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European Urology Today Official newsletter of the European Association of Urology

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Vol. 31 No.4 - August/September 2019

Treating female SUI without meshes

PRECISION Trial had impact on Guidelines

Live stone surgery and hands-on training

The ESFFU examines current return to sling use

MRI now recommended before prostate biopsy in biopsy-naive men

A report from the 3rd edition of joint ESU-ESUT Masterclass

Prof. E. Costantini

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Dr. V. Kasivisvanathan

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Dr. I. Kyriazis

The EAU’s strategy to encourage timely detection of PCa Adjunct-Secretary General Van Poppel urges need to address increasing PCa mortality By Loek Keizer With a remarkable upturn in prostate cancer mortality, the time has come to encourage earlier detection says EAU Adjunct-Secretary General Prof. Hendrik Van Poppel (BE). “For years, prostate cancer screening was synonymous with overdiagnosis and overtreatment. However, with modern approaches to PSA values and the use of biomarkers we can more effectively differentiate between clinically significant and insignificant tumours. As a result of MRI imaging we can be more selective about which patients require biopsies. With active surveillance we can further reduce overtreatment.”

"Through the European Commission’s recommendation we hope to start changing national policies across the continent." The introduction of PSA-based testing has historically led to a significant drop in prostate cancer mortality since the early 1990’s, but with criticism directed at the risk of overdiagnosis and overtreatment. The drop in mortality is stagnating, and in some specific countries, mortality is increasing again: “In the UK, over 65% of the cases of prostate cancer is currently diagnosed in more advanced stages, when cure is more difficult to achieve, and more toxic. In the metastatic stage they are incurable and will become castration-resistant,” says Van Poppel.”

Policy Paper

#EUpledge4p

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ING P S A SCRE E N TE TA S O R P F OR C A NC E R

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rostatecancer

Prostate Canc er:

the issue

Despite prostat e cancer being more than the most commo 417,000 new nly diagnos cases and 92,000 ed cancer in little is perform men, with deaths in Europe ed on prostat e cancer manag recorded each year, very ement at EU level. The Europe an Union can no longer continu cause of cancer e to overloo death in men k the second in Europe. Recent population-bas most commo ed screening evidence demon n programmes decrease mortali strates that for prostate ty rates and cancer are that they increas families. effective, that e the quality they of life of patient s and their Urgent action is required to make sure mandated to that the new support EU European Commi Member States cancer plans. ssion is in prostate cancer screeni ng in their nationa l HOW CAN MEPs SUPPORT THIS? We need MEPs to support the following policy pledges: Pledges Push for a review of on population-bas the 2003 EU Council Recom Tick to pledge mendations ed early detectio screening n to include prostate cancer Ask timely written and oral questio Commission ns to the Europe on prostate an cancer Develop parliam entary resolut for prostate ions which include specifi cancer c targets Push your governm ent’s represe Group on Health ntatives of the Promotion, EU’s Steerin Disease Preven g of Non-Communi tion and Manage cable Disease ment s to address Support the prostate cancer EU Joint Action ‘the Innovat Against Cancer ive Partner ’ to promot ship for Action e concret e actions on Support increas prostate cancer ed EU investm ent in prostat Lend your politica e cancer researc l support to h campaigns prostate cancer and confere in your country nces on . If you agree to support one or all of completed these pledge pledge form s, please return to EUoffice@uro #EUpledge4pr the web.org and ostatecancer. don’t forget to tweet

For more details

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“PSA sampling remains the basis of our early detection options, despite the fact that for many ‘PSA screening’ has negative associations based on earlier screening programmes. Based on the initial PSA test, we can these days avoid overdiagnosis and overtreatment that may be harmful to our patients while still being able to treat those patients who would benefit from early treatment.” “All in all, there is very little that should discourage early detection,” says Van Poppel. More than 92,000 European men die of the disease every year, and in some countries prostate cancer has become the second cause of male cancer death after lung and before colorectal cancer. Profs. Chappel and Van Poppel (centre) discussing the potential of population-based PCa screening programmes with representatives of European national urological societies in Noordwijk, 21 June 2019 The EAU’s approach Following much discussion at the "EAU Meets National Societies" meeting in Noordwijk (NL) in June, Prof. Van Information Working Group is in the final stages of Poppel can lay out the EAU’s strategy to dramatically Appropriately, patient groups are also an important reduce prostate cancer mortality in Europe. part of the EAU’s strategy to improve care for prostate preparing a leaflet on prostate cancer screening. This leaflet will plainly outline the advantages and cancer patients. The EAU Patient Advisory Group or disadvantages of PSA-based early detection, and “Our approach is three-pronged: encourage early EPAG held its first General Assembly at EAU19 in detection from a medical standpoint, lobby to bring explain possible consequences for the patient after Barcelona. EAU-affiliated healthcare professionals detection. If something is detected, this might result prostate cancer on the European political agenda, and and patient organisation representatives from inform patients and the healthy male population bladder, kidney and prostate cancer groups came in a biopsy, or perhaps active surveillance will suffice. At the very least, mortality will decrease.” about the risks and benefits of early screening.” together to discuss ideas and needs and explored ways to collaborate. EPAG’s objective is to increase In 2003, the European Commission recommended patient empowerment and engagement in the "The well-informed patient is an screening for cervical, breast and colorectal cancer, development, dissemination and impact assessment but declined to include prostate cancer screening of guidelines and patient information and to support essential component of our attempts because of the risk of overdiagnosis and educational events for patients and patient advocates. to reduce PCa-related mortality." overtreatment. In 2020, new recommendations are expected to come from the European Commission and Van Poppel: “Patient organisations perform a Van Poppel sees the addition of prostate cancer to this valuable task in raising awareness about conditions “Once people realise that structured PSA-based list as vital for men’s health in Europe. and can sound the alarm in the face of increased screening at age 40-45 can pre-empt much more PCa-related mortality. They lobby their national invasive treatment of more advanced prostate cancer, Examples of initiatives that the EAU has supported or governments and generate attention among the we expect the demand for PCa early detection to (co-)organised on a European level are the bi-annual general population.” increase. By persuading the European Commission to European Prostate Cancer Awareness Day at the support screening for prostate cancer and by European Parliament, as well as the “We think that the well-informed patient is an increasing awareness among patients, we think we #EUpledge4prostatecancer that encourages essential component of our attempts to reduce can be successful in changing national healthcare individuals members of the European Parliament to PCa-related mortality. To that end, the EAU’s Patient legislation in European countries.” bring prostate cancer to the agenda.

see http://e

pad.uroweb.or g/

For almost 40 years the European Associa most pressin tion of Urolog g issues of urological y (EAU) has educational care in Europe addressed initiatives, the , through its as well as its scientific and publications. Clinical guideli nes develop ment is one with the aim of their core to assist clinicia activities ns in making decisions in a given circum informed stance.

The EAU’s Policy Paper on PSA Screening and the PCa Pledge document. Both are available from epad.uroweb.org

Cost is also an important factor: early detection and treatment can significantly decrease the costs associated with the management of more advanced prostate cancer. Prof. Van Poppel: “The cost of a PSA test is very low. It can be performed by a nurse and does not require any further actions, unlike screening for breast cancer, colon cancer or cervical cancer.” “Timely detection means more effective and cheaper treatment options, like radiotherapy or radical prostatectomy. If we detect prostate cancer at too late a stage, the costs can exceed €250,000 per individual to extend someone’s life by one or two years. As urologists, we can detect prostate cancer in an earlier stage when treatment can be offered with fewer side-effects like impotence or incontinence, a higher quality of life, and before the disease progresses.”

Van Poppel: “Healthcare is very much the realm of individual member states, and their laws and departments of health, rather than the European Union. However, through the European Commission’s recommendation we hope to start changing national policies across the continent. Our diagnosis and treatment options have improved significantly since 2003 and, together with patient organisations, we feel that the time has come to add prostate cancer to the screening recommendations. It’s up to individual countries, but the EU can send a strong message.” The EAU’s standpoint is summarised in a recentlypublished Policy Paper on PSA Screening for Prostate Cancer, which is available for download on: epad.uroweb.org “In Noordwijk we spoke to Europe’s national urology societies to, among other things, gauge their interest in recommending national prostate cancer early detection programmes in their home countries, says Van Poppel. “It seems that several countries’ societies are interested in exploring this further. We are going to inventorise each European country’s approach to screening and help where we can.” The informed patient The third prong in the EAU’s approach to reduce mortality and encourage early PCa detection is to inform Europe’s male patients on its benefits and risks. By encouraging awareness in the general population and at-risk men in particular, interest and demand for early detection can be increased. The EAU supports patient advocacy organisations and indeed addresses (potential) patients directly with information campaigns.

August/September 2019

EPAD meeting in the European parliament. From left: Prof. Monique Roobol, Michelle Battye, MEP Lieve Wierinck, Profs. Chris Chapple, Hein Van Poppel, Nicolas Mottet

www.eau20.org

Abstract submission now open! Deadline: 1 November 2019

European Urology Today

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EAU builds stronger ties in Russia 365 Moscow urologists join the EAU as new members Prof. Dmitry Pushkar Co-Chairman EAU Membership Office Moscow (RU)

pushkardm@mail.ru Strengthening ties among urologists around the world are one of the many aspirations that my Co-Chairman Prof. Bernard Malavaud (FR) and I aim to fulfil through the EAU Membership Office. An excellent start for Russia, 365 urologists from Moscow recently joined as en-bloc members and will benefit from the privileges that the EAU membership entails.

High attendance rate in Krasnoyarsk

Patient Information Patient Information (PI) is a growing programme of the EAU which provides a reliable, evidence-based The number of EAU members has steadily increased resources for patients. PI offers easy-to-read text and over the years, thanks to en-bloc agreements with informative videos on various surgical procedures. many national urological societies in and outside These videos are currently being translated into Europe. Through such an agreement, the EAU Russian and will be added soon to the PI website Membership supports urologists throughout their (www.patients.uroweb.org) and PI playlist on EAU’s career through educational programmes, scholarships YouTube channel (https://bit.ly/2yoLeL6). and accredited courses. By providing an international network of peers, the EAU Membership stimulates the Your peers, institutions and national societies knowledge exchange that will advance the field and As you already know, the EAU membership is a boost patient care.

gateway to more opportunities; from increasing one’s knowledge and skills, to linking up with colleagues from around the globe. It creates a ripple effect that can create a cascade of changes that will bolster the field of urology through one valuable EAU member at a time. Know more on how you can enjoy your EAU membership to the fullest via www.uroweb.org/ membership/. Spread the word to your peers and institutions to join the 19,000-strong urological community.

