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European Urology Today Official newsletter of the European Association of Urology

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View the souvenir photos of awardees at EAU18 Copenhagen awardees in pictures

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Vol. 30 No.2 - March/May 2018

Testis cancer and fertility

CAM in urology

Exploring options in preserving male fertility

N. Love-Retinger writes on complementary and alternative medicine in urology

Dr. C. Fuglesang Skjødt Jensen

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N. Love-Retinger

EAU18: Sustaining advances in medicine Challenges remain in integrating patient-centred approaches By Joel Vega

already using molecular markers, despite not being in the guidelines…This is a pressing issue and there’s a lot of uncertainty at the moment.”

With reports from E. De Groot, L. Keizer, and J. Tidman Sustaining advances in medicine whether in the fields of new technology, health administration to research development remains a tough challenge considering current financial constraints, political hurdles and the lack of integration among European healthcare systems.

Advances in onco-urology Consensus and game-changing segments also preceded Plenary Sessions 3 and 5 with the former focusing on advances in onco-urology and the latter highlighting key developments in precision medicine particularly in adolescent urology and prostate cancer (PCa) treatment. In kidney and bladder therapies, Prof. Marc-Oliver Grimm (DE) outlined frontline research trials such as KEYNOTE-045 in urothelial carcinoma and CheckMate 214 in renal cell carcinoma. “Future directions indicate combination therapy with PD-1/PD-L1 inhibitors in RCC with nivolumab plus ipilimumab and PD1/PD-L1 inhibitors plus VEGFR-TKI. For urothelial cancer we have tremilimumab plus durvalumab/nivolumab plus ipilimumab… while adjuvant treatment is PD-1/PD-L1 plus combination,” Grimm said.

This was one of the recurring messages in the recent 33rd Annual EAU Congress held in Copenhagen last March 16 to 20. The second annual congress to be held in Copenhagen since 1984, EAU18 was marked not only by new features in the scientific programme, but also widened the coverage and content by introducing topics and issues that are becoming relevant in recent years. Around 10,880 participants from 122 countries attended the five-day meeting. At the Opening Ceremony, European Commissioner for Health and Food Safety, Prof. Vytenis Andriukaitis (LT) gave the keynote speech where he highlighted the flagship European Reference Networks (ERNs) project. “We have achieved a lot and although it’s important that we recognise that, we also need to look ahead, maximise our potential at the European Reference Networks and ensure sustainability,” he said. “So what challenges lie ahead? Integrating European Reference Networks into the national or regional healthcare systems is the most pressing challenge.“

"Use of biomarkers is evolving into a feasible third pillar..." - A. Stenzl Andriukaitis also noted the efforts of the European urological community as represented by the EAU when he thanked EAU Secretary General Prof. Chris Chapple for the EAU’s commitment to ERNs and the eUROGEN network which currently numbers 29 active units in 11 EU member states. “To ensure the sustainability of this project we need to form partnerships and work on common goals,” Chapple said in his response and opening remarks at the full auditorium where he welcomed participants. In the same evening, recognition were given to new Honorary Members Gunnar Aus (SE), Patrick Coloby (FR), Mani Menon (US) and Ajit Vaze (IN). “For urologists our biggest concern is how to boost our medical and surgical strategies, and balance these without neglecting our core competencies,” said Prof. Vincenzo Mirone (IT), this year’s recipient of the prestigious EAU Willy Gregoir Medal (See Related Articles and Award Photo Gallery on Pages 4-7). Nightmare of litigation Seven Plenary Sessions and 19 Thematic Sessions covered a wide range of urology and urology-related issues, and on top of the comprehensive programme were the specialised and in-depth discussions held during the nine EAU Section Meetings which involved the various section offices. With two simultaneous plenary sessions held each day from Saturday to Monday, and the concluding Plenary Session on stones held on the last day, the programme brought to fore the most hotly debated topics from novel

European Commissioner V. Andriukaitis (left) congratulates EAU General Secretary C. Chapple for the EAU's commitment to eUROGEN

surgical procedures, new medical outcomes, genetic research to patient-tailored therapies, amongst many other issues. The most-talked about was the Nightmare Session (Plenary Session 2) which tackled problematic bladder cancer cases moderated by Tim O’Brien (GB) with expert medical litigation lawyer Bertie Leigh (GB) firing the most inquisitive questions at Maximilian Burger (DE), Morgan Rouprêt (FR), Alexandra Masson-Lecomte (FR) and Hugh Mostafid (GB), who had to justify their treatment decisions. The session brought home the message that doctors often neglect to properly inform their patients, falsely assuming that their decisions are fool-proof and will not be subjected to potential legal scrutiny. “Doctors often hide behind the perceived protection provided by a consented patient but often miss the point of informing the patient,” said Leigh. “It would help if doctors were not always so nice to their patients. At some point you have to share your uncertainty with them and make patients understand the risks or severity of the treatment.” Plenary Session 1 on hot topics in andrology surveyed the most pertinent issues such as delayed fatherhood in Europe, environment and male fertility, surgical therapies for infertile men and case discussions that examined standard and novel fertility procedures. Meanwhile, at the day-long “Technology Strikes Back” session organised by the EAU Section of UroTechnology (ESUT) in collaboration with the EAU Robotic Urology Section (ERUS) and the EAU Section of Urolithiasis (EULIS), live and pre-recorded operations were transmitted in 3D to the eURO Auditorium where spontaneous commentary and expert moderation were given on sophisticated techniques in robot-assisted

High attendance at the day-long Live Surgery Session

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prostatectomy, percutaneous nephrolithotripsy, robotic bladder resection to radical nephrectomy, to name a few. Herlev Hospital played a central role in the complex programme that involved surgeons from various countries. Conventional vs. novel approaches At the Urology Beyond Europe and the Specialty Session on Bladder Cancer which both took place on the first day, some take-home messages hit a raw nerve among the congress participants and on social media. From the joint EAU-Société Internationale d’Urologie session, Prof. Prokar Dasgupta (GB) unleashed a torrent of online reactions with his statement that robotic technology is not viable in the developing world considering the high costs and the lack of convincing data on perceived superior surgical outcomes.

In prostate cancer, the PRECISION study released its results, published in the New England Journal of Medicine (NEJM) at the time of the Annual EAU Congress, which implied that traditional approaches which include 10-12 core TRUS biopsies can be avoided to minimise health risk complications for many men with suspected prostate cancer. “In biopsy naïve men with clinical suspicion of prostate cancer, a diagnostic pathway involving pre-biopsy MRI risk stratification and MRI-targeted biopsy is superior to 10-12 core TRUS biopsy,” said lead coordinator and author Dr. Veeru Kasivisvanathan (GB) who presented the results. His conclusions were warmly welcomed

“Strive to become a better surgeon, particularly if you are in the developing world. Stop obsessing about technology…There are no The Expert Guided Poster Tours prove to be popular among many participants differences in outcomes,” said Dasgupta. “Only 5% of operations are robotic. The cost of robot-assisted procedures rose and applauded by session chair Prof. Peter Albers by 13% in three years, resulting in around $2.5 billion (DE) who described the results as a “a brilliant in additional healthcare costs.” breakthrough” in PCa management. At the bladder cancer session, the Guidelines were subjected to scrutiny as new developments in bladder cancer biomarkers exert their place in treatment decision-making. “The use of biomarkers is evolving into a feasible third pillar,” said Prof. Arnulf Stenzl (DE).”Several speakers and audience members are

The randomised study which recruited 500 men allocated them into two groups, a multiparametric MRI (MPMRI) and a standard 10-12 core TRUS biopsy arm. Key eligibility criteria included a PSA < 20 ng/ml, DRE < T2, no prior biopsy and no contraindication to biopsy/MRI. In the MPMRI arm, areas of the prostate were scored on a five-point scale of suspicion for clinically significant cancer. Kasivisvanathan said the results showed that in detecting clinically insignificant cancer (Gleason 3+3), MRI+TB is superior to TRUS, and also in determining the proportion of cores positive for cancer. MRI + TB is also slightly better in determining maximum cancer core length over TRUS (7.8mm vs. 6.5mm, respectively). The study, led by chief investigators Caroline Moore and Mark Emberton, involved centres in Belgium, Canada, Finland, France, Italy, Germany, the Netherlands, Sweden, United Kingdom, USA, with funding from the EAU Research Foundation, NIHR Clinical Research Network, and a UK NIHR Doctoral Research Fellowship grant for Kasivisvanathan. European Urology Today

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PI Specialty Session addresses unmet needs Efficacy of good communication and collaboration with patient groups Dr. Selcuk Sarikaya EAU Patient Information Co-chair Gulhane Research and Training Hospital Ankara (TR) drselcuksarikaya@ hotmail.com Advocacy for further support and better care for cancer patients were addressed during the Specialty Session on EAU Patient Information at EAU18. The session commenced with an introduction by EAU Secretary General Prof. Chris Chapple (GB) who said, “There is no such thing as brave surgeons, but brave patients. It is essential to know what they deal with because to empower them is to help modern medicine progress." Some of the speakers for the roundtable discussions were cancer survivors themselves, and made this Specialty Session additionally impactful. In his presentation on prostate cancer (PCa), Chairman of Europa Uomo, Mr. Ken Mastris (GB) stated that they are asking the European Union to “help sustain awareness regarding PCa, to provide the means to improve both diagnosis and treatment, and to support equity of management for all.” Founder of Fight Bladder Cancer and another cancer survivor, Mr. Andrew Winterbottom (GB) urged attendees to show their support through six pledges. Pledge 1: Listen to us depicts what patients know because they live it from symptoms, diagnosis, treatment to aftercare. “We can help urologists gain additional insights,” said Winterbottom.

European Urology Today

He urged for more open discussions about the 5th most common cancer in the world for Pledge 2: Talk about bladder cancer. For Pledge 3: Provide accessible patient information, he stated that the development of

Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Dr. F. Sanguedolce, Barcelona (ES) Dr. Z. Zotter, Budapest (HU) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL) 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.

Welcome speech by Prof. Christopher Chapple

European Urology Today

good quality and understandable information packs should involve patients. Winterbottom said that it is not just about the treatment in correlation to Pledge 4: Provide support, Pledge 5: Campaign with us and Pledge 6: Show us you care; but also working together in disseminating information. Dr. Patrick Cabri (BE) cited the results of qualitative study conducted in France, Germany and Spain which illustrated the lack of appropriate information and consistency for prostate cancer patients throughout their disease journey. Cabri said, “There seems to be a need for information that addresses key questions that patients (and their partners) have at each stage based on real-life situations.” Prof. Dr. Rachel Giles (NL) addressed five unmet needs of urology cancer survivors with regard to kidney cancer in her lecture: 1. Awareness of kidney cancer 2. Navigating the options: decision aid tool. Giles spoke of the efforts of the International Kidney Cancer Coalition (IKCC) to generate a decision-aid tool intended for its affiliates – kidney cancer support groups – to talk to patients, discuss with their nurses and go through the different pathways that may or may not be available to the patients in their individual countries. 3. Patient information about clinical trials 4. Promoting evidence and evidence-based approaches 5. Meaningful and sustainable engagement The Specialty Session proceeded with presentations focusing on the importance of good communication between patients and healthcare professionals. Mrs. Corinne Tillier (NL), Chair of EAUN Scientific Congress

Office, discussed how communication between patients and nurses influence the outcome of treatment. Dr. Juan Luis Vásquez (DK) and Dr. Michael Van Balken (NL) talked about what makes communication clear and effective, including illiterate patients. Lectures on other facets of expanding reach included a presentation of Dr. Lydia Makaroff (BE) who discussed policy papers can be used to call for change at a pan-European level. Dr. Tit Albreht (SI) shared insights on how to increase the impact of an awareness campaign. Dissemination of patient information is imperative in reaching more patients and giving them clear and reliable information. A meeting was held after the lectures wherein future strategies were discussed incorporating patient preferences in the development. The EAU Patient Information Group aims to continue to deliver updated, clear and reliable information to patients and their families; to facilitate awareness on the importance of urological health; and to encourage and collaborate with more patient groups.

‘Translating science into practice’ by Prof. Jim Catto

AEU, EAU boost partnership AEU commits to strategies in strengthening alliance Dr. Mario AlvarezMaestro Member ESOU Subcommittee Dept. of Urology Hospital Universitario La Paz Madrid (ES) malvarezmaestro@ hotmail.com At the end of last year, the Recent Board of Directors of the Asociacion Espanola de Urologia (AEU), on behalf AEU chairman Dr. Manuel Esteban, proposed to me the chairmanship of the International Relations Office with the EAU. I accepted the challenge with humility as I have been an EAU member since my second year of residence. I have been the first Spanish urology resident representative in the European Society of Residents in Urology (ESRU). Thereafter, I joined the Young Academic Urology (Endourology Group) and later became a member of the EAU Section of Oncological Urology (ESOU). Although perhaps not well known to many Spanish urologists, the AEU´s International Office

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Excellent presentations by Patient representatives

aims to boost its alliances and collaborative ties in recent years with the EAU. This is the main reason why I and Dr. Juan Gomez Rivas, ESRU chairman and YOU board member, met in Copenhagen on Sunday, 19 March with the EAU Executive Committee, composed of Professors Chris Chapple, Hein Van Poppel and Manfred Wirth and European School of Urology chairman Dr. Joan Palou. During this meeting, we identified the main objectives for the next few years to boost the Spanish participation in scientific courses and workshops, thereby fostering closer ties. The following are the main objectives and projects that were identified: 1. To act as the representative body for Spanish urologists and facilitate the continued development of urology; 2. To encourage urological research and enable the dissemination of results; 3. To establish European standards for training and urological practice; 4. To stimulate, coordinate and organizes postgraduate teaching and educational activities; 5. Guidelines EAU project; 6. European Board of Urology (EBU) project;

7. European School of Urology projects: On-going project: ESU Course on 13 June (Spanish Urological Congress Gijon 2018, for the first time in our National Congress) (New paradigms in bladder cancer; Invited faculty members- Dr. J. Palou, Profs. M. Babjuk and M. Burger and the author); and 8. EAU Patient Information Group: Currently, Dr. Carmen Gonzalez Enguita is working actively in this group with Prof. Thorsten Bach. Future projects: 1. Participation in the EAU National Societies Meeting June 2018 (The Netherlands, with the theme “The Future of Urology”); 2. In our National Meeting a plenary session will tackle the details regarding Spanish participation in international events; 3. September 2018 in Madrid ESU/ESUI Hands-on Training in prostate MRI reading for urologists (Spanish and international urologists); and 4. Ensuring a new era where there are high expectations particularly with regards improving the stature of academics in Europe. The meeting was certainly a forward step and I would like to thank the EAU Executive Committee for the opportunity they gave us during the recent Annual EAU Congress in Copenhagen. March/May 2018


Update from the Guidelines Office Delegates queuing up for Guidelines activities in Copenhagen The 2018 Guidelines print The EAU Annual Congress in March saw the official launch of both the pocket and extended versions of the 2018 EAU Guidelines compilations. The new editions of both publications were given out at the EAU Congress in Copenhagen and were in high demand. Once again, long queues stretched across the congress centre as attendees patiently waited in line to receive their copies. The 2018 Guidelines see the introduction of a new format for the grading of all guidelines recommendations based upon a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. The Guidelines recommendations now take into account the available evidence, the strength and quality of that evidence, the balance between desirable and undesirable consequences of any given recommendation compared with alternative interventions, as well as also taking patients’ values and preferences into consideration. Background information from the Guidelines, including systematic review protocols, literature search strategies and the strength rating forms that underpin recommendations, can be viewed online on the Uroweb pages under ‘Individual Guidelines’. Some of this information is already available, but the content of these pages will expand over the coming months.

Audience members were invited to contribute to the discussion and voted their opinions on each controversy both before and after each debate. On a number of occasions the audiences’ votes differed significantly following the debates. The session drew large crowds, particularly for the discussion on combining systemic treatment of metastatic prostate cancer, and illustrated the kinds of difficulties that can arise in Guidelines development when the evidence upon which a recommendation is based is not robust. The Guidelines Office hopes to hold a similar session in Barcelona in 2019. EAU Guidelines Cup Congratulations to Dr. Dimitrio Deligiannis (GR), who was crowned Guidelines Cup champion in Copenhagen. The Guidelines Cup is a new competition to determine which EAU member has the best knowledge of the EAU Guidelines. The questions posed during the competition ranged over a variety of topics covered by the EAU Guidelines, including Peyronie’s disease, urolithiasis, renal, testicular and penile cancer and much more. Guidelines Office board members Profs. Thomas Knoll (DE) and Maria Ribal (ES) acted as the members of the jury for the session.

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, at the guidelines page.

Recent publications from Guidelines Panels The Guidelines Office is very pleased to announce that several papers from Guidelines Panels have recently been accepted for publication in the pages of European Urology and European Urology Focus and will appear in the coming months: • Risks and Benefits of Adjuvant Radiotherapy After Inguinal Lymphadenectomy in Node-positive Penile Cancer: A Systematic Review, by the European Association of Urology Penile Cancer Guidelines Panel. • Non-molecular Methods to Detect Bacteriuria Prior to Urological Interventions: A Diagnostic Accuracy Systematic Review, by the European Association of Urology Urological Infections Guidelines Panel. • Grading of Urothelial Carcinoma and The New “World Health Organisation Classification of Tumours of the Urinary System and Male Genital Organs 2016”, by the European Association of Urology Non-muscle Invasive Bladder Cancer Guidelines Panel. These papers continue a great start to 2018 for the Guidelines Office, following the publication of two papers in January-February:

Dr. Dimitrio Deligiannis visiting the EAU booth with his certificate and cup

Conference delegates in Copenhagen patiently queue for their copies of the EAU pocket and extended Guidelines

The other Cup Winners 2018 are: Dr. Giorgi Tsabutashvili (GE), who won 2nd Prize, Dr. María Monsalve (ES) won the audience prize, and Dr. Filippo Maria Turri (IT) received the 3rd Prize. (See photos of winners on this page).

• The Risk of Tumour Recurrence in Patients Undergoing Renal Transplantation for End-stage Renal Disease after Previous Treatment for a Urological Cancer: A Systematic Review, by the European Association of Urology Renal Transplantation Guidelines Panel. • Effectiveness and Harms of Using Kidneys with Small Renal Tumors from Deceased or Living Donors as a Source of Renal Transplantation: A Systematic Review, by the European Association of Urology Renal Transplantation Guidelines Panel.

Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 11 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . 12-15 Taking Live Surgery to the next level. . . . . . . 16 Promoting PCa screening at EU level . . . . . . 16 Testicular cancer and fertility – a complicated couple. . . . . . . . . . . . . . . . . . 17 Ten Questions: Riccardo Autorino. . . . . . . . . 18 Renal transplantation: What’s new?. . . . . . . 18 Winners of EAU RF seeding grant set to start new projects. . . . . . . . . . . . . . . . 19 CEM17, BALTIC17 Best Posters featured in Copenhagen. . . . . . . . . . . . . . . . 19 BCa18: New prospects prompt reassessing current treatment. . . . . . . . . . . . 20 ESU section: Advances in new NMIBC masterclass . . . . . . 21 Urology simulation educators. . . . . . . . . . . . 23 ESU’s frontline activities at EAU18. . . . . . . . . 24 ERUS18: Europe’s premier live robotic surgery event. . . . . . . . . . . . . . . . . . 25

EAU Guidelines Controversies Session The EAU Guidelines Controversies session held at the EAU Annual Congress in Copenhagen and chaired by Profs. James N'Dow and Richard Sylvester proved to be an overwhelming success. The aim of the session was to acquaint attendees with recent work of the EAU Guidelines Panels by presenting how the evidence base is used to provide support for and against controversial guidelines topics. The session explored the evidence base underpinning four contentious treatment recommendations in the Prostate Cancer, Bladder Cancer, Testis Cancer and Urinary Incontinence Guidelines. Each controversial topic was introduced by the Guidelines panel chair before two speakers presented arguments for and against the given recommendation. An external reviewer also joined in the debate surrounding each topic in order to give an outside perspective on the issues being discussed.

EAU18 section: EAU18: Sustaining advances in medicine . . . . 1 PI Specialty Session addresses unmet needs. . . 2 AEU, EAU boost partnership. . . . . . . . . . . . . . 2 Update from the Guidelines Office . . . . . . . . . 3 Overview of prizes and awards. . . . . . . . . . 4-7 Souvenir Session take-home messages . . . . . 8 Smart software steps into clinical practice. . . 8 Cancer treatment causes severe psychological stress . . . . . . . . . . . . . . . . . . . . 9 Experimental obesity drug prevents kidney stones. . . . . . . . . . . . . . . . . . . . . . . . . 9 History Office explores origins of Scandinavian urology. . . . . . . . . . . . . . . . . . 10 Fresh insights in prize-winning abstracts. . . 10

Systemic vs. targeted PCa biopsies: Choosing the right tool. . . . . . . . . . . . . . . . . 26 ESFFU: Fixed or adjustable male slings . . . . 27 Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 27 EULIS: Some genetic aspects of renal stone disease. . . . . . . . . . . . . . . . . . 28

The winners of the Guidelines Cup with their certificates. From left to right: Filippo Maria Turri (IT) in 3rd place (far left), audience winner María Monsalve (ES, left), Dimitrio Deligiannis (GR), 1st place (with cup), and Giorgi Tsabutashvili (GE) in 2nd place (right).

YUO section: New ESU HOT: Sharpening your presentation skills . . . . . . . . . . . . . . . . . . . . 29 Lisbon hosts unique laparoscopic urology course. . . . . . . . . . . . . . . . . . . . . . . 29 Hands-on Training (HOT) courses for junior residents. . . . . . . . . . . . . . . . . . . . 30 Inspiring EAU18 congress in Copenhagen. . . 30 Impressions from YUORDay . . . . . . . . . . . . . 31 Urology training around the globe. . . . . . . . 31 EBU re-certifies Ankara University’s Department of Urology. . . . . . . . . . . . . . . . . 33 EBU honours Antoniewicz . . . . . . . . . . . . . . 33 EAU-JUA International Academic Exchange Programme. . . . . . . . . . . . . . . . . . 35 ESOU18 brings the best of uro-oncology. . . . 37 EAUN section: EAUN18: New perspectives in urological nursing . . . . . . . . . . . . . . . . . . . . 38 Complementary and Alternative Medicine (CAM) in urology. . . . . . . . . . . . . . 39

Pictured are Prof. Dr. Fred Witjes (NL) chair of the Muscle-Invasive Bladder Cancer Panel (centre) and Prof. Dr. Nicolas Mottet (FR) of the Prostate Cancer Panel presenting to a packed audience (Left)

March/May 2018

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Overview of prizes and awards EAU Willy Gregoir Medal 2018

EAU Frans Debruyne Life Time Achievement Award 2018

V. Mirone, Naples, Italy - Handed out by C.R. Chapple

D. Jacqmin, Strasbourg, France - Handed out by C.R. Chapple

EAU Crystal Matula Award 2018

EAU Hans Marberger Award 2018

S. Silay, Istanbul, Turkey Supported by LABORIE - From left to right: G. Frazzette (LABORIE), S. Silay and C.R. Chapple

Opening Ceremony Friday, 16 March

D. Dalela, Detroit, USA Supported by KARL STORZ SE & CO.KG - From left to right: : E. Dourver (KARL STORZ SE & CO.KG), D. Dalela and C.R. Chapple

New EAU Honorary Members

G. Aus, Gothenburg, Sweden - Handed out by C.R. Chapple

P. Coloby, Cergy Pontoise, France - Handed out by C.R. Chapple

M. Menon, Detroit, USA - Handed out by C.R. Chapple

EAU Ernest Desnos Prize 2018

EAU Prostate Cancer Research Award 2018

S. Musitelli, Zibido San Giocomo, Italy - Handed out by C.R. Chapple

H. Ahmed, London, United Kingdom Supported by the FRITZ H. SCHRÖDER FOUNDATION - From left to right: F.H. Schröder (FRITZ H. SCHRÖDER FOUNDATION), H. Ahmed and C.R. Chapple

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

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

M. Chevalier, P. Bohner, C. Pieraerts, B. Lhermitte, J. Gourmaud, A. Nobile, S. Rotman, V. Cesson, V. Martin, A-S. Legris, F. Dartiguenave, D. Gharbi, L. De Leval, D. Speiser, D. Nardelli-Haefliger, P. Jichlinski, L. Derré (Lausanne, Switzerland) For the paper: ‘“Immunoregulation of Dendritic Cell Subsets by Inhibitory Receptors in Urothelial Cancer” European Urology, 71 (2017) 854-857 http://dx.doi.org/10.1016/j.eururo.2016.10.009 - Handed out by C.R. Chapple

R. Seiler, H. Al Deen Ashab, N. Erho, B. Van Rhijn, B. Winters, J. Douglas, K. Van Kessel, E. Fransen Van de Putte, M. Sommerlad, N. 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 (Berne, Switzerland; Vancouver, Alberta, Canada; Amsterdam, Rotterdam, The Netherlands; Seattle, Chapel Hill, Houston, Sacramento, USA; Southhampton, United Kingdom; Malmo, Sweden) For the paper: “Impact of Molecular Subtypes in Muscle-invasive Bladder Cancer on Predicting Response and Survival after Neoadjuvant Chemotherapy” European Urology, October 2017, 72, issue 4, 544-554 http://dx.doi.org/10.1016/j.eururo.2017.03.030 - Handed out by C.R. Chapple

Award Gallery Friday, 16 March Prize for the Best Scientific Paper published in European Urology

A. Vaze, Mumbai, India - Handed out by C.R. Chapple

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

F. Porpiglia, M. Manfredi, F. Mele, M. Cossu, E. Bollito, A. Veltri, S. Cirillo, D. Regge, R. Faletti, R. Passera, C. Fiori, S. De Luca (Turin, Italy) For the paper: “Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naïve Patients with Suspected Prostate Cancer” European Urology, Volume 72, Issue 2, August 2017, Pages 282-288

Y. Li, N. Donme, C. Sahinalp, N. Xie, Y. Wang, H. Xue, F. Mo, H. Beltran, M. Gleave, Y. Wang, C. Collins, X. Dong (Vancouver, Canada) For the paper: “SRRM4 Drives Neuroendocrine Transdifferentiation of Prostate Adenocarcinoma Under Androgen Receptor Pathway Inhibition” European Urology, Volume 71, Issue 1, January 2017, Pages 68-78 Supported by ELSEVIER - From left to right: N. Van Dijk (ELSEVIER) and J. Catto

Supported by ELSEVIER - From left to right: N. Van Dijk (ELSEVIER), F. Porpiglia and J. Catto

33rd Annual EAU Congress 4

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at the 33rd Annual EAU Congress Prize for the Best Scientific Paper published on Clinical Research in European Urology B. Escudier, P. Sharma, D. McDermott, S. George, H. Hammers, S. Srinivas, S. Tykodi, J. Sosman, G. Procopio, E. Plimack, D. Castellano, H. Gurney, F. Donskov, K. Peltola, J. Wagstaff, T. Gauler, T. Ueda, H. Zhao, I. Waxman, R. Motzer, on behalf of the CheckMate 025 investigators (Villejuif, France; Houston, Texas, Boston, Massachetteus, Buffalo, New York, Baltimore, Stanford, Seattle, Nashville, Philadelphia, Princeton, USA; Milan, Italy; Madrid, Spain; Westmead, New South Wales, Australia; Aarhus, Denmark; Helsinki, Finland; Swansea, United Kingdom; Essen, Germany; Chiba, Japan) For the paper: “CheckMate 025 Randomized Phase 3 Study: Outcomes by Key Baseline Factors and Prior Therapy for Nivolumab Versus Everolimus in Advanced Renal Cell Carcinoma” European Urology, Volume 72, Issue 6, December 2017, Pages 962-971 Supported by ELSEVIER - From left to right: N. Van Dijk (ELSEVIER) and J. Catto

First Prize for the Best Abstract (Oncology) A. Birtle, M. Johnson, R. Kockelbergh, F. Keeley, J. Catto, R. Bryan, J. Chester, R. Jones, M. Hill, J. Donovan, A. French, C. Harris, T. Powles, R. Todd, L. Tregellas, C. Wilson, A. Winterbottom, R. Lewis, E. Hall (Preston, Newcastle upon Tyne, Leicester, Bristol, Sheffield, Birmingham, Cardiff, Glasgow, London, Southend, Chinnor, United Kingdom) For the abstract: “1017: Results of POUT - A phase III randomised trial of peri-operative chemotherapy versus surveillance in upper tract urothelial cancer (UTUC)” - Handed out by A. Stenzl

Prize for the Best Scientific Paper published on Robotic Surgery in European Urology N. Van Den Berg, T. Buckle, G. KleinJan, H. Van Der Poel, F. Van Leeuwen (Leiden, Amsterdam, The Netherlands) For the paper: “Multispectral Fluorescence Imaging During Robot-assisted Laparoscopic Sentinel Node Biopsy: A First Step Towards a Fluorescence-based Anatomic Roadmap” European Urology, Volume 72, Issue 1, July 2017, Pages 110-117 Supported by the VATTIKUTI FOUNDATION - From left to right: M. Bhandari (VATTIKUTI FOUNDATION), H. Van Der Poel, who accepted the prize on behalf of N. Van Den Berg, and J. Catto

First Prize for the Best Abstract (Non-Oncology) A. Chebbi, A. Giwerc, B. Peyronnet, L. Freton, J. Olivier, Q. Langouet, M. Ruggiero, I. Dominique, C. Millet, S. Bergerat, P. Panayotopoulos, R. Betari, X. Matillon, T. Caes, P. Patard, N. Szabla, N. Brichart, L. Sabourin, K. Guleryuz, C. Dariane, C. Lebacle, J. Rizk, A. Gryn, F. Madec, M. Hutin, B. Pradere, C. Pfister, G. Fiard, F. Nouhaud (Rouen, Rennes, Lille, Tours, Paris, Lyon, Clermont-Ferrand, Strasbourg, Angers, Amiens, Toulouse, Caen, Nantes, Montpellier, Grenoble, France) For the abstract: “127: Is systematic early drainage relevant to treat urinary tract rupture in non-penetrating renal trauma? Results from a multicenter study” - Handed out by A. Stenzl

Award Gallery Friday, 16 March Second Prize for the Best Abstract (Oncology) O. Wegelin, L. Exterkate, D. Somford, J. Barentsz, M. Van Der Leest, A. Kummer, W. Vreuls, P. De Bruin, R. Bosch, H. Van Melick (Nieuwegein/ Utrecht, Nijmegen, The Netherlands) For the abstract: “484: The FUTURE trial; a multicenter RCT on three techniques of MRI targeted prostate biopsy” - Handed out by A. Stenzl

Second Prize for the Best Abstract (Non-Oncology) N. Sopko, H. Matsui, G. Joice, E. Pak, T. Yoshida, X. Liu, J. Hannan, T. Bivalacqua (Baltimore, Greenville, USA; Tokyo, Japan) For the abstract: For the abstract: “980: Major pelvic ganglion neurons express CXCR4, which binds stromal derived factor-1 and enhances neurotrophin protein levels and neurogenesis” - Handed out by A. Stenzl

Third Prize for the Best Abstract (Non-Oncology)

Third Prize for the Best Abstract (Oncology) I. Eder, A. Weber, J. Höfer, H. Klocker, H. Neuwirt (Innsbruck, Austria) For the abstract: “50: Upregulation of cholesterol and steroid biosynthesis pathways in prostate cancer cells is associated with diminished response to enzalutamide in a 3-dimensional spheroid co-culture model” - Handed out by A. Stenzl

B. Pradere, I. Lucas, D. Abi Haidar, S. Doizi, M. Daudon, O. Traxer (Tours, Paris, France) For the abstract: “323: Raman spectroscopy analysis of urolithiasis composition in biological environments: Feasibility study and preliminary results” - Handed out by A. Stenzl

Video Award Session Saturday, 17 March First Video Prize

Second Video Prize

H. Palayapalayam Ganapathi, B. Rocco, F. Onol, T. Rogers, V. Patel (Celebration, USA; Modena, Italy) For the video: “V39: Lessons learned from more than 10,000 robotic assisted laparoscopic radical prostatectomies: An evidence based approach” - B. Rocco who accepted the prize on behalf of H. Palayapalayam Ganapathi

N. Kubin, D. Shkarupa, O. Staroseltseva, E. Shapovalova, A. Zaytseva (St. Petersburg, Russia) For the video: “V38: Adjustable midurethral tape for surgical treatment of stress urinary incontinence: Two-years’ follow-up” - O. Staroseltseva who accepted the prize on behalf of N. Kubin

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Overview of prizes and awards ESUI Vision Award 2018

ESTU - René Küss Prize 2018

A. Alberts, Rotterdam, The Netherlands 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 G. Salomon

K. Decaestecker, Ghent, Belgium For the abstract: “The European experience on robot-assisted kidney transplantation: 2 years after the beginning” Supported by GEBRO PHARMA and ROVI - From left to right: E. Lledó García, V. Gomez Dos Santos, A. Figueiredo, F. Burgos Revilla, K. Decaestecker

ESTU - Research Grant 2018

Section Awards Saturday, 17 March

F. Regis, Suno, Italy For the abstract: “The European experience on robot-assisted kidney transplantation: 2 years after the beginning” Supported by ORGAN RECOVERY SYSTEMS - From left to right: V. Gomez Dos Santos, E. Lledó García, A. Breda, who accepted the prize on behalf of F. Regis, and F. Burgos Revilla

EUSP Best Clinical Scholar Award 2018

EUSP Best Lab Scholar Award 2018

N. Grivas, Ioannina, Greece For the project: “A biomarkers viewpoint on primary prostate cancer and (sentinel) lymph nodes”

J. Olivier, Lille, France For the project:“Historical tissue biomarkers studied in conjunction with mp-MRI and clinical progression for patients under active surveillance for prostate cancer”

Residents Day Saturday, 17 March

- From left to right: N. Grivas, V. Mirone and J. Olivier

First Prize EAU Guidelines Cup 2018 D. Deligiannis, Athens, Greece - Handed out by J. Vasquez

Second Prize EAU Guidelines Cup 2018 G. Tsabutashvili, Tbilisi, Georgia - Handed out by J. Vasquez

Audience Prize EAU Guidelines Cup 2018 M. Rodriguez-Monsalve Herrero, Madrid, Spain - Handed out by J. Vasquez

Third Prize EAU Guidelines Cup 2018 F. Turri, Pisa, Italy - Handed out by J. Vasquez

YAU Awards 2018 - Best paper published in 2017 by a YAU group R. Van Den Bergh, G. Gandaglia, D. Tilki, H. Borgmann, P. Ost, C. Surcel, M. Valerio, P. Sooirakumaran, A. Briganti, M. Graefen, H. Van der Poel, A. De la Taille, F. Montorsi, G. Ploussard On behalf of the European Association of Urology Young Academic Urologists Working Party on Prostate Cancer (EAU-YAUWP) (Amsterdam, The Netherlands; Milan, Italy; Hamburg, Mainz, Germany; Ghent, Belgium; Bucharest, Romania; Lausanne, Switzerland; Oxford, United Kingdom; Toulouse, France) For the paper: “Trends in Radical Prostatectomy Risk Group Distribution in a European Multicenter Analysis of 28 572 Patients: Towards Tailored Treatment” - From left to right: M. Sedelaar, H. Van Poppel, G. Ploussard, who accepted the prize on behalf of R. Van Den Bergh, and S. Silay

