JGomezRivas The European Society of Residents in Urology (ESRU) was founded in 1991 as the body representing young doctors in training in Urology in more than 23 European countries. During the congress of the European Association of Urology, one of the most important meetings of the ESRU Board is held annually with the participation of the National Communication Officers (NCOs). You will find a report on this meeting in the article by Selçuk Sarikaya. Furthermore, in London, a full day programme is organised by and for young urologists and residents, YUORDay17.

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European Urology Today

YUORDay17: EAU Young Urologists Office & European Society of Residents in Urology (ESRU) Special Session As in previous years the special session YUORDay17 was held on 25th of March #EAU17, this is one of the most important events in the ESRU calendar. The main aim of this session was to introduce ESRU, to present our projects and to announce our upcoming activities. ESRU is one of the most active working groups within the EAU and there are lots of issues to present during YUORDay Sessions. Also there were specific presentations about YUO, YAU, EUSP, EBU and ESU. The lectures were especially designed for resident education. The YUORDay17 was introduced by S. Sarikaya, Ankara (TR) and J.P.M. Sedelaar, Nijmegen (NL), stand out the presentations of M.S. Silay, Istanbul (TR) Young Academics Urologist (YAU), European Urology Scholarship Programme (EUSP) Moderators: V.G. Mirone, Naples (IT), J.P.M. Sedelaar, Nijmegen (NL), inspirational words from M.J. Ribal, Barcelona (ES) who remarked that the scholarship programme is "A great research opportunity for young urologists".

Three giants of urology gave us their vision of building up a career in urology, with the readings: “How to become a robotic surgeon?” A. Mottrie, Aalst (BE), “How to Become an Endourologist?” O. Traxer, Paris (FR) and “How to grow big in urology?” F.M.J. Debruyne, Arnhem (NL). Without any doubt, the most exciting moment of YUORDay17 was the Campbell Quiz Challenge, where the knowledge of those present was tested, with interactive voting and masterful moderation by M.J. Ribal (the EAU Guidelines master) from Barcelona Impressions of YUORDay17 (ES), J. Gómez Rivas, Madrid (ES) and M. Waterschoot, Sinaai (BE). Here the winner was Dr. Anna Katarzyna Czech from Poland. the traditional group photo. YUORDay17 concluded with the awards ceremony for the best work done by residents and young urologists, this session was moderated by Selçuk Sarikaya (TR) (Past Chairman of ESRU) and finally

From ESRU we look forward to the next Annual EAU Congress (EAU18) to be held in Copenhagen, where we are convinced that they will welcome us in a friendly and warm atmosphere.

In the Simulation and Training session F. Dal Moro (IT) revived our passion for "Anatomy learning in urology" and raised awareness when L. Martínez-Piñeiro, Madrid (ES) gave us his vision about "Future of training / residency In urology". One of the most exciting sessions of the day was "Surgery: Tips and Tricks" Moderators: D. Duijvesz, Rotterdam (NL) and J.L. Vásquez Mendoza, Copenhagen (DK) which included keynote presentations such as "In bloc transurethral resection of the bladder" by B. Malavaud, Toulouse (FR), "Vesicoureteral reflux" by M.S. Silay, Istanbul (TR), "How to handle iatrogenic lesions" buy V. Ficarra, Udine (IT), and Penile curvature by D.J. Ralph, London (GB).

ESRU group photo at YUORDay17 March/May 2017


EAU-JUA Academic Exchange Programme Fellows experience warm welcome from European hosts Dr. Shinichi Yamashita Tohoku University Graduate School of Medicine Dept. of Urology Sendai (JP) yamashita@ uro.med.tohoku.ac.jp

Dr. Yukiko Kanno Hokkaido University School of Medicine Dept. of Urology Sapporo (JP)

kankankan4kan@ yahoo.co.jp

We also had a great time at the London Eye and had an excellent dinner with Mr. Dan Wood and his colleagues. We also thank Mr. Wei Shen Tan for his kind hospitality throughout our visit at UCL. Again, we were truly inspired by UCL’s high level of clinical and basic research. Visit at Guy’s Hospital We visited Guy’s hospital from March 22 to 23. Prior to this visit, we enjoyed an excellent dinner and pool game with Mr. O’Brien, Mr. Rick Popert and Mrs. Claire Taylor at AMC (Auto Mobile Club). Rick was an excellent pool game player and I won a booby prize. We had a clinical conference, stone seminar and functional urology case conference at Guy’s Hospital on March 22. I was impressed by the presentation on ureterolysis. We also closely observed several procedures, including robotic surgery and ureterolysis. We visited the Gordon Museum of Pathology, renowned for many human original specimens including lymph nodes collected by Thomas Hodgkin to describe