Notable relevant activities The impressive number of urologists from Moscow joining the EAU is one of the many examples of the growing global ties and reach of the EAU. Found below are notable activities aimed at Russian urologists.

European Urology Today Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Dr. D. Karsza, Budapest (HU) 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) Prof. S. Tekgül, Ankara (TR) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL)

ESU Courses Held from 12 to 14 September last year, EAU’s European School of Urology (ESU) organised a course in conjunction with the Eastern Siberian meeting of Impressive turnout of the ESU Course in Yekaterinburg the Russian Society of Urology (RSU) in Krasnoyarsk. Urolithiasis was the central topic of the course since it is one of the most common urological problems in the country. At the end of the course, participants filled out a questionnaire. The results showed that 98% of the participants think that the ESU course helped increase their professional knowledge, and 99% are confident it will improve their patient care. They also expressed satisfaction with the amount of interaction they had with the faculty and they look forward to another ESU course in the future. The ESU held its second course in Russia “Urinary tract infections and erectile dysfunction” during the annual congress of the RSU in 10 November 2018 in Yekaterinburg. The course attracted a high attendance of more than 350 urologists from the European and Siberian parts of Russia, and also from neighbouring countries. This year, the ESU course in uro-oncology was held at St. Petersburg in April; and in September, the ESU course “Modern BPH surgery and Endourology (PCNL and RIRS)” will take place in Rostov-on-Don.

Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL)

Becoming an EAU member now is fast and easy!

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

In a matter of minutes, you can be part of the fast-growing, international community of healthcare professionals from within and beyond Europe. Sign up now to enjoy all the benefits the EAU membership can offer!

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.

Apply for your EAU membership online!

Sample pages of the EAU Guidelines on prostate cancer in Russian

EAU Guidelines The EAU Guidelines offer clinicians the latest frontline scientific data available. To effectively disseminate this vital information, the Guidelines have been translated into multiple languages, including Russian, through a careful and thorough process.

Simply go to www.uroweb.org/membership and click on Membership to receive the best practices and the latest developments in urological research and care. Be an EAU member now!

www.uroweb.org

EAU Membership Office

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European Urology Today

August/September 2019


Seeding Grant Application now open! EAU RF supports highly innovative original research by a junior investigator The EAU Research Foundation (EAU RF) is announcing a new seeding grant, with the aim of supporting highly innovative and original research by a junior investigator. The call for applications is currently open, with deadlines closing on 9 October, 2019 (notification of intent) and 23 October, 2019 (grant application submission). Applicants are invited to submit 1-year research projects with a total budget up to € 25,000. These projects should be designed to collect or strengthen preliminary data and to help the start of clinical trials or other clinical research projects with, possible qualification for future external competitive funding. Preliminary data is not required in the application. Seeding grants will be awarded only in clinical research. Funding for this Call for Application amounts to a maximum of € 50,000 in total for 2 projects. The Applicant must be an academically active researcher/ clinician and member of the EAU and be younger than 40 at submission deadline. The total project period is one year. Successful projects will start in December, 2019 and will end in December, 2020.

The evaluation process Applications that are incomplete or do not comply with the requirements stated in this Call for Applications will not be accepted. Grants will be awarded on a competitive basis. All accepted applications will undergo a two-step selection process. The Review Panel will be composed of the members of the EAU Research Foundation Board and an external expert reviewer, if needed.

"All scientists intending to apply must notify the EAU RF no later than Wednesday, 9 October 2019!" First step Each application will be independently scored by three reviewers. Assignments will be made in order to avoid potential bias (i.e. projects will be not reviewed by their own Division/Center/Institute affiliates). The evaluation criteria for the first step of selection will be the following: • Originality and innovation • Feasibility of the proposed experiments • Potential to be competitive for larger scale funding • Qualification and research experience of the Applicant

Budget The maximum budget request is € 25,000. Funds can be spent on salaries (including the grant holder) and/ or consumables/reagents/subcontracts. Payment of internal facilities/clinical costs is allowed up to € 5,000. The budget description must be accurate and every item must be justified in the appropriate section Reviewers will discuss the scoring results of individual applications and will reach a consensus ranking list. of the application form. Ethical Issues • Research involving human subjects and/or vertebrate animals must comply with the relevant European and national laws. • All funded research must be conducted within the research ethics guidelines of the National Health and Medical Research Council. • Institutional approval by the appropriate ethics committee(s) must be demonstrated prior to release of funds. • Certification that approval has been given should be forwarded with the application or as soon as available. EAU Research Foundation

Second step The top 3-4 applicants will be invited to a personal meeting with the Review Panel, consisting of a brief presentation of their proposal (10 minutes) and a question & answer session. Reviewers will rank the candidates based on the following criteria: • Ability of the Applicant to analyse expected results in the context of a future larger proposal • Balance between innovation and feasibility How to apply Candidates are expected to submit: • Completed application form (.docx) • CV and list of publications

• Copy of passport • Written Project Proposal specifying Background, aims and objectives, project description and a paragraph with future prospects, dissemination and impact. (written project proposal should be max. 5 pages) • Specification of the costs / budget using headlines: laboratory costs, travel costs, personal hours, other expenses. The application form can be found on www.uroweb. org/research or can be requested through the e-mail address below. All details on submission can be found on the application form. Necessary Steps to be taken by the applicant for the seeding grant: 1) All scientists intending to apply must notify the EAU Research Foundation Central Research Office by email (e.spieker@uroweb. org) no later than Wednesday, 9 October, 2019. All applicants will receive a message of receipt. 2) The above-listed documents must be completed according to the specifications above (i.e. project proposal of max. 5 pages) and sent to the EAU RF according to details on the form no later than Wednesday, 23 October, 2019 at 23.59h Central European Summer Time by email (e.spieker@uroweb. org). All applicants will receive a message of receipt. If you miss one of these deadlines 1) or 2), your application can unfortunately not be accepted for evaluation this time. 3) The top 3-4 applicants will be invited for a personal meeting with the Review Panel on Saturday, 16 November, 2019 during EMUC19, held in Vienna. We are looking forward to your applications!

Superpulse Thulium Fibre Laser Are you ready? Dr. Eugenio Ventimiglia Dept. of Urology IRCCS Hospital San Raffaele Milan (IT) eugenio. ventimiglia@ gmail.com

Dr. Luca Villa Member, EAU Section of Urolithiasis Dept. of Urology IRCCS Hospital San Raffaele Milan (IT)

for next-generation laser lithotripsy: the Superpulse Thulium fibre laser (spTFL). It is of utmost importance not to confuse the Thulium fibre laser with the Thulium YAG laser. The former has a fibre laser construct and operates at 1940 nm, as opposed to the solid-state construct of the Thulium YAG laser which operates at 2010 nm.

levels (50mJ) by using smaller fibres (minimum 50µm). All in all, these features can explain the higher dusting efficiency (both in terms of speed and dust production) observed during laboratory-based lithotripsy. Future laboratory and clinical studies will show whether TFL has the potential to become an effective new player in laser intracorporeal lithotripsy.

Therefore, any prior observations or clinical evaluations made on Thulium YAG lasers are not applicable for Thulium fibre lasers.

References

This promising technology offers several advantages over Holmium YAG laser that may extend the boundaries of laser lithotripsy in the near future. We will briefly present and discuss the main characteristics of spTFL in this article.

1. Türk C, Neisius A, Petrik A, Seitz C, Skolarikos A, Thomas K, et al. EAU Guidelines on Urolithiasis 2018. 2. Traxer O, Keller EX. Thulium fiber laser: the new player for kidney stone treatment? A comparison with Holmium:YAG laser. World J Urol. 2019 Feb 6.

Higher ablation efficiency SpTFL is a laser of which the functioning is based on a 10 to 30 m fibre with 10 µm core, doped by active thulium ions and pumped by diode laser. TFL l.villa@hotmail.it emission wavelength is at 1940 nm, more closely matching major water absorption peak in tissue and Despite the superiority of Ho:YAG laser, still considered calculi compared to Ho:YAG (2120 nm, see Figure 1). Therefore, the absorption coefficient of the spTFL the gold standard of endoscopic laser lithotripsy1, the (approximatively 14 mm-1) is more than four-fold need for a more efficient laser lithotripsy prompted higher than Holmium YAG laser (approximatively 3 research to develop new laser sources. mm-1) and results in a higher ablation efficiency in The Ho:YAG laser technology is currently still facing favour of spTFL at equivalent pulse energies. A lower limitations with regard to size of stones amenable to tissue penetration depth may potentially also add to ureteroscopic laser lithotripsy, size of produced the safety profile of the spTFL. fragments and lithotripsy speed2. Although ideal parameters for TFL lithotripsy have not Innovative technology for next-generation laser been determined yet, preclinical laboratory studies lithotripsy gave interesting insights. TFL is capable of working at Absorption spectra of Thulium laser fibre (TmFibre) and Recently, an innovative technology has been explored very high frequencies (up to 2000Hz), very low energy Ho:YAG laser August/September 2019