Best Booth Award 2018 Janssen Oncology - Pharmaceutical Companies of Johnson & Johnson - From left to right: E. Holl, I. Winiger-Candolfi, J. Lencart, J. Engels. C.R. Chapple (EAU), J. Harris

Exhibition 17-19 March

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at the 33rd Annual EAU Congress Best poster presented at EAU 2018 by a YAU group

Reviewer of the year from YAU

G. Russo, M. Albersen, G. Cacciamani, A. Cocci, V. Mirone, G. Morgia, T. Kessler, E. Serefoglu, P. Verze, EAU-YAU Men’s Health working group (Catania, Calenzano, Naples, Catania, Italy; Leuven, Belgium; Zurich, Switzerland; Ankara, Turkey) For the poster: “Clinical efficacy of intralesional therapy for Peyronie’s disease in randomized clinical trials: A systematic review and network meta-analysis” - From left to right: M. Sedelaar, H. Van Poppel, G. Russo and S. Silay

A. Necchi, Milan, Italy - From left to right: M. Sedelaar, H. Van Poppel, E. Xylinas who accepted the prize on behalf of A. Necchi, and S. Silay

First Prize for the Best Abstract by a resident

Second Prize for the Best Abstract by a resident

F. Abdollah, A. Sood, D. Dalela, J. Keeley, Q-D. Trinh, S. Alanee, C. Rogers, J. Peabody, M. Menon (Detroit, Boston, USA) For the abstract: “1151: Testing the impact of adjuvant radiotherapy (aRT) after radical prostatectomy (RP) on overall mortality (OM) in prostate cancer patients with pathologically node positive disease: A nationwide analysis” - Handed out by J. Vasquez

D. Osses, S. Remmers, F. Schröder, T. Van Der Kwast, M. Roobol (Rotterdam, The Netherlands) For the abstract: “266: Screening and prostate cancer mortality: Results of a unique cohort at 19 years of follow-up” - Handed out by J. Vasquez

Third Prize for the Best Abstract by a resident

Residents Day Saturday, 17 March Resident’s Corner Awards - Awards for the two Best Scientific Papers published in European Urology by residents N. Sopko, H. Matsui, D. Lough, D. Miller, K. Harris, M. Kates, X. Liu, K. Billups, R. Redett, A. Burnett, G. Brandacher, T. Bivalacqua (Baltimore, USA; Tokyo, Japan) For the paper: “Ex Vivo Model of Human Penile Transplantation and Rejection: Implications for Erectile Tissue Physiology” - Handed out by J. Vasquez

M. Tyson, J. Alvarez, T. Koyama, K. Hoffman, M. Resnick, X-C. Wu, M. Cooperberg, M. Goodman, S. Greenfield, A. Hamilton, M. Hashibe, L. Paddock, A. Stroup, V. Chen, D. Penson, D. Barocas (Nashville, Houston, New Orleans, Los Angeles, San Francisco, Atlanta, Irvine, Salt Lake, New Brunswick, USA) For the paper: “Racial Variation in Patient-Reported Outcomes Following Treatment for Localized Prostate Cancer: Results from the CEASAR Study” (no photo available)

S. Ernst, J. Heinzelmann, S. Hölters, G. Weber, R. Bohle, M. Stöckle, K. Junker, J. Heinzelbecker (Homburg, Germany) For the abstract: “786: Metastasis in seminomatous germ cell tumours is characterized by a specific miRNA pattern” - Handed out by J. Vasquez

The European Urology Platinum Award 2018

J. Palou, Barcelona, Spain - Handed out by J. Catto C. Evans, Sacramento, USA - Handed out by J. Catto

P. Black, Vancouver, Canada - Handed out by J. Catto

M. Roobol, Rotterdam, The Netherlands - Handed out by J. Catto

International Friendship Dinner

S. Shariat, Vienna, Austria - Handed out by J. Catto

Sunday, 18 March

First Prize for the Best EAUN Poster Presentation

Third Prize for the Best EAUN Poster Presentation

R. McConkey, C. Holborn (Galway, Ireland; Sheffield, United Kingdom) For the poster: “Exploring the lived experience of gay men with prostate cancer: A phenomenological study” Supported by AMGEN - Handed out by R. Haeckel (AMGEN)

J. Avlastenok, K. Rud, H. Køppen, L. Wendt-Johansen, H. Wested, P. Busch Østergren (Herlev, Denmark) For the poster: “Quality of life of spouses living with men undergoing androgen deprivation therapy for prostate cancer” Supported by AMGEN - Handed out by R. Haeckel (AMGEN)

Second Prize for the Best EAUN Poster Presentation P.B. Svankjær, A. Holm Jensen, T. Søndergaard Sørensen, H. HaslundThomsen (Aalborg, Denmark) For the poster: “Grit in the waterworks – patient experiences of living with stones in the upper urinary tract” Supported by AMGEN - Handed out by R. Haeckel (AMGEN)

EAUN Meeting Monday, 19 March

Prize for the Best EAUN Nursing Research Project V. Decalf, R. Pieters, K. Everaert, M. Petrovic, W. Bower (Ghent, Belgium; Melbourne, Australia) For the project: “Prevalence, incidence and associated factors of nocturia on the ward” - Handed out by S. Terzoni

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Souvenir Session take-home messages Selected highlights from the Scientific Programme The concluding plenary session (on urolithiasis) also included the Souvenir Session which traditionally presents some highlights in the scientific programme. Below are selected take-home messages: Prostate Cancer (PCa)- Early detection and screening (presented by A. Villers, FR) Villers stated: “Genetic testing needs to be ready soon for primetime. Genetic counselling and testing options should be clarified.” He added that magnetic resonance imaging (MRI) as a triage test before first biopsies will represent a new practice, possibly along with low prostate-specific antigen density (PSA-D). Moreover, baseline MRI results might be part of active surveillance (AS) selection criteria to reduce reclassification during surveillance. PCa- Localised and advanced disease (presented by P. Albers, DE) Albers said MRI helps classify patients for active PCa treatment and AS should only be taken as an option following initial MRI (referring to low-risk PCa and AS). Albers added that “If MRI is ‘normal’ (including PIRADS 3), use PSA-D to decide on re-biopsy. In this case, systematic biopsies still have to be performed. It is not advisable to rely on MRItargeted (biopsy) to exclude patients with high-grade cancers (ASIST trial).” On radical prostatectomy (RP) and salvage RP, delay of surgery is possible until 180 days; positive margins are only relevant if unfavourable (multiple, > 3mm), and salvage RP causes severe incontinence in at least a third of patients. Urolithiasis and endourology (presented by T. Knoll, DE) 3D Stone measurement (bone window) is more accurate than the 2D measurement, which overrates the stone size. Through better predictability of operating time and usage of instruments such as laser application the surgical planning could be optimized and costs reduced (Abstract #635 by Rassweiler-Seyfried et al.). Data from the MIMIC study shows that in patients with acute ureteric colic who are suitable for initial conservative management, medically expulsive therapy (MET) use has no benefit in spontaneous stone passage, regardless of stone size or stone position and should not be routinely prescribed (Abstract #637 by T.T. Shah, GB).

Andrology (presented by M. Albersen, BE) “We can better predict sympathetic skin response in nonobstructive azoospermia; The use of robotic magnification for vasectomy reversal is feasible and alternative protocols for CCH (collagenase clostridium histolyticum) in Peyronie's disease are effective.” Urothelial cancer (presented by M. Rouprêt, FR) In the study “Long term oncological outcomes following the randomised controlled cystectomy: Open, robotic and laparoscopic (CORAL) trial,” there were no significant differences in RFS (recurrence free survival), CSS (cancer specific survival) and OS (overall survival) between open radical cystectomy, laparoscopic radical cystectomy and robot-assisted radical cystectomy. The absence of port site or intraperitoneal recurrence between the groups does not preclude minimally invasive surgery as an option for treatment (Abstract #377 by K. Omar, GB). Benign prostatic disease Regarding male lower urinary tract symptoms (LUTS), Dr. Jean-Nicolas Cornu (FR) specified surgical treatment-defining positions such as intraprostatic injections; MISP (minimally invasive simple prostatectomy) e.g. laparoscopic or robotic simple prostatectomy; and bipolar vaporisation. Cornu also enumerated non-ablative options such as prostatic urethral lift (which the EAU Guidelines recommends to be offered to men (affected with LUTS) interested in preserving ejaculatory function, with prostates <70 mL and no middle lobe. Other nonablative options include Aquabeam: Waterjet, TIND (temporary implantable nitinol device), and Rezum device.

mixture into tertiary order arteries feeding the tumour. Systemic therapy in genitourinary cancer According to some of the findings presented by Prof. Maria De Santis (GB) on palliative chemotherapy and the impact of cycles of platinum-based first-line chemotherapy for advanced urothelial carcinoma, six cycles are conventional for treating locally advanced unresectable or metastatic urothelial cancer. A study showed four cycles are effective; toxicity was reduced and facilitated a better transition to second-line and switch maintenance therapy. Functional urology In his presentation, Dr. John Heesakkers (NL) mentioned the conclusions of the 21-year follow-up of TAMPUS (Tampere Aging Male Urologic Study), which showed that half of the men aged over 50 with urinary urgency coped with their LUTS even if it is bothersome. The effect of first-line treatments was equal to spontaneous remission which reflects the multifactorial aetiology of urgency. Imaging in urology The feasibility and diagnostic efficacy of 4D ultrasound (US) cystoscopy with Fly Through in detecting and characterising urinary bladder lesions were assessed. Dr. Jochem Walz (FR) said that 33 lesions were detected in 30 patients with cystoscopy; 2D US detected 24 out of 33 (73%) and 4D Fly Through US detected 31 out of 33 (94%).

Basic science According to research developments presented by Prof. Zoran Culig (AT), tracking of genomic evolution using plasma can indicate treatment resistance. Culig said: “Plasma androgen receptor copy number gain Renal cancer and transplantation Prof. Marc-Oliver Grimm (DE) stated that the 3D printed associates strongly with a worse outcome on abiraterone or enzalutamide in both chemo-naive and hybrid model used for training for robotic kidney transplantation was made up of inorganic material for post-docetaxel mCRPC (metastatic castration-resistant the life-sized printed pelvis and kidney transplant, and prostate cancer), which is a biomarker opportunity. organic material of cadaveric iliac arteries and veins. Culig also said that three genes have been identified in Grimm mentioned strategies to facilitate robotic association with enzalutamide resistance: HMGCS2, partial nephrectomy, one of which was pre-operative AKR1C3, and UGT1A1; and that intervening with trans-arterial bland embolization with the supercholesterol synthesis inhibited Du/CAF co-culture selective delivery of lipiodol-indocyanine green spheroids.

Smart software steps into clinical practice Software can diagnose prostate cancer as well as a pathologist Chinese scientists and clinicians have developed a learning artificial intelligence system which can diagnose and identify cancerous prostate samples as accurately as any pathologist. This holds out the possibility of streamlining and eliminating variation in the process of cancer diagnosis. It may also help overcome any local shortage of trained pathologists. In the longer term it may lead to automated or partially-automated prostate cancer diagnosis. Prostate cancer is the most common male cancer, with around 1.1m diagnoses ever year, worldwide1 (for comparison, that’s around x4 the number of men who live in Copenhagen). Confirmation of the diagnosis normally requires a biopsy sample, which is then examined by a pathologist. Now an artificial intelligence learning system, presented at the European Association of Urology congress in Copenhagen, has shown similar levels of accuracy to a human pathologist. In addition, the software can accurately classify the level of malignancy of the cancer, so eliminating the variability which can creep into human diagnosis. “This is not going to replace a human pathologist” said research leader Hongqian Guo (Nanjing, China), “We still need an experienced pathologist to take responsibility for the final diagnosis. What it will do is help pathologists make better, faster diagnosis, as well as eliminating the day-to-day variation in judgement which can creep into human evaluations.” Prof. Guo’s group took 918 prostate whole mount pathology section samples from 283 patients, and ran

these through the analysis system, with the software gradually learning and improving diagnosis. These pathology images were subdivided into 40,000 smaller samples; 30,000 of these samples were used to ‘train’ the software, the remaining 10,000 were used to test accuracy – the results showed an accurate diagnosis in 99.38% of cases (using a human pathologist as a ‘gold standard’), which is effectively as accurate as the human pathologist. They were also able to identify different Gleason Grades in the pathology sections using AI; ten whole mount prostate pathology sections have been tested so far, with similar Gleason Grade in the AI and human pathologist’s diagnosis. The group has not started testing the system with human patients.

"...the results showed an accurate diagnosis in 99.38% of cases (using a human pathologist as a ‘gold standard’)..." Prof. Guo continued “The system was programmed to learn and gradually improve how it interpreted the samples. Our result show that the diagnosis the AI reported was at a level comparable to that of a pathologist. Furthermore, it could accurately classify the malignant levels of prostate cancer. Until now, automated systems have had limited clinical value, but we believe this is the first automated work to offer an accurate reporting and diagnosis of prostate cancer. In the short-term, this can offer a faster throughput, plus a greater consistency in cancer diagnosis from pathologist to pathologist, hospital to hospital, country to country.

Artificial intelligence is advancing at an amazing rate – you only need to look at facial recognition on smartphones, or driverless cars. It is important that cancer detection and diagnosis takes advantage of these changes.” Commenting, Professor Rodolfo Montironi (Professor of Pathology, Polytechnic University of the Marche, Ancona, Italy) said: “This is interesting work which shows how artificial intelligence will increasingly step into clinical practice. This may be very useful in some areas where there is a lack of trained pathologists. Like all automation, this will lead to a lesser reliance on human expertise, but we need to ensure that the final decisions on treatment stay with a trained pathologist. The really important thing though, is that we ensure the highest standard of patient care. The future will be interesting.” Editorial Note: Professor Montironi was not involved in this work – this is an independent comment. The software was developed in conjunction with Nanjing Innovative Data Technologies, Inc (they were not involved in funding this work). The newness of the system means that there is no information yet on costs or on implementation. The authors note some limitations to the work. There were more samples of Gleason Grade 3 and 4 than other grade, which maybe influence the AI calculation to some extent. They are also looking for suitably objective standards to allow direct comparison of Gleason Grade with the AI.

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Cancer treatment causes severe psychological stress Major UK study shows 5 times greater suicide rate in patients with urological cancers A major UK survey has shown that patients with urological cancer such as prostate, bladder or kidney cancer are five times more likely to commit suicide than people without cancer. The analysis also shows that cancer patients generally are around three times more likely to commit suicide than the general population, and that the proportion of attempted suicides which result in a completed or successful suicide was higher in cancer patients, with a higher proportion still in patients with urological cancers. Severe psychological stress is one of the main side-effects of both a diagnosis of cancer and cancer treatment, with depression affecting between 5 and 25% of cancer patients1,2: many are also affected by Post-Traumatic Stress Disorder (PTSD)3. Previous research has shown that the vast majority of cancer patients who have symptoms of depression often go untreated2. This study shows a substantial increase in suicide attempts and successful suicides in cancer patients. The work is presented at the European Association of Urology conference in Copenhagen. This is the largest UK study looking at suicide in cancer patients (see below). The research team led by Mr. Prashant Patel at the University of Birmingham retrospectively examined the records from the England and Wales Hospital Episode Statistics database, from the period 2001 to 2011. They linked this with cause of death statistics from the Office of National Statistics. This is also the first time that a major study has examined suicidal intent in cancer patients – which they defined as the ratio of successful suicides to the rate of attempted suicides. They found that this rate was far higher (1 to 7) in patients with prostate cancer

The numbers • The researchers identified a total of 980,761 (493,234 males and 487,094 female) cancer patients which meant that 13.4 million-person years were included in the final data analysis. The team identified 162 suicides and 1222 suicide attempts. • In the general population, the suicide rate is 10 per 100,000 people. The team found that the all-cancer suicide rate was 30 per 100,000 people. In the urological cancers, the figures are Dr. Afshar continued “Our data confirms research 36 per 100,000 people in kidney cancer, 48 from other countries that suicide rates are higher in suicides per 100,000 in bladder cancer, and 52 cancer patients, and we show this to be higher per 100,000 people in prostate cancer. particularly in patients with urological cancers. • In the general population, there is an average of There are particular issues which are specific to this 25 suicide attempts for each successful suicide. cancer group – for example, men with prostate cancer In kidney cancer, this ratio is 1 suicide for every undergo treatment which can affect their bladder 10 attempts. In bladder and prostate cancer, this function, their bowel function, erectile function and ratio drops to one suicide for every 7 attempts. libido, can result in symptoms similar to the female • The time taken to commit suicide also varies menopause, and entirely alter the personality, leading substantially: median time to suicide is 175 days to relationship problems, anxiety, depression and from diagnosis for kidney cancer, 846 days for post-traumatic stress disorder. prostate cancer, and 1037 days for bladder cancer. We know from a 2014 study2 by Cancer Research UK that the vast majority of cancer patients who have Commenting, EAU Adjunct Secretary General, Prof. symptoms of depression go untreated. We can see Hein Van Poppel (Leuven) said: “This important work from the results of our study that although all cancers shows just how distressing cancer can be, but it also have a higher suicide rate, inferring a higher level of shows that there may be special factors associated psychological distress, there are disparities between with urological cancers which make them even more cancers. This needs to be addressed within our stressful than other cancers. It looks like urological healthcare systems, and more focus is needed on cancers can affect patients’ sense of self in a way that integrating the robust and specialist assessment and many cancers don’t. treatment of mental health needs in cancer care”. The work implies that some urological cancers, such The study also showed significant differences between as kidney cancer, can lead to fairly immediate the time to a successful suicide, which means that some distress, whereas the distress associated with cancer patients are more vulnerable in certain periods. prostate and bladder cancer may take a while to hit than in the general population (1 to 25), which may show a greater determination to commit suicide in cancer patients. “This is important” said first author Dr. Mehran Afshar (St. George’s Hospital, London), “as we know that people who attempt suicide are at higher risk of subsequently being successful in completing a suicide, and we have shown this ‘intent’ to commit to be far higher in our cancer population, thus confirming a real need to address psychological issues early on in the management of these patients”.

home – perhaps when patients begin to take up some of the problems associated with returning to normal life. We also need to put things in context: many patients recover well and don’t reach the stage of despair or distress which brings them to think of suicide. Nevertheless, this is a real problem. We need to recognise that the figures presented here are for suicides, which means that they are at the ‘sharp end of emotional distress’. For every suicide or attempted suicide, there will be many more patients who find difficulty in coping. This distress does not stop when the cancer is removed or contained, and we owe it to patients to ensure that ongoing emotional support and mental health care is fully integrated into cancer care”. Editorial note: Prof. Van Poppel was not involved in this work. He is a specialist in urological cancers. The team noted a limitation of the study: they looked at the general suicide rate, not at the rate of suicides according to age (age-standardised suicide rate), however, a comparison to baseline population suicide rates could only be made using crude suicide rates per 100,000 as this is population-level data available. There was no specific funding for this research. References 1. https://www.cancer.gov/about-cancer/coping/feelings/ depression-hp-pdq 2. http://www.thelancet.com/depression-and-cancer 3. Cancer patients and PTSD, see http://newsroom.wiley. com/press-release/cancer/many-cancer-survivors-areliving-ptsd

Experimental obesity drug prevents kidney stones Early work on drug linked with regulation of fat leads to new discovery Scientists have found that a drug connected with fat regulation prevents the formation of kidney stones in mice. This early work opens the possibility of developing drugs which may help prevent kidney stones in at-risk individuals. Passing a kidney stone in the urine can be extremely painful – it has been described as possibly the worst pain which someone can experience. The developed world is experiencing something of an epidemic of kidney stones. The EAU estimates that around 50 to 60

The congress offers the perfect opportunity to get some answers

March/May 2018

million Europeans suffer from stones – that’s roughly one European in 11, and is equivalent to the population of a large European country, such as the UK, France or Italy. The USA has a similar number of sufferers. Stone incidence has almost doubled over the last 20 years1. Doctors think that this increase is due to increasing obesity, and diet and lifestyle changes. Now a group of Japanese scientists have discovered that an experimental drug leads to a significantly reduced number of kidney stones in mice. They gave 20 mice 1 mg/kg of the β3-agonist CL316243 for 12 days. Then the mice, plus 20 controls, were then injected with glyoxylate, which causes the formation of kidney stones. At various time points, the mice were then checked to see if they had formed stones: the formation of stones decreased to 17.0% in the experimental group, compared with the controls. “This is experimental work for now” said lead researcher Dr. Teruaki Sugino (Nagoya City University Graduate School of Medical Sciences, Japan). “But I believe that this may open the way to the development of the new drugs which can stop the development of kidney stones in at-risk people. So far we have only tested this on mice, but in mice it seems to work.

We were able to analyse the biochemical differences between the control and experimental group, and discovered that the β3-agonist reduced the expression of adipocytokine molecules, which are associated with inflammation.” The researchers believe that free fatty acids cause inflammation and cytotoxic effects in kidneys, which promotes stones. β3-agonists are known to cause white fat cells (which are found in excess in overweight and obese persons) into beige fat cells, which burn extra calories, which is why these molecules are also being considered for antiobesity uses. The researchers suspect that beige cells consume free fatty acids, which may be the cause of inflammation in the kidneys leading to kidney stones. This means that β3-agonists have the potential to prevent not only obesity but also kidney stones. Commenting, Professor Thomas Knoll (Universität Tübingen, Germany) said: “Renal stones affect many people, and have a high economic impact, so it’s a pity that we still have an only rudimentary understanding on why stones form. Metabolic factors definitely play an important role and this work, contributes to unravelling the pathogenesis.

We’ve had decades of urine crystallisation studies, which have not really advanced the field. I hope that this work leads to more researchers doing work on the topic.” Editorial note: Prof. Knoll was not involved in this work, this is an independent comment. Currently, potassium-sodium citrate drugs are used to restrict the development of kidney stones, but some people can’t use these drugs because they need to limit their potassium or sodium intake. The authors note the limitations of the study. It is animal work, so cannot yet be directly applied to humans. The molecule has not been tested for tolerability, efficacy, or cost. It is also an initial ‘proof-of-concept’ study, so needs to be repeated with a larger sample size. There was no external funding for this research. Reference 1. Selected kidney stone prevalence information: Prevalence of Kidney Stones in the United States Charles D. Scales, Jr.,a, Eur Urol. 2012 Jul; 62(1): 160–165. See also https:// www.ndm.ox.ac.uk/osg/epidemiology for England data.

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History Office explores origins of Scandinavian urology Scandinavian Association of Urology founded in Prof. Tuovinen’s sauna in 1956 The interconnectedness of urology in Europe is exemplified by the collaboration that is evident in the Scandinavian countries and the Scandinavian Association of Urology in particular.

terminology in that field. “He was a much-admired tutor and he supervised a huge range of topics as Professor at Herlev Hospital,” Nordling concluded.

On the first day of EAU18, the 33rd Annual EAU Congress in Copenhagen, the EAU History Office welcomed prominent Danish and Scandinavian speakers to give the audience a flavour of the long history of regional cooperation, as well as some biographies of eminent Danish Urological pioneers. Later in the Specialty Session, EAU History Office Chairman Prof. Van Kerrebroeck (Maastricht, NL) gave some background information on the new EAU Ernest Desnos Prize, Dr. Mattelaer (Kortrijk, BE) gave a preview of his latest book and Mr. Jonathan Goddard (Leicester, GB) looked at the role of British urologists in the First World War, this year marking the centenary of the end of the war. Establishing a Nordic Society Prof. Christian Beisland (Bergen, NO) spoke about the long history of urology in the Scandinavian countries, as well as the establishment of an international urological association for the region. Beisland: “The Nordic Surgical Society (NKF) was first founded in 1893, making it one of the oldest surgical societies in the world. It was a relatively slow process of separating urology from general surgery, with the first national societies being established in the 1950s and 1960s.”

EAU Secretary-General Prof. Chapple presents the inaugural Ernest Desnos Prize to Prof. Musitelli

Initially, the Association had a fixed quota of members from each country, over time this arrangement ended, with automatic membership when a urologist joined their respective national society. Iceland joined the Association in 1976. Since 1995, the official language of the Association has been “bad English” (as opposed to “bad Swedish”, in the words of Prof. Jens Andersen (Copenhagen, DK)). The decision to switch to English was to be more inclusive to the Finnish delegates and also to attract more international interest. In a comment, Prof. Andersen recalled that there was a lot of discussion in the Scandinavian Association’s board at the time, with fears of the loss of national identity.

Holm and Hald Drs. Jorgen Kvist Kristensen (Gentofle, DK) and Jørgen In 1950, the foundations of the Scandinavian Nordling (Herlev, DK) presented biographies of Profs. Association of Urology were laid as an informal group, Hans Henrik Holm and Tage Hald respectively, two incredibly influential and respected urologists. Holm a ‘travelling club’ for urologists in Denmark, later was a pioneer in interventional ultrasound, joined by urologists from Norway, Sweden and combining ultrasound with biopsies, treatment of Finland. In 1956, it was proposed to formalise this arrangement in a proper Association, with some initial cysts and percutaneous nephrostomy in the 1960s. scepticism to the idea by representatives from Norway Tage Hald, the 1999 Willy Gregoir Award Winner, was and Sweden. Beisland: “In the end, the Association a founding member of the International Continence was famously founded in the sauna of Professor Society, and was tasked with establishing uniform Tuovinen’s summer house in Ojakkala, Finland.”

Honours Prof. Van Kerrebroeck took the opportunity to introduce the new prize that the EAU will be awarding for services to the field of History of Urology, the Ernest Desnos Prize. The prize was awarded that evening during the opening ceremony to Prof. Sergio Musitelli (Milan, IT), a historian of medicine whose research and publications into the origins of urology were unrivaled over the past decades. “The Desnos Prize honours an individual or a group that contributed to the history of urology. We can think of no-one more deserving than Sergio, who has been affiliated with the EAU History Office since its inception in the early 1990s.” In emphasis of Prof. Musitelli’s long career, Prof. Van Kerrebroeck pointed out that Musitelli received his PhD in the same year that Van Kerrebroeck was born (1953). Prof. Musitelli still regularly publishes new research, his latest chapter is featured in De Historia Vol. 25, launched at EAU18.

Prof. Philip Van Kerrebroeck and Dr. Jens Thorup Andersen chaired the EAU History Office Special Session

The prize bears the name of Dr. Ernest Desnos (1852-1925), as a tribute to this pioneering French urologist who was also an eminent historian of Urology and who wrote the first book devoted solely to the History of Urology. Not least of Desnos’ accomplishments are co-founding the AFU and later the SIU, as well as treating Emperor Napoleon III for a bladder stone in 1873 and major pioneering work on prostate brachytherapy.

The Historical Exhibition featured a broad selection of historico-urological items, from Ernest Desnos-related objects, to instruments used or developed in Denmark and one display case commemorating the centenary of the First World War and the British urologists who participated.

However his most significant contribution was in the field of the History of Urology. Therefore his ‘magnum opus’ is the first book on the History of Urology ever. This book was published in 1914 as “Histoire de l’Urologie” (History of Urology, Paris. Doin éditeur, 1914). The large volume presents, in 294 pages with 196 beautiful black and white illustrations and 9 coloured reproductions, a complete overview on the History of Urological Surgery and Urology from its origins to the beginning of the 20th century. Unique items related to Desnos were displayed at the Historical Exhibition for the duration of the congress.

Fresh insights in prize-winning abstracts Oncology and non-oncology prize winners present their results First prize non-oncology "Is systematic early drainage relevant to treat urinary tract rupture in non-penetrating renal trauma? Results from a multicenter study"

Ala Chebbi, Rouen (FR)

they tested whether SDF1 treatment of major pelvic ganglion (MPG) neurons augments neurogenesis. MPGs were isolated from male Sprague-Dawley rats weighing ~350g. “MPG neurons express the SDF1 receptor CXCR4, which is increased by SDF1 treatment. MPG neurite outgrowth is enhanced by SDF1 treatment, which is prevented by CXCR4 blockade,” Sopko said. Moreover, SDF1 treatment is linked with increased growth factor and neurotrophin protein expression, which may explain the increased neurite outgrowth. “The beneficial effects of SDF1 on erectile function may be in part due to its direct neurotrophic effects on MPG neurons,” added Sopko.

A. Chebbi and colleagues compared the outcomes of an early upper urinary tract drainage (ED) to a conservative management (CM) after a NPRT with a urinary extravasation (UE) at initial CT-scan assessment. They led a multicentre retrospective Third prize non-oncology national study which included all patients treated for renal trauma in 16 centres from 2005 to 2015. “Our "Raman spectroscopy results suggest that CM should be considered for the analysis of urolithiasis management of renal trauma associated with urinary composition in biological extravasation at the initial CT-assessment. CM was environments: associated with good outcomes as 83% of the patients Feasibility study and didn’t required any drainage of their upper tract and preliminary results" the urinary extravasation at repeat CT was still present for 36% of the patients only. Initial clinical Benjamin Pradere, Paris (FR) monitoring and repeat CT-scan to re-assess the urine leak might be useful and less invasive than a B. Pradere et al. assessed the feasibility of Raman systematic ED,” the researchers said. Spectroscopy (RS) in biological environments for stone composition analysis and aimed to develop a Second prize non-oncology laser fiber for intraoperative diagnosis. The researchers analyzed a set of stones (>1000) by the "Major pelvic ganglion gold standard technique. The purest (>85% of same neurons express CXCR4, composition) were selected to be analyzed on a which binds stromal derived specific RS setup. They used a laser with a 785nm factor-1 and enhances wavelength. “Raman spectroscopy analysis of stone neurotrophin protein levels composition in urine is feasible and reproducible and neurogenesis" with a 785nm laser. We identified the best settings for a good analysis (urine diluted, fiber in contact...) and Nikolai Sopko, Baltimore (USA) we were able to perform the analysis in less than 20 seconds. These results show the potential N. Sopko and colleagues have previously shown that applicability of RS for a clinical endoscopic use in penile stromal derived factor-1 (SDF1) injections order to diagnose peroperatively the stone improve erectile function following cavernous nerve composition and adapt laser settings for the destruction of the stone,” the researchers said. injury (CNI). To better understand the mechanism, 10

European Urology Today

First prize oncology "Results of POUT - a phase III randomised trial of peri-operative chemotherapy versus surveillance in upper tract urothelial cancer (UTUC)"

Alison J. Birtle, Preston (UK) The role of post nephro-ureterectomy treatment for UTUC is unclear. In their study, POUT, A. Birtle and colleagues addresses whether adjuvant chemotherapy improves disease free survival (DFS) for patients with histologically confirmed pT2-T4 N0-3 M0 UTUC. Patients (maximum n = 345), WHO performance status 0-1, ≤ 90 days post NU were randomised (1:1) to 4 cycles of gemcitabine-cisplatin (gemcitabinecarboplatin if GFR 30-49 ml/min) or surveillance with chemotherapy given on recurrence if required. The researchers concluded that adjuvant chemotherapy is tolerable and improved metastasisfree survival in UTUC. Recruitment to the POUT trial was terminated early because of efficacy favouring the chemotherapy arm; follow up for overall survival continues. POUT is the largest randomised trial in UTUC and its results support the use of adjuvant chemotherapy as a new standard of care.

Second prize oncology "The FUTURE trial; a multicenter RCT on three techniques of MRI targeted prostate biopsy"

Olivier Wegelin, Utrecht (NL) The FUTURE trial is a multicentre RCT comparing detection rates of (significant) PCa for three techniques of MRI-TB (cognitive TRUS, MR-TRUS

fusion, in-bore MRI). Authors O. Wegelin and colleagues recruited 642 men between 2014 and 2017 with prior negative prostate biopsies and a suspicion on prostate cancer (based on PSA ≥ 4 and/or abnormal DRE), and underwent mpMRI. Imaging was centrally evaluated by an expert radiologist using PIRADS v2. If mpMRI demonstrated PIRADS≥3 lesions patients were randomized 1:1:1 for MRI-TB. In their conclusions, the researchers said: “Based on the results of this multicentre RCT there does not seem to be a significant advantage of one specific MRI-TB technique for the detection of (clinically significant) PCa following prior negative prostate biopsies.”

Third prize oncology "Upregulation of cholesterol and steroid biosynthesis pathways in prostate cancer cells is associated with diminished response to enzalutamide in a 3-dimensional spheroid co-culture model"

Iris Eder, Innsbruck (AT) In a previous study, authors I. Eder and colleagues found that prostate cancer (PCa) cells exhibit diminished response to enzalutamide when co-cultured with cancer-associated fibroblasts (CAFs) as 3-dimensional (3D) spheroids. In their current prize-winning study, they investigated the molecular changes in 3D cultures of PCa cells in the absence or presence of CAFs to identify potential underlying mechanisms of enzalutamide resistance. Spheroids were established in 96 well hanging drop plates by seeding PCa epithelial cells (LNCaP, DuCaP) alone or together with CAFs at a ratio of 1:1. The authors concluded: “We identified 3 pivotal molecules within cholesterol and steroid biosynthesis that were significantly upregulated in PCa cells upon co-culture with CAFs and which could be targeted to intervene with enzalutamide resistance.” March/May 2018


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

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 55 A 75-year-old patient under investigation for persistent microscopic haematuria had a diagnostic ureteroscopy which showed diffuse reddening and contact bleeding of the ureteral mucosa. Several biopsies at different locations were taken. These all demonstrated carcinoma in situ.

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

The patient has a non-functioning kidney on the right side and the MRI (Figure 1) report showed a widening of the left ureter and Fig.1 thickening of the ureteral wall. No definite tumours were reported for the left renal collecting

Case study No. 56 This 79-year-old lady was investigated for intermittent macroscopic hematuria. The CT scan shows a large lesion of the left kidney with presumably hilar and paraaortic lymph node enlargement (Figure 1). No metastatic lesions are seen on the thoraco-abdominal CT. Cystoscopy was normal. The lady is otherwise healthy and fit for her age. She definitely wants treatment.

system. The history also included testicular cancer with radical orchidectomy 40 years ago and curative radiotherapy for prostate cancer seven years ago. Cystoscopy had been normal. Obviously, the patient is not keen on haemodialysis. Discussion points: 1. Are further investigations needed? 2. What options can be offered? Figure 1

UTUC: Balancing oncological outcomes with QoL issues Comments by Prof. Morgan Rouprêt Paris (FR)

eliminate the possibility of blood clots (differential diagnosis) within the urinary tract. Anyway, the existence of a high-risk multifocal UTUC has been confirmed with multiple positive biopsies and the presence of CIS.

and quality of life of an elderly patient under dialysis.