It was our great pleasure to have participated in the EAU-JUA International Academic Exchange Programme from March 19 to 28, 2017. Our five-day visit to the two institutions in London helped deepen our clinical experience as well as broaden our perspectives. We also enjoyed the company of fellow urologists from UK and Taiwan. During our visit to the University College London (UCL) (March 19 to 21) Prof. John Kelly, his principle investigators and fellows gave us special lectures on their clinical and research work in oncology, andrology, male urethral and female reconstruction, adolescent urology and endourology. The lecture on efficacy of chemohyperthermia by Prof. John Kelly provided us a unique and new direction. We observed UCL’s excellent surgical procedures, including robotics and stone surgeries, which inspired us to innovate and improve on our original practice. The entrance of University College London

With Mr. O’Brien, Claire and fellows from Taiwan

Hodgkin’s lymphoma. Mr. O’Brien also brought us to Borough Market, a bustling place full of fresh foods and drinks. And the fellows of Guy’s Hospital took us to the oldest pub in London and an excellent Indian restaurant. Thank you all for your hospitality! (By Yukiko Kanno) EAU17 Congress We participated in the exciting 32nd Annual EAU Congress (EAU17). This scientific congress presented many plenary sessions, thematic sessions, and poster sessions, and were educational and very helpful for our daily medical practice and future research. I also had the opportunity to present in the poster session. I discussed with doctors from many countries and learned various approaches in treatment and research. Moreover, I was very fortunate to have my poster selected as the Best Poster. This is indeed an honour for me and my colleagues. We truly appreciate the opportunity to attend the EAU International Friendship Dinner at the Sheraton Grand London Park Lane Hotel. We were impressed by the venue and atmosphere. It was a wonderful moment when we received from EAU Secretary General Professor Chris Chapple the citation plaques, which confirmed our participation in the academic exchange programme. We will certainly remember that memorable evening.

With Prof. John Kelly

During this academic exchange, we met many colleagues who were willing to provide us with invaluable information and technical expertise. The experiences we had are irreplaceable and we are extremely grateful for the warm welcome we experienced. Finally, we greatly appreciate the EAU and JUA staff members who helped plan and carry out the EAU-JUA Academic Exchange Programme. (By Shinichi Yamashita)

The certificate of participation in the Exchange programme

www.esau17.org

www.cem17.org

ESAU17

CEM17

10th Meeting of the EAU Section of Andrological Urology

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

24-25 November 2017, Malmö, Sweden

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

March/May 2017

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

European Urology Today

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ESUR17 24th Meeting of the EAU Section of Urological Research 12-14 October 2017, Paris, France In collaboration with the EAU Section of Uropathology

Prof. Kerstin Junker ESUR Chair

Fundamentals on research strategies at ESUR17 Participate in riveting, interdisciplinary discussions on vital clinical and research topics at the upcoming 24th Meeting of the EAU Section of Urological Research (ESUR17). The meeting will focus on enhancing the clinicians’ knowledge on research strategies and the researchers’ cognizance of urological challenges.

Furthermore, different in-vitro and in-vivo model systems that reflect tumour complexity will be presented during the meeting. Junker also mentioned that there will be an examination of the technical and ethical aspects of the Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) system.

“ESUR17 is a unique and distinguished platform to meet and collaborate with researchers and clinicians from different urological fields. These international and esteemed experts will deliberate on important clinical questions with varied clinical and research points of view,” said ESUR Chair Prof. Dr. Kerstin Junker (DE) of the Universitätsklinikum des Saarlandes.

Junker added, “DNA repair mechanisms and defects in the related genes play an important role in disease development. Therefore, we will critically examine the role of DNA repair genes for chemotherapy response and therapeutic targets in urological cancers.”

This meeting is organised in collaboration with the EAU Section of Uropathology (ESUP) and will be chaired by Prof. Yves Allory (FR) of the Institut national de la santé et de la recherche médicale (Inserm). Hot topics at ESUR17 Tumour heterogeneity and the implications for therapy with a focus on bladder cancer will be one of the main topics of this year’s meeting. “As it is getting more widely accepted that tumour microenvironment plays an important part in tumour development and progression, one of the major topics at ESUR17 will be tumour complexity and its role concerning tumour progression and therapy. Prominent speakers will discuss the role of nerves and immune cells for tumour progression and drug resistance,” stated Junker.

Additional events on 25 September: • Junior ERUS-YAU Meeting • ERUS-EAUN Robotic Urology Nursing Meeting • European School of Urology (ESU) Courses • EAU Young Academic Urologists (YAU) Meeting

Robotic Live Surgery

Current major challenges in urological research According to Junker, the current major challenges in urological research are identifying the most significant clinical questions and bringing the results from research into clinical practice. “To resolve such challenges, we as researchers and clinicians need open communication, close contact and mutual understanding.” Junker stated that presently, one of the most relevant topics is understanding the high diversity of tumour subtypes, which is mainly possible through molecular characterisation. “This is important for clinics because subtypes are characterised by different prognosis. Also, in the era of molecular targeted therapies, it is essential to know the targets and to select the patients individually for systemic therapies.”