The EAU’s strategy to encourage timely detection of PCa. . . . . . . . . . . . . . . . . . . . . . . 1 EAU builds stronger ties in Russia . . . . . . . . . 2 EAU RF: Seeding Grant Application now open!. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 EULIS: Superpulse Thulium Fibre Laser. . . . . . 3 EBU section: EBU Examinations: To the leading edge…. . . . 4 European Board of Urology Examination, Warsaw 2019 . . . . . . . . . . . . . . . . . . . . . . . . . 4 A German candidate’s perspective on the FEBU examination. . . . . . . . . . . . . . . . 5 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . 8-11 ESFFU: Can we handle female SUI in a world without meshes?. . . . . . . . . . . . . . . 15 ESUO: Practical questions about nocturia. . . 15 EAU RF PRECISION study: MRI ± targeted biopsy superior . . . . . . . . . . 17 ESU section: Mastering stone management . . . . . . . . . . . 19 MRI knowledge: A crucial key competence for urologists . . . . . . . . . . . . . . 21 Are you the ultimate Challenger to beat at UROBESTT20?. . . . . . . . . . . . . . . . . . 21 My impressions of the ESU-Weill Cornell masterclass. . . . . . . . . . . . . . . . . . . . . . . . . . 22 ART in Flexible: Training the pathway for surgeons . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 ESU course: A great success at ROMURO 2019. . . . . . . . . . . . . . . . . . . . . . . 23 Baltic19 focuses on onco-urology. . . . . . . . . 25 Baltic20: New exciting changes are underway in Minsk. . . . . . . . . . . . . . . . . . . . 25 Award winners review Baltic19. . . . . . . . . . . 25 YUO section: Urological volunteering in Uganda. . . . . . . . 26 A wonderful hands-on training for 3rd year trainees . . . . . . . . . . . . . . . . . . . . . 26 ESU/Weill Cornell Masterclass in Urology in Salzburg. . . . . . . . . . . . . . . . . . . . . . . . . . 27 Update from the EAU Guidelines Office. . . . . 29 Obituary Laurent Managadze. . . . . . . . . . . . 29 EUSP: Visiting Professorship in Reggio Calabria . . . . . . . . . . . . . . . . . . . . . . 31 EAUN section: The inception of EAUN & ANZUNS collaboration . . . . . . . . . . . . . . . . . . . . . . . . 10th anniversary post-EAUN meeting in Aarhus, Denmark. . . . . . . . . . . . . . . . . . . Prostate Cancer Specialist Nursing Role in Brisbane. . . . . . . . . . . . . . . . . . . . . . . . . . Prostate SIG group encompasses role diversity . . . . . . . . . . . . . . . . . . . . . . . . 10th Anniversary Hong Kong College of Urological Nursing. . . . . . . . . . . . . . . . . . . . An ESUN course in your own language: It is possible! . . . . . . . . . . . . . . . . . . . . . . . . Workshop improves skills of nurses in Pakistan. . . . . . . . . . . . . . . . . . . . . . . . . .

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EBU Examinations: To the leading edge… EBU improves quality by adopting digital scoring system We are extremely thankful to everybody involved, especially the Board of Examiners. It was a special event because of several revolutionary changes in the structure of the exam and the way it was run using the latest technology. We aimed at increasing objectivity by introducing competency-based scoring.

Prof. Serdar Tekgül Chairman EBU Examination Committee Ankara (TR)

serdartekgul@ gmail.com The 26th FEBU Oral Examination was held simultaneously in 4 venues. We congratulate the 357 successful candidates who received the FEBU title, a mark of excellence in urology. This was a special event for the candidates as for many it marked the end of their long training process.

Polish examination Warsaw European examination Warsaw Turkish examination Istanbul Hungarian examination Budapest TOTAL

Candidates 58 261 41 11 371

A digital system The use of iPads for scoring provides us with real-time data which enables us to monitor the exams at the different centres instantly. We had statistical data on the performance of 8 cases at the different centres, which allowed us to judge the level of difficulty and scoring discrepancies before final approval of the scores.

Switching to a digital system will help us record all relevant data to make a reliable comparison of exams, centres, examiners and cases in PASS Examiners the future. This will certainly contribute to the ongoing 56 35 improvement of our exam. 252 68 38 14 It is almost impossible to run a 11 6 perfect assessment in a surgical 357 123 profession; yet, we try hard to

improve the quality and efficiency of our examinations every year. With the instalment of our new system, improvements will be easier and changes will be decided based on reliable data.

“EBU is proud of its long history as an institution conducting assessments of European urology training and will continue to be a leading organisation in Europe with continuous upgrading.” Example of current audiovisual material

Higher level We are much happier and content that we have taken large steps forward this year and EBU oral exams have reached an even higher level in context, structure and application for a large group of candidates, using different languages at different centres around Europe. EBU is proud of its long history as an institution conducting assessments of European urology training

and will continue to be a leading organisation in Europe with continuous upgrading. Meanwhile the number of FEBUs worldwide has grown to 5,933. EBU is planning to carry its expertise and reputation to international grounds and is preparing to run exams outside of Europe starting from 2020.

European Board of Urology Examination, Warsaw 2019 A remarkable achievement! Prof. Rien Nijman Previous Chair Examination Committee Former EBU president Groningen (NL) riennijman@live.nl The very first European Examination in Urology was organised in 1992. The day before the 10th Annual EAU Congress in Genua, a multiple choice examination covering the whole field of urology was taken by 253 participants. It was considered a milestone in European urology.

The oral examination Over the years, the exam has evolved into a well-recognised oral and written examination. The oral part was added in 1993 and done the day after the written part. The answer sheets (filled out by hand) were taken to the Erasmus University in Rotterdam to be scored in the evening. The first years the exam took place in a congress centre near Leiden (NL). The drive to Rotterdam would normally take a little over half an hour, but as I got stuck in a traffic jam it took me almost 3 hours (and almost all night) to get the job done before the next morning. The oral exams took place the next day and consisted of 3 structured clinical scenarios during a 55-minute session with one examiner. At the end of the day all results were discussed, including the results from the written part. We consulted many people in order to prepare the examinations, including educationalists and representatives from the American Board of Urology.

The first years At that time the examination did not include an oral part. The year before a special meeting was organised National exam locations in Palermo (IT) to translate the English questions (provided by the official delegates to the UEMS section A few years later the oral and written parts were split up: the written part could be done in a central of urology) into 9 different languages. location in each member country, while the oral part continued to be organised once a year in a European city.

Experienced EBU members preparing the translation

I remember that we were ‘locked up’ in the basement of the hotel. A group of secretaries, arranged by our host Professor Pavone-Macaluso, was there to assist us. We all used a desktop computer. Part of the job was the translation, but at the same time we had lively discussions about the format and relevance of the questions. It took us two and a half days to complete the work. A remarkable sense of comradery developed during those days, which stayed with us the rest of the time I was involved in the EBU.

The first EBU exam in 1992

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Over the years we have had many discussions about the language: the EBU offered the examination in 9 different languages, both the written and the oral exam. Other European specialty boards only offered the exam in English. Due to the increase in the number of participating countries it proved impossible to keep increasing the number of languages. The EBU exam is offered in the languages of the countries where it is part of the national specialty qualification, provided that the translation of the questions is done by the national association (e.g. Poland and Hungary). FEBUs per country - Top 15 Germany Poland Spain Italy Greece Turkey Austria France United Kingdom Switzerland Portugal The Netherlands Belgium Hungary Sweden

789 750 589 446 407 301 283 281 268 230 217 192 177 158 103

Participants show their well-deserved diplomas

At the moment the written part is done in English by most candidates and the oral part is still offered in the original 9 different languages + the languages of the countries in which the exam is mandatory for accreditation. It is still considered too difficult for many participants to do the oral exam in English only, as is done by the European Board of Paediatric Urology. It would, however, make the logistics of organising such an exam much easier. Audiovisuals The inclusion of audiovisuals in the examination has been an issue for many years. Once the written examination was converted into an online examination it became much easier to include pictures, X-rays etc. The quality of paper prints was an issue now and then; the digital world makes life much easier. The same goes for the oral examination. The structured clinical cases were always prepared in a paper format, including some prints of relevant X-rays, urodynamic curves and surgical procedures, but the quality of the printed material was not always optimal.

Nowadays, the scoring process is done using the iPad, whereas until last year we had to fill out special forms, which had to be converted into final scores for each individual candidate and examiner. The scores are now automatically included in the database following each session and the results are readily available. Examiners and observers Over the last couple of years each exam was conducted by two people: an examiner and an observer, who is responsible for a fair and objective process. Considering that each candidate is examined by 2 examiners for 55 minutes, you can calculate the total number of examiners and exam rooms that is required to organise this exam. All examiners conduct 8 exams per day. After the certification ceremony a well-deserved dinner in a typical Warsaw restaurant was much appreciated by all of us. Overall, the event was very well organised. Considering all innovations that were introduced in the past decades I can only conclude that the EBU examination has evolved into a mature and very professional institution.

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

Thursday, 12 and Friday, 13 March 2020 Saturday, 27 June 2020

www.ebu.com August/September 2019


A German candidate’s perspective on the FEBU examination Travelling to Warsaw can be quite adventurous Dr. Friederike Haas Klinikum Leverkusen Dept. of Urology Leverkusen (DE)

f.stachuletz@ googlemail.com The first time I heard about the EBU was in my practical year at the end of my study medicine. At first, I was not sure what it meant. However, over the last two years, several colleagues told me about the EBU and thus I became better informed. I work as a urologist in a superregional clinic in Northrhine Westfalia where we aim at providing excellent urological care to our patients according not only to German but also to European guidelines. In 2018, at the Annual EAU Congress in Copenhagen (DK), I attended an EBU session, and inspired, I asked my colleague and friend Mareile to take the examination together. Since our clinical co-director and a few colleagues have the FEBU qualification, we were encouraged to get the title as well, in order to expand our knowledge in clinical work in a European context. We decided to subscribe to EBU examination in 2018 because we both passed the German exam as professional urologists that year and felt it was the best time for us to get this additional qualification too. We proudly passed the Written Examination and

were delighted to get the chance to also participate in the Oral Examination in Warsaw (PL). Trip to Warsaw The journey to Warsaw turned out to be quite adventurous; when we arrived at Düsseldorf airport Friday morning, it turned out that our flight was cancelled. Since the airline was unable to book us on another flight to Warsaw, we decided to take the train via Berlin to Warsaw. We would have arrived in Warsaw late that Friday evening… if the train to Berlin did not have technical problems. Due to a 40-minute delay we missed our connecting train in Berlin and again had to plan another route to Warsaw. On top of that the night trains were fully booked, but we were lucky to get the last tickets for a night bus. Fortunately, we got some sleep on the bus and the bus driver kept his promise to arrive in Warsaw early Saturday morning. We took a cab to the hotel, got a shower and some breakfast and went straight to our examination session that started at 09.00. The examination It was a pleasure to communicate with the EBU organisation, as they really helped us to make the best of the whole situation. They even provided us with two free rooms in the hotel where the examination took place, to recover from the long journey. The examination was perfectly organised and all the staff members were very competent and friendly. The oral exam lasted one hour, during which we discussed three clinical cases with two examiners. The atmosphere was pleasant and professional. At

Mareile Frohmüller (left) and Frederieke Haas (right)

first, we were asked to explain our clinical approach of the case, followed by questions we had to answer. The questions were quite specific sometimes, but in summary the exam was fair and the cases realistic.

journey and the examination, which is always a little stressful. We had a relaxed evening in Warsaw before we got back home the next day. This time we were ‘only’ two hours late.