After careful discussion with this patient and his family, one (protracted) session of conservative endoscopic management could be advocated. 2. What options can be offered? I would attempt to perform it by flexible 1. Are further investigations needed ? One can hypothesise that this man is already living ureteroscopy with full laser vaporisation. In this There is no doubt in my mind that we are dealing with a single kidney and we are thus facing a particular case, I would schedule the patient for a with a primary upper tract urinary cancer (UTUC) situation of high-risk upper tract urothelial carcinoma second look within six weeks. Additionally, I would on the left side. On the other hand, the right kidney (UTUC) in a patient with a solitary kidney. do my best to deliver BCG instillations through a is totally atrophic and, thus, useless. Consequently, Theoretically, a radical nephroureterectomy should be nephrostomy tube with an antegrade percutaneous we are facing once again a difficult situation from proposed as it remains the treatment of choice in technique. It seems to be the safest technique real life: there is a need to find a balance between high-risk UTUC. In addition, the recent POUT trial has (intrapyelic pressure of less than 20 cm H2O; oncological outcomes and quality of life. This demonstrated that there is a benefit of adjuvant favourable tube properties; control of outflow 75-year-old man underwent a good pre-operative systemic chemotherapy after radical before each instillation). There is absolutely no work-up: combination of MRI and flexible nephroureterectomy in patients with positive lymph guarantee that the treatment aim can be achieved ureteroscopy with biopsies. It is quite difficult to nodes. It is not yet in the guidelines, but this study is completely as we are dealing with CIS. Roughly, comment on the MRI from a single coronal image such a big game-changer in the field that it should be we can expect a response in one case out of two. as provided here. From the MRI, we can say that mentioned here as an imminent recommendation. However, this man needs to understand that he the mid-ureter is pathological more or less 10 cm Obviously, this patient will not be a candidate for will have to undergo several ureteroscopic below the uretero-pelvic junction. systemic post-operative cisplatin-based chemotherapy procedures and potentially suffer from subsequent in case of radical surgery. So the first option would be complications (bleeding, obstruction) and/or renal We have no information about the renal function of radical nephroureterectomy alone and immediate insufficiency due to the procedure itself. the patient. If the GFR allows it, a better subsequent dialysis. characterisation of the tumour would be provided Only a detailed discussion with the patient will with a URO-CT which is the gold standard. It would It is, however, a difficult decision to consider as the help us make the smartest decision to take in such be useful to obtain an early (arterial) phase to patient will end-up with dialysis. In addition, the a difficult situation. assess hypervascularity. A late phase would also patient is absolutely reluctant to become dialysisbe useful to assess the defect in the lumen of the dependent and the perspective of oncological References ureter. In addition, a phase without contrast would outcome has to be balanced with his life expectancy Morbidity, mortality and quality of life in the ageing

Discussion points: • Are further investigations needed? • What options should be offered? Case provided by Oliver Hakenberg, Department of Urology, Rostock University, Germany. E-mail: oliver.hakenberg@med.uni-rostock.de

haemodialysis population: results from the ELDERLY study. Seckinger J, Dschietzig W, Leimenstoll G, Rob PM, Kuhlmann MK, Pommer W, Fraass U, Ritz E, Schwenger V. Clin Kidney J. 2016 Dec; Results of POUT: A phase III randomised trial of perioperative chemotherapy versus surveillance in upper tract urothelial cancer (UTUC) Birtle AJ , Chester J D, Jones R J , Johnson M , Michaela Hill M , Bryan RT ... http://ascopubs.org/doi/abs/10.1200/ JCO.2018.36.6_suppl.407 European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2017 Update. Rouprêt M, Babjuk M, Compérat E, Zigeuner R, Sylvester RJ, Burger M, Cowan NC, Gontero P, Van Rhijn BWG, Mostafid AH, Palou J, Shariat SF. Eur Urol. 2018 Jan;73(1):111-122 Endoscopic Treatment of Upper Tract Urothelial Carcinoma. Verges DP, Lallas CD, Hubosky SG, Bagley DH Jr. Curr Urol Rep. 2017 Apr;18(4):31. Antegrade perfusion with bacillus Calmette-Guérin in patients with non-muscle-invasive urothelial carcinoma of the upper urinary tract: who may benefit? Giannarini G, Kessler TM, Birkhäuser FD, Thalmann GN, Studer UE. Eur Urol. 2011 Nov;60(5):955-60

Value of ureteroscopy in kidney-sparing management of UTUC Comments by Prof. Olivier Traxer, Dr. Etienne Xavier Keller, Dr. Vincent De Coninck, Paris (FR)

diagnostic ureteroscopy and concerns about contralateral tumor cell seeding have been mentioned in recent years4. Past history and family history should be reviewed to address the possibility of a non-colonic manifestation of Lynch syndrome5. In suspected cases and/or when losses of mismatched repair proteins are present in tumor biopsies, DNA sequencing should be considered6. Testicular and prostate cancer in this case are not typically associated with Lynch syndrome.

This case of isolated upper tract carcinoma in situ (UTCIS) in the ureter of a solitary functional kidney highlights the challenges encountered in the management of this rare subtype of upper tract urothelial carcinoma. No randomised controlled trial is currently available in literature for this disease and all evidence is based on retrospective single-institution studies1. It therefore remains unclear which strategy would achieve the highest survival and lowest morbidity for such cases.

What options can be offered? If UTCIS was diagnosed on the solitary functional kidney side and the patient refuses to undergo radical nephroureterectomy (RNU), imperative conservative treatment with BCG instillation should be offered, as it has been shown to achieve equivalent long-term survival to RNU7. However, BCG delivery techniques vary and follow-up strategies are unclear8. Even the definition of UTCIS has been shown to be highly variable in a recent literature review, with only one of 10 evaluated series using positive biopsy as a diagnostic criterion1.

Are further investigations needed? Dynamic renal scintigraphy should be considered for evaluation of residual kidney function and exclusion of any urine transport impairment. Since UTCIS is a known predictor of both concomitant and recurrent bladder cancer2,3, scrupulous cystoscopy is mandatory. Enhanced cystoscopy imaging techniques as well as random bladder mapping biopsies may be considered, although their value is uncertain in the present scenario. No study yet evaluated the benefits and risks of contralateral

Close follow-up with ureteroscopy and cross-sectional imaging must be recommended. The value of enhanced imaging techniques such as narrow band imaging remains unclear for UTCIS. In case of remaining ureteral wall thickening and absent papillary tumors, random mapping biopsies of the ureter may be considered to exclude invasive disease. Since segmental ureteral resection has not been evaluated in the setting of UTCIS, it should not be recommended as a kidney-sparing alternative for this particular case.

March/May 2018

If CIS was diagnosed on the non-functional kidney side, an ipsilateral nephro-ureterectomy should be recommended. Considering a 2-6% recurrence rate in the contralateral kidney after treatment, regular surveillance with cross-sectional imaging should be recommended9. Whenever poor renal function would contraindicate the use of contrastmedia, regular contralateral control-ureteroscopy should be considered. References 1. Redrow GP, Guo CC, Brausi MA, Coleman JA, Fernandez MI, Kassouf W, et al. Upper Urinary Tract Carcinoma In Situ: Current Knowledge, Future Direction. J Urol. 2017;197(2):287-95. 2. Pieras E, Frontera G, Ruiz X, Vicens A, Ozonas M, Piza P. Concomitant carcinoma in situ and tumour size are prognostic factors for bladder recurrence after nephroureterectomy for upper tract transitional cell carcinoma. BJU Int. 2010;106(9):1319-23. 3. Xylinas E, Rink M, Margulis V, Karakiewicz P, Novara G, Shariat SF, et al. Multifocal carcinoma in situ of the upper tract is associated with high risk of bladder cancer recurrence. Eur Urol. 2012;61(5):1069-70. 4. Macleod LC, Pham KN, Agoff SN, Dahl KL, Pritchett TR, Corman JM. Cytologic persistence of malignant cells after transurethral resection of bladder tumors: Implications for concomitant manipulation of the urinary tract at the time of endoscopic resection. Cancer Cytopathol. 2017;125(2):114-9. 5. Crockett DG, Wagner DG, Holmang S, Johansson SL, Lynch HT. Upper urinary tract carcinoma in Lynch syndrome cases. J Urol. 2011;185(5):1627-30. 6. Harper HL, McKenney JK, Heald B, Stephenson A,

Campbell SC, Plesec T, et al. Upper tract urothelial carcinomas: frequency of association with mismatch repair protein loss and lynch syndrome. Mod Pathol. 2017;30(1):146-56. 7. Kojima Y, Tozawa K, Kawai N, Sasaki S, Hayashi Y, Kohri K. Long-term outcome of upper urinary tract carcinoma in situ: effectiveness of nephroureterectomy versus bacillus Calmette-Guerin therapy. Int J Urol. 2006;13(4):340-4. 8. Pan S, Smith AD, Motamedinia P. Minimally Invasive Therapy for Upper Tract Urothelial Cell Cancer. J Endourol. 2017;31(3):238-45. 9. Li WM, Shen JT, Li CC, Ke HL, Wei YC, Wu WJ, et al. Oncologic outcomes following three different approaches to the distal ureter and bladder cuff in nephroureterectomy for primary upper urinary tract urothelial carcinoma. Eur Urol. 2010;57(6):963-9.

Case Study No. 55 continued After consideration of potential options and discussions with the patient, we performed complete left ureterectomy with an ileal interposition as replacement for the ureter. Intraoperative flexible endoscopy of the renal collecting system showed no abnormalities. Final histology confirmed widespread carcinoma in situ of the ureter but the margins at the bladder cuff and the renal pelvis were free of carcinoma or dysplasia.

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

tebj@medisin.uio.no

Docetaxel in hormone sensitive metastatic prostate cancer: Only for low-volume disease ? Chemo-hormonal therapy is currently a standard of care in patients with metastatic hormone-naïve prostate cancer. Three large randomized controlled trials trial have assessed this survival benefit. The STAMPEDE and the CHAARTED trials demonstrated a survival benefit by adding docetaxel to androgen deprivation therapy, whereas the AFU-GETUG 15 trial failed to show any difference between both arms. One notable difference between GETUG-AFU 15 versus STAMPEDE and CHAARTED was a better access to new life-prolonging therapies at the castration-resistant stage. Moreover, the long-term follow-up of AFU-GETUG 15 trial has reported a trend in survival improvement in the high-volume disease subgroup, suggesting that stratification by tumour burden for treatment decision-making may be clinically relevant. Docetaxel could be done only in patients with a high-volume disease (and who would benefit the most from this intensive therapy), whereas low-volume patients could be treated only by standard androgen deprivation therapy. In an updated analysis of the CHAARTED trial, the authors have evaluated the long-term survival outcomes and the impact of tumour burden on chemotherapy benefit. At the time of the first publication, few deaths in the low-volume disease groups had occurred limiting strong conclusions from these not-powered sub-group analyses. At a median follow-up of more than four years, the median overall survival was 57.6 months for the chemohormonal therapy arm versus 47.2 months for ADT alone. The hazard ratio was 0.72 with a 95% CI of 0.59 to 0.89 (p = 0.0018). Interestingly, for patients with high-volume disease (n = 513), the benefit from chemotherapy was (51.2 vs. 34.4 months) with a mortality risk reduction of 37% (p=0.001). The median overall survival benefit provided by chemotherapy was 16.8 months. In contrast, the subgroup with low-volume disease showed no evidence of survival benefit when docetaxel was added (HR, 1.04, 100 deaths reported), despite the early analysis suggesting a non-significant hazard ratio of 0.60 (44 deaths reported).

Thus, this updated analysis of the CHAARTED trial confirms the overall survival benefit from addition of docetaxel to androgen deprivation therapy seen at the interim analysis. All the secondary end points (time to clinical progression, time to castration resistance) were also in favour of the combination arm. The benefit from early docetaxel was more pronounced in the high-volume subgroup than in the low-volume subgroup suggesting that the burden of metastases determined by conventional imaging may help the physician to select ideal candidates for this intensive therapy. In 2018, in metastatic hormone naïve prostate cancer patients, we have to make a choice between androgen deprivation therapy alone, or associated with docetaxel or with abiraterone, and the stratification of patients by tumour volume and de novo metastatic presentation would help us for patient counselling and treatment guidance.

Source: Chemohormonal Therapy in Metastatic Hormone-Sensitive Prostate Cancer: Long Term Survival Analysis of the Randomized Phase III E3805 CHAARTED Trial. Kyriakopoulos et al. J Clin Oncol 2018 DOI: https://doi.org/10.1200/JCO.2017. 75.3657

Refractory urgency urinary incontinence: Should we go for toxin or neuromodulation? While the efficacy of sacral neuromodulation (SNM) and onabotulinumtoxinA (BTX) has been well demonstrated for treating urgency urinary incontinence, the choice between the two treatments is not driven by a strong level of evidence. The present article reports the outcomes’ analysis from a comparative, effectiveness trial assessing the efficacy and the safety of SNM to BTX in women with idiopathic, refractory urgency urinary incontinence. This study was conducted in four years at nine participating sites. Exclusion criteria were neurologic disease, post-void residual > 150 ml, previous treatment with either study intervention, or >Stage 3 prolapse. Change from baseline in mean daily incontinence episodes over 24 months was the primary endpoint. Bladder diaries were collected at baseline and at months 1–6, 9, 12, 18, and 24. Overall, 386 women were randomized to undergo SNM (n = 194) or BTX (200 UI) (n = 192), and outcome data were available for 260/298 (87%) clinical responders. Regarding the primary endpoint, no difference in decreased mean urgency urinary incontinence episodes was found over 24 months (-3.88 vs. -3.50 episodes/day, p = 0.15). In addition, another interesting finding was the complete cure rate, defined by the absence of incontinence episodes after treatment initiation.

Overall, sustained and similar reductions in mean daily urgency The benefit from early docetaxel urinary incontinence episodes were was more pronounced in the obtained with both treatments, high-volume subgroup than in the although the six-month complete low-volume subgroup suggesting resolution rate was significantly that the burden of metastases determined by conventional imaging greater in the BTX group may help the physician to select At six months, 22% of women were completely dry after BTX compared with only 8% after SNM. Thus, at ideal candidates for this intensive this first time point, the BTX group was more likely to therapy experience complete resolution with a treatment The other assessed secondary endpoints such as time to castration resistant prostate cancer and time to clinical progression also demonstrated that mainly patients with high-volume disease benefited from chemohormonal treatment. Another meaningful factor of stratification is the history of prior local therapy. In the subgroup analysis of those patients previously locally treated, docetaxel did not provide a significant survival benefit in low-volume disease patients (p = 0.55), but a not significant survival improvement was reported in high-volume subgroup (median survival, 66.9 vs. 51.7 months, HR 0.72).

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difference of -18% (p < 0.001). Overtime, these differences decreased between groups. At 24 months, comparable rates of complete resolution were reported (5% each). The percentages of women experiencing a > 75% reduction were also comparable between the two groups (22% versus 21%). Regarding secondary endpoints, a higher treatment satisfaction rate was reported in the BTX group as well as higher treatment endorsement and treatment preference. Concerning adverse effects, the rate of recurrent urinary tract infections was higher in women undergoing BTX treatment (24% vs. 10%; p < 0.01). Intermittent catheterization post-injection was required in 6% of cases. Given the higher satisfaction

rate in the BTX cohort and the 1% of BTX women that chose a dose reduction, the authors stated that performing intermittent catheterization did not greatly impact quality of life. In the SNM group, device revision and removals were low occurring in 3% and 9% patients, respectively. All surgical revisions were due to decreased efficacy. Compared with series assessing BTX at the dose of 100 UI, injection at 200 UI seemed to offer a longer duration of effect. The reinjection intervals remained similar after the first and second injections. Overall, sustained and similar reductions in mean daily urgency urinary incontinence episodes were obtained with both treatments, although the six-month complete resolution rate was significantly greater in the BTX group. Thus, both therapies seemed to offer similar long-term benefits with different safety profile. Cost-effectiveness analyses have not been evaluated in this trial. These findings may help physician for patient counselling and shared treatment decision-making. However, it is worthy to note that these results cannot be extended to the use of 100 UI of BTX.

Source: Two-Year Outcomes of Sacral Neuromodulation Versus OnabotulinumtoxinA for Refractory Urgency Urinary Incontinence: A Randomized Trial. Amundsen, et al. Eur Urol 2018 https://doi.org/10.1016/j.eururo.2018.02.011

Differential functional outcomes between local treatments for prostate cancer depends on initial risk classification Surgery or radiotherapy? The debate goes on. Functional outcomes may differ according to the chosen treatment and should be part of the patient counselling. Recent data from the PROTECT and the patient-related outcomes analyses have provided meaningful comparisons. Nevertheless, functional outcomes have not been stratified by pre-treatment risk distribution. Indeed, little is known about how the effects of treatment on patient-reported function vary by disease severity. In the present study, the authors used the data from the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study to assess effectiveness and harms of contemporary management strategies in function of the three well-known risk groups. This study is a longitudinal, population-based, prospective observational cohort study including men diagnosed with localized prostate cancer. Among the 2,117 CEASAR participants, 817 (39%) had low-risk disease, 902 (43%) intermediate-risk disease, and the remaining 398 (19%) high-risk disease. Impact of radiotherapy and surgery was assessed on incontinence, sexual, hormone, and bowel domains by testing the hypothesis that the effect of treatment on patient-reported urinary, bowel, hormone, and sexual functions would vary by prostate cancer severity according to the D’Amico risk classification system.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com cancer severity for the bowel, hormone, or irritative domain scores. In this prospective, longitudinal, population-based study of functional outcomes after contemporary prostate cancer treatment, the patterns of sexual dysfunction after treatment for prostate cancer differed according to the severity of disease at diagnosis. For men with low- and intermediate-risk prostate cancer, radiotherapy was associated with better sexual function scores at 3 yr than surgery. In contrast, sexual function scores at 3 yr were similar between both procedures in high-risk prostate cancer patients.

In this prospective, longitudinal, population-based study of functional outcomes after contemporary prostate cancer treatment, the patterns of sexual dysfunction after treatment for prostate cancer differed according to the severity of disease at diagnosis Interestingly, when using a binary definition of sexual function (erections firm enough for intercourse), no major differences were noted between arms at 3 yr whatever the initial risk stratification. This longitudinal assessment supports the finding that the type of treatment chosen in high-risk prostate cancer patients would not affect functional outcomes after treatment, even sexual function. [BOLD] Source: Effect of Prostate Cancer Severity on Functional Outcomes After Localized Treatment: Comparative Effectiveness Analysis of Surgery and Radiation Study Results; Tyson et al. Eur Urol 2018 https://doi.org/10.1016/j.eururo.2018.02.012

MRI-targeted biopsy: Its time has come? For the last 25 years, men with an elevated PSA level or an abnormal digital rectal examination have been typically offered a transrectal ultrasound-guided biopsy. However, it is clear that this approach misses some clinically significant cancers and more recently it has been shown that men with low-risk cancers rarely benefit from radical treatment.

Regarding the sexual function, the cancer severity significantly modified the impact of treatment on that outcome. Low-risk patients undergoing radiotherapy reported better three-year sexual function scores those receiving radical prostatectomy (12 points higher; p < 0.001). Difference was less marked in intermediate-risk patients with a 11-point improvement in the radiotherapy group (p < 0.001). In high-risk patients, reported scores were only six points higher in patients receiving radiotherapy compared with surgery patients.

Multiparametric magnetic resonance imaging (MRI) gives improved anatomic imaging and single-centre studies suggest that obtaining MRI-targeted biopsy cores alone has similar or higher rates of detection of clinically significant cancers. The PRECISION trial aimed to evaluate prospectively whether multiparametric MRI (mpMRI), with targeted biopsy in the presence of an abnormal lesion, was non-inferior to standard transrectal ultrasonography–guided biopsy in the detection of clinically significant prostate cancer in men with a clinical suspicion of prostate cancer who had not undergone biopsy of the prostate previously.

Whereas high-risk surgery patients reported sexual function scores that were 7.6 points lower than those of low-risk RP patients (95% CI, 3.5–12; p < 0.001), high-risk EBRT patients reported scores that were 14 points lower than those of low-risk EBRT patients at 3 yr (95% CI, 8.1–20; p < 0.001). This finding suggests that radiotherapy may lead to comparatively larger declines in sexual function when low- and high-risk patients are compared. In contrast with sexual domain, cancer severity did not modify the effect of treatment on incontinence scores. The differences in function between both procedures did not vary over time between risk groups. There were no clinically significant interactive effects between treatment and

In 25 centers, they randomized men with a clinical suspicion of prostate cancer to either undergo mpMRI, with or without targeted biopsy, or standard 10 to 12 core transrectal ultrasonography–guided biopsy. Participants were required to have a PSA level of 20 ng per milliliter or less, a digital rectal examination that did not suggest extracapsular disease, and to be suitable candidates for biopsy of the prostate and for MRI. MRI was performed with a pelvic phased-array coil on either a 1.5T or 3.0-T scanner, with or without an endorectal coil. Areas on the multiparametric MRI that were suggestive of prostate cancer were categorized by a local radiologist according to the PI-RADS v2 scheme.

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Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ hotmail.com Men in the MRI-targeted biopsy group underwent a targeted biopsy (without standard biopsy cores) if the MRI was suggestive of prostate cancer (PI-RADS 3+). A maximum of three areas that were suggestive of prostate cancer were permitted to be chosen for targeted biopsy, with a maximum of 4 biopsy cores obtained per area, resulting in a maximum of 12 biopsy cores obtained per participant. Matching of the image of the target on MRI with the real-time image of the prostate during biopsy could be performed either by cognitive or software aided fusion and could be carried out through the transrectal or transperineal route, according to local expertise. Men whose MRI results were not suggestive of prostate cancer were not offered biopsy. The primary outcome was the proportion of men who received a diagnosis of clinically significant cancer. Secondary outcomes included the proportion of men who received a diagnosis of clinically insignificant cancer. 500 men underwent randomization. In the MRItargeted biopsy group, 71 of 252 men (28%) had MRI results that were not suggestive of prostate cancer, so they did not undergo biopsy. Among the men who underwent biopsy in the MRI group a median of 4 cores were obtained. Clinically significant cancer was detected in 95 men (38%) in the MRI-targeted biopsy group, as compared with 64 of 248 (26%) in the standard-biopsy group (adjusted difference, 12 percentage points; 95% confidence interval [CI], 4 to 20; p = 0.005). MRI, with or without targeted biopsy, was non-inferior to standard biopsy, and the 95% confidence interval indicated the superiority of this strategy over standard biopsy. Among men with a positive result on MRI, the percentage of men with clinically significant cancer was highest among participants with a PI-RADS v2 score of 5 (83%), followed by those with a score of 4 (60%) and those with a score of 3 (12%). Fewer men in the MRI-targeted biopsy group than in the standard-biopsy group received a diagnosis of clinically insignificant cancer (23 men [9%] vs. 55 [22%]; p < 0.001).

…the era of blindly firing needles into the prostate in the hope of hitting the cancer must surely be coming to an end Despite the fact that there was only moderate agreement between the site and central radiologist reporting mpMRIs, this study demonstrated that mpMRI-targeted biopsy detects more clinically significant cancers whilst allowing over a quarter of men to avoid biopsy altogether. Concerns will be raised about capacity and training for uro-radiologists reporting these scans (radiologists in the study were reporting a median 300 MRIs per year). However, the era of blindly firing needles into the prostate in the hope of hitting the cancer must surely be coming to an end.

Source: MRI-targeted or standard biopsy for prostate-cancer diagnosis. Kasivisvanathan V, Rannikko AS, Borghi M, et al.

The PLCO and ERSPC trials undertook repeated PSA testing at intervals of one, two, or four years. Less intensive strategies, such as longer screening intervals or one-off screenings, have been predicted to reduce over-detection, overtreatment, and costs; however, “opportunistic testing” may increase over-detection without reducing prostate cancer mortality. The Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP) was designed to determine the effects of a low-intensity, single invitation PSA test and standardized diagnostic pathway on prostate cancer– specific and all-cause mortality while minimizing over-detection and overtreatment. This was a primary care-based cluster randomized trial of an invitation to a single PSA test followed by standard prostate biopsy in men with PSA levels of 3ng/ml or greater. (ProtecT trial of treatments for localized prostate cancer was embedded in this study). 911 primary care practices geographically located near eight hospital centers in England and Wales were randomized to the intervention and control groups prior to practice recruitment and obtaining consent. All men aged 50 to 69 years in the randomized practices were sent a single intervention to a nurse-led clinic appointment, where they were given information about PSA testing. After giving consent they were offered a PSA test. Those men with a PSA above 3ng/ml were offered a standard 10-core transrectal biopsy. In the control practices information on PSA testing was provided only to men who requested it. Cases of prostate cancer that were detected among men in the intervention group who did not attend the nurse-led session and among the control group were identified using the National Health Service Digital Organization and the Office for National Statistics for deaths and cancer registrations, and supplemented with routine hospital data from the study centers. Just 639 (0.15%) of men could not be traced. Data on metastases was difficult to obtain but stage and grade at diagnosis and death from prostate cancer was robust.

The results of the CAP trial show that even a low-intensity strategy aiming to reduce over-detection leads to an increased detection of low-risk prostate cancer cases,… Among 415,357 randomized men (mean [SD] age, 59.0 [5.6] years), 189,386 in the intervention group and 219,439 in the control group were included in the analysis (n = 408 825; 98%). In the intervention group, 75,707 (40%) attended the PSA testing clinic and 67,313 (36%) underwent PSA testing. PSA testing in the control group was indirectly estimated at between 10-15% over 10 years. After a median follow-up of 10 years, 549 (0.30 per 1000 person-years) died of prostate cancer in the intervention group vs. 647 (0.31 per 1000 personyears) in the control group rate ratio [RR], 0.96 [95% CI, 0.85-1.08]; p = .50). The number diagnosed with prostate cancer was higher in the intervention group (n = 8,054; 4.3%) than in the control group (n = 7,853; 3.6%) (RR, 1.19 [95% CI, 1.14-1.25]; p < .001). More prostate cancer tumors with a Gleason grade of 6 or lower were identified in the intervention group (n = 3,263/189,386 [1.7%]) than in the control group (n = 2,440/219,439 [1.1%]) (p < .001). In the analysis of all-cause mortality, there were 25,459 deaths in the intervention group vs. 28,306 deaths in the control group (RR, 0.99 [95% CI, 0.94-1.03]; p = .49). In the instrumental variable analysis for prostate cancer mortality, the adherence-adjusted causal RR was 0.93 (95% CI, 0.67-1.29; p = .66).

NEJM. 2018; http://dx.doi.org/10.1056/NEJMoa1801993

PSA screening for prostate cancer: Can we do it differently? Randomised clinical trials, conducted in Europe and USA, have failed to resolve the controversies surrounding PSA-based prostate cancer screening. The prognosis for low- and intermediate-risk localized prostate cancer is excellent, and although there is fair-quality evidence that screening by PSA testing reduces prostate cancer deaths, debate continues about the trade-off between the mortality benefit and risks of harm from over-detection and overtreatment. Key articles

March/May 2018

A between-center analysis of the ERSPC trial suggested that more intensive screening reduces mortality relative to no screening, but also that intensive screening strategies detect higher numbers of low-risk prostate cancer cases and leads to a strong positive correlation between the extent of the benefits gained and the harms caused. The results of the CAP trial show that even a low-intensity strategy aiming to reduce over-detection leads to an increased detection of low-risk prostate cancer cases, without benefit in reducing mortality from the disease. It is likely that a median follow-up is too short. The cumulative incidence of prostate cancer mortality in the intervention and control groups appeared to diverge after 12 years of follow-up and extended follow-up of the CAP trial is crucial to ascertain whether the evidence of increased detection from the

screening intervention coupled with treatment related effects on the occurrence of metastases translate into longer-term survival benefits

Mr. Philip Cornford Section editor Liverpool (GB)

Source: Effect of a low-intensity PSA-based screening intervention on prostate cancer mortality. The CAP randomised clinical trial. MRI-targeted or standard biopsy for prostatecancer diagnosis. Martin RM, Donovan JL, Turner EL et al.

philip.cornford@ rlbuht.nhs.uk

JAMA. 2018; 319(9):883-95. This paper suggests that among patients with Gleason 9-10 prostate cancer, treatment with EBRT+BT What is the best treatment for score with androgen deprivation therapy was associated Gleason 9-10 prostate cancer? with significantly better prostate cancer–specific mortality and longer time to distant metastasis Whether radical prostatectomy (RP) and radiotherapy compared with EBRT with androgen deprivation offer equivalent outcomes for high-risk prostate cancer therapy or with radical prostatectomy. remains controversial, with no clear evidence from randomized trials. Although studies have suggested a However, it is not clear why local failure to control disease would have led to an excess number of biochemical control benefit to adding brachytherapy boost (BT) to external beam radiotherapy (EBRT), as prostate cancer related deaths in the first five years an extreme form of dose escalation, in such patients. and not later. Yet again this paper shows the issues with retrospective data. If the urological community To date the relatively low event rate even in high-risk wants to compare EBRT and radical prostatectomy, patients has lead to a need to include patients with high-risk patients are the only way to establish the long follow-up and consequently older treatment relative merits of the different treatments but in a regimes. This study attempts to avoid that by only randomized controlled trial and not a retrospective including men with Gleason 9-10 prostate cancer and cohort study. comparing clinical outcomes in a consortium of patients treated across 12 tertiary centres. Source: Radical prostatectomy, external beam Institutional databases from 12 tertiary referral centers were queried for patients with biopsy Gleason score 9-10 prostate cancer treated between 2000 and 2013. Inclusion criteria included documentation of clinically localized disease and treatment with definitive intent. 1,809 patients were identified and de-identified data was shared. Patients were grouped into three cohorts, ERBT (734 men), ERBT+BT (436 men) or RP (639 men). Patients treated with RP were significantly younger than those treated with either EBRT or EBRT+BT, had significantly lower initial PSA levels, and were less likely to have Gleason score 10 disease (p < .001 for all comparisons). The majority of EBRT and EBRT+BT patients had androgen deprivation therapy as part of their initial treatment strategy (89.5% and 92.4%, respectively), but the duration of the therapy was significantly shorter among patients receiving EBRT+BT (median 12.0 months vs. 21.9 months; p < .001). Salvage radiotherapy was used in 34.1%of patients treated with RP. Local salvage procedures after EBRT and EBRT+BT were rarely performed (rates of 2.5% and 0.1%, respectively). Focus was placed upon prostate cancer-specific mortality, distant metastasis and overall survival as end points.

If the urological community wants to compare EBRT and radical prostatectomy, high-risk patients are the only way to establish the relative merits of the different treatments but in a randomized controlled trial and not a retrospective cohort study By 10 years, 91 RP, 186 EBRT, and 90 EBRT+BT patients had died. Adjusted five-year prostate cancer–specific mortality rates were RP, 12% (95% CI, 8%-17%); EBRT, 13% (95% CI, 8%-19%); and EBRT+BT, 3% (95%CI,1%-5%). EBRT+BT was associated with significantly lower prostate cancer–specific mortality than either RP or EBRT (HRs of 0.38 [0.21-0.68] and 0.41 [0.24-0.71]). In addition adjusted five-year incidence rates of distant metastasis were RP, 24% (95% CI, 19%-30%); EBRT, 24% (95% CI, 20%-28%); and EBRT+BT, 8% (95% CI, 5%-11%). EBRT+BT was associated with a significantly lower rate of distant metastasis (propensity-score-adjusted cause-specific HRs of 0.27 [95% CI, 0.17-0.43] for RP and 0.30 [95 % CI, 0.19-0.47] for EBRT). This data suggests a selection bias in these non-randomized groups. As prostate cancer death so shortly after curative local treatment is driven by the presence of metastatic disease at presentation rather than failure to treat the primary disease. After the first 7.5 years, the HRs for all-cause mortality between ERBT+BT and RP and EBRT were 1.16 (95% CI, 0.70-1.92) and 0.87 (95% CI, 0.57-1.32) respectively. Suggesting that the effect of missed microscopic metastatic disease at diagnosis had dissipated.

radiotherapy or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with Gleason score 9-10 prostate cancer. Kishan AU, Cook RR, Ciezki JP, et al. JAMA. 2018; 319(9):896-905.

Cycling and female sexual and urinary function Bicycle riding has become an increasingly popular mode of transportation and exercise, especially among women, and previous studies have demonstrated a relationship between cycling and sexual dysfunction, albeit using non-validated questionnaires. Thus, the authors aimed to explore the relationship between cycling and sexual and urinary dysfunction. Cyclists were recruited to complete a survey through Facebook advertisements and outreach to sporting clubs across five English-speaking countries. Swimmers and runners were recruited as a comparison group. Participants were queried using validated questionnaires, including the Female Sexual Function Index, the American Urological Association Symptom Index, and non-validated questions about history of urinary tract infections (UTIs), genital numbness, and genital saddle sores (all self-reported).

The investigators found that women cyclists were no more likely to report sexual dysfunction or urinary symptoms than swimmers or runners 3,118 (53.3%) Women completed the survey, comprising 1,053 (34%) non-cyclists, 1,656 (53%) low-intensity cyclists, and 409 (13%) high-intensity cyclists. After adjusting for age, body mass index, hypertension, diabetes, ischemic heart disease, tobacco use, race, marital status, urinary symptoms, and sexual activity, high-intensity cyclists had lower odds of self-reported sexual dysfunction compared to non-cyclists (adjusted odds ratio [aOR] 0.7, p = .02). There were no statistically significant differences in urinary symptoms across groups. Compared to non-cyclists, both low- and high-intensity cyclists had higher odds of reporting a previous UTI (aOR 1.4, p < .001, and aOR 1.4, p = .009, respectively), genital numbness (odds ratio [OR] 6.5, p < .001, and OR 9.1, p < .001, respectively), and saddle sores (OR 6.3, p < .001, and OR 22.7, p < .001, respectively). This is the largest study comparing cyclists to other athletes with respect to sexual and urinary function. The study is limited by its cross-sectional design and sampling methods. The investigators found that women cyclists were no more likely to report sexual dysfunction or urinary symptoms than swimmers or

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Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de runners. However, women cyclists were more likely to report other genitourinary conditions, including UTIs and genital numbness.

Source: Cycling and Female Sexual and Urinary Function: Results From a Large, Multinational, Cross-Sectional Study. Gaither TW, Awad MA, Murphy GP, Metzler I, Sanford T, Eisenberg ML, Sutcliffe S, Osterberg EC, Breyer BN. J Sex Med. 2018 Apr;15(4):510-518. doi: 10.1016/j. jsxm.2018.02.004. Epub 2018 Mar 13.