Register before 8 August 2017 and benefit from an early fee! www.esur17.org

Another major challenge in urological research is the development of biomarkers. “Many potential biomarkers for diagnosis, prognostic evaluation and therapy response prediction have been identified. Now, they have to be validated in clinical practice. We need defined criteria similar to therapeutic studies. Liquid biopsies are very promising in this regard,” stated Junker. Breakthroughs in the coming decade Junker said that the focus in the coming years should be individualised therapy for patients. “The use of biomarkers is key. The molecular and cellular backgrounds, especially of metastasis, will be deciphered in a more complex way. This includes cell-to-cell communication. Then based on these, new therapeutic options will be identified,” Junker concluded.

ERUS17 14th Meeting of the EAU Robotic Urology Section Experts of today vs. rising stars of tomorrow 26-27 September 2017, Bruges, Belgium

Abstract submission deadline: 1 June 2017 Early registration deadline: 15 June 2017

Additional events on 26 & 27 September: • ESU/ERUS Hands-on Training in Robotic Surgery

14th ERUS has more to offer for the young urologist The EAU Robotic Urology Section meeting is set to offer delegates the latest and best in this fast-moving field. With a strong emphasis on live surgery and with no less than three other meetings held concurrently, ERUS17 is not to be missed for the technology-minded urologist. ERUS17 starts on September 25th with a special half-day programme for residents and young urologists, the Junior ERUS–Young Academic Urologists (YAU) meeting. This is followed by an afternoon of courses offered by the European School of Urology. Similarly, the ERUS-EAUN Robotic Urology Nursing Meeting has a fullday meeting designed for nurses who are involved in robotic surgery. The YAU will also have its own (closed) meeting on the 25th. The regular ERUS scientific programme begins on the 26th. We spoke to Dr. Geert De Naeyer (Aalst, BE), who is a member of the ERUS17 Local Organising Committee and in charge of this year’s Junior ERUS-YAU meeting. Cutting-edge Live Surgery “As with previous editions of ERUS, our goal is to cover the most common robotic operations,” De Naeyer explains. “This year, the surgery is taking place in the OLV Hospital in Aalst, where we have three robotic systems at our disposal (2 Si and 1 Xi). It’s the only centre with three systems in Belgium. We will schedule to have all three operating rooms running simultaneously. This allows us to have 16

cases instead of the usual 12, and the moderators will be able select the most important parts of every operation.” “From feedback we learned that delegates want to see more complex surgery, so this year at least two cystectomies are scheduled, as well as a salvage lymphadenectomy. More rare indications will be shown if cases are available: adrenalectomy, a paediatric case (a live first for ERUS!), robotic adenomectomy, and a vasovasostomy.” The slogan for ERUS17, which is reflected in the scientific programme is “Experts of today vs. the rising stars of tomorrow.” De Naeyer explains this duality in the live surgery: “Compared to previous editions, this year we didn’t necessarily want to feature the same surgeons for the whole live surgery programme. So we will be starting with the famous, established ‘star surgeons’ like Vip Patel, Alex Mottrie, and Peter Wiklund, but we will also incorporate new, upcoming surgeons into the programme.” Other lectures will cover current topics like PSMA, mpMRI, and emerging new technologies. Delegates can also look forward to a comprehensive updates on paediatric robotic surgery, and costeffectiveness, an important topic for robotic urologists and robot users in general. Young Urologists ERUS17 features the 7th Edition of the Junior ERUS Meeting,

Dr. Geert De Naeyer (Aalst, BE)

combined this year with the Young Academic Urologists. Young urologists and residents have special wishes and needs for their meeting, and Dr. De Naeyer knows what it takes to design a specialised programme: “We are offering a practical programme, providing many tips and tricks for the starting robotic surgeon. Our goal has always been to target the novice robotic surgeon, in sessions presented by other young urologists (age 40 or younger). Specific attention is given to difficult steps, and the starting up of a robotic surgical unit, which is not covered in the regular programme.” “Junior ERUS has been very well received in the past years. Last year in Milan we managed to offer live surgery for the first time. We have also been featuring more scientific content as well: we’ve found that a critical literature update is much appreciated.” Of all the EAU’s Section Meetings, ERUS is unique in having its own “Junior” programme. Dr. De Naeyer points to the potential of robotic surgery as being attractive for younger urologists. “It’s become clear that robotic surgery is here to stay. We are attracting young surgeons because they are the future of our specialty Junior ERUS-YAU wants to be there for them. Furthermore, robotic surgery is teamwork, usually between a senior surgeon and a junior table assistant. There are different learning curves for both parties.”