A great success After the examination we had to wait in the hotel with the other participants until the entire session was over. In the evening we got the results: we both passed. Fortunately, there were only few candidates who did not pass.

Proud to be FEBU We are happy and proud of our decision to take the examination. The FEBU title is a proof of qualification for us; it means that we are providing good clinical practice for our patients. We would certainly recommend others to take the examination as It is important to have a European comparison and know that your standards in urology are the same as the ones all over Europe. Finally, it's a mark of quality in our curricula vitae.

After the positive results, we took a cab to the city centre and finally arrived in the apartment we had booked in advance. We were exhausted from the

Successful candidates EBU Oral Examination 2019 European Exam in Warsaw Nawar Abbara, Germany Ahmed Magdy Abdel Aal, Austria Ali Abdullah, France Mohamed Ismat Abdulmajed, United Kingdom Rami Abualsuod, Germany Jose Francisco Aguilar Guevara, Spain John Ronald Åkerlund, Sweden

Janis Auzinš, Latvia Omar Mohammed O Bahassan, Germany Isabel Barceló Bayonas, Spain Jens Peter Bedke, Germany Arben Belba, Italy Begoña Beneto Alducin, Spain Juraj Beniak, Czech Republic Jan Berx, Belgium

Daniel Camacho Rovira, Spain Juan Pablo Campos Hernández, Spain Jorge Caño Velasco, Spain Fabio Castiglione, United Kingdom Carlos Castillo Pacheco, Spain Jacqueline Coenen, The Netherlands Ruben Cremers, The Netherlands François Crettenand, Switzerland

Eva Erne, Germany Johannes Falke, The Netherlands Rainer Fenkart, Austria Álvaro Amancio Fernández Alcalde, Spain Esaú Fernández Pascual, Spain Cristina Ferreiro Pareja, Spain Lauri Flöjt, Finland Hendrik-Jan Florin, Belgium

Waseem Akhter, United Kingdom Mhd Yasir Al Nouilati, Germany Ghanem Albasha, Germany Eduardo Mariano Albers Acosta, Spain Simone Albisinni, Belgium Salahedein Alkeilanei, Germany Atieh Almahdawi, Germany Majdi Abdallah Mohammad Alnatour, Germany

Reem Betari, France Felix Blasl-Kling, Germany Katharina Böhm, Germany Malin Böös, Sweden Johannes Böttge, Germany Magdaléna Božiková, Slovakia Ricardo Brime Menéndez, Spain Anna-Lena Katarina Brink, Sweden

Radu Croitoru, United Kingdom Adriana Cseriová, Slovakia Mercè Cuadras Solé, Spain Roderick De Bruijn, The Netherlands Stefanie De Prycker, Belgium Leticia De Verdonces Román, Spain Aleksandar Dimitrov, Germany Joana Cândida Dinis Paquim Alfarelos, Portugal

Raquel Forcén Condón, Spain Jan Franken, Belgium Mareile Frohmüller, Germany Maria Furlan, Italy Marc Alain Furrer, Switzerland Ahmed Wagdy Mohamed Gaafar, Germany Marina Garcés Valverde, Spain Sotirios Gatsos, Greece

Mahdi Zuhair Faeq Alqaisi, Germany David Philipp Josef Ambühl, Switzerland Iulia Madalina Andras, Romania Pontus Ola Gunnar Andrén, Sweden Christos Antonopoulos, Greece Mikael Anttinen, Finland Luis Fernando Arenas da Silva, United Kingdom Grégoire Assenmacher, Belgium

Tim Brits, Belgium Oscar Brouwer, The Netherlands Sarah Hjartbro Bube, Denmark Gonzalo Bueno Serrano, Spain Meelan Bul, The Netherlands Thomas Burtscher, Austria Victor Fernando Calderon Plazarte, Belgium Jehanne Calvès, France

Christoph Dippelreiter, Austria Florian Alfons Distler, Germany Sarah Dormeus, Belgium Chantal Ducret, Italy Till Eichenauer, Germany Ibrahim El Younsi, Germany Kaisa Erkkilä, Finland Anna Franziska Erl, Germany

Christos Georgiadis, Greece Faisal Iftikhar Ahmed Ghumman, United Kingdom Philipp Gild, Germany Pedro José Giral Villalta, Spain Cristina González Ruiz de León, Spain Ward Goossens, The Netherlands Evangelia Goulimi, Greece César Jesús Gracia Francis, Spain

August/September 2019

European Urology Today

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Successful candidates EBU Oral Examination 2019

6

Alexandra Gregušová, Czech Republic Christer Groeben, Germany Bernhard Grubmüller, Austria Tanja Gschliesser, Austria Friederike Haas, Germany Benjamin Dietrich Hager, Germany Ulrike Hähnlein, Germany Masoud Haji Mhd, Germany John Hartell, Sweden Verena Hauser, Austria Roman Herout, Germany Ernesto Herrero Blanco, Spain Manuel Hevia Palacios, Spain Lucas Andreas Hirner, Germany Robin Hoendervangers, The Netherlands Toni Peter Benedikt Huber, Germany Markéta Hulová, Czech Republic Gallus Beatus Ineichen, Switzerland Wissam Janjal, Germany Florian Jansen, The Netherlands Maximilian Janssen, Germany Cordula Annette Jilg, Germany

Haitham Mustafa, Germany Ferenc Nagy, Finland Salam Najjar, Romania Mathilde Nedelec, France Julia Esther Neuenschwander, Switzerland Jan Novák, Czech Republic Peter Martin Nowak, Germany Mohamed Ismail Nussir, Czech Republic Martin Nyberg, Sweden Karl Erlingur Oddason, Sweden Pedro Daniel Oliveira Rocha E Costa, Portugal Víctor Parejo Cortés, Spain Dinka Pavicic Dobrev, Germany Stefanos Pavlakis, Greece Luka Penezic, Croatia José Carlos Pereira Santos, Portugal Javier Pérez Ardavín, Spain Andry Alfred Perrin, Switzerland Ingrid Peterschinek, Austria Alberto Piller Hoffer, Switzerland Pierre Pillot, France Tibor Pinczés, United Kingdom

Sijntje Van Deun, Belgium Charles Van Praet, Belgium Yavor Vaptsarov, Austria Rodrigo Vasquez Soares Coelho Gouveia, Czech Republic Consolación Velarde Muñoz, Spain Guillermo Velilla Díez, Spain Angelo Maria Viggiano Romano, Spain Wolfgang Hermann Paul Moritz Von Büren, Germany Martin Von Ribbeck, Germany Robert Blazej Wachala, Germany Alida Cornelia Weidenaar, The Netherlands Freek Werdmölder, The Netherlands Lukas Wernli, Switzerland Laura Wiemer, Germany Riman Yaghchi, Germany Musaab Yassin, United Kingdom Tariq Yousef, Germany Maria Zerva, Greece Georgios Zervopoulos, Greece Yefang Zhu, The Netherlands Kristin Zimmermann, Germany

Piotr Paweł Merena Wojciech Michalak Rafał Mieleszko Adam Andrzej Niesluchowski Ewa Katarzyna Niezabitowska Adam Piotr Nowakowski Michał Łukasz Olszewski Adam Ostrowski Maciej Karol Oszczudlowski Piotr Wiesław Piatek Adam Marcin Pietrowski Krzysztof Jan Ratajczyk Sławomir Piotr Salwa Mariusz Ireneusz Skoneczny Wojciech Jerzy Skrodzki Emil Sledz Krzysztof Stanisław Soltys Jan Jacek Sporny Piotr Supronik Gabriel Surdacki Wojciech Swierczynski Jakub Tomasz Szmer

Claude Jungels, Spain Georghios Kallis, Greece Andreas Katsios, Switzerland Martin Kivi, Estonia Mohammad Wael Kodmany, Germany Maximilian Johannes Königbauer, Germany Konstantinos Kostakopoulos, Greece Boris Košuta, Slovenia Laura-Maria Krabbe, Germany Ulrich Alexander Krafft, Germany Jorien Tannette Krediet, Germany Ashish Kumar, United Kingdom Julien Kushner, Germany Janna Marie Lammers, The Netherlands Lauri Laru, Finland Eva Maria Lausenmeyer, Germany Jana Lederleitnerová, Slovakia Sami Ramzi Leyh-Bannurah, Germany Riccardo Lombardo, Italy Agostinho José Lopes Cordeiro, Portugal Ferdinand Luger, Austria Benjamin Lyttwin, Switzerland Heleen Maes, Belgium

Elvira Polo Alonso, Spain Barbora Polová, Czech Republic Paula Ponce Blasco, Spain Hugo Manuel Pontes Antunes, Portugal Stanford Putman, Switzerland Juliane Putz, Germany Francesca Quadrini, Italy Mohammad Rahimi Shahmirzadi, Austria Isabell Rektorik, Switzerland Tiago Manuel Ribeiro De Oliveira, Portugal María Rodríguez Monsalve Herrero, Spain Fiorella Lizzeth Roldán Chávez, Spain Ana Ángeles Román Martín, Spain Astrid Marijke Paul Roosendaal, Switzerland Robert Benjamin Rosenblatt, Sweden Mercedes Ruiz Hernández, Spain Roman Rusman, Estonia Ester Asunción Ruz Saunie, Spain Árni Saemundsson, Sweden Juan José Salamanca Bustos, Spain Jörg Schachtner, Austria Katrin Schlack, Germany Daniel Schlager, Germany

Valentin Zumstein, Switzerland

Karol Unifantowicz Damian Widz Jacek Piotr Wilamowski Łukasz Maciej Wojtowicz

Giuseppe Magistro, Germany Jenny Magnusson, Sweden Nina Mahne, Austria Thomas Andreas Maier, Germany Kristina Maier, Germany Cristóbal Marchal Escalona, Spain Julian Marcon, Germany Ahmed Marie, Germany Alberto José Marques Da Silva, Portugal Daniel José Marques Matos De Oliveira Reis, Portugal Paul Henri Nicolas Martel, Switzerland David Alejandro Martín Way, Spain Laura Martínez Cayuelas, Spain Markéta Matejková, Czech Republic Simone Maurelli, Italy Olga Mayordomo Ferrer, Spain Daniel Miller, Austria Enric Miret Alomar, Spain Ninja Frederike Molfenter, Germany Marta Molina Bravo, Spain Dana Mueller, Germany Pierre Munier, France