Serenoa repens + selenium + lycopene vs. tadalafil 5 mg in treating LUTS secondary to BPO In a randomized, open label, not-inferior clinical study, the investigators aimed to compare the efficacy and tolerability of Serenoa Repens (SeR) + Lycopene (Ly) + Selenium (Se) therapy versus Tadalafil 5 mg in patients affected by lower urinary tract symptoms (LUTS). From 2015 to 2017, 427 patients were enrolled in 21 different centres (ISRCTN73316039). Inclusion criteria were: age between 50 and 80 years old, international prostate symptom score (IPSS) ≥ 12, peak flow ≤ 15 ml/s, post-void residual (PVR) <100 ml. Participants were randomized into two arms in a 2:1 ratio: arm A (SeR-Se-Ly 1 tablet per day for six months) and arm B (Tadalafil 5 mg 1 tablet per day for six months). The primary endpoint of the study was the non-inferiority variation of the IPSS and peak flow in Group A vs. Group B after six months of treatment.

…treatment with SeR-Se-Ly was not inferior to Tadalafil 5 mg in terms of improving of IPSS and peak flow 404 patients completed the full protocol. When comparing both therapies, group A was statistically not inferior to Group B considering IPSS (-3.0 vs. 3.0; p <0.01), IPSS-QoL (-2.0 vs. -2.0; p<0.05) and peak flow (2.0 vs. 2.0; p<0.01). The authors found statistically significant differences in the increase of at least three points of the peak flow (38.2% versus 28.1%; p = 0.04) and at least 30% of the peak-flow (39.2% versus 27.3%; p <0.01) in arm A compared to arm B. The percentage of patients with an increase of at least three points of the IPSS and a decrease of at least 25% of the IPSS was not statistically different between the two arms. Regarding the percentage of adverse events, four patients in arm A (1.44%) and 10 arm B (7.81%) (p <0.05) reported side effects. The investigators concluded that treatment with SeR-Se-Ly was not inferior to Tadalafil 5 mg in terms of improving of IPSS and peak flow.

Source: Serenoa repens + selenium + lycopene vs. tadalafil 5 mg for the treatment of LUTS secondary to benign prostatic obstruction: a phase IV, non-inferiority, open label, clinical study (SPRITE Study). Morgia G, Vespasiani G, Pareo RM, Voce S, Madonia M, Carini M, Ingrassia A, Terrone C, Gentile M, Carrino M, Giannantoni A, Blefari F, Arnone S, Santelli G, Russo GI; SPRITE investigators.

In a double-blind, multicentre, prospective, randomized, controlled trial 181 patients with moderate to severe lower urinary tract symptoms related to benign prostatic hyperplasia underwent transurethral prostate resection or Aquablation. The primary efficacy end point was the reduction in International Prostate Symptom Score at 6 months. The primary safety end point was the development of Clavien-Dindo persistent grade 1, or 2 or higher operative complications.

Surgical prostate resection using Aquablation showed non-inferior symptom relief compared to transurethral prostate resection but with a lower risk of sexual dysfunction

and transurethral prostate resection (33 vs. 36 minutes, p = 0.2752) but resection time was lower for Aquablation (4 vs. 27 minutes, p < 0.0001). At month 6 patients treated with Aquablation and transurethral prostate resection experienced large I-PSS improvements. The pre-specified study noninferiority hypothesis was satisfied (p < 0.0001). Of the patients who underwent Aquablation and transurethral prostate resection 26% and 42%, respectively, experienced a primary safety end point, which met the study primary non-inferiority safety hypothesis and subsequently demonstrated superiority (p = 0.0149). Among sexually active men the rate of anejaculation was lower in those treated with Aquablation (10% vs. 36%, p = 0.0003). Surgical prostate resection using Aquablation showed non-inferior symptom relief compared to transurethral prostate resection but with a lower risk of sexual dysfunction. Of note, larger prostates (50 to 80 ml) demonstrated a more pronounced superior safety and efficacy benefit. Longer term follow-up would help assess the clinical value of Aquablation.

Source: WATER: A Double-Blind, Randomized, Controlled Trial of Aquablation vs Transurethral Resection of the Prostate in Benign Prostatic Hyperplasia. Gilling P, Barber N, Bidair M, Anderson P, Sutton M, Aho T, Kramolowsky E, Thomas A, Cowan B, Kaufman RP Jr., Trainer A, Arther A, Badlani G, Plante M, Desai M, Doumanian L, Te AE, DeGuenther M, Roehrborn C. J Urol. 2018 Jan 31. pii: S0022-5347(18)30108-3. doi: 10.1016/j.juro.2017.12.065. [Epub ahead of print]

Fosfomycin is an effective alternative to carbapenems in treating MDR E. coli in uncomplicated UTIs Fosfomycin has become an attractive treatment alternative for urinary tract infections (UTIs) due to increasing multidrug-resistance (MDR) in Escherichia coli. In this study, investigators evaluated the pharmacokinetic and pharmacodynamic (PK/PD) indices of fosfomycin and its in vivo activity in an experimental murine model of ascending UTI. Subcutaneous administration of fosfomycin showed that the mean peak plasma concentrations of fosfomycin were 36, 280, and 750 mg/L following administration of a single dose of 0.75, 7.5, and 30 mg/mouse, respectively, with an elimination half-life of 28 min; and urine peak concentrations of 1100, 33400, and 70000 mg/L expected to sustain above the MIC of the test strain (NU14, 1 mg/L) for 5, 8 and 9.5 h, respectively.

…fosfomycin shows concentrationdependent in vivo activity and the results suggest that fosfomycin is an effective alternative to WATER: A double-blind, randomized, controlled trial of carbapenems in treating MDR E. coli in uncomplicated UTIs Aquablation vs. TURP in BPH

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It is concluded that fosfomycin shows concentrationdependent in vivo activity and the results suggest that fosfomycin is an effective alternative to carbapenems in treating MDR E. coli in uncomplicated UTIs. The data for effectiveness on the MDR isolates along with PK/PD modeling should facilitate further development of improved recommendations for clinical use.

Source: Pharmacokinetics and Pharmacodynamics of Fosfomycin and its Activity against ESBL-, Plasmid-mediated AmpC- and Carbapenemase-Producing Escherichia coli in a Murine Urinary Tract Infection Model. Zykov IN, Samuelsen Ø, Jakobsen L, Småbrekke L, Andersson DI, Mean total operative time was similar for Aquablation Sundsfjord A, Frimodt-Møller N.

BJU Int. 2018 Mar 22. doi: 10.1111/bju.14209. [Epub ahead of print]

The investigators compared the safety and efficacy of Aquablation and transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia (BPH).

twice (q36h), fosfomycin significantly reduced the CFU/ ml in urine of susceptible strains, including clinical MDR strains, except for one clinical strain (p = 0.062). A variable degree of reduction was observed in the bladder and kidneys. No significant reduction in CFU/ ml was observed with the resistant strains.

The optimal PK/PD indices for reducing urine colony counts (CFU/ml) were determined to be AUC/MIC 0-72h and Cmax/MIC based on the dose-dependent bloodstream PK and evaluation of six dosing regimens. With a dosing regimen of 15 mg/mouse

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

Authors reviewed 1,133 patients who underwent RC for bladder cancer at their institution between 2003 and 2013; 815 patients (72%) underwent orthotopic diversion, 274 (24%) ileal conduit, and 44 (4%) continent cutaneous diversion. 90-day postoperative UTI incidence, culture results, antibiotic sensitivity/ resistance and treatment were recorded through retrospective review. Fisher's exact test, KruskalWallis test, and multivariable analysis were performed.

Antimicrob Agents Chemother. 2018 Mar 26; DOI: 10.1128/AAC.02560-17 PMID: 29581117

…UTI is a common complication and cause of re-admission following Relying on clean catch urine radical cystectomy and urinary samples may lead to significant diversion over-diagnosis of UTIs The aim of the present study was to evaluate the utility of catheterized samples in reducing overdiagnosis of UTI based on voided specimens among patients presenting with a range of urinary symptoms. Authors also aimed to determine variables that may modify the predictive value of the voided midstream urine culture. Patient charts were reviewed to identify female patients referred to a voiding dysfunction clinic with a range of complaints warranting urine studies (5/2014-8/2016). Patients with a positive voided urine culture who also had a catheterized urine culture in the local system were included. Multiple logistic regression analysis was performed to identify patient characteristics associated with a negative catheterized specimen despite a positive voided specimen.

The study suggests that in female patients who have vague symptoms of UTI, obtaining catheterized specimens may be beneficial in avoiding the over-diagnosis of UTIs and the overuse of antibiotics One hundred and seven women were included in the study. Eighty percent of the cohort was postmenopausal. Although all patients had positive voided specimens, only 53 (49.5%) had positive catheterized specimens. On multivariate analysis negative nitrites on clean catch UA was a significant predictor of a negative catheterized sample (adjusted OR 8.9, 95%CI 2.2-43.7, P = 0.003). WBC/HPF < 10 on clean catch UA trended towards significance (adjusted OR 4.72, 95%CI 1.1-26.1, P = 0.05). Investigators concluded that relying on clean catch urine samples may lead to significant over-diagnosis of UTIs. The study suggests that in female patients who have vague symptoms of UTI, obtaining catheterized specimens may be beneficial in avoiding the over-diagnosis of UTIs and the overuse of antibiotics.

Source: Utility of catheterized specimens in reducing overdiagnosis of urinary tract infections in women. Aisen CM, Ditkoff E, RoyChoudhury A, Corish M, Rutman MP, Chung DE, Badalato GM, Cooper KL.

A total of 151 urinary tract infections were recorded in 123 patients (11%) during the first 90 days postoperatively. 21/123 (17%) had multiple infections and 25 (20%) had urosepsis in this time span. Gram-negative rods were the most common etiology (54% of positive cultures). 52% of UTI episodes led to re-admission. There was no significant difference in UTI rate, etiologic microbiology (Gram-negative rods, Gram-positive cocci, fungi), or antibiotic sensitivity and resistance patterns between diversion groups. Resistance to quinolones was evident in 87.5% of Gram-positive and 35% of Gram-negative bacteria. In multivariable analysis, Charlson Comorbidity Index > 2 was associated with higher 90-day UTI rate (OR = 1.8, 95% CI 1.1-2.9, p = 0.05) and Candida UTI (OR 5.6, 95% CI 1.6-26.5, p = 0.04). It is concluded that UTI is a common complication and cause of re-admission following radical cystectomy and urinary diversion. These infections are commonly caused by Gram-negative rods. High comorbidity index is an independent risk factor for postoperative UTI, but diversion type is not.

Source: Urinary tract infections following radical cystectomy and urinary diversion: a review of 1133 patients. Clifford TG, Katebian B, Van Horn CM, Bazargani ST, Cai J, Miranda G, Daneshmand S, Djaladat H. World J Urol. 2018 Jan 25; DOI: 10.1007/s00345-0182181-2. PMID: 29372354

Drain or not to drain? Interesting results from the first RCT on robotic-assisted radical prostatectomy The insertion of a prophylactic pelvic drain after a radical prostatectomy has been widely questioned, especially nowadays that –when indicatedlymphadenectomy needs to be extended. Several studies have addressed this issue arguing the actual benefit of a routine placement of pelvic drainage against the potential side effects: whilst a drain may prevent a lymphocele and show an active bleeding or urine leakage by draining lymph, blood or urine, it may cause pain or peritoneal irritation and ileus, especially if transperitoneal approach is performed.

Neurourol Urodyn. 2018 Mar 31; DOI: 10.1002/nau.23553 Robotic-assisted radical prostatectomy (RARP) is PMID: 29603811 usually performed transperitoneally, especially if extended lymphadenectomy needs to be performed. this approach, lymphorrea is usually self-limited UTI is a common complication With with reabsorption of lymphatic liquid from the and cause of readmission peritoneum, so that insertion of pelvic drain might not be necessary to prevent lymphatic-related following radical cystectomy complications. The objective of this study was to investigate the incidence and microbiology of urinary tract infection (UTI) within 90 days following radical cystectomy (RC) and urinary diversion.

A US centre has undertaken the difficult task to perform a randomised controlled trial comparing two groups of patients selected for RARP where a drain was randomly inserted: main inclusion criteria were

EAU EU-ACME Office

European Urology Today

March/May 2018


absence of urinary leakage after having proven watertightness of vesico-ureteral anastomosis with the injection of 120 mls of saline, as well as suboptimal haemostasis at the prostatic fossa.

relevant surgical approach according to the UK Office of Population Census and Surveys classification (OPCS-4th edition). This is an important aspect to consider since in many European countries a separate reimbursement code for RARP is not available, so that also when the technology is available it may be not rentable for the institutions to use, especially in the setting of public care.

“micro-costing” analysis included all the direct and indirect costs involved in the management and usage of the devises, like operative room costs, labour costs for processing the devices (sterilization for reusable ones, disposal for single-use ones), consumables, etc. Cost of reusable ureteroscopes per procedure was estimated by amortising the costs of the scopes and repairs normalised for the average of life-span of devices before repair or disposal. All of these costs were based on local OR usage tariffs, employee salaries, providers reimbursement fees and type of contracts with providers. The final results showed similar costs for both procedures.

The RCT was well-designed and statistically sound, with a sample size calculated in 312 patients (or 156 on each arm) on the basis of a non-inferiority incidence of complications for the no-drain (ND) versus pelvic-drain (PD) groups, with a margin of 10% of difference. Database of the Hospital Episodes Statistics was used to identify the proportion of men experiencing any severe urinary complication and stricture-related The authors concluded that complications, requiring admission and intervention.

surgeons experience may be a reliable factor in discerning cases where a pelvic drain is necessary, in contrast to the classic concept of the utility of routine prophylactic drain insertion Unfortunately, after four years of accrual, authors were unable to reach the due number of patients, so that final analysis was based on the 189 patients (=60%) recruited at the time of the trial closure. Demographics of the two groups were comparable, with most of the patients receiving extended lymphadenectomy (70.7 vs.79.4% for ND and PD, respectively).

The main outcome was the lack of statistical difference of post-operative (<90 days) complications, either minor (Clavien 1-2) or major (Clavien 3-4) ones. The authors concluded that surgeons experience may be a reliable factor in discerning cases where a pelvic drain is necessary, in contrast to the classic concept of the utility of routine prophylactic drain insertion. On the other hand, other important outcomes were not demonstrated in the trial: a difference of prevalence of ileus was not shown and drain-related pain was not available; the former issue may be accounted by the low number of events (consequence of the low number of patients recruited) and the latter due to the lack of measurement tools to appropriately track and record the pain symptoms.

Source: Prospective randomised non-inferiority trial of pelvic drain placement vs no pelvic drain placement after robot-assisted radical prostatectomy. Chenam A, Yuh B, Zhumkhawala A, et al. BJU Int. 2018 Mar;121(3):357-364. doi: 10.1111/bju.14010. Epub 2017 Sep 22.

A final cohort of 17,299 patients was analysed: the three groups accounted a comparable number of patients (n = 6,873 open radical prostatectomy –OPR), (n = 5,479 laparoscopic radical prostatectomy –LRP) and 4,947 RARP. Interestedly, a trend towards more RARP was noticed over the years, this latter procedure being mostly performed in the last year in observation (40.1% of the patients undertaking surgery in that year). Among the variables considered were socio-economic deprivation, centres volume according to number of radical prostatectomies (< 50, 50-100, > 100), Charlson score index and pelvic lymphadenectomy, besides the surgical approach. Authors found that RARP showed a lower rate of both the urinary complications and urethral stricture with respect to the ORP and LRP approaches. As a potential explanation they emphasised an alleged more common use of the continuous sutures used in the vesico-urethral anastomosis with RARP, which may allow a less ischaemic and more watertight anastomosis, as well as facilitating the robotic platform in performing the reconstruction of the posterior fibro-muscular structure of the pelvic floor (Rocco’s stitches). The large number from a real-life national population-based cohort is among the strengths of the paper; however, confounding factors such as the inability to control for suture techniques and a larger proportion of lymphadenectomy performed in patients undertaking ORP- somehow limit these findings.

Authors found that RARP showed a lower rate of both the urinary complications and urethral stricture with respect to the ORP and LRP approaches

Single-use digital flexible ureteroscopes have been recently introduced in the market in an attempt to provide practitioners with the best visibility, manoeuvrability and efficiency of scopes at every procedures, considering the unresolved limited life-span of the reusable devices and their ‘not always’ optimal conditions. However, evidences in literature are lacking on this regard; further concerns also involve costs and environmental effects of their (eventual) systematic use in the clinical practice. Three different papers have been recently published addressing these issues.

1) A systematic review has been conducted retrieving 11 papers, with only two studies performing a comparison with non-disposable ureteroscopes for the treatment of renal stones; moreover, in-vivo and in-vitro studies were also selected, so that quality of the meta-analysis is poor. By pooling out data of 466 patients, the authors By reviewing national data, authors have analysed the found no difference between single-use scopes hospital readmission rate within two years from the and reusable ones in terms of the clinical procedure to treat late urinary complications across outcomes in observation like stone-free rates the English NHS Trusts. (77.8 ± 18 versus 68.5 ± 33%, p = 0.76), complication rates 15.3 ± 10.6 versus 15 ± 1.6%, Data were available from the National Cancer p = 0.3) and procedure duration (73 ± 27 versus Registry and collected on the basis of International 74 ± 13 min, p = 0.99). Classification of Diseases, 10th revision (ICD-10) 2) A micro-costing analysis was also recently codes to identify the population of interest (i.e. conducted between two small groups of patients patients with prostate cancer) diagnosed between undergoing a renal endoscopic procedure one 2008 and 2012. Similarly, patients undertaking with a reusable fibreoptic scope versus another radical prostatectomy were categorised for the one with a single-use digital scopes. The Key articles

March/May 2018

…single-use devices may not necessarily be considered as a competitor to reusable ones, and an ideal strategy to optimise integration of the two technologies is still under evaluation

Overall, these latest evidences may provide more convincing arguments for a wider use of this new Source: National cohort study comparing severe technology. It should be kept in mind that single-use medium-term urinary complications after robot- devices may not necessarily be considered as a assisted vs laparoscopic vs retropubic open competitor to reusable ones, and an ideal strategy to radical prostatectomy. Sujenthiran A, Nossiter J, optimise integration of the two technologies is still under evaluation. Parry M, et al. BJU Int. 2018 Mar;121(3):445-452. doi: 10.1111/bju.14054. Epub 2017 Nov 15. Sources:

Open vs. laparoscopic vs. Single-use digital flexible robotic radical prostatectomy: ureteroscopes: A new era has The English National Health started? System experience The recurring question of whether robotic-assisted radical prostatectomy (RARP) has any advantage with respect to open or laparoscopic approach has been recently tackled by a group of British researchers. Though most of the practitioners advocate substantial advantages provided by the Da Vinci system, up to date evidences have not yet demonstrated a convincing superiority of this technique and technology over the others, as reflected also in the latest version of the EAU Guidelines on Prostate Cancer.

However, the main factor seemed to be a shorter operative time -as it translated into lower OR expenses- in favour of the single-use group: this outcome might be somehow expected as evidences in literature have reported a benefit of digital scopes in a quicker operative-time with respect to fibreoptic scopes, so that it cannot be ruled out that if the comparison had involved a reusable digital scope, the cost analysis results would have been not such in favour of the disposable devices. 3) A thorough analysis of the environmental impact of single-use vs. reusable scope has been recently performed by estimating the CO2 emissions during the whole life cycle of the devices, encompassing their manufacturing, use (including sterilization and repairs for reusable scopes) and disposal. Authors concluded that carbon footprint of single-use and reusable flexible digital ureteroscopes are comparable.

1) Single-use flexible ureteropyeloscopy: a systematic review. Davis NF, Quinlan MR, Browne C, et al.

World J Urol. 2018 Apr;36(4):529-536. doi: 10.1007/ s00345-017-2131-4. Epub 2017 Nov 24.

2) Micro-Costing Analysis Demonstrates Comparable Costs for LithoVue Compared to Reusable Flexible Fiberoptic Ureteroscopes. Taguchi K, Usawachintachit M, Tzou DT, et.

J Endourol. 2018 Jan 12. doi: 10.1089/end.2017.0523. [Epub ahead of print]

3) Carbon Footprint in Flexible Ureteroscopy: A Comparative Study on the Environmental Impact of Reusable and Single-Use Ureteroscopes. Davis NF, McGrath S, Quinlan M, et al. J Endourol. 2018 Feb 21. doi: 10.1089/end.2018.0001. [Epub ahead of print]

Long-term development of measured glomerular filtration rate in living kidney donors is not different to that of the general population The rate of measured GFR change in kidney donors years after donation has not been adequately addressed. Whether this change is accelerated in the setting of one kidney is also understudied.

≥60 ml/min/1.73m, 14.0% had a GFR between 45-60 ml/min/1.73m and 1.4% had a GFR < 45 ml/ min/1.73m. Between visit 1 and 2, 56.5% had a GFR decline, 36.0% increase, and in 7.5% there was no change. Overall, GFR declined at a rate of -0.42 ml/min/1.73m per year. Of GFR estimating models, only CKD Epidemiology Collaboration - Creatinine equation produced a slope that was steeper than measured GFR.

Nearly two decades after donation, GFR declined at a rate similar to that seen in the general population and in one-third, GFR continues to increase Nearly two decades after donation, GFR declined at a rate similar to that seen in the general population and in one-third, GFR continues to increase.

Source: Measured Glomerular Filtration Rate After Kidney Donation: No Evidence of Accelerated Decay. Berglund DM, Zhang L, Matas AJ, Ibrahim HN. Transplantation. 2018, doi: 10.1097/ TP.0000000000002215. [Epub ahead of print]

Outcome of second transplantation may be impaired after nephrectomy of first transplant, retrospective study suggests The impact of allograft nephrectomy on the outcome of a subsequent (second) renal transplant is unclear. This study was conducted to assess the effects of the first allograft nephrectomy on outcomes of a second transplant. This retrospective study included 118 patients who received a second transplant between 1994 and 2015. Before the second transplant, 59 patients did not undergo a first allograft nephrectomy (group A). Group B comprised 59 patients who had undergone a first allograft nephrectomy. We compared sensitization, acute rejection, and survival of the second graft between groups. The risk factors of a second graft loss were assessed. The first graft survival was significantly longer in group A than in group B (100.6 vs 3.7 months; P < .001). Prevalence of preformed donor-specific antibodies before the second allograft was similar between both groups (28.8% vs 39.0% for group A vs group B; P = .243). Numerically higher acute rejection rates occurred in group B than in group A (23.7% vs 15.3%; P = .245). In group A, graft survival rates at one, three, and five years were 93.0%, 87.0%, and 82.3% and were significantly higher than for group B (76.7%, 69.1%, and 62.5%; P < .05).

We recommend that recipients of second transplants should be considered as high risk if they had undergone prior allograft nephrectomy] On multivariate analysis, survival of the second graft was affected by acute rejection (hazard ratio = 2.24; 95% confidence interval, 1.10-4.45; P = .027) and the interval from first graft loss to second transplant (hazard ratio = 1.11; 95% confidence interval, 1.02-1.19; P = .008). A first allograft nephrectomy was associated with inferior second graft survival. We recommend that recipients of second transplants should be considered as high risk if they had undergone prior allograft nephrectomy.

214 randomly selected donors underwent serial GFR measurements of nonradioactive iohexol. eGFR at each visit was calculated using the CKD EPI and MDRD Source: Impact of Allograft Nephrectomy on study equations. Second Renal Transplant Outcome. Muramatsu GFR visits were 4.8 ±1.3 years apart and the second occurring 16.9±9.1 years after donation. The majority (97.7%) were White; 60.8% female and 78.5% were related to their recipient. Most, 84.6%, had a GFR

M, Hyodo Y, Sheaff M, Gupta A, Ashman N, Aikawa A, Yaqoob M, Puliatti C.

Exp Clin Transplant. 2018, doi: 10.6002/ect.2018.0046. [Epub ahead of print]

EAU EU-ACME Office

European Urology Today

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Taking Live Surgery to the next level Three days of live surgery in the home town of Ferrari Dr. Jan Klein ESUT Board Member Ulm (DE)

jtk171272@gmx.net Organised in conjunction with the Italian Endourological Association (IEA), Modena, Italy, will host more than 600 uro-technology experts from 24-26 May 2018. With three days of live surgeries, broadcast to Modena from all over the world, the 6th Meeting of the European Section of Uro-Technology (ESUT18) is the meeting that will update the urological community on the most recent technological advances in urological surgery and treatment. The meeting will host well-known experts in different urological surgical fields.

Join the conversation at #ESUT18 The ESUT live surgery day during the 33rd Annual EAU Congress in Copenhagen was a full success with 2,262 attendees in the eURO Auditorium. This reflects that live surgery is still of major interest in the urological community. Especially the “Technology strikes back” struck a chord with many attendees. Building on this, the ESUT18 meeting will show 25 live surgery cases and 27 pre-recorded semi-live cases dealing with the latest developments and trends in uro-technology.

Live surgery As a new concept, many of the procedures are transmitted from the home hospitals of the surgeons all over the world including China, India, Brazil and many more, reducing the stressful situation of a typical live surgery setting. The trend of including semi-live content is also integrated as a major part of the live surgery sessions. So it is possible to properly demonstrate new technologies to the auditorium in a safe way and without the pressure of strict time schedules and limited transmission times.

ESUT18-IEA

24-26 May 2018 Modena, Italy

www.esut18.org

www.esut18.org

ESUT18-IEA 6th Meeting of the EAU Section of Uro-Technology in conjunction with the Italian Endourology Association (IEA)

Live surgery starts on Thursday, with different approaches for performing stone surgery procedures. That day, the pre-recorded cases will address endoscopic prostate surgery as well as endoscopic bladder tumour procedures. The live cases on Friday will include advanced laparoscopic and robotic kidney surgery, complex stone surgery and robot-assisted reconstructive and ablative surgery. The pre-recorded cases will show new developments and techniques in retrograde intrarenal surgery (RIRS) of stones and TCC.

Live Surgery

24-26 May 2018, Modena, Italy This event has been accredited with 20 CME points by the EACCME®

Saturday will focus on prostate surgery. Robotic techniques as well as laparoscopic techniques will be shown. The future of robotic surgery will be addressed in the pre-recorded sessions. In summary, the live surgery programme will show even more procedures and techniques in comparison to the live surgery day of EAU18. There will also be the possibility to discuss the procedure with the surgeon during the case, as well as with the moderators.

The hometown of Ferrari will be the perfect place to host the attendees and it will add beautiful surrounding conditions to the meeting. We are proud to present a meeting of this format to the urological community and we are happy to join forces with our friends of the second largest Italian Urological In addition to the surgical demonstrations, there will be lectures dealing with the handling of complications Association (IEA). that might occur during and after the surgical procedure, and how to avoid or treat them. The concept of combining a national meeting (IEA) with For the complete Scientific the ESUT meeting gives the opportunity to join forces Programme visit www.esut18.org and to add surgical techniques displayed on high resolution screens to a local meeting. The moderators and the surgeons were chosen according to their speciality and experience.

Promoting PCa screening at EU level EAU strengthens engagement in prostate cancer issues Sarah Collen Senior Policy Manager Brussels (BE)

Sarah.Collen@ nhsconfed.org

Sarah Collen is Senior Policy Manager for the NHS in Brussels and supports the EAU in EU matters. A new European Union (EU) ‘Joint Action’ (JA) on cancer has started with a Joint Action Kick-off Meeting in Luxembourg, 16-17 April last, bringing into focus a new phase of European cooperation on cancer. The beginning of this new JA also marks another milestone in the EAU’s engagement with the EU to encourage an approach to prostate cancer screening which is in line with the gold-standard approach recommended by the EAU’s Prostate Cancer screening guidelines.

One of the main results of the previous JA on cancer, known as ‘CanCon’ (the Cancer Control Joint Action), was the European Guide on Quality Improvement in Comprehensive Cancer Control. This includes a chapter on cancer screening programmes, where it builds on work that had begun at EU level in 2003, when the Council of the European Union issued recommendations setting out principles of best practice in the early detection of cancer. The recommendations called on all EU countries to take common action to implement national, populationbased screening programmes for breast, cervical and colorectal cancer (not prostate cancer). The EAU engaged with CanCon and the EU’s work on cancer screening to promote the approach taken by the EAU guidelines on Prostate Cancer screening. To this end, the EAU’s White Paper on Prostate Cancer was published in February 2017. Although the white paper was warmly welcomed by a number of high level EU stakeholders, the conclusions on prostate cancer screening in the JA are rather weak:

“In light of currently available evidence, some prostate This is a significant step in the right direction and cancer screening policies may be cost effective but since January 2018, the EAU has been actively questions remain on the optimal benefit-harm balance.” engaging with the coordinators of the new JA on cancer to ensure that we can contribute to the Boosting prostate cancer awareness prevention work package which will look at screening. We have made it clear that we are ready to However, the EAU did not stop its lobbying efforts become a collaborative partner in this Joint Action to and continued to push for an approach aligned to the EAU Prostate Cancer screening guidelines at support this work. We are also willing to organise the European Prostate Cancer Awareness Day another event in the European Parliament later in (EPAD), which took place in the European 2018 to promote the state of the work of the JA on screening. Parliament on 27th September 2017. This was a successful event, which included presentations from both European Commissioner for Health and To ensure that prostate cancer screening stands a Food Safety Vytenis Andriukaitis and CanCon chance of finally being included in the EU’s coordinator Tit Albreht. coordinated approach on National Screening Plans, we need to continue to ensure that the EAU is not Shortly after the EPAD meeting, in responding to a only promoting a solid multidisciplinary approach, written parliamentary question from a Member of the but also bringing alongside a multi-stakeholder European Parliament, Commissioner Andriukaitis said community, including patients, payers of healthcare, on behalf of the Commission: “The Commission will ministries of health, politicians, EU officials. Step by support … a Joint Action to collect additional evidence step we are determined to ensure that prostate cancer screening gets the attention it deserves at European for a possible inclusion of prostate cancer screening programmes in the National Cancer Plans.” level.

Joint Actions are co-funded by the European Union’s Health Programme and conducted by national authorities (such as the Ministry of Health) and other public bodies or non-governmental organisations from the EU Member States or other participating countries. JAs are highly specific in that they address the priority health policy needs identified by European Member States and the European Commission. 16

European Urology Today

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Testicular cancer and fertility - a complicated couple Options in preserving fertility should be explored when counselling patients Christian Fuglesang Skjødt Jensen Dept. of Urology Herlev and Gentofte Hospital University of Copenhagen Herlev (DK) fullejensen@gmail.com

Male infertility and testis cancer are both diagnosed at a relatively young age with testis cancer being the most common cancer in men 15-34 years of age1. The association between the two conditions is complicated.

Testis cancer may negatively affect the man’s reproductive health Several studies have shown that spermatogenesis may already be impaired in men with testis cancer before orchiectomy. Consequently, it is estimated that up to 50% of the men diagnosed with testis cancer have poor semen quality at baseline. This might be due to local and systemic effects induced by the cancer itself including increased body temperature, changes in the hypothalamic-pituitary-gonadal axis, cytokine effects and metabolic changes6. It might also be due to a common underlying pathophysiology between male infertility and testis cancer as previously discussed.

Treatment of testis cancer further compromises the man’s reproductive health. In a study evaluating On one hand, male infertility is associated with an 208 testis cancer patients with a semen analysis increased risk of testis cancer, and on the other hand after orchiectomy, only 27% of patients had sperm a diagnosis of testis cancer is a significant threat to counts greater than 10 million per ml7. Additional the reproductive health of the man. In the following, treatment including radiation and chemotherapy an overview on the complicated interconnected might further deteriorate reproductive health as the relationship between male infertility and testis cancer rapid cell division involved in spermatogenesis is will be provided. very sensitive to these treatments. This is illustrated by data from a Norwegian multi-center follow-up Male infertility is associated with an increased risk survey evaluating spermatogenesis and paternity of testis cancer rates in men with prior treatment of unilateral When a couple presents with infertility and a desire to testis cancer. have a biological child the main focus naturally becomes achieving a pregnancy. However, it is Looking at spermatogenesis in long-term survivors important that the physician approaches the infertile of testis cancer the group found that among 342 man in a holistic way given the fact that male men 29% had oligozoospermia and 11% had reproductive health and semen quality may serve as a azoospermia at a median of 11 years after proxy for the man’s general health. treatment8. The overall post-treatment paternity rate among the men was 71% ranging from 48% in men In this regard, men with infertility have an increased treated with high-dose Cisplatin to 92% in the risk of testis cancer compared to fertile men. This has surveillance group9 (See Figure). Another potential been shown in several retrospective cohort- and risk related to testis cancer treatment is the risk of case-control studies with highly varying risk sympathetic nerve damage during retroperitoneal estimates. A large analysis of U.S. claims data lymph node dissection resulting in ejaculatory including 76,083 infertile men, 112,655 men who disorders. underwent vasectomy and 760,830 controls found a hazard ratio of 1.99 (95% confidence interval 1.47 – Although it has been shown that spermatogenesis 2.70) and 1.50 (1.01 – 2.22) for testicular cancer in might recover after testis cancer treatment10 this is far infertile vs. control and infertile vs. vasectomy from certain. In a longitudinal study on 217 men groups2. In general, it seems that there is a two-fold evaluated with a semen analysis at different time increased risk for testis cancer in infertile men points after orchiectomy, the frequency of compared to fertile men. azoospermia was almost 25% at six months and almost 10% after 36-60 months11. In the men who received more than four cycles of chemotherapy the frequency of azoospermia remained above 50% after "...According to the current EAU 36-60 months. As a consequence it is vital to counsel guidelines, there is a grade A men with testicular cancer on gonadotoxic effects of recommendation for offering semen cancer treatment and the possibilities for fertility preservation.

cryopreservation to all men who are candidates for chemotherapy, radiation or surgery that might interfere with spermatogenesis12..."