For more information about this meeting, please visit www.erus17.org 36

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March/May 2017


EULIS17

#EULIS17

4th Meeting of the EAU Section of Urolithiasis 5-7 October 2017, Vienna, Austria Prof. Kemal Sarica, Chairman EULIS

www.eulis17.org

Discover new advancements on stone management at EULIS17 The 4th bi-annual meeting of the EAU Section of Urolithiasis (EULIS17) will bring new, exciting developments on the management of stone disease. EULIS Chairman, Prof. Dr. Kemal Sarica (TR) of the Dr. Lufti Kirdar Training and Research Hospital, introduces some of the meeting’s highly-anticipated updates. “There are numerous reasons to look forward to the upcoming EULIS meeting. In terms of technology, there is the miniaturization of percutaneous scopes used in clinical practice, new digital flexible ureteroscopes, and newly-designed disposable ‘single-use’ flexible ureteroscopes. This meeting will also showcase emerging concepts of ureteral stone management, the new methods in gaining access to the kidney during percutaneous stone removal, and endoscopic-combined management of large and complex renal stones with percutaneous nephrolithotomy (PNL),” stated Sarica. He adds that standardisation of the training in endourologic procedures, and management of the stone in cases under anticoagulant medication are significant topics that will also be deliberated during EULIS17. Major challenges in stone management Proper diagnosis, stone management through the use of the most appropriate procedures without leaving any significant residual fragment, and major complications pose the biggest challenges according to Sarica.

To address said challenges, Sarica suggested to further increase knowledge and experience particularly in complex cases and paediatric patients. “Moreover, we should also have all the relevant instruments and systems in our operating theatres. We should also remain patient throughout the procedures and follow the guidelines of minimallyinvasive stone management whenever applicable. These can increase the success of stone-free rates and decrease complications.” Future breakthroughs Sarica expects in majority of cases in the future, there will be “easy, safe and practical puncture of the kidney during PNL and newlyestablished, precise methods.” He foresees that indications for flexible ureteroscopic stone management will have thinner, digital scopes; and PNL with smaller instruments will make stone removal further less invasive. He added, “Robotic flexible ureteroscopic management, and disposable ‘single-use’ flexible ureteroscopes will be commonly used in five to ten years. These will lower the cost of flexible ureterorenoscopy (fURS). Biodegradable stents will be customary, and clinical introduction of new and more effective medical agents for stone management will be another advancement in the treatment of stones.” Lectures at EULIS17 Sarica will be one of the many esteemed speakers at EULIS17.

For over 30 years and in addition to the commonly applied procedures performed in cases concerning all age groups, Sarica has focused on the minimally invasive surgical management of stones in paediatric cases with emphasis on the metabolic evaluation and medical management of the calculi in this specific population. Furthermore, percutaneous management of renal stones (particularly the effect of miniaturization process on this procedure) is one of his favourite areas to work with in the last decade. “I chose these lecture topics that I believe I have enough experience with, so that I can pass it on to the participants of the meeting. These topics will still have some points that need further discussion and examination,” shared Sarica. In his preparation for EULIS17, he said that he researches and evaluates newly-introduced techniques on treatment concepts of urinary stones, and the minimally-invasive treatment alternatives used in safe and practical management of most urinary calculi. “Technological developments have changed considerably throughout the years. In order to make a contemporary and accurate presentation on a certain urolithiasis-related subject, I have to be remain aware and thorough on the advancements on the medical and surgical management of stones.” EULIS17 will take place in Vienna, Austria from 5 to 7 October 2017.

For more information about this meeting, please visit www.eulis17.org

www.esui17.org

ESUI17 Abstract submission deadline 1 July 2017

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

New technologies and limited resources

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

16-19 November 2017, Barcelona, Spain

Implementing multidisciplinary strategies in genito-urinary cancers 9th European Multidisciplinary Meeting on Urological Cancers In conjunction with the • 6th Meeting on the EAU Section on Urological Imaging (ESUI) • EAU Prostate Cancer Centre Consensus Meeting (EPCCCM) • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) • European School of Urology (ESU)

www.emuc17.org March/May 2017

European Urology Today

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18th EAUN Meeting in London Meeting gathers 350 delegates for latest research and practical insights Over 350 urology nurses from Europe and around the world gathered in London to learn updates and practical insights in a programme that featured practical workshops, courses, as well as state-of-theart lectures on cancer management and follow-up, kidney failure and rare diseases, among other topics.

capable of choosing or deciding on the best treatment, an issue which sparked a lot of discussion and cordial laughter. The session was formatted in the style of the ‘Westminster House of Commons’ debate where only ‘Hear, hear’ comments can be heard. This new session format was very much appreciated and will be repeated next year in Denmark.

The following report is an overview of the wideranging programme that took place from March 25 to 27: Following the welcome remarks by Stefano Terzoni (EAUN Chair), Chris Chapple (EAU Secretary General) and Jane Taylor (BAUN Honorary President), the threeday event acknowledged the difference between specialist nursing and nursing specialists during the plenary session. In the first session on Saturday morning the potential role of specialist nurses, nurse-led clinics and future challenges were explored by Jerome Marley (IE) and Philippa Aslet (UK).