Gina Schlumberger, Germany Vanessa Anke Schneider, Germany Martje Schotman, The Netherlands Christoph Schregel, Germany Rie Brandt Seifert, Denmark Arnau Serra Deola, Spain Michail Siegel, Germany Pedro Miguel Simões De Oliveira, Portugal Husein Slaiman, Germany Charlotte Mieke Soenens, Belgium Karl Spiteri, Malta Thomas Georges Antoine Sprockeels, Belgium Jefim Stepanow, Switzerland Fleur Story, France Julian Struck, Germany Michał Sut, United Kingdom Dorothee Hélène Tiedje, Germany Christian Torbrand, Sweden Leonardo Tortolero Blanco, Spain Christopher David Tschung, Switzerland Tom Tuytten, Belgium Angel Daniel Urbina Lima, Spain Tim Van der Sluis, The Netherlands

Adrian Ludomir Czekaj Krzysztof Robert Czurak Tomasz Drabarek Krzysztof Julian Eicke Grzegorz Gacki Michał Krzysztof Gierek Katarzyna Danuta Gronostaj Dawid Bernard Halek Adam Maksymilian Halinski Mateusz Antoni Józefczak Maciej Michał Jurczak Mateusz Jan Kadlubowski Marek Kasprowicz Adam Kolodziejczyk Ignacy Piotr Korzelik Marcin Wiesław Kosowski Filip Ryszard Kowalski Krzysztof Karol Kubicki Marcin Kuligowski Tomasz Mateusz Kupski Piotr Kutwin Marcin Piotr Malinowski Michał Andrzej Matuszewski

European Urology Today

Hungarian exam in Budapest Dan Hadrian Dance Máté Ganyecz Csaba Halász Péter Liptay Tünde Mezei Zoltán Monostori Donát Péter Sarlós János Szalontai Tamás Széll Adél Ágnes Szikszai László Vrecenár Polish exam in Warsaw Adrian Łukasz Abramczyk Jan Zygmunt Adamowicz Marek Andrzej Bar Andrzej Baranowski Michał Janusz Bielski Jarosław Chojnacki Artur Ryszard Cholewa

Turkish exam in Istanbul Ergün Alma Ahmet Asfuroglu Mehmet Kazım Asutay Hüseyin Besiroglu Kaan Çömez Mesut Berkan Duran Mehmet Remzi Erdem Batuhan Ergani Kemal Ertas Hakan Bahadır Haberal Nurullah Hamidi Ruslan Jafarov Nejdet Karsiyakali Övünç Kavukoglu Ahmet Keles Mert Kiliç Harun Kiliççalan

Murat Can Kiremit Faruk Küçükdurmaz Musab Ali Kutluhan Emin Mammadov Cihat Özcan Harun Özdemir Kubilay Sabuncu Murat Sahan Aytaç Sahin Ilker Fatih Sahiner Sercan Sari Metin Savun Kamil Gökhan Seker Mehmet Giray Sönmez Ahmet Tahra Emre Tokuç Tuncay Toprak Mehmet Mazhar Utangaç Sedat Yahsi Mustafa Yüksekkaya Alpaslan Yüksel

August/September 2019


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

Oliver.Hakenberg@ med.uni-rostock.de

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

Case study No. 61

Discussion points: 1. How should the bulbar urethra be assessed? Ultrasound? MRI? Intraoperative exploration? 2. How should the urethral reconstruction be done? And should it be a one- or two-stage procedure? 3. How can the erectile dysfunction be managed? 4. What should be done about the fertility issue?

This 33-year-old Libyan soldier suffered a blast injury during the civil war in 2011 which resulted in the loss of the left testicle together with a urethral injury. Meatus and distal penile urethra are normal up to the penile base (fig.1). The patient has normal continence and urinates from a perineal urethrostomy. He also complains of erectile dysfunction since the trauma. He is not married yet and wishes to father his own children.

Case study No. 62 A 24-year-old Arabian man was referred with the diagnosis of Zinner syndrome for further treatment. Zinner syndrome is a rare congenital syndrome resulting from an abnormality of the Wolffian duct defined as the triad of unilateral renal agenesis , ipsilateral seminal vesicle cyst and ipsilateral obstruction of the ejaculatory duct. The patient complained of intermittent left lower abdominal pain which is compatible with the clinical picture of this syndrome. An MRI investigation (fig.1 a-c) led to the diagnosis. On all images, the left kidney was absent. The patient wanted treatment but was concerned about fertility. A sperm count was normal.

Case provided by Dr. Amin Bouker, Dept. of Urology, Clinique Taoufik, Tunis, Tunisia. email: aminbouker@gmail.com

Figure 1

Definitely a 2-stage procedure Comments by Dr. Paul Anderson Dudley (UK)

if unresponsive, give intracavernosal prostaglandin E1. If this does not work, a penile implant is the last resort.

from the meatus since there will be no normal ejaculatory propulsion. In some cases, the semen has to be milked out of the reconstructed urethra manually. The issue of semen deposition therefore has to be discussed with the couple.

4. Ejaculation and intravaginal semen delivery will be an issue after urethral reconstruction. Tubular repair will lead to the semen flowing out slowly 1. Flexible cystoscopy is quite adequate to assess the residual bulbar urethra and to make sure that it is healthy, has a good width and whether sphincter function is adequate. Abnormalities on flexible cystoscopy might require a urethrogram or MRI. 2. With my personal experience with blast injuries, I favour a two stage approach. This particular man apparently has good surrounding soft tissue to support and cover a urethroplasty but often this is not the case. Here, I recommend a two stage buccal mucosal graft urethroplasty, splitting the scrotum at the first procedure and place a buccal graft of about 2.5 cm width. At the second procedure, after a two layer tubularisation of the buccal graft urethral replacement, the scrotum is reconfigured over the repair to provide good soft tissue cover. Single stage tubes do less well and scrotal skin for a tubular flap is likely to lead to anastomotic strictures and would involve hair-bearing skin poorly suited for the urethra. 3. With blast injuries, damage to cavernosal nerves is likely but not certain. I would check testosterone levels and try PDE5 inhibitors and,

Case study No. 61 continued Flexible cystoscopy showed normal sphincter contraction and no proximal urethral abnormalities. Dissection between the two urethrostomies showed no residual urethra (fig. 1). Due to an unusual large oral cavity in this man, we only needed a single buccal mucosa graft that was sutured onto the cavernous bodies. Six months later, there was some contraction of the graft but soft surrounding skin (fig. 2). The graft was tubularized (fig. 3) and Dartos flaps were brought on to the reconstructed urethra (fig. 4). The catheter was removed after three weeks. Micturition was normal after that. There was no response to PDE5 inhibitors but good erections with intracavernosal PGE1 injections. Due to the loss of the bulbar urethra there is hypospermia and artificial reproductive techniques will have to be used.

Figure 1

Figure 4 Figure 1 a-c

Discussion points 1. Are further investigations needed? 2. Are there other diagnoses that should be considered? 3. What treatment would you advise?

Figure 3

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

Figure 4

European Urology Today - Manuscript Submission European Urology Today, the EAU newsletter is published five times each year. Its main role is to function as the European Association of Urology’s bulletin, as a platform for the EAU to present their meetings, the various sections and offices, as well as discuss general issues of interest to their members. Another important objective is to have a platform that allows for the inclusion of a range of scientific papers which are considered of interest to a large readership.

Editorial Policy Manuscripts are submitted with the explicit understanding that the decision to include material will be made by the Editor-in-Chief in conjunction with his Section Editors. All authors have read and approved the manuscript subject to submission. It is the author’s responsibility to obtain permission to reproduce any parts of other publications (i.e., tables, figures). Precise reference to the original work must be given in the legends. Statements in articles or opinions expressed by any contributor in any article are not the responsibility of the editors or the publisher. The publisher is not responsible for the loss of manuscripts through circumstances beyond their control.

August/September 2019

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Manuscripts and questions regarding manuscript submission may be directed to: European Urology Today Editorial Office E-mail: EUT@uroweb.org Submission of an article signifies the author’s consent to transfer copyright to the EAU, publisher of European Urology Today.

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European Urology Today

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Key articles from international medical journals Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk

Low sexual desire in middleaged men: relevant factors Although low sexual desire is one of the most common sexual dysfunctions in men, there is a lack of studies investigating associated factors in large, population-based samples of middle-aged men.

tachycardia. The secondary outcome was any hospitalization or visit for myocardial infarction (MI) or stroke. Patients receiving mirabegron were matched with up to 4 patients receiving other OAB agents (anticholinergic agents) on age (±3 y), sex, index date (±3 mo), and high-dimensional propensity score (HDPS; within 0.2 SD). Characteristics were compared between groups using standardized differences and used Cox proportional hazards regression models accounting for the matched nature of the data to compare mirabegron with other agents.

Mirabegron was not associated with an increased risk of MI or stroke compared with other OAB drugs

The investigators matched 16,948 patients who received mirabegron to 21,870 patients who received of other OAB drugs. The median age was 76 The aim of this trial was to survey the prevalence of (interquartile range, 71-83), and 64.9% were female low sexual desire in a population-based sample of (25 189). Hypertension (30,393 [78.3%]) and diabetes 45-year-old German men and to evaluate associations (13,757 [35.4%]) were highly prevalent in the cohort. with a broad set of factors. The 1-year cumulative incidence (adjusted for person-years) of arrhythmia or tachycardia events Data were collected between April 2014 and April was similar between exposure groups (3.6% for 2016 within the German Male Sex-Study. Participants mirabegron vs. 3.8% for other OAB drugs; HR, 0.93; were asked to fill out questionnaires about 6 95% CI, 0.80-1.09; Table 2). Mirabegron was not sociodemographic, 5 lifestyle, and 8 psychosocial associated with an increased risk of MI or stroke factors, as well as 6 comorbidities and 4 factors of compared with other OAB drugs (HR 1.06; 95% CI, sexual behaviour. Simple and multiple logistic 0.89-1.27). regressions were used to assess potential explanatory factors. The findings of this study suggest that mirabegron was not associated with a higher risk of CV events compared with other treatments. These results appear The authors found a notable to support current prescribing patterns and give a balanced view of real-world safety. prevalence of low sexual desire

in middle-aged men and detected associations with various factors 12,646 men were included in the analysis, and prevalence of low sexual desire was 4.7%. In the multiple logistic regression with backward elimination, 8 of 29 factors were left in the final model. Men having ≥2 children, higher frequency of solo masturbation, perceived importance of sexuality, and higher sexual self-esteem were less likely to have low sexual desire. Premature ejaculation, erectile dysfunction, and lower urinary tract symptoms were associated with low sexual desire. Low sexual desire is common in middle-aged men, and associating factors that can potentially be modified should be considered during assessment and treatment of sexual desire disorders.