Different mechanisms might explain the epidemiologic link between male infertility and an increased risk of testis cancer. Male infertility is a complex and heterogeneous condition and the etiology is often unknown. Many of the idiopathic cases of male infertility are thought to be due to genetic defects. In fact, thousands of genes contribute to spermatogenesis and it might be that alterations in these genes also play a role in the development of testicular cancer. However, the connection is likely multifactorial and the mechanisms responsible are overlapping. Thus, another theory describes a link between male infertility and testis cancer explained by the testicular dysgenesis syndrome where an underlying genetic predisposition and exposure to endocrine disrupters during fetal development results in disruptions of testicular development and function3. The disrupted embryonal programming might act as a common underlying cause for impaired semen quality, testis cancer, cryptorchidism and hypospadias. Of note, men with cryptorchidism have a four to five times increased risk of testis cancer4 and most of them have impaired semen quality in spite of early orchidopexy5. Other possible explanations include environmentaland occupational factors5. To account for the increased risk of testis cancer infertile men should preferably be evaluated by a urologist with expertise in both reproductive health and testis cancer, and the men should be assessed by ultrasonography as part of their evaluation whereas the performance of a testicular biopsy is more debatable. March/May 2018

Fertility preservation in the context of testis cancer According to the current EAU guidelines, there is a grade A recommendation for offering semen cryopreservation to all men who are candidates for chemotherapy, radiation or surgery that might interfere with spermatogenesis12. It is preferable to perform semen cryopreservation before orchiectomy and in any case it should be performed before radiation or chemotherapy. If time permits at least two ejaculates separated by a 24-48 hour abstinence period should be obtained. In cases of anejaculation both penile vibratory stimulation and electroejaculation can be used to obtain an ejaculate. If semen cryopreservation is not an option due to azoospermia, the men can undergo surgical sperm retrieval with cryopreservation of retrieved testicular sperm cells before further gonadotoxic treatment is initiated13. In pubertal boys it can be difficult to obtain an ejaculate however masturbation is still the absolute first choice. If this fails, penile vibratory stimulation, electroejaculation and surgical sperm retrieval can be used in a step-wise approach. Pre-pubertal boys do generally not have haploid spermatozoa and spermatids in their testicles making fertility preservation a significant challenge. They do however have spermatogonial stem cells and testicular tissue can be cryopreserved with good results but strategies for transplantation still need to be established to restore fertility and the treatment is considered experimental14. Conclusions Male infertility and testis cancer are often diagnosed at a young age. Male infertility is associated with an increased risk of testis cancer possibly due to common underlying mechanisms including genetic defects and exposure to endocrine disrupters during fetal development. Spermatogenesis is often reduced at the time of diagnosis of testis cancer and treatment for testis cancer further deteriorates spermatogenesis

Fig. 2: Actuarial post-treatment paternity rates in each treatment group for patients who attempted conception without the use of cryopreserved semen. P <.001 from two-sided log-rank test. RPLND = retroperitoneal lymph node dissection; RT = radiotherapy; cis = cisplatin. Vertical bars indicate 95% confidence intervals. From: Brydøy M, Fosså SD, Klepp O, Bremnes RM, Erik A, Wist EA, Wentzel-Larsen T, Dahl O. Paternity Following Treatment for Testicular Cancer. JNCI: Journal of the National Cancer Institute, Volume 97, Issue 21, 2 November 2005, Pages 1580–1588, https://doi.org/10.1093/jnci/dji339. (Courtesy of Oxford University Press)

and semen quality. As a consequence all men should be counselled on the gonadotoxic effects of cancer treatment and should be offered cryopreservation of semen. If this is not possible other strategies for fertility preservation should be explored including surgical sperm retrieval and cryopreservation of retrieved testicular sperm cells. References 1. Shanmugalingam T, Soultati A, Chowdhury S, Rudman S, Van Hemelrijck M. Global incidence and outcome of testicular cancer. Clinical epidemiology. 2013;5:417-27. 2. Eisenberg ML, Li S, Brooks JD, Cullen MR, Baker LC. Increased risk of cancer in infertile men: analysis of U.S. claims data. The Journal of urology. 2015;193(5):1596-601. 3. Skakkebaek NE, Rajpert-De Meyts E, Main KM. Testicular dysgenesis syndrome: an increasingly common developmental disorder with environmental aspects. Human reproduction (Oxford, England). 2001;16(5):972-8. 4. Venn A, Healy D, McLachlan R. Cancer risks associated with the diagnosis of infertility. Best practice & research Clinical obstetrics & gynaecology. 2003;17(2):343-67. 5. Hanson BM, Eisenberg ML, Hotaling JM. Male infertility: a biomarker of individual and familial cancer risk. Fertility and sterility. 2018;109(1):6-19. 6. Ostrowski KA, Walsh TJ. Infertility with Testicular Cancer. The Urologic clinics of North America. 2015;42(3):409-20. 7. Hendry WF, Stedronska J, Jones CR, Blackmore CA, Barrett A, Peckham MJ. Semen analysis in testicular cancer and Hodgkin's disease: pre- and post-treatment findings and implications for cryopreservation. British journal of urology. 1983;55(6):769-73. 8. Brydoy M, Fossa SD, Klepp O, Bremnes RM, Wist EA,

Bjoro T, et al. Sperm counts and endocrinological markers of spermatogenesis in long-term survivors of testicular cancer. British journal of cancer. 2012;107(11):1833-9. 9. Brydoy M, Fossa SD, Klepp O, Bremnes RM, Wist EA, Wentzel-Larsen T, et al. Paternity following treatment for testicular cancer. Journal of the National Cancer Institute. 2005;97(21):1580-8. 10. Eberhard J, Stahl O, Giwercman Y, Cwikiel M, CavallinStahl E, Lundin KB, et al. Impact of therapy and androgen receptor polymorphism on sperm concentration in men treated for testicular germ cell cancer: a longitudinal study. Human reproduction (Oxford, England). 2004;19(6):1418-25. 11. Isaksson S, Eberhard J, Stahl O, Cavallin-Stahl E, Cohn-Cedermark G, Arver S, et al. Inhibin B concentration is predictive for long-term azoospermia in men treated for testicular cancer. Andrology. 2014;2(2):252-8. 12. A. Jungwirth TD, G.R. Dohle,, Z. Kopa CK, H. Tournaye. EAU Guidelines on Male Infertility. 2016. 13. Schrader M, Muller M, Sofikitis N, Straub B, Krause H, Miller K. "Onco-tese": testicular sperm extraction in azoospermic cancer patients before chemotherapy-new guidelines? Urology. 2003;61(2):421-5. 14. Martinez F. Update on fertility preservation from the Barcelona International Society for Fertility PreservationESHRE-ASRM 2015 expert meeting: indications, results and future perspectives. Fertility and sterility. 2017;108(3):407-15.e11.

Editorial Note: This article was originally submitted for the EAU18 Congress Newsletter as part of Thematic Session 3: “Testis cancer: Important topics”

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

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• What do you think is the biggest challenge in urology? One of the biggest challenges is to offer the least invasive but most effective treatment. 20 years ago the main goal was to remove the cancer. Nowadays patients are concerned with quality of life issues. • If you were not a urologist, what would you be? It’s difficult to see myself doing something else at this point of my life. As a kid, I probably dreamt of being a sports champion. • What is your most important piece of advice for doctors just starting out? Commitment and investing time and energy in training and refining your skills are important. Above all, try to find good mentors. • What is the most rewarding aspect of being a doctor? The feeling that you can help people and see your patient cured or treated. Making a big difference in the life of others is certainly rewarding. Teaching and mentoring younger colleagues also give fulfilment. • What is your advice to other physicians on how to avoid burnout? One has always to find a balance between work and private life. Finding quality time to spend with your family, children, or friends is crucial. Try to unplug when you can. Take care of yourself. • If you could change something in the healthcare system, what would it be? I believe doctors and healthcare providers should be more involved in the decision-making process because they know the pitfalls and patients’ needs. Unfortunately, decisions are often exclusively left to administrators. • What´s the last wonderful book you have read? "Being Mortal" by Atul Gawande. Touching and inspiring, as most of the things this author (who is a physician) writes. • What’s the last thing that surprised you? With Internet and social media, we are overwhelmed daily with all sorts of crazy news. I am more surprised when I hear about good news. My kids also surprise me with little things. • What’s your favourite hour in a day and why? Very early in the morning, when the day starts. But also arriving at home after work, as I can finally relax and see my family again.

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

Age: 43 Specialty: Urology City: Richmond (USA) Current Position/Awards: Attending Urologist, Division of Urology, VCU Medical Center; Clinical Associate Professor of Urology, VCU School of Medicine, Richmond, Virginia, USA; Winner, 2017 EAU Hans Marberger Award

• What is the one thing you wished you have said to your patient but did not? More than what I say, however, it is very important for me “to listen” to my patients. It is not easy, for example, when you must tell somebody that you found a cancer. Breaking bad news is always a challenge.

RICCARDO AUTORINO

Renal transplantation: What’s new? Update of the Guidelines on Renal Transplantation and two systematic reviews Dr. Romain Boissier Dept. of Urology & Renal Transplantation APHM, La Conception Academic Hospital Aix-Marseille University Marseille (FR) romain.boissier@ap-hm.fr

Since its formation in 2015 the Renal Transplantation Guidelines panel have completely updated the previously discontinued 2009 Guideline. The 2018 Guidelines has been developed by an international multidisciplinary group of urological surgeons, a nephrologist and a pathologist, chaired by Dr. Alberto Breda. All new and relevant evidence was identified, collated and appraised through a broad and comprehensive literature search covering a ten year period. A total of 2,601 unique records were identified, retrieved and screened for relevance. Making this one of the most comprehensive evidence-based guidelines for renal transplantation available to urologists today. Topics covered include: organ retrieval and transplantation surgery; donor and recipient complications; matching of donors and recipients; immunosuppression after kidney transplantation; immunological complications and follow-up after transplantation. The 2018 Guidelines have established the endoscopic (laparoscopic) approach as the preferred technique for living-donor nephrectomy (LLDN), in established kidney transplant programmes. Several systematic reviews and meta-analysis, which have compared its safety and efficacy to open donor nephrectomy, provide strong evidence in support of the Guidelines Guidelines Office

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recommendation1. Laparoscopic living-donor nephrectomy is associated with similar rates of graft function and rejection, urological complications and patient and graft survival. However, measures related to analgesic requirements, pain, hospital stay, and time to return to work are significantly better for laparoscopic procedures1. Systematic reviews on renal transplantation and oncology The Renal Transplantation Guidelines panel have also published two highly topical systematic reviews in the first half of 2018. The first, published in European Urology, assessed the risk of tumour recurrence in patients undergoing renal transplantation for end-stage renal disease after previous treatment for a urological cancer2. The systematic review included 32 retrospective studies with a total of 2,519 patients (1,733 dialysis patients and 786 renal transplantation patients). The primary outcome was time to tumour recurrence.

"Although the level of evidence was poor, the risk of recurrence was similar between transplantation and dialysis for renal cell carcinoma (RCC) and prostate cancer (PCa)..." Although the level of evidence was poor, the risk of recurrence was similar between transplantation and dialysis for renal cell carcinoma (RCC) and prostate cancer (PCa), especially for low grade/ stage PCa, for which the risk of recurrence was low and consistent with nomograms. For low stage/ grade RCC the recurrence rate was significant for both dialysis and renal transplantation; however, recurrences were mainly contralateral RCC with no impact on patient and graft survival. For urothelial carcinomas, studies mainly included upper urinary tract urothelial carcinoma in the context of aristolochic acid nephropathy, for which the rate of

synchronous bilateral tumour was 10% to 16% and the rate of contralateral recurrence was 31% to 39%. Testicular cancer had a low risk of recurrence but case reports highlighted the possibility of late recurrence even for stage I tumours. This implies that a kidney transplant candidate with a history of low stage/ grade PCa or RCC could be proposed for a renal transplantation without any additional delay compared to a cancerfree patient. However, according to the low level of evidence, more studies are needed to standardise waiting periods before renal transplantation2. The second systematic review, published in European Urology Focus, assessed the effectiveness and harms of using kidneys with small renal tumours from deceased or living donors as a source for renal transplantation3. The systematic review included 19 studies with a total of 109 patients. Tumour excision was performed ex vivo in all cases except for two. The vast majority of excised tumours were RCCs (88/109 patients), and clear-cell subtype was most common. The 5 year overall survival and graft survival rate were 92% and 95.6%, respectively. This systematic review, although with low-level evidence, suggests that kidneys with small renal masses are an acceptable source for renal transplantation and do not compromise oncological outcomes with similar functional outcomes to other donor kidneys3. References 1. A. Breda (Chair), K. Budde, A. Figueiredo, E. Lledó García, J. Olsburgh (Vice-chair), H. Regele. Renal Transplantation Guidelines. Available from: http:// uroweb.org/guideline/renal-transplantation/

2. Boissier R, Hevia V, Bruins HM, Budde K, Figueiredo A, Lledó-García E, et al. The Risk of Tumour Recurrence in Patients Undergoing Renal Transplantation for End-stage Renal Disease after Previous Treatment for a Urological Cancer: A Systematic Review. Eur Urol. 2018 Jan;73(1): 94–108. 3. Hevia V, Hassan Zakri R, Fraser Taylor C, Bruins HM, Boissier R, Lledo E, et al. Effectiveness and Harms of Using Kidneys with Small Renal Tumors from Deceased or Living Donors as a Source of Renal Transplantation: A Systematic Review. Eur Urol Focus. 2018 Feb 9.

March/May 2018


Winners of EAU RF seeding grant set to start new projects Effects of primary PCa tumour removal and in-vivo study of penile squamous cell carcinoma By Loek Keizer

The envisioned research helps to fill this gap. As it is difficult to recruit patients with rare diseases for clinical trials, xenograft models may be used for preclinical in-vivo trials to select drugs that should be further tested in the human setting.”

Earlier this year, the EAU’s Research Foundation (EAU RF) announced the availability of two new grants for short-term studies, so-called ‘seeding grants’. A final selection from the 21 submissions was made during the Annual EAU Congress in Copenhagen, last March, following personal interviews with three of the candidates. The EAU RF is pleased to introduce the two recipients who will be granted €25,000 each for a one-year research project, the results to be presented at EAU19 in Barcelona. Dr. Maarten Albersen (Leuven, BE) will be developing and validating a patient-derived xenograft NMRI nude mouse model for the in-vivo study of penile squamous cell carcinoma. The second recipient is Dr. Johannes Linxweiler (Homburg, DE). His research will concern tumour-metastasis crosstalk in prostate cancer, and examining the effects of primary tumour removal and the Dr. Johannes Linxweiler role of exosomes in an (Homburg, DE) orthotopic xenograft model. “We were impressed by the great number of good applications,” EAU RF Chairman Prof. Anders Bjartell (Malmö, SE) said, looking back on the application process. “In this case we were delighted to support two projects that displayed an advanced methodology and a clear translation approach and aiming at clinical implementation.” Penile cancer Dr. Albersen heard about the new grant from one of the residents at the University Hospital in Leuven, and then found out more online. “I applied to this grant because I thought a project that I had been contemplating for a while fitted this call perfectly,”

“Basic and translational research on penile cancer are lagging behind compared to the ‘big’ urological cancers: prostate, kidney, bladder." Asif Muneer, UCLH London, co-applicant and educational lead on rare urogenital cancers in eUROGEN (left), and Maarten Albersen, Uinersity Hospitals Leuven, applicant and clinical lead on rare urogenital cancers in eUROGEN (right)

Albersen explains. “The seeding grant is designed for young but independent researchers with a proven track record who want to start a new project and need starter’s funding in order to obtain larger funding later on when preliminary data is available. Hence, I believed that I had a quite good chance of making it to the last round of the selection process.” The final interview process was a good experience for Albertsen, discussing details of the project with Prof. Bjartell and Scientific and Clinical Research Director Dr. Wim Witjes (Arnhem, NL). “They were sincerely interested in the project and we had a pleasant conversation in a friendly atmosphere in which we discussed project details, particularly pertaining to feasibility and valorisation issues, that had not been described in the rather short online application.” Penile cancer is a relatively rare condition, and as a result, there are still large gaps in the understanding of the disease: “Basic and translational research on penile cancer are lagging behind compared to the ‘big’ urological cancers: prostate, kidney, bladder. Nonetheless, penile cancer is an aggressive disease in which we to date have failed to provide very effective and personalised systemic and targeted treatments.

CEM17, BALTIC17 Best Posters featured in Copenhagen The best posters awarded at the EAU 17th Central European Meeting (CEM17) and the 4th Baltic Meeting (BALTIC17) were featured during a special session at the 33rd Annual EAU Congress in Copenhagen, Denmark, highlighting the dynamic work being done by young urologists in Central Europe. CEM17 took place in September last year in Plzen, Czech Republic under the auspices of the 63rd Annual Conference of the Czech Urological Society (CUS). The meeting gathered around 1,346 participants from the Czech Republic and 13 other countries. In Vilnius, BALTIC17 attracted more than 250 participants. On the first day of EAU18 In Copenhagen, 12 posters from CEM17 were presented with the session chaired

by Professors Piotr Chlosta and Milan Hora. Meanwhile, Professors Feliksas Jankevicius (LT) and Mindaugas Jievaltas (LT) chaired the session on award-winning posters selected from BALTIC17. Views and insights were exchanged during the discussion and the audience had a glimpse of the original work by young urologists. The CEM17 Best Posters included both Non-Oncology and Oncology. Winners in the Non-Oncology category were P. Macek (1st Prize). A. Dick (2nd Prize) and G. Varga (3rd Prize). Awardees in the Oncology category were B. S. Sandu (1st Prize), Š. Nykodymova (2nd Prize) and I. Minarik (3rd Prize). From the BALTIC17 meeting, the selected posters were authored by V. Mäkelä, L. Suslov, F. Kowalski, M. Kincius, S. Polyakov, and P. Veskimäe.

Primary goals and next steps The primary goals of the experiments planned within this one-year project are to show that i) the removal of Albersen’s project aims to establish reliable, validated the primary tumour in an orthotopic prostate cancer and genomically stable xenograft avatar-mice xenograft model has an impact on further disease mimicking metastasised penile cancer. “In a progression and metastatic spread (slowing it down) continuation of the project -and we hope that the and that ii) it is methodologically possible to isolate extracellular vesicles (EVs) from mouse serum and results of the EAU RF seeding grant will enable us to apply for larger funds to continue this line of tissue samples from primary tumours and metastases. research- we will be able to preselect drugs that are Linxweiler: “The verification of our basic working hypotheses and the establishment of experimental effective in penile cancer with a certain genomic fingerprint and mutational burden that will be techniques will then pave the way for a larger project (two to three years) focusing on the EV-mediated promising for application in clinical practice. The model will further provide us with a detailed mutual exchange of biomolecules between primary understanding on mechanisms of drug response and tumours and metastases in prostate cancer and its –resistance in penile cancer.” role in disease progression and therapy resistance.” “In further applications on the long term, we will use these models to test new systemic drugs that may be used in the setting of advanced or metastasised penile carcinoma, and study the biology of this rare tumour including mechanisms of resistance in order to explain and in the future overcome classically poor response rates to systemic therapy in penile cancer patients.” Albersen and his team will collaborate intensively with Trace, a patient-derived tumour xenograft platform at the University of Leuven, who will provide them with the expertise of setting up and validating the xenograft models. “We aim to start with tumours of both HPV positive and -negative tumours of different squamous cell carcinoma subtypes. Ethical approval amendments and applications have been submitted, and as soon as they are approved, we are ready to start.”

March/May 2018

Dr. Albersen’s research project will be developing and validating a patient-derived xenograft NMRI nude mouse model for the in-vivo study of penile squamous cell carcinoma

On the envisioned effect that the research will have: “First, our project will provide high-level preclinical evidence for or against the use of cytoreductive radical prostatectomy in oligometastatic prostate “UZ Leuven is currently a high-volume penile cancer centre within eUROGEN, and we aim to have sufficient cancer. Second, it will help to unravel the molecular mechanisms of primary tumour-metastasis patients recruited and consented to start the first engraftment procedures end of summer-beginning of interaction, thereby not only contributing to a better understanding of this emerging and paramount fall. We aim to have the first preliminary results by aspect of cancer biology but also providing new the Annual EAU Congress next year, and if not, we approaches for biomarker discovery and therapeutic aim to have the full project completed by EAU20.” intervention.” Primary tumour removal Dr. Linxweiler will now start to organise all Dr. Linxweiler was familiar with the activities of the administrative matters that go together with the start EAU Research Foundation and found out about the of a new, externally-funded project, also setting up a seeding grant through the monthly EAU e-mail newsletter. Linxweiler: “I was excited to read that the multidisciplinary project team and planning and discussing the experiments in detail. “I will be the EAU RF was for the first time announcing seeding project leader and will be able to perform most grants for highly-innovative projects, also including experiments on my own as I have the opportunity to basic and translational research.” get regular time (usually one day a week) free from clinical duties to fully dedicate myself to scientific His impression of the selection process was “very competitive but fair. When preparing my application I activities.” was actually not very confident in being selected as “I will be supported by the head of urological one of the two grantees, considering both the broad research at our department (Prof. Kerstin Junker) and spectrum of high level research activities within the EAU community and the fact that -though scientifically her laboratory team, the clinical director (Prof. active since the beginning of my residency four years Michael Stöckle) and members from the prostate cancer team (Dr. Matthias Saar, Dr. Türkan Hajili) at ago- I am standing rather at the beginning of my our department as well as members of the academic career.” departments of clinical-experimental surgery, experimental radiology and medical biochemistry, so “I was delighted to be invited as one of the final the project team will comprise about 5 to 10 people.” contestants. The interview itself in Copenhagen was very demanding but also a unique experience as I EAU RF Chairman Prof. Bjartell is confident of the had the opportunity to discuss the strengths and future potential of the seeding grant programme: weaknesses of my planned project including “There is certainly a need for supporting similar scientific, financial, infrastructural and personal projects in the future. The EAU RF will play an aspects for almost an hour with three highlyimportant role in promoting high-quality research of renowned urologic scientists: Profs. Bjartell and various kinds.” Sharokh Shariat (Vienna, AT), and Dr. Witjes.” The concept of primary tumour removal in oligometastatic prostate cancer has been a matter of intense debates over the past few years, with evidence (primarily from retrospective studies) suggesting a beneficial effect of cytoreductive prostatectomy. Prospective trials examining the benefit of cytoreductive prostatectomy are currently underway, however it might be difficult to recruit patients for such trials and it will take several years until reliable results will become available.

Presentation of the best posters of CEM17 and BALTIC17 at EAU18

tumour removal in metastatic prostate cancer in a highly standardised, sophisticated in-vivo model,” Linxweiler explains. “We are aiming to gain insights into the biological mechanisms underlying the crosstalk between primary tumour and metastases, which are still largely unknown.”

“In our project, we will examine the effect of primary

0,1 mm Transmission electron microscopy image of exosomes (scale bar = 100nm) from Dr. Linxweiler's project

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BCa18: New prospects prompt reassessing current treatment Emerging treatment options in BCa management requires critical look on standard therapies The emergence of new treatment options such as immunotherapy, progress in genomic markers and molecular classification in bladder cancer have prompted experts to reassess and critically examine standard therapies, a challenge that implies further adjustments in current management strategies. “Diagnosis, treatment and follow-up strategies are the key areas. New markers with better negative predictive value, sequential adjuvant treatment, chemo-hyperthermia are among the factors that are going to change or are changing the established guidelines,” said Dr. Joan Palou (ES), chairman of the European School of Urology (ESU). The ESU, in collaboration with the European Association of Urology (EAU) and the European Society for Medical Oncology (ESMO) is organising in Munich, Germany, the two-day EAU Update on Bladder Cancer (BCa18) to be held on 8 and 9 June. Part of the onco-urological series offered by the EAU, the meeting is recommended to specialists for its highly interactive format and focused discussion on key clinical issues and their impact on the current treatment of both non-muscle invasive bladder cancer (NMIBC) and aggressive disease.

Register now for the late fee! Deadline: 6 June 2018 Compact and to-the-point, the meeting will present a systematic and critical look on major issues with Palou speaking right on the first day on the EAU and ESMO Guidelines on NMIBC, assessing what needs to be changed in the context of new developments in diagnosis and clinical treatment. Stressing the necessity for specialists to be in the forefront of new treatment approaches, Palou said the meeting aims to provide not only pertinent guidelines for physicians to tackle problematic BCa cases but also requires them to

optimal benefits from treatments such as BCG immunotherapy. The lectures will be followed by break-out sessions with the faculty and participants splitting into three groups. The three-hour case discussions will look into specific real-life cases, and participants can present their views or query the faculty for a more detailed assessment of management decisionmaking. critically look into their own practice and decision-making processes. “Among the main challenges in managing bladder cancer are in early, correct diagnosis employing, for instance, complete TURBT. There is also the challenge of timely decision-making in cases of adjuvant treatment, or the option of radical surgery in non-muscle invasive bladder cancer,” he said. He also noted that management of muscle invasive bladder cancer (MIBC) also differs across disciplines and the physician’s expertise. “The management can vary a lot and is still evolving particularly with the entry of new drugs, which is changing the management and treatment landscape of bladder cancer,” he added. The WHO 2016 classification and its implications in clinical practice will be presented by Prof. Rodolfo Montironi (IT) who will present updates in molecular classification. Since BCa typically exhibits tumor heterogeneity, clinicians Prof. Rodolfo Montironi need insights on patient stratification based on specific disease characteristics. Another update lecture from Dr. Ashish Kamat (US) would discuss immunotherapy in NMIBC, looking into the crucial role of maintenance schedules, route of administration, dosing and viability to achieve

“Ongoing trials are coming up with fresh insights and how to employ or integrate new knowledge and translate them into bedside practice for effective patient management are the main goals of this update Prof. Hein Van Poppel meeting,” said Prof. Hein van Poppel, member of the Steering Committee together with Profs. Francesco Montorsi and Manfred Wirth. For two days, according to Van Poppel, participants will have the opportunity to examine forwardlooking treatment options and clinical opportunities. The second day, for instance, will examine topics such as the evolving landscape of molecular classification, particularly the impact of genomics in clinical practice (to be presented by S. Lerner), immunotherapy for metastatic bladder cancer (T. Powles), and unresectable tumours and the palliative management of Muscle Invasive Bladder Cancer (MIBC) and the role of surgery post-chemoProf. Seth Lerner therapy (M. Brausi).

8-9 June 2018 Munich, Germany

www.bca18.org Additionally, post-operative management issues will examine enhanced recovery after radical cystectomy (ERAS) and immune-nutrition in bladder cancer patients. The case discussions will also provide opportunities to participants to learn insights on practices that will optimise peri- and post-operative management and managing complications in radical cystectomy, and selection and optimal treatment in bladder sparing for muscle invasive bladder cancer (MIBC), among other issues. “By presenting challenging situations in management or actual clinical scenarios, the faculty would prompt participants to critically look into new approaches or other options in treating bladder cancer. Experts can also directly share insights they gained from their clinical practice. The learning process would be a synthesis of the speaker’s expertise and the participants own experience,” Palou said. With CME accreditation and the partnership between the EAU and specialist organisations such as the ESMO, participants can expect a range of views and expertise that will shed insights on management dilemmas in bladder cancer treatment. To learn more about the meeting and for details on the educational objectives, visit the meeting website at www.bca18.org.

For the complete Scientific Programme visit www.bca18.org

Apply for your EAU membership online!

EAU Update on Bladder Cancer

8-9 June 2018 Munich, Germany

www.bca18.org

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European Urology Today

EAU onco-urology series

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!

March/May 2018


Advances in new NMIBC masterclass ESU, ESOU hold first NMIBC masterclass in Prague Prof. Marek Babjuk Chairman, EAU Guidelines Panel NMIBC Prague (CZ)

marek.babjuk@ fnmotol.cz Modern techniques of transurethral surgery, new diagnostic technologies, and brainstorming dedicated to improve clinical practice were the core of the 1st ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer (NMIBC18). The masterclass was comprised of five modules held last February 1 and 2 in the picturesque city of Prague, Czech Republic. Together with Dr. Joan Palou (ES), Chairman of the European School of Urology (ESU), and Prof. Maurizio Brausi (IT), Chairman of the European Section of Oncological Urology (ESOU), we welcomed the delegates to this anticipated masterclass.

Coverage of Day 1 The first day commenced with lectures by Dr. Antonín Brisuda (CZ) on the epidemiology and aetiology of bladder cancer; by Dr. Ondrej Hes (CZ) on the classification of urothelial tumours of the World Health Organization; and by Prof. Brausi on the work-up of patients with haematuria which included the role of urine cytology and new diagnostic urinary markers. These were followed by highly-educational live surgeries which demonstrated difficult cases wherein expert surgeons showed techniques in monopolar and bipolar transurethral resection of bladder tumour (TURBT), and the use of narrow-band imaging (NBI) and photodynamic diagnosis (PDD). In the afternoon, there were lectures on endoscopic diagnosis, current options in tumour visualisation and techniques of resection, as well as, semi-live surgeries. The interactive session on the management of TURBT complications led by Dr. Palou and Prof. Morgan Rouprêt (FR) was a masterclass’ highlight which engaged participants in insightful discussions. Focus on patient risk stratification and review of intravesical therapies concluded Day 1. The speakers discussed traditional approaches and new deviceassisted modalities such as intravesical microwave thermochemotherapy (RITE), hyperthermia or electromotive drug administration (EMDA) of Mitomycin C (MMC).

Visual learning aids

NMIBC Masterclass faculty welcomes participants

fluorescence in situ hybridization (FISH) test were also examined. Moreover, indications to radical cystectomy in high-risk patients with NMIBC and the importance of extended lymph node dissection were reviewed. In addition, Prof. Bernard Malavaud (FR) explained in detail the en-bloc technique using monopolar and bipolar currents, and Dr. Alberto Breda (ES) discussed the innovative Thulium laser resection. Their lectures

were followed by live surgeries demonstrating enbloc techniques. We express our sincerest appreciation to the delegates for their dedication to the field and their motivation to enhance their skills and their clinical practice; and to the speakers who have presented their vital insights and cutting-edge research. Thank you for making this masterclass a huge success.

Day 2 activities State-of-the-art lectures opened the second day of the masterclass. Indications to treatment using Bacillus Calmette-Guérin (BCG), definition of BCG failure and BCG-refractory disease were covered. Topics such as maintenance schemes, follow-up methods (e.g. ultrasonography, urinary cytology and markers),

www.esuurolithiasis18.org

2nd ESU-ESUT Masterclass on Urolithiasis 22-23 June 2018, Patras, Greece

Practical examples through video presentations An application has been made to the EACCME® for CME accreditation of this event

NMIBC18 testimonials Dr. Emanuela Altobelli (Campus Biomedico University of Rome): “For me, the emphasis on the en-bloc resection of the bladder tumour and correct selection of the adjuvant treatment were the highlights of this masterclass. There were outstanding demonstrations of en-bloc resection using various devices during the live surgeries, and detailed lectures on intravesical treatment options and new promising methods. “The practical approach in the management of complications encountered in daily clinical practice, the superb presentations, the friendly atmosphere and the riveting debates were noteworthy elements of the NMIBC masterclass. To young urologists who aim to receive comprehensive updates on NMIBC management, I strongly recommend attending this masterclass next year.” Dr. Joana Do Carmo Silva (Motol University Hospital): “If you enjoy learning about bladder cancer and are interested in new trends, technologies and techniques, then this masterclass is for you. I especially liked the live surgeries using new diagnostic and resection techniques such as NBI, PDD, laser and en-bloc resection. Clinical case discussions and management of complications were among my favourites.

March/May 2018

“There was a good balance between theoretical and practical aspects. We had the opportunity to review the current EAU Guidelines and the latest updates on diagnostics and disease management. Interaction with the speakers and other delegates led to rewarding and interesting discussions.” Dr. Tim Muilwijk (University Hospitals Leuven): “My highlights of the NMIBC masterclass were the excellent updates on intravesical treatment options and their indications; BCG failure and further treatment options for the patients. These gave valuable insights in newer and older therapeutic options. The masterclass provided an exemplary update on all recent developments in the field and an overview of what to look forward to.” Dr. Bruno Jorge Pereira (Centro Hospitalar Cova da Beira): “It was an immersive and extensive masterclass on NMIBC. The masterclass was well-organised, and the faculty members were well-selected and conducive to participation and brainstorming. Even if you know a lot about NMIBC and how to manage it, and you consider yourself an expert in TURBT, this masterclass is nonetheless a unique opportunity to refresh your expertise and improve your knowledge. There are always some tips and tricks that one can change in routine practice which benefit NMIBC patients.”

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EAU Education Online presents:

www.esusalzburg18.org

E-Course Thromboprophylaxis

Prostate Cancer

NMIBC (Non-Muscle Invasive Bladder Cancer)

How well do you know the Guidelines on thromboprophylaxis?

ESU - Weill Cornell Masterclass in General urology

Renal Cell Carcinoma (RCC)

Urolithiasis

Men's Health

The e-course features questions formulated by experts in the field, reviewed by the EAU Guidelines Office and the Young Urologists Office.

Thromboprophylaxis

EAU Education Online e-Platform is fully accredited

uroweb.org/education

1-7 July 2018, Salzburg, Austria An application has been made to the EACCME® for CME accreditation of this event

European School of Urology ESU courses, masterclasses and meetings 2018

May 24-25 E-BLUS and ESTs1 Exams at the 6th Meeting of the EAU Section of Uro-Technology in conjunction with the Italian Endourological Association (ESTU-IEA), Modena (IT) 26 ESU course on Bladder cancer at the 5th Baltic Meeting in conjunction with the EAU, Riga (LV) June 8-9 EAU Update on Bladder Cancer (BCa18), Munich (DE) 12 ESU course on Erectile dysfunction and infertility at the national congress of the Polish Urological Association, Katowice (PL) 13 ESU course on New paradigms in bladder cancer at the national congress of the Spanish Urological Association, Gijon (ES) ESU course on Advances in male urinary symptoms (LUTS) at the national congress of the 15  Ukrainian Urological Association, Kiev (UA) 22-23 2nd ESU-ESUT Masterclass on Urolithiasis, Patras (GR) 28-30 E-BLUS training and exam at the Challenges in Laparoscopy and Robotics 2018, Leipzig (DE) July 1-7 ESU – Weill Cornell Masterclass in General urology, Salzburg (AT) 6-7 ART in Flexible programme – step 1, Milan (IT) 12-14 E-BLUS training and exam at the Urofair, Singapore (SG) 19-20 ART in Flexible programme – step 2, Berlin (DE) Augustus 31-5 Sept. 16th European Urology Residents Education Programme (EUREP), Prague (CZ)

www.esukidneytransplant.org

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

New Masterclass

September ESU-ERUS courses at the 15th Meeting of the EAU Robotic Urology Section (ERUS), Marseille (FR) 5  11-14 Hands-on training skills programme on Laparoscopy and Endourology, Caceres (ES) 14-15 2nd EAU Update on Prostate Cancer (PCa18), Milan (IT) 14 ESU course on Urolithiasis at the Eastern Siberia international meeting of the Russian Society of Urology, Krasnoyarsk (RU) 19-22 E-BLUS training at the 18th International Annual Conference UROALEX, Alexandria (EG) 20-22 ESU-ESFFU Masterclass on Functional urology at the European Lower Urinary Tract Symptoms meeting (ELUTS18), Milan (IT) 22 ESU course on Immunotherapy, new perspectives in bladder cancer at EAU 13th South Eastern European Meeting (SEEM), Belgrade (RS) 28 ESU course on Update in urology at the national congress of the Armenian Urological Society, Yerevan (AM) October 4 ESU course on Clinical and histopathological basics and main research questions in prostate cancer at the 25th Meeting of the EAU Section of Urological Research (ESUR), Athens (GR) 13 ESU course on Recent developments and broadening indications in treatment of urolithiasis at the national congress of the Hellenic Urological Association, Athens (GR) 18 ESU course on Urodynamics in daily practice: How to perform and how to interpret at the national congress of the Czech Urological Society, Ostrava (CZ) 27 ESU course on Update on prostate and bladder cancer at the national congress of the Turkish Association of Urology, Bafra (CY) 30-31 5th Confederación Americana de Urologia Residents Education Programme (CAUREP), Punta Cana (DO) November 8-11 ESU courses on Daily practice in the management of metastatic prostate cancer and Immunotherapy for urological tumours at the 10th European Multidisciplinary Congress in Urological Cancers (EMUC), Amsterdam (NL) 10 ESU course at the national congress of the Russian Society of Urology, Yekaterinburg (RU) 15-16 1st ESU-ESTU Masterclass on Kidney transplant, Madrid (ES) 16-17 ESU Urology Bootcamp, Lisbon (PT) 22-23 5th ESU-ESUT Masterclass on Lasers in urology, Barcelona (ES) 30 ESU course at the national congress of the Georgian Association of Urology, Tbilisi (GE) December 5 ESU course on Paediatric urology at the national congress of the Egyptian Association of Urology, Cairo (EG) 13-14 3rd ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer, Paris (FR)

www.uroweb.org/education

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March/May 2018


Urology simulation educators Training the trainers Dr. Ben Van Cleynenbreugel University Hospitals Leuven Leuven (BE)

Ben.Vancleynenbreugel@ uzleuven.be

Mr. Chandra Shekhar Biyani St. James’s University Hospital Leeds (GB)

shekharbiyani@ hotmail.com

Mr. Bhaskar Somani University Hospital Southampton NHS Trust Southampton (GB)

bhaskarsomani@ yahoo.com

Mr. Sunjay Jain St. James’s University Hospital Leeds (GB)

sunjayjain@nhs.net

“Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” Simulation-based education (SBE) is not easy or intuitive; clinical experience alone is not a proxy for simulation instructor effectiveness1. As simulation increasingly becomes part of the health professional education, so does the need for skilled teachers.