Jane Brocksom presenting on the consequences of Brexit

Urostomy and urinary diversion The latter, the ESU Course on “Urostomy/urinary diversion: Clinical pathway for the management of patients who undergo a cystectomy”, drew a high attendance and was well appreciated. The entire patient care pathway was examined; ranging from pre-operative counselling to side-effects and post-surgical follow-up. One of the presenters, Kyla In a session on Sunday afternoon, organised in Rogers (UK, Mitrofanoff Support President) gave good collaboration with the British Association of Urology Nurses (BAUN), current issues in urological care were learning insights from the patient perspective. Health care workers did not take her seriously and she had to taken up. Chaired by Jane Taylor and Paula Allchorne wait for a long time before she finally got help. Her (EAUN Board member) the session noted that case is a good example that second opinion has urological nurses are using advanced nursing practices throughout Europe despite the differences in benefits and that a health care worker should encourage patients in difficult cases to ask for a second culture and clinical approaches. opinion. It is frustrating for a urologist, for instance, Jane Brocksom opened the session by highlighting the not to be able to help a patient, and asking a colleague for some help should not be perceived as failure. importance (despite common perceptions and the UK’s decision to exit the EU) of European links, Follow-up after surgery cross-country communication and collaboration, which are essential to foster relations and ensure the There is a high rate of cystectomy patients who get complications. Thus, side-effects over time such as advancement of research, education and networking erectile dysfunction, sexual problems for women and of clinical practice. The next three speakers all fatigue should be properly attended to. The patients demonstrated in their presentations how nurses in need follow-up by an oncology nurse or other advanced roles can provide cost-efficient, effective, patient-centred care that would also ensure quality in specialist nurses following surgery. Finally, the need for investing in further research regarding side-effects nursing care. Using research- based medicine to over the long-term became apparent, and this topic design and re-model services, they also emphasise should be emphasised in the training and education the importance of collaborative work. of health care professionals, particularly doctors.

E-health and empowerment was another interesting and current topic. The use of a webcam as a consultation tool was of course unheard 20 years ago. But, today, informing patients for them to go online and download hospital instructions and information is now quite normal, and which leads to reduced paper use and postal costs. Using a webcam system to provide language translator service works efficiently in medical consultations. However, the electronic world also presents some challenges since whenever patients consult “Dr. Google” the information they get may not

Training psychomotor skills in the Robotics HOT Course for nurses

In the following three patient care improvement presentations (by Pauline Bagnall, United Kingdom, Lone Aarvig and Kathrine Melchiorsen both from Denmark) the speakers highlighted the very similar aims despite the equally different approaches by specialist nurses to improve patient care, regardless of their country of origin. Obviously, we all strive to achieve this common goal despite the variations across Europe. As the EU motto states “In varietate concordia” or ‘United in diversity.’ A remarkable range of topics that cover many key issues in urological nursing were presented, as well as two collaborative EAUN-European School of Urology (ESU) courses which addressed the ‘learning curve in urological surgery’ and ‘urinary diversion’.

For nurses working in the operating theatre there was also a lot to gain from this meeting, particularly in sessions such as in the ESU course on the learning curve in urological robot-assisted surgery and a hands-on robotics skills training.

Overall, the 17 posters and presentations in the two poster sessions were of a very high level and provided evidence-based results, as well as practical information that could be used in every day practice. This fulfils the session’s goal to serve as a platform for knowledge sharing. All presented abstracts, posters and lecture slides can be found in the Resource Centre at www.eaun17.org. The EAUN Scientific Committee is working to have equally interesting poster sessions in Copenhagen and is ready to provide support to all colleagues who are interested to join the abstracts sessions next year. Don’t miss this opportunity! Abstract submission is open from 1 July until 1 December 2017 at www.eaun18.org Full meeting rooms at the sessions in London

Nurses looking for practical topics for their daily practice benefited from the sessions which tackled topics such as nursing solutions in difficult cases, challenges with urine incontinence, acute and chronic kidney failure, challenges in testicular cancer care, the urology nurse as patient advocate, stoma care of a patient with trisomy and autistic tendencies, among many other issues. This year, the state-of-the-art lectures covered challenges in nursing practice such as the counselling of patients with acute and chronic kidney failure, drug resistant micro-organisms, and the issue of patient education in a challenging environment (or poor patient literacy). Furthermore, the delegates were informed on developments such as a Danish nurse-driven survivorship clinic and urodynamic studies with air-filled catheters performed in Belgium (shown during the video session on Sunday). Guidelines session In a well-attended Guidelines session on Saturday, Susanne Vahr updated the delegates on the latest research regarding intermittent catheterisation. She handed over a new edition of the EAUN guidelines on intermittent catheterisation (a very handy pocket version) to Maria Aberg Hakansson of Wellspect HealthCare, who supported the production of the pocket guidelines. Participants were offered copies of the pocket guidelines besides learning key take-home messages.