Source: Factors associated with low sexual desire in 45-year-old men: Findings from the German male sex study. Meissner VH, Schroeter L, Köhn FM, Kron M, Zitzmann M, Arsov C, Imkamp F, Hadaschik B, Gschwend JE, Herkommer K. J Sex Med. 2019 Jul;16(7):981-991. doi: 10.1016/j. jsxm.2019.04.018. Epub 2019 Jun 10.

Investigating the relationship between mirabegron and cardiovascular adverse effects Recently, mirabegron, the first β3-adrenoceptor agonist, has more often been prescribed to treat overactive bladder (OAB) than antimuscarinic agents. The β3 agonist medications have limited adverse effects compared with antimuscarinic agents. However, β3-adrenoreceptors are associated with increases in contractile force and reductions in inotropic effects, actions which raise concerns of cardiovascular (CV) adverse effects. The authors conducted a population-based cohort study to evaluate the risk of cardiac arrhythmias and other CV events in a population of patients of 66 years and older receiving mirabegron. They used health care administrative data from 38,818 patients of 66 years or older who initiated treatment between June 1, 2015, and March 31, 2017. New users of OAB treatments were identified and followed up for 1 year or until they discontinued or switched therapy. The primary outcome was any hospitalization or emergency department visit for arrhythmia or Key articles

8

Source: Association of mirabegron with the risk of arrhythmia in adult patients 66 years or older-a population-based cohort study. Tadrous M, Matta R, Greaves S, Herschorn S, Mamdani MM2, Juurlink DN, Gomes T. JAMA Intern Med. 2019 Jul 15. doi: 10.1001/ jamainternmed.2019.2011. [Epub ahead of print]

5α-reductase inhibitors, time to diagnosis and mortality in prostate cancer 5α-Reductase inhibitors (5-ARIs), commonly used to treat benign prostatic hyperplasia, reduce serum prostate-specific antigen (PSA) concentrations by 50%. The association of 5-ARIs with detection of prostate cancer in a PSA-screened population remains unclear. The trial was initiated to test the hypothesis that prediagnostic 5-ARI use is associated with a delayed diagnosis, more advanced disease at diagnosis, and higher risk of prostate cancer-specific mortality and all-cause mortality than use of other or no PSAdecreasing drugs. This population-based cohort study linked the Veterans Affairs Infrastructure with the National Death Index to obtain patient records for 80,875 men with stage I-IV prostate cancer diagnosed from 2001 to 2015. Patients were followed up until death or December 31, 2017.

adjusted elevated PSA to diagnosis was significantly greater for 5-ARI users than 5-ARI nonusers (3.60 [95% CI, 1.79 - 6.09] years vs.. 1.40 [95% CI, 0.38 3.27] years; p < .001) among patients with known prostate biopsy date. Median adjusted PSA at time of biopsy was significantly higher for 5-ARI users than 5-ARI non-users (13.5 ng/mL vs.. 6.4 ng/mL; p < .001). Patients treated with 5-ARI were more likely to have Gleason grade 8 or higher (25.2% vs. 17.0%; p < .001), clinical stage T3 or higher (4.7% vs. 2.9%; P < .001), node-positive (3.0% vs. 1.7%; p < .001), and metastatic (6.7% vs. 2.9%; p < .001) disease than 5-ARI nonusers. In a multivariable regression, patients who took 5-ARI had higher prostate cancer-specific (subdistribution hazard ratio [SHR], 1.39; 95% CI, 1.27-1.52; p < .001) and all-cause (HR, 1.10; 95% CI, 1.05 - 1.15; p < .001) mortality. Results of this study demonstrate that prediagnostic use of 5-ARIs was associated with delayed diagnosis and worse cancer-specific outcomes in men with prostate cancer. These data highlight a continued need to raise awareness of 5-ARI-induced PSA suppression, establish clear guidelines for early prostate cancer detection, and motivate systemsbased practices to facilitate optimal care for men who use 5-ARIs.

Source: Association of treatment with 5α-reductase inhibitors with time to diagnosis and mortality in prostate cancer. Sarkar RR, Parsons JK, Bryant AK, Ryan ST, Kader AK, McKay RR, D'Amico AV, Nguyen PL, Hulley BJ, Einck JP, Mundt AJ, Kane CJ, Murphy JD, Rose BS.

tebj@medisin.uio.no estimated blood loss (EBL) of 200 ml, median hospital stay of 1 day and median catheter removal of 7 days. Pelvic lymphadenectomy was performed in 78% of the patients, with a median of 8 nodes removed. An overall of 8.1% of complication rate was reported, involving Clavien II only complications. Positive margins were recorded in 28% of the patients, 19% in grade group ≤ 2 and 55% in grade group > 3. The authors concluded that the SP-RALP is as safe and effective as the multiport approach. They also emphasised that even in the most experienced hands of robotic surgeons a learning curve is necessary to reduce operation time, positive surgical margins and the EBL.

Source: Initial experience with da Vinci singleport robot-assisted radical prostatectomies. Agarwal DK, Sharma V, Toussi A, Viers BR, Tollefson MK, Gettman MT, Frank I. Eur Urol. 2019 Apr 19. pii: S0302-2838(19)30280-5. doi: 10.1016/j.eururo.2019.04.001. [Epub ahead of print]

JAMA Intern Med. 2019 May 6. doi: 10.1001/ jamainternmed.2019.0280. [Epub ahead of print]

Single-port radical prostatectomy: A new standard to come? Radical prostatectomy is one of the major urological surgery procedures performed worldwide. Development of new technologies and techniques has been carried out continuously. Robotic-assisted laparoscopic prostatectomy (RALP) has replaced conventional laparoscopic and/or open radical prostatectomy in some countries. Techniques to improve outcomes have included the reconstruction of the Denonvillier’s fascia (the so-called Rocco’s stitches), the Retzius-sparing approach or even the revival of the transperineal RALP. The latest and most awaited novelty involves the single-port robot-assisted laparoscopic prostatectomy (SP-RALP). The initial series have been published in the last few months, after the Food and Drug Administration approved the new Da Vinci single-port robotic platform for urological procedures last year. The largest of the cohorts published included 49 patients operated by three experienced surgeons, in the framework of an IDEAL phase 2a study to show safety and feasibility of the procedure. All surgeons were trained in cadaveric and animal models in order to familiarise them with the new robotic platform.

Results of this study demonstrate that prediagnostic use of 5-ARIs was associated with delayed diagnosis and worse cancer-specific outcomes in men with prostate cancer

In the video attached to the article, all surgical steps are described, starting with the insertion of the single-port trocar and the assistant. Two important technical variations were highlighted. First, after few cases, the authors abandoned the use of the gel-point system, fitting the single-port trocar directly into the mini-laparotomy (2.5 cm). Second, they performed some of the RALP with the Retzius-sparing technique. Given the versatility of the SP daVinci platform, they could position the camera at 6 o’clock which facilitated a better anterior vision by increasing the degree of manoeuvrability of the flexible camera arm. Accordingly, the surgeons’ impression was that the new robotic platform may facilitate the Retziussparing technique.

The primary outcome was prostate cancer-specific mortality (PCSM). Secondary outcomes included time from first elevated PSA (defined as PSA ≥ 4 ng/mL) to diagnostic prostate biopsy, cancer grade and stage at time of diagnosis, and all-cause mortality (ACM).

In the video attached to the article, all surgical steps are described, starting with the insertion of the single-port trocar and the assistant.

Median (interquartile range [IQR]) age at diagnosis was 66 (61-72) years; median [IQR] follow-up was 5.90 (3.50 - 8.80) years. Median time from first

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

Intra-operative outcomes were in line with literature, with median operative time of 161 minutes, median

Artificial Intelligence: ‘helper’ or ‘competitor’ of future urological practice? In the last 3 decades, a significant proportion of urological publications was focused on statistical models that could predict outcomes, based on linear relationships between independent variables and events. This has significantly supported the decisionmaking of urologists in many fields of our practice, especially in onco-urology. In the last years, advances in technology have made it possible to programme computer machines to learn from existing data, to process them without making statistically-based assumptions, and finally to be able to make predictions about new unseen data. This process is better known as Artificial Intelligence (AI), and its applications are quickly expanding in the urology practice.

Overall, the authors found that AI outperformed conventional statistical models in 71.8% of the studies analysed... A group of British scholars has recently performed a systematic review to explore in which fields of urology AI has been tested and eventually to compare its performances with the traditional statistic predictive models. After screening and reviewing 111 publications, the authors found that AI has been widely tested in urology, especially in the field of uro-oncology (prostate, urothelial and renal cancer) to predict diagnosis, prognosis and other clinical outcomes (e.g. hospital stay and urinary incontinence after robotic radical prostatectomy). AI was also found to have been employed in some benign conditions, such as the vesico-ureteral reflux and stone disease. One of the most attractive and promising areas of AI application is the automation of MRI imaging and biopsy histology interpretation. With the aid of deep learning, some authors have shown that AI was able to provide high diagnostic accuracy while reducing time-consumption and inter-observer variability. Overall, the authors found that AI outperformed conventional statistical models in 71.8% of the studies analysed with respect to diagnosis and outcome predictions. However, in some studies

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Prof. Oliver Reich Section editor Munich (DE)

appropriate questionnaires (VAS, IPSS, SF-36 and OABSS), counting use of painkillers and reviewing the medical records.

oliver.reich@ klinikum-muenchen.de

At both time points, the authors showed significantly better overall VAS and IPSS scores in favour of the CUI-stent group; although no difference was seen in term of SF-36 scores, quality of life index and daytime frequency on the OABSS again favoured the new stent group.

these results were not confirmed. The authors of the systematic review emphasise that the performance of AI is heavily dependent on the number of cases used for the learning development of the algorithms. Due to the empirical nature of the system performance, the lower the number of patients feeding the databases, the lower the ability of the algorithms to adequately process the different features and their multiple interconnections.