To achieve better outcomes, it is important that simulation educators encourage active learning and communicate the high standards to aim for. They should help cultivate communication between educators and learners; develop reciprocity and cooperation among learners; provide prompt and appropriate feedback; and respect diverse talents and different ways of learning. Boosting skills for endourological training Training in endourological and laparoscopic procedures forms an important part of the training programme for urologists. Trainers may require specific and distinctive educational skills to effectively support learning through simulation. The national endoscopy training programme in the United Kingdom provides “Training the Trainer’s Course” and has demonstrated excellent benefits2. But there is limited data available on faculty training in urology. While there are many faculty development programmes in simulation-based education, there are no programmes dedicated to enhancing skills for endourological training.

"As non-technical skills become increasingly important in surgical trainings and in the operating room, the course aims to help participants develop these skills as well." During discussions at the European Urology Residents Education Programme (EUREP) in 2016, a survey among new prospective EUREP tutors was performed. Then at the Annual EAU Congress held last year in London, they were invited to facilitate endourological or laparoscopic skills. Using a validated teaching assessment tool, two expert trainers evaluated each prospective tutor for specific skills. Following a consultation with the European School of Urology, the course “Training the Trainer” was organised in Leeds, UK. The course included learning the basic skills needed to be an excellent trainer. A total of nine participants were selected to attend the course. They were also asked to fill out a Teaching Motivation Questionnaire. “Training the Trainer” course content After outlining the learning objectives, participants receive a short lecture from a consultant gastroenterologist which highlights the systematic approach adapted by the Joint Advisory Group in gastrointestinal endoscopy (GI) to train and maintain the standard for trainers. This is followed by lectures

Table 1: Programme of the "Train the Trainer" course

Time

Topics

A

C

B

D

Figure 1: Course introduction by Dr. Ben Van Cleynenbreugel (A); basic model as teaching tool for knot tying (B); Participant [centre] teaches knot tying to a medical student [left] as other participant [right] assesses (C); participants practice laparoscopic teaching skills (D).

(Table 1). The course has received positive feedback (Figure 2).

on the characteristics of an endourological trainer; adult learning theory; how to reduce cognitive load; non-technical skills; terminologies in endourology skills training; and the ureteroscopy training model. Participants are also introduced to the need for assessment and effective feedback.

The “Training the Trainer” course provides a conducive, friendly environment for new trainers to hone their teaching skills because “training” is a term that should not be taken lightly. As trainers enhance their teaching skills, they help boost the knowledge of learners and, in the end, help raise the quality of clinical practice and patient care.

As non-technical skills become increasingly important in surgical trainings and in the operating room, the course aims to help participants develop these skills as well. They join the practical activities which included role play, knot tying and suturing, followed by specific laparoscopic European Basic Laparoscopic Urological Skills (E-BLUS) and ureteroscopic exercises (Figure 1). Specific skills stations were designed in collaboration with the chairman of the European School of Urology. The participants acted as an assessor and as a trainer. A complete debriefing on their performance was carried out after each activity wherein everyone contributed to the discussions

References: 1. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003–2009. Med Educ. 2010; 44(1):50–63. doi:10.1111/j.1365-2923.2009.03547.x. PubMed PMID:20078756.Epub 2010/01/19. 2. Coderre S, Anderson J, Rostom A, McLaughlin K. Training the endoscopy trainer: from general principles to specific concepts. Can J Gastroenterol. 2010 Dec;24(12):700-4

Figure 2: Feedback from the participants

Feedback The training covered everything I had expected The training has equipped me with enhanced knowledge, understanding and/or skills I feel that my personal learning objectives were met

08:00 – 08:30

Coffee and registration

08:30 – 08:40

Welcome and introduction

08:40 – 09:10

Training the Trainers in GI Endoscopy – Setting Standards

What did you think of the course/Did you enjoy it? The course material was well organised The aims and objectives of the course were clearly stated There was a clear introduction about the course

09:10 – 09:30

Endourology Trainer Characteristics and Role

09:30 – 10:00

Practical: Equipment, Tools and Models A group discussion on standardising terminology for teaching endourological procedures on EST-1 (Endoscopic Stone Treatment step 1)

10:00 – 10:15

Coffee break

10:15 – 10:35

Trainee assessment

10:35 – 11:00

How to give feedback

11:00 – 12:00

Practical

12:00 – 12:30

Lunch break

12:45 – 14:45

Practical

14:45 – 15:15

Group discussion and feedback

March/May 2018

0 Strongly Agree

Agree

Neutral

1

2 Disagree

3

4

5

6

7

8

9

Strongly Disagree

Practical (specific) Practical (general - simple surgical task) Assessment and Feedback Practical – Equipment, tools and models Standardising terminology for teaching Endourology Trainer Characteristics and Role Training the Trainers in GI Endoscopy – Setting Standards 0 2 4 6 8 Acknowledgments This project was funded by the European Association of Urology and Ethicon. In addition, we would like to express our Strongly Agree Agree Neutral Disagree Strongly Disagree appreciation for the excellent support from Mr. Luke Gordon, (Urology Business Manager), Karl Storz Endoscopy (UK) Ltd., Simon Duffield (Cook), Joanne Johnson, Lesley Wood and Louis Owen (Medical Education, Leeds Teaching Hospital).

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ESU’s frontline activities at EAU18 Dedication to enrich knowledge and boost skills The dynamic activities of the European School of Urology (ESU) during EAU18 in Copenhagen were designed to meet the educational needs of young urologists and to enhance the knowledge of the experienced. The ESU brings training to a whole new level: fine-tuning skills and know-how with a comprehensive coverage on theory and practice, and further enriching its activities with insights from the participants themselves. Read on for a quick overview of ESU’s frontline activities at the Annual EAU Congress.

HOT updates and future prospects Thirteen varieties of Hands-on Training (HOT) courses were vital components of ESU activities during EAU18. The three most popular were ESU/ESFFU HOT Course in Urodynamics, ESU/ESUI HOT Course in Prostate MRI reading for urologists, and ESU/ESUT/EULIS HOT Course in Endoscopic stone treatment – step 1. Participants’ knowledge gained from the HOT courses, particularly in basic laparoscopy and endoscopic stone treatment, were put to the test in Copenhagen. Participants who have learned the usage of various instruments and technologies for stone fragmentation and extraction had their newly-acquired skills evaluated during the ESTs1 (Endoscopic Stone Treatment step 1) Exam, a first at an EAU Congress. More than 60% of participants passed the ESTs1 exams.

This is where augmented reality steps in. This technology has matured over the last years and has become accessible. This could help make the HOT courses more feasible in various venues, including those in remote areas.”

UROlympics: A blowby-blow report Representatives of over 130 countries contended for who has the best endoscopic skills at none other than at the ultimate endoscopic test: the UROlympics.

Pre- and post-tests enhance ESU Courses To ensure the quality of ESU Courses, pre- and post-tests were implemented during EAU18 to gauge the participants’ knowledge. Comprised of multiplechoice questions, the test results show which topics need priority, efficacy of teaching methods, and quality of course materials. “The results of the pre- and post-tests provided a good indication of what the participants know before One of the many live surgeries during EAU18 and after the ESU course. It was interesting to see their improvement,” Prof. Dr. Eva Compérat (FR), Chair of ESU Course 09: Practical aspects of caner pathology for urologist. The 2018 WHO novelties. “The overall feedback mentioned that the key messages should be further elaborated. There’s always room for fine-tuning and that’s the whole point of the tests.”

Access these EAU18 live surgery videos for free A graphical result from the pre- and post-tests of an ESU course

prostate (TURP) or Holmium laser enucleation of the prostate (HoLEP); massive prostate; and median lobe. The best live surgery videos at EAU18 showcased during the Meeting of the EAU Section of UroTechnology (ESUT) in cooperation with the EAU Robotic Urology Section (ERUS) and the EAU Section of Urolithiasis (EULIS) – Technology Strikes Back are available on the Surgery in Motion School website. Access this and other exclusive selection of videos with no login needed. Visit https://surgeryinmotionschool.org for more information.

[left to right] UROlympians Ashkeyev, Yap and Hugues

HOT courses offers multi-faceted sessions

Enhancing basic laparoscopic and suturing skills, including psychomotor skills such as depth perception and bimanual dexterity, were part of the European Basic Laparoscopic Urological Skills (E-BLUS) training programme. These skills were evaluated through E-BLUS exams. Esteemed HOT tutor for five years, Prof. Dr. Hashim Hashim (GB) said "I enjoy training in a practical setting. The HOT courses provide the quintessential environment to share expertise and build skills. And the HOT team is experienced, efficient, and easy to work with.”

Qualifying rounds started in the morning of 17 March. Participant after participant set their best times at the Educational Square. By late afternoon, 16 leading qualifiers were selected. Names were randomly drawn to see who competes with whom the next day. A showdown at noon on 18 March took place as the qualifiers battle against each other in pairs on two stations. The ones who finished first qualified for the quarter finals. They face off and the top qualifiers move on to the semi-finals until only two were left to vie for first place in the finals. After the riveting final round, the UROlympics winners (a.k.a. UROlympians) were announced. Dr. Lee Chien Yap (IE) won first place, followed by Dr. Guillaume Hugues (FR) in second, and Dr. Birzhan Ashkeyev (KZ) in third. The UROlympians were honoured during the medal ceremony at the Cook Medical booth.

The E-LUS (European Laparoscopic Urological Skills) step 2 will be the next step of the laparoscopy training pathway. The programme is currently under development and will consist of five tasks: vesicourethral anastomosis, pyeloplasty, kidney tumour enucleation and renorraphy, hilum dissection, and major vessel injury repair. These tasks were selected by a cohort of experts and the ESU training research group in close collaboration with experts of the EAU Section of Uro-Technology (ESUT).

Making every second count during the endoscopic test

When asked how he prepared for the completion, Dr. Yap said, “Unbeknown to me, my preparations for the UROlympics already started when I performed my first cystoscopy several years ago as a senior house officer (SHO). Since then, I have had the opportunity to train in a wide range of endoscopic surgeries. Familiarity with the equipment, concentration, and practice are the key elements to progressing with endourology. A steady hand always helps, too!” He added, “I thoroughly enjoyed the UROlympics. It was a great way to meet other trainees and delegates at the congress. The competition was exhilarating and “HOT courses are increasingly becoming more nerve-racking. My fellow finalist had an early lead and that put extra pressure on me. My friend and important,” said ESU Board Member Dr. Ben Van colleague who was watching on the sidelines gave Cleynenbreugel. “These are presently offered as a supplement at congresses and meetings. The aim is to me technical advice and words of encouragement which ultimately helped me focus and win. Given it offer them as stand-alone courses at dedicated was St. Patrick's weekend, perhaps a little bit of Irish training centres.” He added, “HOT training opportunities are sought after but with more luck also came my way.” streamlined costs and with the same level of quality.

Participant learns by doing with a da Vinci® surgirical system

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Sample pre-test question

Looking at the overall results, there is clear significant improvement from those who have attended," said Prof. Dr. Florian Wagenlehner (DE), Chair of ESU Course 35 – Dealing with the challenge of infection in urology?. "There were more participants who have taken the post-test compared to the pre-test. The general outlook is optimistic and we aim to keep on improving."

ESU achieves further success at EAU18 The success of the ESU Courses at the EAU18 Congress in Copenhagen was apparent as the 53 courses were well-attended and the programmes constituted of quality, expert-led lectures. The top three courses with the most attendance were the following: ESU Course 32: Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips, tricks and indications with 129 attendees, ESU Course 39: Ultrasound in urology with 85, and ESU Course 46: Percutaneous nephrolithotripsy (PCNL) with 76.

Ten ESU courses accompanied by the tests were “Adrenals for urologists” (ESU Course 04); “Practical aspects of cancer pathology for urologists. The 2018 WHO novelties” (ESU Course 09); “Paediatric urology for the adult urologist. Congenital problems of the urinary tract: Obstruction and reflux and long-term outcome” (ESU Course 11); “Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips and tricks, indications” (ESU Course 32); “Dealing with the challenge of infection in urology” (ESU Course 35); “Updated renal, bladder and prostate cancer guidelines 2018, what is changed?” (ESU Course 43); “Post-surgical urinary incontinence in males” (ESU Course 44); “Prostate biopsy - tips and tricks” (ESU Course 45); “Renal transplantation: Technical aspects, diagnosis and management of early and late urological complications” (ESU Course 47); and “How will immunotherapy change the multidisciplinary No empty seats available management of urothelial bladder cancer?” (ESU Course 52). As part of the expanding curriculum, three new courses were also launched during the Congress: ESU Course 07: Prosthetic surgery in urology, ESU Course 16: Lymphadenectomy in urological malignancies and ESU Course 49: How to optimize the everyday management of your patients.

Learning thru visual demonstrations

The Specialty Session – European Urology “Surgery in Motion School Session: Nerve-sparing Robot Assisted Radical Prostatectomy (RARP), different ways to skin a cat” was an innovative video-based course which took place on the third day of the Congress. Experts shared cutting-edge techniques of key steps in nerve-sparing RARP. The demonstrations included bladder neck, lateral dissection, apical dissection, and anastomosis. The two-hour Specialty Session also featured the management of complex cases such as the use of indocyanine green (ICG) for peri-prostatic artery identification; ureteral orifices close to bladder neck management; post-transurethral resection of the

A full house at ESU Course on flexible ureterorenoscopy and restrograde intrarenal surgery

March/May 2018


ESU Course 07 covered surgical techniques and surgical tips for male slings and artificial urinary sphincters. Participants were introduced to prosthetic surgery in female urology (e.g. injectables, sacral neuromodulation, and female tapes). The course also focused on penile prosthesis surgery including surgical techniques, managing intraoperative complications, and revision penile prosthesis surgery. Presentations during ESU Course 16 corroborated the indications when a lymphadenectomy has to be performed during surgery for urological malignancies, the templates, the techniques using different approaches, the oncological and functional outcomes. ESU Course 49 critically reviewed key papers published last year centred on the management of prostate cancer patients with a particular focus on diagnosis, staging, local treatments and systemic therapies. Take-home messages from each paper applicable to daily clinical practice were thoroughly discussed.

Test your Thromboprophylaxis knowledge Intrigued about the latest developments on Thromboprophylaxis in urological surgery? Wonder no more. The ESU offers you its new e-course “EAU Guidelines on Thromboprophylaxis” which debuted during the EAU18 Congress in Copenhagen.

Welcome to the guidelines course: Thromboprophylaxis This course compiles the most recent clinical guidelines edited by the EAU on Thromboprohylaxis. The Thromboprophylaxis guidelines course is divided in 3 learning units. Each learning unit consists of multiple choice questions that you can answer by navigating to the corresponding chapter of the Thromboprophylaxis guideline. The questions are offered for self-assessment of your knowledge of the EAU Guidelines on Thromboprophylaxis.

Test your knowledge on Thromboprophylaxis

The EAU Guidelines are available online in a number of different electronic formats. The full list of EAU Clinical Guidelines can be accessed through this link: http://uroweb.org/guidelines/ Good luck and enjoy learning!

Through this e-course, you can also test your existing knowledge on Thromboprophylaxis and boost your expertise to further provide optimum care to your patients. The e-course is divided into three Learning Modules which consist of multiple-choice questions. The first module is an introduction to post-surgery thromboprophylaxis, followed by the second module which focuses on thromboprophylaxis for specific surgical

procedures. The e-course’s final module is the peri-operative management of antithrombotic agents in urology. Navigate to the corresponding chapter in the EAU Guidelines on Thromboprophylaxis to choose the best answer per question. The e-course is available in English and will take you approximately 60 to 90 minutes to finish. You will receive one European CME credit (ECMEC) upon completion.

Introduction page for the e-course

Enhance your knowledge and accumulate more CME credits with other ESU e-courses. The topics range from non-muscle-invasive bladder cancer, metastatic prostate cancer and more! Visit http://uroweb.org/education/ online-education/e-courses/ for more information.

ERUS18: Europe’s premier live robotic surgery event Robotics section to make a push for enhanced patient recovery programme Dr. Jochen Walz Chair, ERUS18 Local Organising Committee Marseille (FR)

walzj@ipc.unicancer.fr

The fifteenth annual meeting of the EAU Robotic Urology Section is taking place this September in Marseille, on France’s Mediterranean coast. We spoke to Dr. Jochen Walz (Marseille, FR), chairman of the ERUS18 Local Organising Committee and de facto host of the meeting, about his plans for the meeting and the preliminary scientific programme.

“The slogan for ERUS18 is ‘Optimising clinical pathways with robotic surgery’, which reflects the ERAS programme that we are trying to popularise across Europe,” Dr. Walz emphasises. ERAS stands for “Enhanced Recovery After Surgery”, although Walz thinks “Around Surgery” might be a term that better reflects the programme. The three pillars of ERAS are: minimally invasive surgery, the ‘active patient’ and a standardised protocol. “As robotic surgeons, we have much to gain from this approach. We’ve seen ERAS implemented in colorectal surgery, and it’s been in discussion for bladder cancer for several years now. As ERUS, we’d like to see it expanded to other procedures.”

patients for surgery, and patient management during and after surgery,” Walz explains. “This helps improve the outcome for the patient. Key is the standardisation of the pathway, perhaps even more important than optimising it. ERAS will be an important part of the first half of the ERUS18 meeting.”

Abstract submission now open! Deadline: 1 June 2018

“We will be showcasing the multidisciplinary, or rather multiprofessional approach of ERAS by inviting anaesthesiologists and nurses to speak at ERUS18. Together, we’ll be explaining the different modules, how each profession is involved. Nurses are most closely involved with the patient, coordinating “ERAS is a multidisciplinary approach that joins prehabilitation, the management before and after surgeons and anaesthesiologists in setting up an optimal pathway to manage patients: both in preparing surgery, and generally mobilising the patient. It’s impossible to implement ERAS without the involvement of nurses or anaesthesiologists.” ERUS18 is set to showcase demonstrations of how the protocol is already working in some centres. Walz: “At our institution in Marseille, implementation of ERAS was a major game changer. We will be hearing other personal experiences. We hope to

www.erus18.org

ERUS18 15th Meeting of the EAU Robotic Urology Section

5-7 September 2018 Marseille, France

www.erus18.org As for which procedures delegates can expect in September? “We have set up an interesting programme of the main urological robot-assisted procedures. As a cancer centre, we focus on oncological cases such as prostatectomy, partial nephrectomy, cystectomy, and lymph node dissections. However, there will be also several cases of benign and reconstructive surgery, all done by international experts.” In terms of demonstrations of new technology, most of the innovations will be seen at the technical exhibition, rather than in the operating theatres. “We might be able to show delegates the new single-port Intuitive system, but only as a demo model, not an official launch.” Apart from the live surgery and special attention for ERAS, ERUS18 will feature a block that looks at the ever-changing economics of robotic surgery. Walz postulates that as medical treatment for metastatic

Robotic Live Surgery

Optimising clinical pathways with robotic surgery

5-7 September 2018, Marseille, France In conjunction with: Junior ERUS-YAU Meeting European School of Urology (ESU) Courses ESU/ERUS Hands-on Training in Robotic Surgery

· · ·

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

Live surgery at ERUS17

create a manual where all the different tools and protocols are collected and summarized, so that people can apply these tools and protocols at their home institutions.” Live surgery As a meeting devoted solely to all aspects of robotic urology, delegates can of course expect the best in live surgery demonstrations in Marseille. Up-to-date scientific presentations and discussions will be mixed with the live surgery to create a packed, non-stop scientific programme. Surgery will primarily be performed at Walz’s own Institut Paoli-Calmettes, as well as at the Hopital Nord, a second academic centre in Marseille. Walz: “After considering Paris or Aalst as a location to test long-distance transmission, we finally decided that the ideal situation would be a second centre in Marseille, which allows the performing surgeons to also take part in the meeting.” March/May 2018

PCa is getting more expensive, robotic surgery looks more affordable than it did even a couple years ago. The main ERUS18 programme will take place on 6-7 September. On September 5th, there will be a special day for young (robotic) urologists. In the morning there is the Junior ERUS-YAU Programme, and the afternoon is reserved for robotic-related courses by the European School of Urology and the Technology Forum with a look into the future of robotic surgery. “ERUS18 will be an attractive and interesting meeting. It’s a nice time of year in Marseille, so we can offer a nice package for science as well as social events. Marseille definitely is worth a visit for ERUS18.”

For the complete Scientific Programme visit www.erus18.org

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Systemic vs. targeted PCa biopsies: Choosing the right tool Compact, interactive PCa18 Update Meeting in Milan Detecting high-risk prostate cancer remains a tough challenge for clinicians, but with advances in imaging and the recent results of large multi-centre studies on prostate cancer detection physicians are now better equipped to identify aggressive disease and develop an optimal treatment plan. “With the recently published data from the PROMIS and PRECISION trial it is clear that multiparametric MRI (mpMRI)-guided biopsies are superior to systematic biopsies. First, when using mpMRI as a stratification tool pre-biopsy, about one in four men will avoid unnecessary biopsies,” said Prof. Wouter Everaerts (BE), speaker and faculty member at the upcoming second EAU Update on Prostate Cancer (PCa18) to be held in Milan on 15 and 16 September. Everaerts will speak on the opening day of the meeting during the session on ‘Updates in Diagnosis and Staging’, tackling the issue of prostate biopsy options. Doctors often face the Prof. Wouter Everaerts dilemma which biopsy tools to use, whether systematic biopsy or targeted, or both, to avoid complications from invasive procedures.

strongly depends on the definition of clinically significant cancer and comes at the cost of increased (over)detection of insignificant tumours,” he pointed out. “Thus, targeted biopsies, similar to all other solid organ cancers, is for me the preferential initial approach in men with a suspicion of prostate cancer. Systemic biopsies should be reserved for patients with contra-indications for MRI and/or those with red flags despite previous negative targeted biopsies.

Register now for the early fee! Deadline: 21 June 2018

Everaerts: “The biggest challenge for urologists remains to better stratify prostate cancer patients and selecting the best therapeutic approach for the individual patient.”

Pitfalls of random biopsies With recent outcomes from large studies such as the PRECISION trial and incremental progress in genomic markers, Everaerts noted such developments further reinforce the message that doctors should exercise due caution with regards blind and random biopsies.

“The most important message from the different trials, using either pre-biopsy MRI or genomic markers is that we should avoid going straight to blind random biopsies in asymptomatic men with an elevated PSA. Both MRI and genomic tests can improve our risk-stratification and avoid unnecessary biopsies in a subset of these patients,” “MRI-targeted biopsies detect more clinically significant he said. prostate cancer, while reducing the over-detection of insignificant prostate cancer. Finally, fusion biopsies Moreover, according to Everaerts, pre-biopsy MRI has mean less complications than systemic biopsies,” now become standard of care to guide subsequent explained Everaerts who specialises in uro-oncology biopsies. and robotic surgery at UZ Leuven in Belgium. “Concerning treatment strategies, these tests can help us to better risk stratify patients that are suitable for There is, however, a caveat in combined biopsies, according to Everaerts, as he noted that the benefits active surveillance. EAU guidelines strongly recommend the use of MRI before confirmatory biopsies in patients from newer techniques must be carefully balanced with concerns regarding over-detection. on active surveillance and the PRECISION trial enforces this recommendation,” he said. “Adding systemic biopsies to MRI-targeted biopsies can increase the detection rate of clinically Patient stratification significant cancers; however, the added value of Among the issues confronting attending physicians combined biopsies is not very pronounced, and and specialists is how to improve their skills in

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

www.pca18.org

classifying patients into various risk groups. During the PCa18 meeting in Milan, Everaerts said participants will get a comprehensive update on the current standard and future development of diagnostic tools to risk-stratify patients with localised and metastatic prostate cancer and how to implement these in treatment decisions.

EAU onco-urology series

He also noted that an aspect of urology that is underappreciated is the actual process of shared decision-making and patient counselling. “These issues are important particularly with regards patients’ individual concerns and preferences. How to discuss uncertainties about oncological benefit and potential side effects and their impact on quality of life are equally relevant matters,” said Everaerts.

14 -15 September 2018 Milan, Italy

www.pca18.org views, making the PCa18 Update series a unique educational event. “PCa18 is a time-effective way to get a comprehensive update in recent prostate cancer developments. The multidisciplinary approach, with case-based discussions will facilitate the implementation of these new scientific insights into our daily practice,” said Everaerts. Core topics in the agenda will include updates on local treatment, management of systemic disease, best practices in surgery, and assessment of insights from results of new research. Pre- and post-testing of all participants will also be conducted to enable both participants and organisers to identify areas for further learning. For details on the aims of PCa18 and details on the Scientific Programme, speakers, registration and other information, visit the meeting website at www.pca18.org.

Highly interactive programme Faculty members will directly interact with participants in small breakout session groups to facilitate a point-by-point discussion and exchange of

For the complete Scientific Programme visit www.pca18.org

ELUTS18 European Lower Urinary Tract Symptoms meeting

20-22 September 2018 Milan, Italy

www.eluts18.org

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Fixed or adjustable male slings Do we have good evidence to choose? Prof. Frank Van Der Aa UZ Leuven Dept. of Urology Leuven (BE)

frank.vanderaa@ uz.kuleuven.ac.be Despite the advance of anatomical knowledge and the advent of minimal (robot-assisted) invasive techniques to surgically treat prostate cancer, male post-prostatectomy incontinence (PPI) is still an important problem. The number of anti-incontinence surgeries for PPI in Europe is rising and given the strong regional spread of this type of surgery, it is probably still underused in many regions1.

The down side of these adjustable sling systems is a relatively high revision rate, with explant rates up to 35% in certain series. Some systems are still evolving, meaning that reported studies were using a different design than the currently available system. In general, these types of slings seem to be comparable to AUS, both at the level of targeted population as at the level of revisions and complications. Long-term consequences of the obstructive design of these symptoms have not been reported. It has to be noted that no long-term prospective data have been published on any of these sling systems.

Fixed slings Fixed slings can have an obstructive or a retroluminal design. The first have a working mechanism that is comparable to the adjustable slings. They offer gentle pressure to the bulbar urethra to regain continence. Once inserted, no adaptations can be made. The latter are positioned retroluminal to the bulbar urethra and The treatment of PPI deserves an important role since are believed to offer a posterior support to the the majority of men, even after non-curative resection urethral closing mechanism. Retroluminal slings are of prostate cancer, will live for more than 10 years still the best studied slings. They have low after surgery2. The advent of male slings has widened complication rates with explantation rates between 0 treatment possibilities. Patients with mild to moderate and 3%. Reported success rates are good, provided incontinence who are not willing to undergo an that they are implanted in well selected patients. artificial urinary sphincter (AUS) implant, often do Patients with mild to moderate PPI that did not want to undergo a male sling implant3,4. undergo radiotherapy are candidates for these sling types. As such, these slings serve a different Several types of slings exist but not all types have the population than the above-mentioned adjustable same profile. The majority of the evidence to date slings and the AUS. These slings should not be offered comes from retrospective cohort studies. Only a few to patients with severe incontinence or patients after slings have prospective cohort studies or comparative radiotherapy. data with other slings systems. As will be pointed out in this article, it is not useful to compare all types of For more detailed information on these types of slings slings or to compare some sling designs with AUS, as and the respective data that exists in different patient they serve other patient populations (for example, populations, several reviews exist6,7. mild versus severe incontinence). Therefore, caution The SATURN trial: An ESFFU initiative to improve has to be made for bold statements and there is a knowledge need for further prospective data collection of different devices. Only one type of sling has mid-term In collaboration with the EAU Research Foundation, ESFFU is currently running a multinational follow up data (three years)5. prospective cohort study to register the objective and subjective outcomes of different types of devices to Adjustable or fixed? treat male PPI. This trial will include AUS and all Adjustable slings exert gentle pressure against the different sling types with a follow up until five years bulbar urethra. By adjusting the pressure to the desired threshold, urinary continence can be achieved after implant. The initial goal is to include 500 patients. Inclusion started in 2017 and as more centres while voiding is still possible. Adjustable slings offer join the register, inclusions will hopefully be reached the theoretical benefit of changing the urethral in 2019 or 2020. Centres that are performing male PPI pressure after the initial surgery. Depending on the type of sling, this can be achieved by a subcutaneous surgery can still join this initiative. port or by other systems that require small surgical Conclusion revision. The advent of slings to treat male PPI is a welcome addition to the long-standing AUS. To the question These late adjustments can offer several advantages. whether fixed or adjustable systems are better, the Initially, one can start with the minimal pressure esteemed necessary to achieve continence. Depending answer clearly is: we need both. It is important to realise that many adjustable systems target on the patient's status later on, adjustments to the different populations than some of the fixed system can be made in agreement with the patient. systems. As such they cannot/should not be On the other hand, overcorrection resulting in compared. Only systems that target the same obstructive flow or even urinary retention can be solved by releasing the tension. In general, these type population should be compared. of slings have reported good outcome even in patients It is also clear that we need more and better with moderate to severe incontinence. On some evidence! Hopefully, the SATURN register under the series, also irradiated patients had good outcome. umbrella of the ESFFU and the EAU Research Foundation will provide us with some answers in EAU Section of Female and Functional Urology the coming years.

References 1. Ventimiglia E, Folkvaljon Y, Carlsson S, et al. Nationwide, population-based study of post radical prostatectomy urinary incontinence correction surgery. J Surg Oncol. 2018;117(2):321-327. doi:10.1002/jso.24816. 2. Trock BJ, Han M, Freedland SJ, et al. Prostate cancerspecific survival following salvage radiotherapy vs observation after radical prostatectomy. JAMA. 2008;299(23):2760-2769. doi:10.1001/jama.299.23.2760. 3. Kumar A, Litt ER, Ballert KN, Nitti VW. Artificial Urinary Sphincter Versus Male Sling for Post-Prostatectomy Incontinence-What Do Patients Choose? J Urol. 2009;181(3):1231-1235. doi:10.1016/j.juro.2008.11.022. 4. Comiter C V. Male incontinence surgery in the 21st

Prof. Paul Meria Section Editor Paris (FR)

paul.meria@ sls.aphp.fr

Gender Affirmation: Medical and Surgical Perspectives The field of transgender medicine and surgery has evolved since the first gender-affirming procedures were performed at the beginning of the 20th century. Currently, many physicians are involved in the management of transgender patients and specific teaching is delivered in academic centres. Consequently, a new specialty is now growing, which requires training programmes and the dissemination of information.

The first chapter deals with facial feminisation surgery, an important part of the treatment, which aims to obtain natural results with the use of specific and well-protocolled techniques. The subsequent chapters are dedicated to speech modification and top surgery. Indeed, male-to-female gender voice change can require special techniques since breast volume usually needs a dedicated procedure.

Resonance

®

M E TA L L I C U R E T E R A L S T E N T

Various techniques of male-to-female gender affirmation vaginoplasty and female-to-male gender affirmation phalloplasty are described in the succeeding chapters. These chapters provide the

MEDICAL

© COOK 01/2017 URO-D32084-EN-F

century: Past, present, and future. Curr Opin Urol. 2010;20(4):302-308. doi:10.1097/MOU.0b013e328339b795. 5. Bauer RM, Grabbert MT, Klehr B, et al. 36-month data for the AdVance XP® male sling: results of a prospective multicentre study. BJU Int. 2017;119(4):626-630. doi:10.1111/bju.13704. 6. Van Bruwaene S, De Ridder D, Van Der Aa F. The use of sling vs sphincter in post-prostatectomy urinary incontinence. BJU Int. 2015;116(3):330-342. doi:10.1111/ bju.12976. 7. Kretschmer A, Nitti V. Surgical Treatment of Male Postprostatectomy Incontinence: Current Concepts. Eur Urol Focus. 2017;3(4-5):364-376. doi:10.1016/j. euf.2017.11.007.

Book reviews

This textbook was edited by C.J. Salgado, S.J. Monstrey and M.L. Djordjevic, with the help of about 40 worldwide experts in the field of transgender medicine and surgery. A global approach was offered by the authors with the aim to cover all aspects of managing patients, either transmen or transwomen.

Provide sustainable patency.

March/May 2018

Figure 1: Numbers of post prostatectomy urinary incontinence (PPI) correction surgery per year and PPI correction surgery per 1,000 radical prostatectomies performed during two preceding years. RP: radical prostatectomy

Book reviews

reader with an exhaustive overview of such core techniques. They are supplemented by a special chapter dedicated to various implants in transmen. Complications and unfavourable results of phalloplasty are addressed in two dedicated chapters. The concluding chapters consider medical treatments and hormonal therapies, either in adolescents or in adults, before addressing mental health problems in various age groups. Sexual health and gender expression are also considered in the concluding chapters. This textbook is an original and excellent work which delivers exhaustive information for all practitioners involved or with interest in transgender medicine and surgery. An ebook version is available and includes videos of key procedures. Editors ISBN e-Book Published Publisher Edition Pages Illustrations Binding Price Website

: C.J. Salgado et al. : 9781626236837 : available : 2016 : Thieme Medical Publishers : First : 320 : 274 : Hardback : € 179.99 : www.thieme.com European Urology Today

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Some genetic aspects of renal stone disease Experts anticipate new insights in kidney stone formation Prof. Robert Unwin Board member, EAU Section of Urolithiasis (EULIS) University College London London (GB) robert.unwin@ ucl.ac.uk The genetic landscape of nephrolithiasis is changing rapidly. This short article cannot be comprehensive, but will endeavour to highlight some newer genetic aspects of renal stone disease (for more details, see1).

have identified some novel, though still rare, gene mutations in patients with renal stones or nephrocalcinosis. These studies have been carried out in relatively small numbers of mainly younger patients with a family history of stones or nephrocalcinosis, and especially with known consanguinity; even then the proportion with an identifiable gene mutation in this highly selected group was no more than 30%, but it did demonstrate an age-related pattern for the age at presentation for the identified genes5. Interestingly, there was some correspondence with an earlier large-scale GWAS study6, which had been limited by the available clinical details and phenotype (reported or documented ‘stone’ versus ‘no stone’ in most cases), but was fairly comprehensive nonetheless.