The gathered presidents and representatives of 11 European urology nurses societies after a fruitful meeting with the EAUN Board in London

always be accurate. This can lead to potential conflicts or misunderstanding between the patient and medical professionals. The key messages in the session reminded the delegates of the crucial and yet tricky role of electronic tools.

Robotic skills training A first, the ERUS-ESU hands-on training course for nurses on Robotic skills and communication was held with the support of Mimic Technologies, 3D Systems and Stan Institute. The session took up the demanding team work in the operating room and made the participants very much aware of each other’s role and the importance of communication. Moreover, it was possible to test and improve psychomotor skills by performing various team exercises. The course was very successful and to follow up on this success the EAUN is currently organising a three-day meeting on robotics in Bruges, Belgium in conjunction with ERUS17.

In the thematic sessions important oncology topics were covered such as testicular cancer, NMI bladder cancer, a survivorship care programme in surgical oncology, lymphedema after lymph node dissection and many others. In the session on testicular cancer care, the delegates were given updates on the importance of supporting men at key stages of their disease and about ethical challenges that health professionals encounter with this type of patients.

Opponents and Speaker of the House Mr. Ronny Pieters at the 'Westminster session'

Debby Watson (NL) and Brian McGowan (IE) debated the contentious question of whether patients are

18th International EAUN Meeting

London, United Kingdom 25-27 March 2017

EAUN Award Winners First prize for Best EAUN Poster Presentation Schmidt M.L.K., Midtgaard J., Ragle A-M., Avlastenok J., Sønksen J., Østergren P. (Copenhagen, Herlev, Denmark) For the poster: ‘Transition from hospital-based supervised exercise to unsupervised exercise in the community: Experiences from men with prostate cancer’ Second Prize for Best EAUN Poster Presentation Newman D.K., O’Connor C., Clark L (Coeur D’Alene, Idaho, Milwaukee, Philadelphia, United States of America) For the poster: ’Is re-use of intermittent urethral catheters safe and preferred? Real world data from the United States’ Third prize for Best EAUN Poster Presentation Avlastenok J., Rud K., Køppen H., Føns F., Østergren P. (Herlev, Denmark) For the poster: ‘A descriptive study of experienced burden by spouses living with men undergoing androgen deprivation therapy for prostate cancer’ Prize for the Best EAUN Nursing Research Project – March 2017 E. Van Muilekom, S. Horenblas, S. Ottenhof, J. Kieffer (Amsterdam, The Netherlands) For the paper: ‘Quality of life in penile cancer patients: a survey of patient reported outcomes’ Prize for the Best EAUN Nursing Research Project – September 2016 R.N. Knudsen, E. Grainger, M. Svejstrup, B. Jensen, H. Kruse Larsen, J. Bjerggaard Jensen (Aarhus, Denmark) For the paper: ‘Quality Assurance Project: Nephrostomy catheters and bandages’ Best EAUN Nursing Research Project Prizes supported with an educational grant from Wellspect HealthCare

For photos please check page 8.

32nd Annual EAU Congress 38

European Urology Today

March/May 2017


34th World Congress of Endourology Thought-provoking sessions on urological practices Sue Osborne Urology Nurse Auckland (NZ)

sue.osborne@ waitematadhb.govt.nz In November 2016, I had the pleasure of attending the 34th World Congress of Endourology in the culturally rich city of Cape Town, South Africa. Many of your urologic colleagues were also in attendance with a strong representation from the United Kingdom and Europe. We were blessed with day after day of blue skies, making the pre and post session views of Table Mountain and Victoria and Alfred Harbour quite spectacular. The South African hosts were friendly and welcoming, and the entire experience was a real pleasure.

Another interesting African-based presentation was by Prof. André Van Der Merwe, Head of Stellenbosch University's division of urology in South Africa. He informed the audience of how traditional circumcision practices often result in disfigurement and complications leading to organ loss. Young men are naturally deeply traumatised by these events with psychological illness and even suicide not uncommon in this group. In response, and as part of a pilot study, Van Der Merwe’s team performed the world’s first penis transplant in December 2014. It was for a 21-year-old man whose penis had to be amputated after he developed severe complications from a circumcision. Prof. Van Der Merwe explained how the surgical team had spent many months researching the techniques used by face transplant surgeons before attempting the penis transplant. They used the same type of microscopic surgery to connect the blood vessels and nerves in the nine-hour operation. After nearly two years, the young man has regained all urinary, reproductive and sexual functions with his transplanted organ, and he considered the successful surgery as having changed his life, significantly improving his psychological well-being and self-esteem.