Analgesic use was also lower in the CUI-stent group; moreover, 4 patients of the conventional stent group needed the stent to be removed prematurely versus no-one in the other stent group. Interestingly, the study was designed for patients without distal stones, which apparently will be part of a further development of the study. Overall, the CUI-stent showed to be safe and effective in reducing stentrelated symptoms.

MDR bacteria common among patients with urinary stones in China

Dr. Francesco Sanguedolce Section editor Barcelona (ES)

The purpose of this study was to investigate the prevalence of MDR bacteria in patients with urinary stones and the risk factors for its formation. A retrospective study was performed among patients with urinary stones in Beijing Tsinghua Changgung Hospital from December 2014 to May 2018. Patients with positive urinary cultures and drug sensitivity results were included. MDR were defined as any bacteria that have resistance to at least one agent in at least three classes of antibiotics. Bacteria distribution and resistance patterns were calculated.

fsangue@ hotmail.com

before enrolment. Phase 2 patients had circulating tumour cell (CTC) counts assessed before and after treatment

1,655 patients with urinary stones were eligible for This study assesses the use of analysis, among which 367 patients had positive urinary culture, yielding 457 isolates of 45 species. dose fractioning in an attempt to Escherichia coli remained the most common organism Source: Efficacy and safety of complete administer higher doses safely with a prevalence of 29.3%, followed by Enterococcus intraureteral stent placement versus faecalis (12.0%), Proteus mirabilis (10.5%), and This is why nowadays one of the strategic plans in conventional stent placement in relieving ureteral stent related symptoms: A randomized, Klebsiella pneumonia (6.8%). Forty-nine men received fractionated doses of medicine is the development of robust platforms of 177Lu-J591 ranging from 20 to 45 mCi/m2 x2 two ‘big data’ (e.g. the PIONEER project in prostate prospective, single blind, multicenter clinical cancer), which are extensive databases whose trial. Yoshida T, Inoue T, Taguchi M, Matsuzaki T, 44.4% of isolates were identified as MDR. The three weeks apart. The dose-limiting toxicity in phase 1 was most common Gram-negative bacteria were neutropenia. The recommended phase 2 doses were multiple covariates can be processed thanks to the AI Murota T, Kinoshita H, Matsuda T. Escherichia coli, Proteus mirabilis, and Klebsiella in order to support and guide clinical decisionJ Urol. 2019 Jul;202(1):164-170. doi: 10.1097/ 40 mCi/m2 and 45 mCi/m2 x2. At the higher dose (45 pneumoniae, with an MDR rate of 84.33%, 62.5%, JU.0000000000000196. Epub 2019 Jun 7. mCi/m2 x2), 35.3% of patients had reversible grade 4 making. and 48.39%, respectively. neutropenia, and 58.8% of patients had It is also likely that AI may become a useful tool to thrombocytopenia. This dose showed a greater reduce workload, especially in the field of imaging decrease in PSA levels and longer survival (87.5% Short-term ureteral stenting 44.4% of isolates were identified with any PSA decrease, 58.8% with > 30% decrease, and pathology. associated with low load of 29.4% with > 50% decrease; median survival, 42.3 as MDR. The three most common months [95% confidence interval, 19.9-64.7]). Source: 1. Current status of artificial intelligence viable and visible bacteria in Gram-negative bacteria were applications in urology and their potential to Fourteen of 17 (82%) patients with detectable CTCs encrustation experienced a decrease in CTC count. Overall, 79.6% influence clinical practice. Chen J, Remulla D, Escherichia coli, Proteus mirabilis, of patients had positive PSMA imaging; those with Nguyen JH, Aastha D, Liu Y, Dasgupta P, Hung AJ. and Klebsiella pneumoniae… BJU Int. 2019 Jun 20. doi: 10.1111/bju.14852. [Epub ahead less intense PSMA imaging tended to have poorer of print]. responses. Current knowledge of the urinary tract microbiome is 2. https://prostate-pioneer.eu limited to urine analysis and analysis of biofilms Drug-resistant rates were different between MDR and non-MDR in ampicillin, cefazolin, ceftriaxone, Targeting of PMSA with radiopharmaceuticals has formed on Foley catheters. Bacterial biofilms on ureteral stents have rarely been investigated, and no cefepime, gentamicin, amikacin, and levofloxacin (all increased with the use of PMSA ligands for imaging. This study supports the results from Australia with with p value < 0.05). cultivation-independent data are available on the How to reduce stent-related 177Lu-PMSA-617 which were reported recently microbiome of the encrustations on the stents. symptoms - results from an In multivariate analysis, indwelling catheters (OR 3.1, although without the previously reported high 95% CI 1.07-8.98) and antibiotics use in the last 3 incidence of xerostomia as the salivary gland doesn’t The typical encrustations of organic and inorganic RCT employing a complete urine-derived material, including microbial biofilms months (OR 2.14, 95% CI 1.04-4.38) were significantly appear to be targeted with 177Lu-J591. Fractionated intraureteral stent administration certainly allows higher cumulative formed during 3-6 weeks on ureteral stents in patients associated with MDR formation. dosing, but myelosuppression remains the dose treated for kidney and ureteral stones, and without limiting toxicity reported urinary tract infection at the time of stent The authors conclude that MDR bacteria were insertion, were analysed. Next-generation sequencing common among patients with urinary stones in our Despite the fact that international guidelines do not recommend the insertion of a JJ stent after an of the 16S rRNA gene V3-V4 region revealed presence centre and achieved high drug-resistant rates in Source: Phase 1/2 study of fractionated dose ampicillin, first-generation and part of thirduncomplicated ureteroscopy with lithotripsy for upper of different urotypes, distinct bacterial communities. Lutetium-177-labelled anti-prostate-specific tract urinary stones, it is well known that stent Analysis of bacterial load was performed by generation cephalosporins, and fluoroquinolones. membrane antigen monoclonal antibody J591 Indwelling catheters and antibiotics used in the last 3 (177Lu-J591) for metastatic castration-resistant insertion is routinely performed by more than 80% of combining quantification of 16S rRNA gene copy numbers by qPCR with microscopy and cultivationmonths were independent risk factors for MDR urologists. prostate cancer. Tagawa ST, Vallabhajosula S, formation. dependent analysis methods, which revealed that Christos PJ, et al. Cancer. 2019; 125:2561-9. The clinical consequences of the insertion of a JJ stent ureteral stent biofilms mostly contain low numbers of Tailored antibacterial strategies still should be in the ureter are mostly overlooked by urologists, bacteria. Fluorescence microscopy indicates the although it has been demonstrated that stent-related presence of extracellular DNA. established according to the local bacterial spectrum and patient condition. symptoms may affect a large proportion of stented The evolution of prostate Bacteria identified in biofilms by microscopy mostly patients, up to nearly 80%. The severity of the cancer radiotherapy Source: An evaluation of multidrug-resistant had morphogenic similarities to gram-positive symptoms may vary. In some cases it can lead to (MDR) bacteria in patients with urinary stone bacteria, in few cases to Lactobacillus and premature removal of the stent at the patient’s disease: data from a high-volume stone request. Corynebacterium, while sequencing showed many management centre. Wang S, Zhang Y, Zhang X, Prostate cancer is the most common male malignancy additional bacterial genera. Weddellite crystals were Li J. absent in biofilms of patients with Enterobacterales diagnosed in Europe, with an estimated economic The lack of the distal loop was World J Urol. 2019 Apr 25; 1-8. DOI: 10.1007/s00345and Corynebacterium-dominated microbiomes. burden across the European Union of € 8.43 billion. 019-02772-0 PMID: 31025083 Not only is it expensive but expanding indications for considered crucial for patients to radiotherapy means an ever-increasing demand upon have a significant reduction of pain Bacteria identified in biofilms by limited radiotherapy resources.

and discomfort...

Many strategies have been followed to reduce the clinical impact of stent insertion, such as developing new stent designs, testing stents, or scheduling symptomatic medical therapies. A Japanese group of scholars has recently tested a Complete Intraureteral Stent (CUI-Stent) in a randomised controlled trial in comparison with the performance of the conventional ureteric stent (CU-Stent). The stent has the classical proximal loop but not the distal, so that the lower edge of the stent is designed to stay proximal to the ureteric orifice and attached to a string for urethral pull out. The lack of the distal loop was considered crucial for patients to have a significant reduction of pain and discomfort as this is supposed to be among the main factors causing irritation of the bladder trigone, which eventually triggers the symptoms. The special design is not completely new but this was the first time that such a stent was tested in an RCT. The authors recruited 80 patients with a 1:1 randomization after the URS and before the stent insertion. They evaluated the impact in terms of pain, discomfort to the patients and complications at two time points (post-operative day 3 and 14), by using Key articles

August/September 2019

microscopy mostly had morphogenic Novel treatment with 177Lusimilarities to gram-positive J591 for mCRPC bacteria… This study provides novel insights into the bacterial burden in ureteral stent encrustations and the urinary tract microbiome. Short-term (3-6 weeks) ureteral stenting is associated with a low load of viable and visible bacteria in ureteral stent encrustations, which may be different from long-term stenting. Patients could be classified according to different urotypes, some of which were dominated by potentially pathogenic species. Facultative pathogens however appear to be a common feature in patients without clinically manifested urinary tract infection.