Until quite recently, the only widely known genetic causes of familial renal stone disease encountered or considered by most urologists and nephrologists were primary hyperoxaluria (PH), presenting mainly in childhood, and cystinuria, often diagnosed in adulthood.

As a result, the claudins have come to the fore, of which there are several types, and which may interact among themselves; these are tight junction proteins involved in the regulation of absorptive epithelial fluid and ion transport between cells, including calcium, and are likely to play an important role in urinary calcium and magnesium excretion. However, it is There are three genetically defined forms of autosomal recessive PH, types 1, 2 and 3, all resulting important to recognise that while genes regulating renal fluid or solute transport, including ions such as from enzymatic defects in glyoxylate metabolism, calcium and magnesium, phosphate or citrate, could leading to increased oxalate production and urinary play a role in stone formation or in stone risk, genes excretion. PH type 1 accounts for around 80% of cases, most diagnosed in childhood; however, roughly controlling wider metabolism, PH being an example, but also of calcium and vitamin D (e.g., CYP24A1), can 5% of cases of PH have no, as yet, defined genetic also be important. cause, which means there is still scope for new gene discoveries, and a justification for genotyping PH patients whenever possible. Urinary screening for excretion of glycolate (PH1), gylcerate (PH2), 4-hydroxy-2-oxoglutarate (PH3), and dihydroxyglutarate (PH3) can help in more selectively targeted genotyping. Newly identified genes will extend our understanding of oxalate metabolism, including factors that may affect its absorption and/or excretion. As to treatment, specific and directed (liver) gene therapy is still a long way off, but one recently tractable target is inhibition of the liver enzyme glycolate oxidase, which is likely to benefit all forms of PH2. Cystinuria is another familial autosomal recessive (though to complicate things, it can also be dominant with incomplete penetrance) disease associated with renal stone formation and, it seems, also a higher risk of developing chronic kidney disease, and associated with more hypertension, making it an important cardiovascular risk factor in its own right. Its genetic basis is more complex, involving mutations in at least two genes, SLC3A1 and SLC7A9 (which can be mutated independently), the products of which interact to bring about cystine reabsorption, as well as of the dibasic amino acids ornithine, arginine and lysine, in the renal proximal tubule (and in some cases also the small intestine). However, as with PH, mutations in these genes do not account for all cases of cystinuria, so there is still much to learn, and again an argument for more widespread genotyping. Another disease commonly associated with renal stones is distal renal tubular acidosis (dRTA), which can also have a monogenic basis, involving at least two renal transport target proteins, the H-ATPase (‘proton pump’) and the chloride-bicarbonate exchanger (similar to the red blood cell ‘band 3’ protein). Recent data also suggest that a mild dRTA phenotype might be more common in patients with renal stones, and that polymorphisms in H-ATPase subunits could underlie many cases of calcium phosphate or mixed phosphate and oxalate stones, although without the more obvious signs of dRTA3. Advances in genomics have moved rapidly in the last decade from candidate gene testing, to positional cloning to identify new familial genes, to genomewide association studies (GWAS; which also identify broader genetic regions of interest), unbiased whole exome (exon) sequencing (all protein-coding genes), and whole genome sequencing, the latter two (particularly whole genome) requiring massive data storage capacity and computer power for bioinformatic analysis to identify potentially causative genes. While two recent papers using either a more targeted approach for likely monogenic causes4, or a more agnostic whole exome sequencing approach5, EAU Section of Urolithiasis (EULIS)

28

European Urology Today

"...roughly 5% of cases of PH have no, as yet, defined genetic cause, which means there is still scope for new gene discoveries, and a justification for genotyping PH patients..."

Finally, there are many reported developmental defects and syndromes associated with renal stones or nephrocalcinosis, including medullary sponge kidney (MSK), with, for example, hemihypertrophy7; the assumption here is that there is an underlying anatomical kidney defect predisposing to renal stone formation. The important message, I think, is that renal stone disease is a potential ‘treasure chest’ of genetic causation, given that around 40% of patients with renal stones will have a family history of some kind. It is essential that this should be properly documented and every effort made to consider and, if possible, define a genetic cause or contributor. Only in this way can we hope to improve our understanding of the processes leading to renal stone formation, and go beyond what has been so successfully and thoroughly documented in relation to the importance of urine composition, diet, environment, and lifestyle; these have all proved difficult to modify in clinical practice, and so we must move more ‘upstream’ in trying to understand what factors may drive, interact with, underlie or predispose to renal stone formation – new insights will emerge!

NaPi2a

TRPV5

Ca2+ Ca2+

CaSR

P042-

UMOD/THP *Claudin-14

*Claudin-14 is a negative regulator (increases calcium excretion) of claudins 16 and 19 and can be epigenetically regulated

Calcium excretion

Figure 1 shows some of the gene products (transporters) identified by GWAS studies, their location along the nephron, and in some cases how they might affect renal calcium excretion. NaPi2a, sodium-phosphate cotransporter; TRPV5, TRPV cation (calcium) channel; CaSR, calcium-sensing receptor; UNMOD/THP, uromodulin/Tamm-Horsfall protein.

6. Thorleifsson G, Holm H, Edvardsson V, Walters GB, Styrkarsdottir U, Gudbjartsson DF, et al. Sequence variants in the CLDN14 gene associate with kidney stones and bone mineral density. Nat Genet. 2009 Aug;41(8):926–30.

7. Mezzabotta F, Cristofaro R, Ceol M, Del Prete D, Priante G, Familiari A, et al. Spontaneous calcification process in primary renal cells from a medullary sponge kidney patient harbouring a GDNF mutation. J Cell Mol Med. 2015 Feb 18;19(4):889–902.

Make sure we have your up-to-date address details! Log in to your My-EAU account on uroweb.org to update your e-mail and correspondence addresses. www.uroweb.org/My-EAU

www.eulis19.org

EULIS19 5th Meeting of the EAU Section of Urolithiasis 3-5 October 2019, Milan, Italy An application has been made to the EACCME® for CME accreditation of this event

References 1. Mohebbi N, Ferraro PM, Gambaro G, Unwin RJ. Tubular and genetic disorders associated with kidney stones. Urolithiasis. Springer Berlin Heidelberg; 2016 Nov 28;:1–11. 2. Liebow A, Li X, Racie T, Hettinger J, Bettencourt BR, Najafian N, et al. An Investigational RNAi Therapeutic Targeting Glycolate Oxidase Reduces Oxalate Production in Models of Primary Hyperoxaluria. Journal of the American Society of Nephrology. 2016 Jul 18;:1–10. 3. Dhayat NA, Schaller A, Albano G, Poindexter J, Griffith C, Pasch A, et al. The Vacuolar H+-ATPase B1 Subunit Polymorphism p.E161K Associates with Impaired Urinary Acidification in Recurrent Stone Formers. Journal of the American Society of Nephrology. 2015 Oct 9. 4. Halbritter J, Baum M, Hynes AM, Rice SJ, Thwaites DT, Gucev ZS, et al. Fourteen Monogenic Genes Account for 15% of Nephrolithiasis/Nephrocalcinosis. J Am Soc Nephrol. 2015 Feb 27;26(3):543–51. 5. Daga A, Majmundar AJ, Braun DA, Gee HY, Lawson JA, Shril S, et al. Whole exome sequencing frequently detects a monogenic cause in early onset nephrolithiasis and&nbsp;nephrocalcinosis. Kidney Int. Elsevier Inc; 2018 Jan 1;93(1):204–13.

Save the date!

March/May 2018


Young Urologists/Residents Corner New ESU HOT: Sharpening your presentation skills The EAU18 experience Dr. Juan Gómez Rivas Chairman of ESRU YUO/EAU Board Member ESUT-YAU member La Paz University Hospital Madrid (ES) juangomezr@gmail.com

Co-author: Dr. Domenico Veneziano The ability to communicate information accurately, clearly and as intended, is a vital life skill and something that should not be overlooked. Professionally, if you are applying for jobs or looking for a promotion, you will almost certainly need to demonstrate good communication skills. Communication skills are needed to speak to many types of people whilst maintaining good eye contact, using appropriate language, listening effectively, presenting ideas clearly, writing concisely, and working efficiently in a group.

Uro-technology and Communication Working Party of the Young Academics Urologist (YAU) during the 2018 Annual EAU Congress (EAU18) and chaired by Dr. Domenico Veneziano (YAU Uro-Tech chair), with Dr. Juan Gómez Rivas and Dr. Aurus Dourado as tutors. In this course we delivered tips and tricks for inspiration, energy, and confidence in a presentation style. The course was performed in TED format, with no podium available and itinerant talks using slides. At the end of the course, the attendees must be able to use their voice effectively, optimize the use of body language, connect with the audience, and improve their skills on software used for presentations. The course programme included a brief introduction, interactive lectures on how to deliver an effective talk, teaching how to use verbal and non-verbal language, TED talks: how to structure a successful presentation and optimizing your presentations with the latest software and hardware. The participants also joined an exercise to demonstrate how mistakes often occur in oral presentations with one of the participants giving a short lecture and the rest, including the tutors, giving comments on his presentations skills.

During the last part of the course, the attendees, together with Dr. Veneziano, made a quick An effective communicator needs flexibility, energy and presentation about their experience at the course using the newest software, and provided positive feedback. enthusiasm. Making a presentation places you before public scrutiny, and an audience does not only receive your ideas, but also responds to the way you use your We thank the EAU, ESU and also the participants for their collaboration and we plan to provide the same voice and body. You need more than a well-written opportunity during up-coming meetings. presentation to make an impact: you will also need to deliver it in a lively, flexible and interesting manner. We thank the European Association of Urology, the European School of Urology and also the participants The new European School of Urology’s “Hands-on for the wonderful collaboration and we plan to provide Training Course: Sharpening your presentation skills the same opportunity during upcoming meetings. Course tutors share tips in effective public speaking at the new ESU course presented in Copenhagen and improve your career” was organised by the

Lisbon hosts unique laparoscopic urology course Joint educational project offers extensive training Dr. Nuno Domingues Hospital das Forças Armadas CUF Urology Dept Lisbon (PT)

nunodomingues87@ gmail.com

Dr. Domenico Veneziano Dept. of Urology and Kidney Transplant G.O.M Bianchi Malacrino Morelli Reggio Calabria (IT) info@ domenicoveneziano.it The first edition of the Postgraduate Course on Human Cadaveric Advanced Laparoscopic Urology took place last February 8 to 10 at the Nova Medical School in Lisbon, Portugal. This was a unique opportunity and a historic moment for the Portuguese Association of Urology, since it was the first course in Portugal that used human cadavers for laparoscopic urological training. The course was a joint project of the Nova Medical School, the Urology Department of the Hospital das Forças Armadas, Hospital de S. José and CUF Academy. Fifteen urologists and 23 experts in laparoscopic surgery from seven countries attended the course. Besides participants from Europe, we had colleagues coming from China, Pakistan and Brazil. The course was also accredited by a medical university with five European Credit Transfer System (ECTS), which gave a mark of excellence at both European and international levels. March/May 2018

The course programme consisted of two parts, the e-learning and the hands-on training sessions. The e-learning part was delivered online one month (January 2018) before the actual course with an introduction, bibliography and video demonstrations of the laparoscopic surgeries. This enabled participants to study and prepare for the training sessions before going to Lisbon. The second part was conducted from 8 to 10 February and covered various topics. Laparoscopic renal surgery The first day focused on renal surgical techniques. Prof. Goyri O’Neill, head of the Anatomy Department of the Nova Medical School, presented his unique embalming techniques that allow an almost perfect look and feel of the cadaveric tissues. Prof. Arnaldo Figueiredo, head of the Urology and Renal Transplant Department in Hospital Universitário de Coimbra, served as chairman and gave tips and tricks on pyeloplasty, ureterorrhaphy, partial nephrectomy and radical nephrectomy. The second day was Prostate Day. Dr. Domenico Veneziano, coordinator of EUREP hands-on training, discussed the EAU Certifications in Laparoscopic Surgery and offered the participants a vision of how the future of surgical simulation will look like. Chairman of Day 2 was Prof. Renaud Bollens who

Dr. D. Veneziano discusses EAU certifications

provided key insights in pelvic lymphadenectomy, Millin prostatectomy and radical prostatectomy.

feedback from all participants. We look forward to the second edition. See you in Lisbon in February 2019!

Last day was the Bladder Day and included the Postgraduate Course Evaluation. The session chairman was Prof. Estevão Lima, head of the Urology Department of Hospital de Braga and CUF Department, who provided step-by-step tutorials on how to perform pelvic lymphadenectomy, ureteral re-implantation and radical cystectomy. The Postgraduate Course evaluation included the assessment of surgical skills, a written multiple choice test and submitting a written essay regarding urology and laparoscopy.

Trainees during the step-by-step tutorials on pelvic lymphadenectomy

More than 100 cumulative hours of surgeries were performed on human cadavers. After two years of planning and preparation, we are proud of the enthusiastic European Urology Today

29


Young Urologists/Residents Corner Hands-on Training (HOT) courses for junior residents An ESRU/ESU survey Table 1: Hands-on Training courses delivered by the ESU and EAU Dr. Moisés Rodriguez Socarrás European Training Center of Endourology Fellow – Ospedale San Raffaele Turro Milan (IT) @EAU_YAUrotech group

Dr. Juan Gómez Rivas Chairman of ESRU YUO/EAU Board Member ESUT-YAU member La Paz University Hospital Madrid (ES) juangomezr@gmail.com

Simulation training in technical and non-technical skills is crucial for residents for them to acquire necessary skills to safely perform surgery. Various Hands-on Training (HOT) courses are complementary activities to the national resident training programme. Some of the elements practiced during HOT procedural training may be transferable among different procedures and years of training. One way to enhance learning experience is to provide skills training aimed at different training levels.

collaboration between ESU and the European Society of Residents in Urology (ESRU) to assess the needs of junior residents for HOT courses. The survey was uploaded to the platform SurveyMonkey (link: https://www.surveymonkey.com/r/KHYD7F3 ), and was distributed via NCOs (National Communicator Officers) using the email address list of the ESRU members and social media (Facebook, Twitter). Potential respondents in 23 countries under the umbrella of the ESRU across Europe were surveyed from November 2016 to March 2017. We obtained 102 responses, (88.24% residents), mainly from Spain, Hungary, Denmark and Italy; 81.37% were from teaching hospitals, 11.76% associated with teaching hospital and 6.86% from non-teaching hospitals. It is interesting to note that 95% of the respondents would prefer HOT courses targeted at junior residents during the EAU congress (Figure 1). In addition, 86% of respondents believed that the duration of the courses should be two to four hours. When respondents were asked "Which of the following procedures would be useful in the teaching session?" (Figure 2), there was a strong agreement for instruments for endourology (66%), cystoscopy and stent (31%) and flexible cystoscopy (30%). Moreover, when respondents were asked "Would you prefer a HOT course at the EAU or a two-day course dedicated to junior resident skills?", 63% responded that they prefer a two-day course and 36.27% answered that they preferred a course during the EAU congress. From Residents AEU (@ResidentesAEU), we published data about urological training in Spain. In

The European School of Urology (ESU) has developed innovative HOT courses (in partnership with the EAU Sections) which offer practice and development of individual skills. These courses are offered at various EAU events. Lively interaction among participants, course director and tutors makes this experience an effective and outstanding way to gain and consolidate knowledge and skills. Topics in HOT courses are available at (http://eau18.uroweb.org/scientificprogramme/hands-on-training-courses/) Moreover, during the Annual EAU congress there are a variety of ESU courses (Table) that are also available in http://eau18.uroweb.org/scientific-programme/ hands-on-training-courses/. These courses are mainly for senior urology trainees. We feel there is a lack of HOT courses for junior residents, which prompted us to conduct a survey in

Technical skills Hands-on Training Course in Robotic surgery (ESU/ERUS) Laparoscopy (Basic laparoscopy & E-BLUS exam) Diagnostics and follow-up (ESU/ESFFU) HOT in Urodynamics HOT in MRI fusion biopsy (ESU/ESUT/ESUI) HOT in Prostate MRI (ESU/ESUI) Functional Urology - HOT in OnabotulinumtoxinA for OAB (ESU/ESFFU) HOT in Sacral neuromodulation (ESU/ESFFU) Endoscopy - HOT in Thulium laser prostate vaporesection (ESU/ESUT) HOT Course in endoscopic stone treatment (ESU/ESUT/EULIS) Non-technical skills HOT in Non-technical Skills in Surgery (ESU) HOT in Sharpening your presentations skills and improve your career (ESU)

this survey 58% of the respondents claimed to have attended the laparoscopy HOT courses, compared to 90% who responded as never having attended HOT courses in TURB, TURBP or endourology. Furthermore, from ESRU, we have done a survey about the current state of urology training in Europe and we hope to publish the data soon. A good example of initiatives in HOT for new urology residents is the Urology Simulation Boot Camp developed by Leeds Hospital (UK), a five-day course to enhance baseline surgical skills, and which has been delivered since 2015 (website: https://www.medicaleducationleeds.com/event/

Would you like an organized hands-on training of practical procedures for junior residents at the EAU congress?

Figure 1: Survey about HOT courses for junior residents during EAU congress

the-3rd-urology-simulation-boot-camp/, twitter: @UrologyBootCamp, youtube: https://youtu.be/lhf0jEX-JkE ). European resident experience of the Leeds simulation boot camp has been published in the previous January 2018 edition of this newsletter. We look forward to the October 2018 boot camp, which will surely be a success as the previous editions. We hope that with these data, future collaborations can lead to the design and development of a HOT course aimed at junior residents, and held during the annual congress of the EAU or in a separate event.

Which of the following procedures would be useful in the teaching session?

Figure 2: Survey about HOT courses for junior residents. Procedures would be useful in teaching sessions

Inspiring EAU18 congress in Copenhagen View of a local resident Dr. Stine Frost Hedegaard Resident Dept. of Urology University Hospital of Zealand Roskilde (DK) sfrosthedegaard@ gmail.com The 33rd Annual EAU Congress in Copenhagen was the first time I attended an EAU congress. Being at the beginning of my career as a future urologist, it has been a great experience to attend the EAU 2018 in my own city.

you’d soon realize that you know quite a few people, which means you cross paths with former, current and future colleagues. Meeting other residents and hearing their suggestions on what sessions to attend meant that my plans for the EAU Congress changed right on the first day. The ESU courses held at the Congress gave a broader perspective on various urological subspecialties. Meeting highly respected and well-known surgeons who gave their perspectives through state of the art treatments on managing stone disease, guideline updates with bladder, prostate and renal cancer were amongst a broad range of courses. YOURday was also a highlight of the conference with an exchange of knowledge among residents.

Long before March 16, my attention was drawn to the EAU Congress, an important annual event that a urologist would want to prioritize. A consultant advised a number of residents (including me) to select two or three subspecialties sessions, such as prostate and renal cancer. With the best intentions to stick to my preliminary plan, I arrived at the Bella Center on Friday. The congress was well organized, with areas marked by colour enabling one to easily find the location of the various sessions. Arriving at the conference site 30

European Urology Today

Besides the congress sessions, there were several side events after the congress, which offers the chance to meet other junior (urology) doctors from all over the world. On March 16, the French-Danish Connection Party was held at the meat-packing district of Copenhagen, which showed not only the city’s cultural life, but also gave the participants the opportunity to network. ESRU ended the Saturday programme with delicious food, drinks and the meeting of junior doctors from various countries. The 33rd EAU Annual Congress in Copenhagen was a great experience for a young doctor. The four congress days in which I participated provided inspiration and I look forward to next year’s Annual EAU Congress in Barcelona.

Residents at the EAU Congress (author in the middle)

Robot simulator

The set-up of live surgery from Herlev Hospital was well performed. As a resident, it was a great inspiration to watch all the different live surgeries from radical robot-assisted prostatectomy, stone management to robot-assisted partial nephrectomy, and many others. The fact that one can try various simulators during the Hands-on Training such as laparoscopy and robot simulator gave the live surgery an extra dimension.

From the French-Danish Connection Party

March/May 2018


Young Urologists/Residents Corner Impressions from YUORDay A productive and inspiring day at EAU18 Copenhagen Dr. Musab Ilgi University of Health Sciences Sisli Hamidiye Etfal Research and Training Hospital Urology Clinic Istanbul (TR) ilgimusab@gmail.com

More than 11,000 healthcare professionals from around the world gathered in Copenhagen for the Annual European Association of Urology (EAU) Congress. The Residents Day, now named as YUORDay (Young Urologist and Residents Day) was held on the second day, following tradition. YOURDay's programme is organized by the European Society of Residency in Urology (ESRU) and the Young Urologist Office (YUO). These two working groups exert a lot of effort and initiatives among residents and urologists, and to provide a series of experts' lectures useful in urology training and daily clinical practice. Following the speech of YUO chairman J.P.M. Sedelaar Nijmegen (NL) and ESRU president J.L. Vásquez, Herlev (DK), the first session started with the EAU governance lectures, under the moderation of M. Ilgi, Istanbul (TR) and A. Cocci, Calenzano (IT). J.

Rassweiler, Heilbronn (DE) gave a presentation on EAU activities related to young urologists. J. Palou, Barcelona (ES) discussed the activities of European School of Urology, while M.S. Silay, Istanbul (TR), who was honored with the prestigious 2018 Crystal Matula Award, highlighted the importance of being part of the YAU. A whole session took up the European Urology Scholarship Programme (EUSP), which is one of the most significant opportunities the EAU provides to residents. The session started with the presentation “EUSP Programme: Does it deserve your attention?” The answer is simple: YES, since the scholarship delivers a lot of opportunities that can aid residents' long-term career prospects, as shown by the achievements of EUSP scholars. Emerging EUSP partnerships were also discussed, and the audience showed a lot of interest on EUSP activities. The next session was dedicated to a hot topic in urology, the role of lymphadenectomy in urological cancers. Penile, testicular, urothelial and prostate cancers were discussed respectively in accordance with the latest scientific developments and articles. Then, the long-awaited roundtable discussion took place with panelists from different countries debating on intermediate-risk prostate cancer. R SanchezSalas, Paris (FR) shared his ideas on focal therapies as these therapies mean an effective alternative for prostate cancer with low rates of adverse events in

well-selected patients. L. Klotz, Toronto (CA) summarized data on active surveillance marking its superiority in low-risk prostate cancer patients since surgery do not contribute to survival rates in this patient population.

"J. Gómez Rivas, Madrid (ES) gave an inspiring talk on augmented reality, emphasizing the benefits of this emerging technology during medical interventions and training...." P. Sooriakumaran, London (GB) debated on the oncological safety of curative treatments such as radical prostatectomy or radiotherapy because they have good oncological control. The second part of the so-called 'Challenging the EAU guidelines' section discussed large kidney stones. Panelists from around the world reviewed various treatment modalities such as PNL, flexible URS and laparoscopic procedures. The afternoon sessions begun with the surgical tip and tricks presentations. Experts presented excellent lectures on the pitfalls of surgical procedures such as URS, HoLEP, Botox, and orchidectomy. Following this session, new topics related to the future of

urology were discussed. J. Gómez Rivas, Madrid (ES) gave an inspiring talk on augmented reality, emphasizing the benefits of this emerging technology during medical interventions and training, and patient care. Z. Okrohov, Orange (US) talked about 3D printing and sampling and showed how they make procedures easier, whilst giving a unique approach to perform surgeries. D. Veneziano, Reggio Calabria (IT) proved that artificial intelligence had already arrived. Artificial intelligence can be perceived as complementary rather than something to be seen as a threat since it enhances our knowledge and reduces our workload. One of the highlights of YOURDay was definitely the Guidelines Cup. The finalist teams from Georgia, Greece and Italy, battled it out for the title under the moderation of M.J. Ribal, Barcelona (ES) and T. Knoll, Sindelfingen (DE). The teams were selected based on their results during selection rounds. The audience also had the chance to answer the questions with their voting pad. Team Greece came out as champion followed by Georgia and Italy. María Monsalve, Madrid (ES) was the winner from the audience. Residents who submitted the best abstracts during the congress were also awarded. At the end of this productive day, it was clear that every resident was already looking forward to the next meeting in Barcelona in 2019. See you all next year!

Urology training around the globe Focus on Algeria Dr. Redha Hocine Kettache Annaba University Hospital Annaba (DZ)

kettacher@gmail.com @KettacheR Since I have completed my five years of residency in Annaba University Hospital, I would like to share some insights regarding my training years in urology. As expected, the initial year, which is the same across all specialties, includes surgical work where we perform our first procedures in the operating room. Our mornings are mostly spent at the General Surgery Department, while our long nightshifts are dedicated to the emergency room. In my experience, I was to a certain extent very fortunate to have spent my second year training in various departments such as obstetric gynaecology, paediatric surgery, nephrology – haemodialysis and renal transplantation. In the Obstetric Gynaecology Department, we worked in the operating room and learned to perform C-sections and hysterectomies. The paediatric surgery training was very interesting as we managed surgical emergencies (acute appendicitis, bowel obstruction, abdominal trauma) and followed a daily programme which covered the whole range of paediatric surgery, with particular focus on urologic surgery (hypospadias/epispadias, testicular ectopia, hydrocele, inguinoscrotal hernia, etc.). And at the Nephrology –Haemodialysis and Renal Transplantation Department, we spent three months learning how to manage emergencies such as acute renal failure and placing a dialysis catheter, amongst others. We also worked with candidates for renal transplantation, preparing their cases and preforming the follow-up after the intervention. I truly regard this experience as interesting and rewarding. However, starting from the third training year, we integrate the activities with that of our specialty. But despite the transition, the daily life of March/May 2018

an Algerian urology resident remains essentially the same. Lack of training exchanges Unfortunately, there are no exchanges among urology training centers in Algeria. Residents, therefore, would spend all their training in the same urology department. Moreover, they are linked with the post-graduation department of medical school and is prevented from moving to another city until only after they complete a complicated administrative procedure. As for our legal status, we are referred to as urologists in post-graduate training in medical sciences, and enrolled in special medical studies which are overseen by Public Health and Higher Education Ministries.

"...half of the residents are satisfied with the theoretical and practical training.." Our diploma is granted after the final exam which ranks the candidates who have succeeded enabling them to further determine their career choice. The exam is organized by a jury of urology professors, following an annual selection process managed by the Ministry of Higher Education. During the residency, there are no specific educational objectives in theory or in practice. However, third-year residents learn how to manage urological emergencies, while the fourth-year residents learn the medical and surgical management of BPH, malformative uropathy and urolithiasis during their last year. Residents are introduced to oncology, andrology, and pelvic floor disorders. Survey According to a study entitled, “My urology training and career opportunities," presented at the 1st International Meeting of Residents in Urology (National Urology Meeting of Annaba – May 2017) there are eight urologist training centers. A total of 74 residents were interviewed regarding their assessment of their training and expectations, but only a third responded. The small number of respondents prompted us to ask for the reason behind the weak response. Evidently, there is no

contact platform for Algerian urologists-in-training (a mailing list, coordination among hospitals, and social networks ). In addition, there are only a few events related to residents during the Algerian urology meetings, with only a few meetings devoted to young urologists on the national and international levels (workshops, training courses). To be frank, our final exam is seen as a unique opportunity for us to meet after five years. This is one of the main issues that has a negative impact on our careers as there is no opportunity for any fruitful collaboration. On the other hand, I would like to highlight the way the residents themselves feel about the training in general. As a matter of fact, half of the residents are satisfied with the theoretical and practical training, but if 50% are confident enough to perform a minor surgery, only 15% are confident in performing a major surgery (radical cystectomy, prostatectomy). Around 85% of residents claim that scientific research has little or no impact in their training. Currently, I am the only one who has published a scientific article. Regarding endo-urology, 75% are confident doing a cystoscopy but only 40% believe they can perform a flexible ureteroscopy. We can say, however, that one in two residents is confident in doing a percutaneous nephrolithotomy. Furthermore, there is an ‘peculiar’ Algerian perception regarding public service. It is an obligation to spend one to four years in a public health facility, but it's not the same thing to work in a modern town or in the far Algerian Sahara. Opinions differ on this matter as some people

believe there is a positive impact (continue learning surgery and improve their learning curve), while others point out the absence of supervision in some centres. There are cases where a young urologist has to manage a public health unit alone. Career development With regards career development what can be expected by young Algerian urologists? Less than half who were interviewed want to practice in the private sector due to financial rewards and lack of hierarchy. The response of the other half showed a split between the university hospital sector (doing major surgery, teaching medical students) and the public health sector (access facilities, lower workload).

"Around 85% of residents claim that scientific research has little or no impact in their training." One proposal was to create the Algerian Young Urologists Association to provide easier contact, enhance skills and support for better national and international mobility. An ideal solution would be to boost the dynamics in research and publication activities, increased the opportunies for residents to train in various Algerian hospitals, and promote learning through simulation for residents to gain confidence in major surgeries and new technologies. We do have an ambitious programme! But as Henry Ford said: "Getting together is a start, staying together is progress, working together is success". European Urology Today

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www.baltic18.org

www.seem18.org

BALTIC18

SEEM18

5th Baltic Meeting in conjunction with the EAU

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

25-26 May 2018, Riga, Latvia

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

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

Call for Abstracts Deadline 1 July 2018

www.esur18.org

www.cem18.org

ESUR18

CEM18

25th Meeting of the EAU Section of Urological Research

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

4-6 October 2018, Athens, Greece

12 October 2018, Cluj Napoca, Romania In collaboration with the EAU Section of Uropathology

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

Call for Abstracts

Call for Abstracts

Deadline 8 July 2018

Deadline 15 July 2018

European Urology Today

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EBU re-certifies Ankara University’s Department of Urology Ensuring a high quality residency training programme Prof. Yasar Bedük Professor of Urology Dept. of Urology Ankara University Medical Faculty Ankara (TR)

ybeduk@gmail.com Ankara University School of Medicine was established in 19 October 1945. It was the first medical school of the Turkish Republic and the Department of Urology was established under the leadership of Professor Kemal Serav. The Urology Department is located in Ibn-i Sina Hospital (one of the two main hospitals affiliated to Ankara University). The department has 52 beds for adult patients and 12 beds for the paediatric patients located in the Children’s Hospital of Ankara University. Our department was EBU-certified in 2006 for the first time and recertified in 2012 and 2017. Annually, 9,500 patients are treated in our outpatient department and 3,500 surgical procedures are performed. Dedicated academic staff are employed in the subspecialties of uro-oncology, paediatric urology, endourology and stone disease, functional urology, andrology and infertility, and robotic surgery. Training programme In Turkey, the residency training programme of urology (RTPU) lasts for five years. This duration is justified by the Directory of Ministry of Health since 2002. After medical school, in order to apply for a residency programme a national exam has to be taken. The aim of the RTPU is to train and educate the residents in contemporary urology and give them know-how in their professional and social life. At the end, a resident should be competent in every sub-section of modern urology including both practical and academic aspects. A graduate from this EBU Certified Centres

residency programme should also gain the ability to direct a separate urology clinic with full responsibility. Residency training is categorised in seven separate areas in our department. 1. General urology 2. Uro-oncology 3. Paediatric urology 4. Neuro-urology and Gynaecologic urology 5. Andrology and infertility 6. Endourology and SWL 7. Robotic surgery Our department is also certified by the Turkish Board of Urology and the residents are obliged to keep a logbook focused on the training activities. However, our department strongly insists on the EBU certification as well in order to maintain an additional external control mechanism. Besides, EBU certification also provides excellent educational opportunities for residents such as The European Urology Residents Education Programme (EUREP) and the European Urology Scholarship Programme. The Ankara University School of Medicine - Academic Staff residents are strongly encouraged to apply for these activities and to date 22 residents benefited from these training opportunities. Wednesday is reserved for educational activities. During the five-year residency programme, the Journal club or seminars are presented by the residents also have rotations in departments of residents under the supervision of an academic staff. general surgery, nephrology, and anaesthesiology. Case presentations of both ordinary and Moreover, the residents spend 12 months in our extraordinary cases are also performed for paediatric urology department which is certified by educational purposes. Additionally, a monthly the European Society for Pediatric Urology (ESPU). meeting is held on mortality and morbidity, Additionally, separate outpatient clinics offer services multi-department uro-oncology, uro-radiology, and in paediatric urology, functional urology, urouropathology. In these meetings, the residents also oncology, and infertility. The residents have the actively participate in case presentations. They are opportunity to practise in these subspecialty clinics also encouraged to participate in the educational with dedicated tutors who provide consultations in meetings organised by the local urological societies both in-patient and out-patient basis. at least twice a month. Resident training Currently, there are 11 residents in our department and they actively participate in the scientific activities as well. The residents are obliged to present at least three abstracts in the national meetings and at least one abstract in international meetings. They are also expected to contribute in the publication of at least three scientific papers before completing the residency. During the weekly programme, every

EBU honours Antoniewicz Board cites Antoniewicz’s contributions to better EBU Exams At the Eurpoean Board of Urology (EBU) Board Meeting, organised by the Georgian Urological Assocation in Tblisi in October 2017, the EBU Board honoured Dr. Artur Antoniewicz for his dedicated service to the EBU.

From left: H.P. Schmid, A. Antoniewicz, J. Nawrocki at the EBU Board Meeting last October European Board of Urology (EBU)

March/May 2018

During the paediatric urology rotation, the residents participate in open and endoscopic paediatric urology cases under the supervision of a dedicated paediatric urology team. During the last year of residency, the residents perform open radical prostatectomy and cystectomy. They also perform bedside assistance for robot-assisted laparoscopic surgery and train in patient preparation and robot docking. They also have the opportunity to practise in the robotic simulator and a laparoscopic training box. In the future, a rotation programme in the transplantation section is also planned. We believe that EBU certification is not only a mark of excellence for our department but also acts as an external and independent authority that helps ensure the high quality of our training programme.

ANNOUNCEMENT The Fellow of the European Board Examinations (FEBU) consist of 2 parts: Written and Oral Examination. The next EBU Written Examination 2018 is held: Date: Friday 16 November 2018 Time (local): 14.30-16.30 hrs. EBU Written Examination The examination consists of 100 Multiple Choice Questions (MCQ) and concerns the entire range of urological topics including basic science. This web-based test is organised at Pearson VUE test centres.

EBU Secretary Prof. Hans-Peter Schmid cited Dr. Antoniewicz’s long years of contribution. Antoniewicz received both the “EBU Gold Pin” and the Distinguished Service Award from Mr. Jan Nawrocki, President. The board members also gave Antoniewicz a well deserved standing ovation. Antoniewicz was appointed as EBU delegate by the Polish Urological Association in 2002. He served on the EBU Accreditation and Examintion Committees, and from 2011 to 2017 he was chairman of the EBU’s Examination Committee.