The congress programme was varied with the main plenary and poster sessions allowing me plenty to pick and choose from to suit my advanced nursing "..those patients with stents with practice interests. The timetable also included topics specifically relevant to the African continent, but of strings had less sexual intercourse importance to all of us, like the ‘save the rhino’ while the stent was in place, than presentation given by Karen Trendler. Trendler is a passionate speaker, personally involved in those with traditional stents." rehabilitating young rhinos orphaned by poaching. She explained how the highly-skilled staff at the rhino calf orphanage aims to achieve healthy, viable, Thought-provoking sessions self-sustaining rhinos that can be successfully One of many thought-provoking plenary sessions was released back into the wild. a panel presentation where urologists from a variety of settings presented their views on the optimal This process starts with the initial rescue and recovery management of different small renal masses. The of the rhino calves from the wild, a very challenging panellists presented rationales for active surveillance, procedure. They have often been alone for days renal mass biopsy, partial nephrectomy and ablative before they are located and have developed blood techniques. The factors that influenced their sugar abnormalities, temperature control issues, decision-making included: size and characteristics of dehydration, starvation, and immune compromise. the mass on imaging; renal biopsy findings if She stated that the rhino calves also commonly exhibit performed; and patient’s age and co-morbidities. The merits (or otherwise) of treating CT-diagnosed symptoms of post-traumatic stress disorder. Urologically they have a high incidence of UTI and Bosniak 3 cysts were also discussed. The general cystitis, and can also develop a burst bladder as they consensus was to closely follow these patients are often too weak to stand and they are anatomically although the tendency in young, fit patients was to treat Bosniak 3 lesions as there is a 50-60% chance unable to urinate if lying down. It was a most interesting presentation and food for thought on how that they will in fact be renal cell carcinomas. the world’s population needs to strongly support antiThis session followed on well from the previous poaching activities and the work organisations such presentation expounding the value of ‘more diagnosis as hers are doing to preserve a species on the verge and less treatment’ of small renal masses. American of extinction. urologist Ralph Clayman noted the increase in the number of incidentalomas being detected due to the large number of CT scans now performed annually. European Association of Urology Nurses He reported that more than 30% of diagnosed renal

masses are smaller than 3 cm, presenting urologists with (in his view) a strong indication to biopsy these lesions so that they know exactly what they are dealing with. He commented that there are many reasons as to why fewer biopsies are performed than perhaps one would expect. These include a perception that the results won’t change the management plan, the risk of tumour seeding, the risk of false positive and false negative results, the risk of complications from the procedure, and the lack of infrastructure in medical centres to enable the procedure to be conducted safely. Clayman then went on to use literature and personal experience to dispute these reasons, urging the audience in his closing statement to get a tissue diagnosis with biopsy then decide whether or not to treat. Other speakers were less convinced that biopsy was always necessary. The general consensus appeared to lean towards the first issue Clayman raised- whether tissue diagnosis would change the treatment plan. A session on novel imaging of renal masses added to the discussion with a report on the potential merits of performing a Sestamibi SPECT/CT scan to determine the histology of renal tumours. This scan can differentiate benign oncocytomas from other renal tumour histologies with excellent specificity and sensitivity. This raises the possibility of its use for pre-treatment stratification of patients presenting with an indeterminate renal mass in the future, pending confirmatory studies. Another imaging modality presented as having promise is PSMA scans, for the imaging of metastatic clear cell renal cell carcinoma. Large prospective studies were called for in the novel imaging arena. The same panel format was used to explore the potential risks and benefits of the various renal and ureteric calculi treatment modalities. It was an excellent presentation using case discussions to illustrate varied clinical scenarios. The points made during the discussions clarified my thinking in this

area of practice, leading me to increased confidence in my ability to educate and support calculi patients back in my hospital. Another useful session discussed strategies to reduce ureteric stent discomfort. Stent omission after ureteric stone treatments is associated with an increased risk of unplanned medical visits due to complications, including pain. Speakers reported that alpha-blockers prescribed with anticholinergics are more effective for stent discomfort than a single agent. Tadalafil has also been shown to help. Study results disappointedly indicated that patient education regarding stent-related symptoms did not reduce patients overall discomfort. Patients were reported to have a strong preference for stents with removal strings over those requiring cystoscopic removal. The data indicated however those patients with stents with strings had less sexual intercourse while the stent was in place, than those with traditional stents. In our unit we use both types of stents; it seems it might be timely to explore our patient’s preferences prior to their placement!

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

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

www.eaun.uroweb.org

HYPERLINKS

The International Journal of

Urological Nursing

- the official Journal of the BAUN International Journal of

Urological Nursing the journal of the baun

ISSN 1749-7701

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!

March/May 2017

Associate Editor Jerome Marley wileyonlinelibrary.com/journal/ijun

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

Subscription Offer to EAUN members

35% discount

European Association of Urology European Nurses Association of Urology Nurses

The International Journal of Urological Nursing is a must have for urological professionals. The journal is truly international with contributors from many countries and is an invaluable resource for urology nurses everywhere.

Call for papers Visit: bit.ly/2jgOqQj 16-268105

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

Editor Rachel Busuttil Leaver

www.eaun.uroweb.org

Apply for your EAUN membership online!

Volume 10 • Issue 2 • July 2016

Visit: www.wileyonlinelibrary.com/journal/ijun

European Urology Today

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ERUS17

Robotic Urology Nursing

ERUS-EAUN Robotic Urology Nursing Meeting 25-27 September 2017, Bruges, Belgium

Inviting all robotic urology nurses to Bruges Increase your knowledge of procedures, competences and team work in the OR There is no harmonised training for nurses and RNFAs at this moment and this meeting aims to fill this gap with a high quality nurses programme. The 2017 edition of the ERUS-EAUN Robotic Urology Nursing Meeting in Bruges is a unique meeting for nurses and RNFAs working in robotic urology. By collaborating with EAU and ERUS we are able to provide an educational programme based on best practice with a very high standard. The aim of the ERUS-EAUN Robotic Urology Nursing Meeting to become the educational platform for OR nurses and RNFAs working with robot-assisted urology surgery. The programme will include the latest research in our field of expertise and also look ahead at what the future will bring. The meeting will offer theoretical in-depth knowledge and optional hands-on training for nurses working in robot-assisted urology surgery (for hands-on training seperate registration applies). The first day will be completely dedicated to the operating room nurse / assistant role in theory and practice and includes state-of-the art lectures on safe positioning, avoiding

complications, radical prostatectomy, kidney and bladder cancer, amongst others. Team training, trouble shooting, ethics and educational video presentations are some of the other important topics that will be discussed with the audience by highly skilled and experienced speakers. On day 2 and 3 the nurse delegates will attend the lectures and live surgery sessions of the regular ERUS programme, to return home completely updated on the latest developments in the field. Aims and objectives • Increase the understanding of the bedside role of the nurse in the operating room • Offer extensive in-depth knowledge of the most common urologic procedures such as prostate cancer, kidney cancer and bladder cancer as performed today • Deepen the knowledge of the patient´s pathway from diagnosis to surgery • Increase awareness of the importance of having the right competences in the operating room

• Define the role of the operating room nurse in robotic surgery • Enable the participant to take part in discussions how to handle minor and major complications in robotic assisted urology surgery • Address the importance of a skilled robotic team and team efficiency in the operating room, including crucial knowledge on how robotic surgery affects the patient • Inspire both OR Nurses and RNFA´s in their daily work in the operating room to achieve a higher satisfaction and joy in their field of expertise Don’t miss it!

Register before 15 June 2017 and benefit from an early fee!

Register now at www.erus17.org

More information: www.erus17.org/special-meetings/erus-eaun

Bladder cancer in depth 3rd Course of the European School of Urology Nursing 27-28 October 2017, Amsterdam, the Netherlands

Join us at the 3rd ESUN course in Amsterdam Are you looking for an update in the field of bladder cancer? Do you appreciate a state-of-the-art lectures and applicable recommendations from Europe’s top experts? Are you an experienced practising nurse specialist who treats bladder cancer patients and teaches other health care professionals to treat them?

50 places available

If so, you will most certainly want to join us at the 3rd ESUN Course in Amsterdam 27-28 October 2017. This course combines all the best features of an educational event – interaction, group work, latest updates and established evidence-based recommendations. We have invited renowned experts in the field, from a theoretical and practical point of view, who will train you with the purpose to help you spread the latest insights in the field. The preliminary programme consist of the following modules: Module 1 - Principles of treatment of non-muscle invasive bladder cancer - K. Hendricksen (NL) Module 2 - Principles of treatment of muscle-invasive and metastatic bladder cancer - R.P. Meijer (NL) Registration fee for the full Module 3a - Neoadjuvant chemotherapy & chemoradiotherapy - t.b.c. course is €100 for EAUN Module 3b - Immunotherapy - t.b.c. members and €130 for Module 4 - Intravesical therapy - S. Vahr (DK), K. Chatterton (GB), non-EAUN members. W.M. De Blok (NL) The EAUN covers your hotel Module 5 - Patient’s perspective and unmet needs in bladder cancer arrangement for one night C. Paterson (GB) and reimburses your flight Module 6 - Group work - Part 1 or train ticket. Module 7 - Adherence to treatment - t.b.c. Module 8 - Prevention of bladder cancer - B.T. Jensen (DK), S. Vahr (DK) Module 9 - Nursing role from haematuria to cancer - K. Chatterton (GB) Module 10 - Group work - Part 2 Please send an email to eaun@uroweb.org before 26 June to receive an application form, the application deadline is 30 June 2017. A selection will take place based on experience, work environment and educational background. An accreditation application in The Netherlands is pending. For more info please visit eaun.uroweb.org

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

We are looking forward to receiving your application! The Organising Committee: Willem De Blok (NL), Bente Thoft Jensen (DK), Susanne Vahr (DK) This course is supported with an educational grant from Medac and Bristol-Myers Squibb

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www.eaun18.org March/May 2017

European Urology Today March/May 2017  

European Urology Today (EUT) March/May 2017. EUT is the official newsletter of the EAU.

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