During the training programme, the residents also have the advantage of working with a dedicated uro-radiologist within the urology department, perform ultrasound examinations and learn transrectal prostate biopsies. They also learn to perform and evaluate urodynamic studies. The residents should be capable in performing common endo-urology procedures such as TURP, TURB, ureteroscopy, retrograde intrarenal surgery, and

simple laparoscopic procedures. They are also trained in percutaneous nephrolithotomy (in both prone and supine positions) and have the opportunity to participate in complicated procedures such as endoscopy and combined intrarenal surgery.

Eligibility criteria The applicant meets one of the following criteria:

From left: A. Figueiredo, A. Antoniewicz, J. Nawrocki, M. Çek at the EBU Oral Examination 2016 in Brussels

Under his leadership, the EBU examinations were developed and expanded considerably. After the EBU Written Assessments had been delivered in print for more than 20 years, he facilitated the transition to web-based testing. The first EBU Online Written Examination was held in 2013 and the first In-Service Assessment was delivered in 2014 as an online test. Online testing has proven to be more efficient, reliable and accessible to a larger audience. He was also instrumental in the implementation of an online MCQ platform for Examination Committee members, and the introduction of new technology in the oral examination. The considerable increase in numbers of candidates taking the EBU examinations during his committee chairmanship testifies to his commitment and dedication. His personal participation in 61 EBU meetings and 15 EBU Oral Examinations represented an exceptional achievement and contribution.

• Final-year resident: Trained as part of an official national urology training programme in a UEMS/EBU member country. The training must be completed before 31 October 2019. • Certified urologist: Fully qualified as a urologist by the recognised national authority. UEMS/EBU member countries Austria, Belgium, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom. Pearson VUE test centres Pearson VUE has a large network of test centres. The centres provide a secured environment for this high-stakes examination.

Online registration Available July-August 2018. For more information visit our website www.ebu.com

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www.esunmibc19.org Cutting-edge Science at Europe’s largest Urology Congress

2nd ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer 21-22 February 2019 Prague, Czech Republic An application has been made to the EACCME® for CME accreditation of this event

Abstract submission opens 1 July 2018 www.eau19.org

34th Annual EAU Congress

www.esui18.org

ESUI18

Abstract submission deadline 1 July 2018

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

Getting it right: Indications for modern urological imaging

Call for Abstracts Deadline 1 July 2018

8-11 November 2018 Amsterdam, The Netherlands An application has been made to the EACCME® for CME accreditation of this event

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

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EAU-JUA International Academic Exchange Programme Exchange visit inspires young Japanese urologists Dr. Kiyoshi Takahara Dept. of Urology, Fujita Health University School of Medicine, Toyoake, Aichi (JP) takahara@ fujita-hu.ac.jp

Dr. Takashi Dejima Dept. of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka (JP)

Skane University Hospital (14-15 March) We visited Skane University Hospital in Malmö from March 14 to 15. Prior to this visit hospital, we had dinner with Prof. A.S. Bjartell and his colleague at Sky Bar on 13 March. Unfortunately, the fog was so dense that we couldn’t see anything at the beginning, but finally in the evening the fog lifted and we have had a beautiful night. In live surgery, we observed advanced penile implants and many basic and clinical lectures

dejima@uro.med. kyushu-u.ac.jp Our first visit was Hamburg and Prof. Tilki and members of the Martini-Klinik team welcomed us during our stay from March 10 to 13, 2018. The Prostate Cancer Center of Martini-Klinik is one of the most famous hospitals for treating prostate cancer with patients from all over the world. More than 2,000 patients annually are treated with radical prostatectomy, and the number of cases is the highest in the world. Currently, most cases of radical prostatectomy in the Martini-Klinik are performed with robotic assistance. During this period, we

from Germany and Switzerland whom we previously met in Canada. Our experience of the poster sessions were inspiring, giving us added motivation in our own work.

observed two cases of robot-assisted radical prostatectomy (RARP). It was an exciting and wonderful experience for us to learn excellent and unique surgical techniques performed by the Martini-Klinik team. We also had a wonderful time with the Martini-Klinik staff members including during lunches and dinners, and we enjoyed the sightseeing in Hamburg. We truly appreciate the heartwarming welcome by Prof. Tilki and her colleagues.

With Prof. Fredrik Liedberg

We were also invited to the EAU President’s & International Friendship Dinner held on March 18 at the Copenhagen City Hall. And it was a wonderful moment when we received the certificate of participation on stage. We will never forget the exciting night and warm hospitality. 2018 EAU/JUA International Academic Exchange Programme members

on stone management, bladder, prostate and penile cancers at Skane University Hospital. In particular, we had an interesting seminar on the molecular classification of bladder cancer led by Prof. Liedberg. These lectures were wonderful and inspired us to work harder in both clinical setting and basic research. The lectures on operative procedure prior to the live surgery enabled us to better understand the live surgery. We are also thankful for the generous and excellent dinner hosted by Prof. A.S. Bjartel and his wife on 14 March. 33rd Annual EAU Congress (16-20 March) We participated in the 33rd Annual EAU Congress (EAU18) at Copenhagen. The congress had many plenary, oral and poster sessions, and we acquired many updates and information. One of us also had the opportunity to present during the prostate poster session and join the discussions with doctors and researchers from many countries. We met friends

We met a lot of people and experienced so much during this Exchange Programme. We also had a wonderful time with three Taiwanese exchange fellows. It was important for us to learn not only about novel findings and excellent procedures in urology but also the cultures of Scandinavian countries. We sincerely appreciate the efforts of all EAU and JUA members who organized this Exchange Programme — truly a memorable and life-changing experience for us!

With A.S. Bjartel and fellows from Taiwan

Taiwanese urologists gain fresh insights on European urology Dr. Tzu-Chun Wei National Yang-Ming University Dept. of Urology Taipei (TW)

tony720714@ gmail.com Co-authors: Dr. Yi-Huei Chang, The China Medical University Hospital, Taichung (TW) and Dr. Che-Yuan Hu, National Cheng Kung University Hospital, Tainan (TW) Thanks to the European Association of Urology (EAU) and Taiwan Urology Association, we had the chance to join the 10-day European academic trip. It was one of the most memorable professional experiences we ever had, and we were impressed by the warm welcome from the EAU organisers and our friends in Germany and Sweden, especially Profs. Graefen and Bjartell. Martini Klinik After a 20-hour journey, we finally arrived in Hamburg where Prof. Tilki and her staff welcomed us at the Martini Klinik. The Martini Klinik is the biggest prostate cancer center in Europe, and the number of radical prostatectomy it performed in a year is more than the total cases at Mayo Clinic and Cleveland Clinic in United States. There are four Da Vinci robotic systems and 11 prostate cancer specialists in the hospital. Each physician has his own field of expertise. At the Martini Klinik we learned about MRI fusion-guided prostate biopsy, with techniques that have not yet been developed in Taiwan. We also

observed the robotic RRP performed by Prof. Graefen. The surgical techniques we saw were impressive, particularly the whole-mount frozen section technique. We learned that real-time whole-gland frozen section is a very effective method to ensure either the surgical margin or neurovascular bundle preservation, as well as the pre-docking special wound setting for intra-operative retrieval of the prostate gland. The real-time whole-gland frozen section requires close cooperation of the pathologist and the urologist. We also learned new insights on apex irrigation and urethral sphincter preservation. Martini Klinik’s centralised faculty system and efforts to improve clinical outcomes are some of the reasons why this institute has earned a solid reputation. The work environment is liberal and the doctors impressed us with their competence and dedication. We thank Profs. Graefen and Tilki and the fellows in Martini Klinik, Susan, Raisa and Laurence, for their hospitality. Aside from introducing us to Hamburg, Prof. Tilki and Prof. Graefen also planned a sight-seeing tour on the second day which showed us German hospitality and prepared us for the rest of the academic tour. We then took a train trip to Rubeck University and visited Prof. Mersburger. He took us to the wards, clinics and laboratories, and briefed us on their management system.

Taiwanese delegates at the EAU18 Congress in Copenhagen

At Lund University, we joined the daily morning meetings of the Urology Department and experienced the Swedish practical approach. Government policies require that certain diseases can only be treated in specific centres. This makes the Lund University Hospital very special in rare areas, such as prostate, bladder, and penile cancers. Prof. Bjartell also introduced us to the very impressive basic research facilities in prostate cancer, which combine both clinical and translational aspects. Using unique facilities such as special animal image and bone scan, they can do more studies on either functional or anatomical models.

Prof. Bjartell’s modesty even though he is a great scholar and doctor and despite all his outstanding achievements, makes him a role model. A cardiology Off to Sweden professor also briefed us on the medical history of After a three-day stay in Germany, we left for Denmark Sweden, which was very informative and enlightening. where we took a bus to Malmö. In Sweden, Prof. Bjartell arranged an intensive course for us. This not Annual EAU Congress only gave us an in-depth overview of the work being It was also our first time to participate in the five-day done in Lund University, but also gave us a glimpse Annual EAU Congress in Copenhagen, an impressive into the university’s basic research activities, which event that offered so much new information, ranging inspired me to think about future prospects in urology. from clinical and basic research, novel surgical advances, summary and comparison of new trials, developments in technical equipment, among many others. In the live surgeries we witnessed excellent surgical skills.

Certainly, the EAU Congress in Copenhagen was a wonderful five-day event marked by knowledge exchanges and memorable friendship. This European journey will remain a memorable experience that we will always cherish. For this amazing experience, our sincere thanks to the EAU. We also wish to express our appreciation to Prof. Chapple. He even came to Taiwan to give a lecture on the highlights of EAU18 after the annual conference! Finally, we would like to thank the coordinator at the EAU Office, Ms. Terberg, who arranged such a great tour for us. This trip really broadened our horizons and enriched our minds. This was an unforgettable journey, and we got a lot of inspiration from all the people we have met. Thank you very much!

There were also many Taiwanese urologists attending the EAU Congress. It seems the EAU has a more international tradition and communication style among the urological associations.

Dinner with Prof. Graefen and his team'

March/May 2018

Prof. Tilki (second from left) with fellows Dr. Chang, Dr. Hu and Dr. Wei

We were honored to be invited to the Friendship Dinner where we again met Profs. Bjartell, Tilki, and our co-exchange fellows from Japan. It was an inspiring evening where we experienced the dynamics of the urological community. The sense of community has certainly inspired us to work harder.

Research poster on NMIBC by the Lund Bladder Cancer Group

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BAVARIAN NORDIC IS STRIVING TO BRING NOVEL TARGETED VACCINES TO MAXIMIZE IMMUNOTHERAPY IMPACT FOR CANCER PATIENTS Our innovative oncology platform is designed to specifically target a variety of challenging tumor types. We have developed a portfolio of active cancer immunotherapies, designed to alter the disease course by eliciting a robust and broad anti-cancer immune response while maintaining a favorable risk-benefit profile. Multiple clinical trials are ongoing in collaboration with the NCI, NIH, academia and industry partners. Through numerous industry collaborations, we seek to explore the potential synergies of combining our immunotherapies with other immune-modulators.

BAVARIAN-NORDIC.COM 36

European Urology Today

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ESOU18 brings the best of uro-oncology

ESOU 18

Meeting delivers the newest research and cutting-edge technologies Prof. Maurizio Brausi Chairman, EAU Section of Oncological Urology Modena (IT)

advanced disease but the oncologic benefit of lymph node dissection (LND) in high-risk renal cell carcinoma (RCC) remains unproven. She mentioned the controversial results in the adjuvant setting – the new data with Pazopanib shows no overall survival or disease-free survival (DFS) benefit. Additionally, Cabozantinib represents a potential new treatment option in 1st line mRCC for intermediate- and poor-risk mRCC (phase II trial).

26-28 January 2018 Amsterdam, The Netherlands

www.esou18.org

detection of positive LNI possibly improves survival through adjuvant therapies.

Prof. Markus Graefen (DE) discussed the European views which included performing ePLND in mauriziobrausi@ intermediate-risk PCa if gmail.com Prof. A. Noon (GB) cited a study by Moss et al on the estimated risk of urothelial cancer that there is better molecular positive lymph node Controversial issues in uro-oncology were addressed characterisation of UCC (urothelial carcinoma) patient exceeds 5%, and performing ePLND in and the latest research was presented during the 15th groups, and that we currently have molecularly defined patient “subgroups”. He stated that new high-risk PCa. He added Meeting of the EAU Section of Oncological Urology subgroups can be subject of randomised clinical trials that LND, and LND in (ESOU18) which took place from 26 to 28 January of existing or novel targeted therapy. Noon heeds low-risk disease should 2018 in historic Amsterdam, The Netherlands. caution when using biomarkers. not be performed. Prof. M. Gallucci during partial nephrectomy debate According to Prof. Current top research Covering the topic on testis and penile cancer, Prof. M. Graefen, the uncertainty Innovative research on prostate, renal, urothelial, Salagierski (PL) said that the miR-317a-3p appears a on the impact of lymph node dissection on prognosis Hands-on training in prostate MRI reading for urologists testis and penile cancers from 2017 were collated promising germ cell tumours (GCT) marker. is recognised. He stated that the increase of morbidity and Kidney Cancer. and presented during “The best of uro-oncology in Salagierski advises to minimise long-term toxicity and with increasing extent of PLND is proven and the 2017”. Prof. Giorgio Gandaglia (IT) cited relevant restrict adjuvant therapy in high-risk GCT patients. functional outcome is not impaired. “There is no prostate cancer (PCa) studies such as the research of The hands-on training course was comprised of an doubt about the diagnostic value of PLND,” said Prof. introduction to magnetic resonance imaging (MRI) by James et al. with an update regarding systemic Roundtable discussion Graefen. “Randomised control trials are needed to therapies. The research states that men with locally sequences, scoring systems, and the Prostate The riveting lectures of the session “Treatment identify patients that benefit PLND.” advanced or metastatic prostate cancer who receive Imaging Reporting and Data System (PI-RADS); androgen deprivation therapy (ADT) plus modalities for intermediate risk prostate cancer: treatment implications of an mpMRI-driven diagnostic surgery vs. hypofractionation” which focused on ESU Courses abiraterone and prednisolone have significantly pathway; and familiarity with the MIM Software to focal therapy, active surveillance, hypofractionated Two innovative courses organised by the European higher rates of overall and failure-free survival than name a few. radiotherapy and radical prostatectomy concluded School of Urology (ESU) were incorporated in the those who receive ADT alone. that patient selection is key. comprehensive ESOU18 programme: the ESU/ESUI The ESU course on kidney cancer covered diagnosis, On renal cancer, Dr. Estefanía Linares Espiños (ES) biopsy and staging. Videos on radical nephrectomy, said that there is an increased interest in locally Varying points of view partial nephrectomy, focal therapy and active American and European perspectives on the necessity surveillance were presented and the course of LND in PCa were deliberated during the wellproceeded with a roundtable discussion on how to attended meeting. Prof. Christopher Evans (US) stated avoid and manage complications such as bleeding, that selection of patients for primary pelvic lymph prolonged ischemia, decreased renal function, urinary node dissection (PLND) should be >5% risk of lymph and vascular fistulae. node involvement (LNI). Extended lymph node dissection (ePLND) detects greater number of lymph At ESOU meetings, expect nothing less than the latest node metastasis especially along the internal iliac developments in research and technologies in the artery chain but results in higher complication rate. field of uro-oncology. See you next year in Prague, Survival improvement with ePLND is not proven and Czech Republic for ESOU19! Well-attended for the whole three days ESU’s Hands-on training course in prostate MRI reading

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Join us!

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

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

Give us one good reason not to get checked out! Don't settle for discomfort!

Save the date!

When your main priority is to enjoy life and to spend quality time with loved ones, your urological health becomes priority, too. Start now to know more about the prevention of prostate cancer. Ask your questions direct from a trusted source. Talk to a Urologist.

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

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

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

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EAUN18: New perspectives in urological nursing Highlighting Painful Bladder Syndrome, BCa to leadership issues Eva Wallace, RN National Rehabilitation Hospital Dept. of Urology Dunlaoighre Co Dublin (IE) ewallace116@ gmail.com

Laura Noble Uro-Oncology Clinical Nurse Specialist Freeman Hospital Dept. of Urology Newcastle upon Tyne (UK) laura.noble@ nuth.nhs.uk

Vasiliki Katsarou Head Nurse Santorini General Hospital Athens (GR)

vkatsarou@ hotmail.gr The 19th International Meeting of the European Association of Urology Nurses (EAUN18) held in Copenhagen last March attracted around 342 delegates from over 30 countries. With the participation of 45 faculty members together with the EAUN Board and EAUN Scientific Committee (chaired by Corinne Tillier), EAUN18 presented a comprehensive programme with 29 sessions and four courses. Two European School of Urology (ESU) courses and two plenary sessions not only drew a high number of attendance but were also marked with enthusiastic discussions. Networking and updates on membership took place at the EAUN Booth and the social activities included the Nurses’ Dinner held at Nørrebro Bryghusactivities which reflected the dynamic collaboration among European urological nurses.

discussed the differential diagnosis for PBS/IC. PBS/ IC / PBS is a clinical diagnosis based on symptoms of urgency, frequency, and pain in the bladder and/or pelvis. “The complaint of supra-pubic pain related to bladder filling and accompanied by other symptoms such as increased daytime and night-time frequency in the absence of urinary infection or other obvious pathology,” according to ICS 2002. PBS is a very debilitating, chronic condition that is difficult to diagnose (Davis et al, 2015). It was first diagnosed in the 19th century by S.D. Gross in 1876. Two years later in 1878 Skene identified it as chronic inflammatory lesion of the bladder wall. In 1915 G.L Hunner, using eight case histories identified urge, frequency, nocturia, suprapubic pain, visible lesions / ulcers on bladder wall. This is now known as Hunners Ulcers, a rare condition with only 10-15% of cases actually showing ulcers (Gupta et al, 2015). In the UK, there are approximately 400,000 people with this condition (Nickel et al, 2010). This complaint is seen predominantly in female patients (Cashley et al, 2012), and some clinicians doubt the validity or existence of the condition (Warren 2014). However, there can be a lack of consensus on the terminology (Ghosh & Imoh-Ita 2014). Further discussion continues around diagnosing PBS/IC, which is most often made when long-standing urinary frequency, urgency, and pelvic pain exist in the absence of a readily identifiable signs, such as urinary tract infection. This was further discussed using some case studies. Underactive bladder issues V. Phé discussed underactive bladder, a symptom suggestive of detrusor underactivity and is usually characterised by prolonged urination time with or without a sensation of incomplete bladder emptying, usually with hesitancy, reduced sensation on filling, and a slow stream. For those with UAB careful neurologic and urodynamic examinations are required for correct diagnosis. In managing UAB, the avoidance of upper tract damage, prevention of over distension, and reduction of residual urine are paramount. Conservative treatment can include timed voiding, double voiding, medication such as alpha-blockers, and intermittent self-catheterization. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5740034/

Dr. Stefano Terzoni passes on the Chair chain to Dr. Susanne Vahr, the new Chair of the EAUN

Profound consequences Over time it is clinically recommended to see a specialist for on-going symptoms to rule out any imaging, including magnetic resonance imaging possible differential conditions prior to diagnosing (MRI), computed tomography (CT) scanning, and interstitial cystitis. The consequences of a diagnosis of pelvic ultrasonography, may be performed when PBS/IC are profound since it is a chronic condition clinically indicated to evaluate for a suspected pelvic without universally effective therapy. Ward-Smith in mass that is causing compression of the bladder or for 2009 stated that there is an estimated 13 million an adjacent inflammatory process (e.g. diverticulitis). individuals experiencing some type of incontinence Cystography and voiding cystourethrography may be and 85% of these are women! In general the used to evaluate the bladder for other causes of lower symptoms of PBS/IC are characterised by urinary urinary tract symptoms, such as intravesical masses, frequency urgency, and/or pain pelvic and can affect stones, bladder diverticula, urethral diverticula, the following types of conditions- infectious or urethral stricture, meatal stenosis and neurogenic or inflammatory, gynaecologic, urologic, or neurologic. non-neurogenic voiding dysfunction (Rovner et al 2017). There are also many complications which include reduced bladder capacity caused by stiffening of the Urodynamic Studies (UDS) are optional and not bladder wall, which reduces bladder capacity. Most generally part of routine evaluation for PBS/IC. The importantly, it can reduce quality of life due to findings maybe suggestive of an alternative diagnosis frequent urination and lack of sleep that affect daily such as detrusor over-activity or pelvic floor activities, social/work events, etc. Another important dysfunction but there are no specific UDS findings. aspect of PBS/IC is the effect it can have on personal During UDS procedure on bladder filling, many relationships and sexual intimacy. Patients can be patients do have increased sensation with decreased affected by psychological /emotional issues which can volume, however, pain with bladder filling that also impact on their sexual health, caused by the reproduces the patients' PBS/IC symptoms is very difficulty dealing with the side effects of chronic pain, supportive of a diagnosis of interstitial cystitis. and the lack of sleep associated with interstitial cystitis can lead to depression. It is imperative that Cystoscopy can be described as the most important each person has individualised treatment plans to diagnostic tool for assessing a patient who may have include a physical examination, appropriate clinical PBS/IC. In general, this is performed while the patient tests, all done in a timely manner for their diagnosis is under anaesthesia in order to provide sufficient to increase their knowledge and awareness of bladder distention to examine for co-existing urethral condition. and bladder pathology (e.g., transitional cell Continued on page 39 carcinoma) and features of interstitial cystitis, such as

Copenhagen 17-19 March 2018

Chronic bladder problems (report by E. Wallace) It was a pleasure to be part of Europe’s biggest urological nursing event as a member of the Special Interest Group (SIG) during the EAUN18 in Copenhagen. As an SIG committee member, we collaborated with our colleagues with the goal to deliver optimal patient care.

EAUN Award Winners

The SIG organised a one-hour session format with three (15-minute) talks followed by a discussion which Nurses share their ideas on the development of a Curriculum was very well received. Thanks to Jeannette Verkerkon urology nursing at EAUN18 Geelhoed, who chaired the session despite a short notice after the chairperson cancelled due to health reasons. Another lecture took up differential diagnosis for PBS/ The session took up the management of chronic IC which remains just as difficult today even more bladder problem with Sharon Holroyd discussing the than a century after it was first described. There are misunderstanding on Urinary Tract Infections, Painful no specific pathognomonic findings with regards Bladder Syndrome (PBS), Interstitial Cystitis (IC), and patient history, physical examination, laboratory, or Bladder Pain Syndrome (BPS). Veronique Phé (FR) cystoscopy findings. The exclusion of other clinical shared her views on diagnosing and treating entities remains the foremost goal of the work-up and underactive bladder, while speaker Eva Wallace evaluation of patients suspected of this condition. IC/PBS is diagnosed when the symptoms occur without evidence for other causes (Taylor, B. 2007). A full medical history and physical examination are essential. Urinalysis and urine culture are also vital to rule out urinary tract infections (UTI). A voiding/ bladder diary is helpful in establishing baseline voiding frequency. Other tests include a pelvic examination, bladder biopsy, urine cytology, and very rare a potassium sensitivity test, and it turned out that nobody in the audience had used this test.

Sharon Holroyd delivers a lecture on painful bladder syndrome in the Thematic Session on Chronic bladder problems, organised by the EAUN Special Interest Group

Hunner Ulcers and glomerulations. During cystoscopy, bladder capacity can also be evaluated. The characteristics of Hunners ulcer are rarely seen to confirm the diagnosis (Rovner et al 2017). Diagnosis can be made based on cystoscopic findings, for patients with PBS/IC and can be classified as either Hunner-type/classic IC (HIC), presenting with a specific Hunner lesion, or non-Hunner-type IC (NHIC), presenting with no Hunner lesion, but posthydrodistension mucosal bleeding ( Maeda D et al Published: Nov 20, 2015). Diagnosis is still one of the exclusions as there are no defined indicators, no aetiology or pathophysiology available.

There are no specific radiographic, ultrasonographic, imaging findings specific for PBS/IC, unless when ruling out alternative diagnoses. Cross-sectional

First Prize for the Best EAUN Poster Presentation R. McConkey, C. Holborn

Second Prize for Best EAUN Poster Presentation P.B. Svankjær, A. Holm Jensen, T. Søndergaard Sørensen, H. Haslund-Thomsen

University Hospital Galway, Urology Department, Galway, Ireland; Sheffield Hallam University, Faculty of Health and Wellbeing, Sheffield, United Kingdom

Aalborg University Hospital, Clinical Nursing Research Unit, Department of Urology, Aalborg, Denmark

With the poster “Exploring the lived experience of gay men with prostate cancer: A phenomenological study”

With the poster “Grit in the waterworks – patient experiences of living with stones in the upper urinary tract”

Third Prize for the Best EAUN Poster Presentation J. Avlastenok, K. Rud, H. Køppen, L. Wendt-Johansen, H. Wested, P. Busch Østergren Herlev Hospital, Department of Urology, Herlev, Denmark With the poster: “Quality of life of spouses living with men undergoing androgen deprivation therapy for prostate cancer”

Prize for the Best EAUN Research Project Plan Presentation V. Decalf, R. Pieters, K. Everaert, M. Petrovic, W. Bower Ghent University Hospital, Belgium; Royal Melbourne Hospital, Australia With the Nursing Research Project: “Prevalence, incidence and associated factors of nocturia on the ward”

19th International EAUN Meeting 38

European Urology Today

March/May 2018


to review this as we felt it was not relevant unless the patient have had significant side effects from their treatment. The opinions of the experts were helpful which enabled me to provide some feedback to my colleagues at our centre. This resulted in this practice been withdrawn and the decision of taking blood post-treatment is now left to the clinical decisionmaking of the nurse specialist providing the individual patient care.

Continued from page 38

IC/PBS is a chronic, complex and poorly diagnosed condition. Pain is one of the primary symptom, which affects mainly the females. Often times they have suffered for many years with misdiagnosis, and overuse of antibiotics. Many would have tried multiple unsuccessful treatments, maybe be labelled as challenging and difficult, hypochondriac, anxious or mad. But inevitably, all will have a reduced quality of life. For the future, a general consensus on definition, diagnosis and treatment would be of benefit. The Leadership Course was a first and very well-received

Thematic Session on BCa (Report by L. Noble) At EAUN18 I attended the Thematic Session 10 on bladder cancer with the theme “Evolution and Management of BCG,” an area which I focus on as a urology clinical nurse with a sub-specialty in non-muscle invasive bladder cancer. I found the session very useful in understanding the history, in detail, of Bacillus Calmette–Guérin (BCG), a drug which many nursing professionals do not fully understand, particularly the mechanisms of how it works. It was valuable to hear the insights of experts which gave me a better understanding of BCG as a complex drug. With the worldwide shortage it was valuable to recognise how other disciplines try to plan and work around this, enabling me to inform my centre of how other healthcare professionals manage these shortages, reducing the negative impact on patients’ treatment schedules. As I was also unaware of the

process involved in developing each batch, and the length of time this takes, it was beneficial to understand how these shortages can occur, with little warning, such as during incidents of ‘a bad’ batch. The management of side effects and a patientcentred approach were also very informative issues. In my centre we take a very patient-centred approach and it was reassuring to see that we are providing this treatment at the same level as other centres. I will, however, use the new information I have learned and with renewed confidence continue to manage the side effects as effectively as possible, thereby ensuring patients are able to continue their treatment. I also asked questions regarding a practice that we have done historically, which is to take UE, FBC and LFT bloods following each cycle of BCG. We planned

Overall, my knowledge of BCG has greatly improved and I feel more confident in discussing the drug with patients and colleagues. In my view, the more knowledge we have regarding these drugs, the better then we can provide the right care and treatment to our patients. In my experience, when we can confidently respond to their questions, they develop more trust and can feel more relax during their treatment.

In my view, the leadership course was effective as I improved my knowledge on the essential skills and techniques in leadership. I also gained insights on how to communicate with patients, teams, colleagues and surgeons. The programme was truly useful to participants and we had opportunities to interact with various healthcare professionals from all over Europe. I value the experience and insights since these can be useful in implementing the recommendations of management consultants, and thereby improving patient care and the way we work. A reminder- now is a good time to plan for next year’s abstract sessions. There are four ways to submit your work, either an abstract, video, research plan or a difficult case. We look forward to meet you in 2019!

Leadership course (A report by V. Katsarou) The Annual EAUN Meeting has made valuable contributions in high-quality urological nursing care by providing new scientific and practical inputs including medical technology, drug therapy and outcomes from current studies. At this year’s meeting in Copenhagen I participated in the interactive course “Nurses in a Leadership role: Cultivating your leadership” which presented recommendations on how to boost a leadership role, tips on how to overcome challenges in the workplace, distinguishing technical challenges from adaptive challenges, how to observe a work system, and receiving feedback on personal leadership.

Nurse delegates get a good idea of the tasks of the console surgeon in the robotics simulation HOT course

Complementary and Alternative Medicine (CAM) in urology Despite weak evidence, adoption of CAM widens in many countries Nora Love-Retinger, MS, RN, CURN, OCN Memorial Sloan Kettering Cancer Center Dept. of Nursing New York (USA)

In 1999, the American Urological Association (AUA) established a ‘Committee on CAM’ with Dr. William Fair, known as the ‘Father of CAM in Urology,’ as the first chairman. It was his own experience with cancer that led him to incorporate complementary techniques as a means to complement, not replace, conventional therapies. Dr. Fair believed in using a scientific approach to these treatments and techniques and held them to the same standard as mainstream medicine.

management of chronic pain, hypertension, and symptoms associated with heart disease and cancer is well documented.

loven@mskcc.org Some of these CAM therapies for urologic diseases that have been studied are as follows: For those who are entrenched in modern medicine, it may be difficult to think of alternative medicine and urology as being practised together. Nevertheless, the use of complementary and alternative medicine to treat many different diseases is on the rise in many countries, including Western nations. The United States has seen an increase in complementary and alternative medicine (CAM) usage from 33.8% in 1990 to 42.1% in 1997 which has remained stable over the last decade. This appears to be similar to the European countries as reported by the Swiss Health Survey in 2007 and 2012. The user profile in Switzerland was comparable to other countries, such as Germany, United Kingdom, United States and Australia. In their surveys in 2002 and 2007, the National Center for Complementary and Alternative Medicine (NCCAM) reported that 30% to 75% of patients suffering from cancer globally use CAM therapies that include biological, herbal, and dietary-based approaches. This report stated that about 60% of men with prostate cancer utilize some of these CAM treatments. In the US alone, 83 million adults spent over $50 billion per year on CAM, which accounts for over 11% of the total out-of-pocket expenditure on health care. The NCCAM has grouped CAM into five major domains. These include: • Alternative medical systems, such as homeopathy, traditional Chinese medicine, and Ayurveda. • Mind-body interventions, such as meditation, prayer and mental healing. • Biological-based therapy, such as vitamins, minerals, amino acids, herbal and special diets. • Manipulative and body-based methods, such as chiropractic manipulation and massage. • Energy-based therapies, such as biofeedback therapy, Qi Gong, Reiki and therapeutic touch.

• Phytoestrogens and isoflavones (soy products, green tea): General nutrition, fruits and vegetables. Many reports suggest that calorie restricted diets low in saturated fats but rich in fibre, carotenoids, phytoestrogens and isoflavones may reduce the incidence and improve the course of LUTS, BPH, prostatitis and even prostate cancer. This type of diet can be seen in the Asian populations versus the Western populations, which may explain the lower incidence of prostate diseases observed there. • Phytotherapeutic preparations (saw palmetto, African plum tree bark, South African star grass root, pumpkin seeds): Plant extracts are commonly prescribed as the first choice of therapy in many European countries and are increasingly used in the US. They are usually less expensive and regarded as ‘natural’ products. The STEP (Saw-palmetto Treatment for Enlarged Prostate) and CAMUS (Complementary and Alternative Medicine for Urological Symptoms) trials failed to indicate statistical significance; however, some clinicians point out some design flaws in these studies. • Selenium, vitamin E, carotenoids, and zinc: Results from a double-blind trial of dietary selenium on non-melanoma skin cancer in high-risk individuals, showed a statistically significant lower incidence (63%) of prostate cancer than those receiving placebo. The role of vitamin E came from a result of a Finnish study in 1998 on men who smoked to evaluate whether either vitamin E and/or beta-carotene supplements could prevent lung cancer. There was a surprising result showing a 32% reduction in incidence and a 41% decrease in mortality from prostate cancer in the study subjects. • Ginseng for Erectile Dysfunction (ED): Ginseng and erectile functioning are presently being looked at in a large Cochrane Review. Supplements have

Networking is an important part of the annual meeting

been used for centuries; however placebocontrolled studies have shown placebo responses of 25-41%. • Cranberry juice and Urinary Tract Infections: The Cochrane renal group conducted a systematic review and concluded overall results indicate that, compared to placebo, cranberry juice and tablets may reduce the risk of developing symptomatic UTIs in sexually active women. • Red wine consumption and prostate cancer: The agent responsible for the effect of reduction of cancer is supposed to be the polyphenol resveratrol, a naturally occurring plant antibiotic found in grape skins and red wine. The effects include antioxidant activity, immunomodulation, growth-inhibiting activity, anti-androgenic, anti-inflammatory and inhibition of angiogenesis.

• Yoga: An exercise regime with a 5,000-year history. For patients with urinary incontinence, cystocele, rectocele, vaginal and uterine prolapse, chronic orchitis and interstitial cystitis, the practice of yoga postures can be beneficial. Yoga can increase a patients’ self-awareness of muscles. • Music therapy: Patients undergoing TURP showed a reduction in blood pressure and anxiety with music therapy. • Biofeedback: This technique requires equipment such as electromyography, thermal biofeedback or electroencephalography. Studies have shown a hastened recovery of urinary control and reduction in severity of urinary incontinence. • Physical activity: In a cross-sectional study of 111 prostate cancer patients treated with external beam radiotherapy, physical activity significantly improved sexual function. In a systematic review of 11 studies involving over 43,000 men detected an association between vigorous physical activity and reduced risk of BPH and LUTS. The number of patients using CAM therapies is ever increasing world-wide. As practitioners in urology, we should avail ourselves of information, both scientific as well as that which has not been demonstrated by evidence, in this growing field. Understanding the compositions, actions and potential side effects of these therapies to complement our conventional treatments can only benefit in the healing of our patients.

In addition to these biological based therapies, mind-body methods have also been studied in the urology patient: • Acupuncture: ‘Qi’ or ‘life energy’ flows through meridians that connect the body organs. Interruption in this flow is thought to produce disease state. Some acupuncture points coincide with ‘trigger points’ which are anatomic sites of enriched innervation. Biophysiologic and imaging studies indicate that acupuncture triggers the release of neurotransmitters and other endogenous substances. Studies have found a 50-70% reduction of treatment-associated hot flashes in men with prostate cancer. • Mind-body therapies: The role of mediation in health care has been subjected to study in the West for at least three decades. Its value in the

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

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

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Fellowship Programme

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20th International EAUN Meeting

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European Urology Today (EUT) January/February 2018. EUT is the official newsletter of the EAU.

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