Source: Encrustations on ureteral stents from patients without urinary tract infection reveal distinct urotypes and a low bacterial load. Buhmann MT, Abt D, Nolte O, Neu TR, Strempel S, Albrich WC, Betschart P, Zumstein V, Neels A, Maniura-Weber K, Ren Q. Microbiome. 2019 Apr 13; 7(1):60. DOI: 10.1186/s40168-019-0674-x PMID: 30981280

Men undergoing curative radiotherapy treatments have conventionally received 2.0 Gy fractions to a typical total dose of 74-78 Gy. However, several reports suggest hypofractionation could increase the The concept of targeting radiation emitting particles therapeutic ratio as well as reduce health costs and directly to tumour cells in bone and soft tissue is decrease patient inconvenience. Several large phase 3 exciting. Prostate-specific membrane antigen (PMSA) trials have confirmed moderate hypofractionation has been suggested as a prostate cancer target gives similar efficacy and toxicity to conventional because it is highly specific, widely expressed and schedules. Ultra-hypofractionation regimes offer the functions as an internalising cell surface receptor. next step in the evolution of prostate cancer However, initial trials with the radiolabelled radiotherapy. The concern is the heightened risk of anti-PMSA monoclonal antibody J591 found that reversible mucosal injury during and immediately although it had efficacy it caused dose-limiting following treatment and later on the progressive myelosuppression. This study assesses the use of dose irreversible deterioration in bowel and urinary fractioning in an attempt to administer higher doses function. safely. In the Scandinavian HYPO-RT-PC open-label, Men with metastatic castration-resistant prostate randomised, phase 3 non-inferiority trial, men up to cancer refractory to or refusing standard treatment 75 years of age with intermediate-to-high-risk options with normal neutrophil and platelet counts prostate cancer were recruited and randomly were enrolled in initial phase 1b dose-escalation assigned to ultra-hypofractionation (42.7 Gy in seven cohorts followed by phase 2a cohorts treated at fractions, 3 days per week for 2.5 weeks) or recommended phase 2 doses comprising 2 conventional fractionated radiotherapy (78.0 Gy in 39 fractionated doses of 177Lu-J591 2 weeks apart. fractions, 5 days per week for 8 weeks). The 177Lu-J591 imaging was performed after treatment, maximum PSA permitted was 20 ng/ml and no but no selection for PSMA expression was performed androgen deprivation therapy was allowed. The

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Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com primary endpoint was time to biochemical or clinical failure, analysed in the per-protocol population. The prespecified non-inferiority margin was 4% at 5 years, corresponding to a critical hazard ratio (HR) limit of 1.338. Physician-recorded toxicity was measured according to the Radiation Therapy Oncology Group (RTOG) morbidity scale and patient-reported outcome measurements with the Prostate Cancer Symptom Scale (PCSS) questionnaire. 1,200 patients from 12 centres were randomly assigned to either conventional fractionation (n = 602) or ultra-hypofractionation (n = 598). Ten patients withdrew their consent, eight were found ineligible for the trial, and two died (unrelated to prostate cancer) just before or after radiotherapy. Leaving 1,180 patients (591 conventional fractionation and 589 ultra-hypofractionation) to constitute the per-protocol population. All analyses were done on the perprotocol population. After a median follow-up time of 5.0 years (IQR 3.1–7.0), 102 primary events (biochemical or clinical failure) had occurred in the conventional fractionation group and 100 in the ultra-hypofractionation group. Across both treatment groups, PSA relapse was detected in 193 patients, local recurrences in six patients, and distant metastases in three patients as a first primary event, with each event equally distributed between the groups. Failure-free survival at 5 years was 84% (95% CI 80−87) in the ultrahypofractionation group and 84% (80−87) in the conventional fractionation group (log-rank p = 0.99). The cumulative incidence of primary events, analysed with non-prostate cancer death as competing risk, was 16% (95% CI 13–20) at 5 years in both treatment groups (Gray’s test p = 0·95).

Patient-reported outcomes revealed significantly higher levels of acute urinary and bowel symptoms in the ultra-hypofractionation group compared with the conventional fractionation group… Given the predetermined critical non-inferiority HR limit (1.338), ultra-hypofractionation was found to be non-inferior to conventional fractionation (adjusted HR 1.002, 95% CI 0.758−1.325). Patient-reported outcomes revealed significantly higher levels of acute urinary and bowel symptoms in the ultrahypofractionation group compared with the conventional fractionation group but no significant increases in late symptoms were found, except for increased urinary symptoms at 1-year follow-up, consistent with the physician-evaluated toxicity. This study is the first randomised study to report the outcomes of ultra-hypofractionated radiotherapy for prostate cancer. The results are encouraging for men with intermediate disease, although the results from other ongoing similar studies (PACE trial, HEAT trial and NRG GU005) and longer follow-up is awaited. More research is also needed in the high-risk group and the role of anti-hormone therapy remains to be elucidated in this treatment paradigm.

Source: Ultra-hypofractionated versus conventionally fractionated radiotherapy for prostate cancer: 5-year outcomes of the HYPO-RT-PC randomised, non-inferiority, phase 3 trial. Widmark A, Gunnlaugsson A, Beckman L, et al. Lancet. 2019; 393: http://dx.doi.org/10.1016/S01406736(19)31131-6.

Less is more for haematuria Existing recommendations for the evaluation of haematuria vary widely from uniform evaluations of varying intensity to patient-level risk stratification. This raises concerns not only about variation in cost Key articles

10

but also the potential harms of CT radiation exposure. A major concern following the tripling of CT examination over the last 2 decades. This group developed a microsimulation model to assess each of the following guidelines (listed in order of increasing intensity) for initial evaluation of haematuria: Dutch, Canadian Urological Association (CUA), Kaiser Permanente (KP), Haematuria Risk Index (HRI), and American Urological Association (AUA). Participants comprised a hypothetical cohort of patients (n = 100,000) with either microscopic of frank haematuria aged 35 years or older. Interestingly the EAU guidelines were not included.

Source: Validation of the Kidney Donor Profile Index (KDPI) to assess a deceased donor's kidneys' outcome in a European cohort. Dahmen M, Becker F, Pavenstädt H, Suwelack B, The authors performed a retrospective analysis from a Schütte-Nütgen K, Reuter S. determine the epidemiology of bacterial and fungal agents in kidney transplant PF cultures and identify risk factors associated with positive PF cultures.

national database between October 2015 and December 2016 of the donor and recipient characteristics, the transplantation, infections in donors and PF microbiological data. Out of 4,487 kidney transplant procedures including 725 (16.2%) from living donors, 20.5% had positive PF cultures (living donors: 1.8%; deceased donors: 24.1%). Polymicrobial contamination was found in 59.9% (485/810) of positive PF cultures. Coagulasenegative staphylococci (65.8%) and Enterobacteriaceae (28.0%) were the most commonly cultured microorganisms.

…potential harms of CT radiation exposure. A major concern following the tripling of CT examination over This study gives a surprisingly high the last 2 decades rate of positive PF cultures and finds predisposing factors related to Under the Dutch and CUA guidelines, patients receive cystoscopy and ultrasonography if they were 50 years contamination... or older (Dutch) or 40 years or older (CUA). Under the KP guidelines only patients with a history of frank haematuria received CT and cystoscopy; smokers, males, and anyone 50 years or older received cystoscopy and ultrasonography, whereas nonsmoking female patients younger than 50 years did not undergo any evaluation. Under the Haematuria Risk Index (HRI) guidelines, each patient had a calculated HRI scores to determine their evaluation method (none for low-risk, cystoscopy and ultrasonography for moderate-risk, and cystoscopy and CT for high-risk patients). Under the AUA guidelines, all patients 35 years or older receive cystoscopy and CT urography. Guidelines were compared for urinary tract cancer detection rates, radiation-induced secondary cancers (from CT radiation exposure), procedural complications, false-positive rates per 100,000 patients, and incremental cost per additional urinary tract cancer detected.

The simulated cohort included 100,000 patients with haematuria, aged 35 years or older. A total of 3,514 patients had urinary tract cancers (estimated prevalence, 3.5%; 95% CI, 3.0%-4.0%). Of these, 2,978 were bladder cancer, 443 were RCC and 93 were upper tract TCC. The AUA guidelines missed detection for the fewest number of cancers (82 [2.3%]) compared with the detection rate of the HRI (116 [3.3%]) and KP (130 [3.7%]) guidelines. However, the simulation model projected 108 (95% CI, 34-201) radiation-induced cancers under the KP guidelines, 136 (95% CI, 62-229) under the HRI guidelines, and 575 (95% CI, 184-1069) under the AUA guidelines per 100,000 patients. The CUA and Dutch guidelines missed detection for a larger number of cancers (172 [4.9%] and 251 [7.1%]) but had 0 radiation-induced secondary cancers. The AUA guidelines cost approximately double the other 4 guidelines ($939/ person vs. $443/person for Dutch guidelines), with an incremental cost of $1,034,374 per urinary tract cancer detected compared with that of the HRI guidelines. This study demonstrates the value of risk stratification in the evaluation of patients presenting with haematuria. As the intensity of investigation increases beyond an optimal level the growth in advantages slows while harms and cost rise rapidly. If we accept that no protocol will detect every cancer it becomes easier to debate just what is the benefit and cost of any particular diagnostic algorithm.

Source: Comparison of the harms, advantages and costs associated with alternative guidelines for the evaluation of haematuria. Georgieva MV, Wheeler SB, Erim D et al. JAMA Intern Med. 2019 doi:10.1001/ jamainternmed.2019.2280

High rate of positive bacterial cultures of organ preservation fluid in renal transplantation from deceased donors

Factors associated with an increased risk of positive PF in deceased donor kidneys in multivariable analysis were intestinal perforation during procurement (OR 4.4, CI 2.1-9.1), multi-organ procurement (OR 1.4, CI 1.1-1.7) and en-bloc transplantation (OR 2.5, CI 1.3-4.9). The use of a perfusion pump and antibiotic donor treatment were associated with a lower risk of positive PF cultures (OR = 0.4, CI 0.3-0.5) and OR = 0.6, CI 0.5-0.7, respectively). This study gives a surprisingly high rate of positive PF cultures and finds predisposing factors related to contamination during organ procurement. However, the clinical relevance for the recipients remains undetermined.

Source: Microbiological epidemiology of preservation fluids in transplanted kidney: a nationwide retrospective observational study. Corbel A, Ladrière M, Le Berre N, Durin L, Rousseau H, Frimat L, Thilly N, Pulcini C. Clin Microbiol Infect. 2019, doi: 10.1016/j. cmi.2019.07.018. [Epub ahead of print]

Donor age remains the single most important factor for post-transplant renal function The Kidney Donor Profile Index (KDPI) was introduced in the United States in 2014 to guide the often difficult decision making with respect to accepting or declining a donated kidney. To evaluate whether the KDPI can be applied to a European cohort, the researchers retrospectively assessed 580 adult patients who underwent renal transplantation (brain-dead donors) between January 2007 and December 2014 at their centre and compared their KDPIs with their short and long-term outcomes.

...the donor's age may serve as a simple reference for future graft function... In this retrospective analysis, the authors found two significant associations: one between the KDPI and the estimated glomerular filtration rate at one year (1-y-eGFR) and the other between the KDPI and the death-censored allograft survival rate (both p < 0.001). They then analysed the individual input factors of the KDPI to assess their potential to evaluate the quality of a donor organ. We found that a donor's age alone is significantly predictive in terms of 1-y-eGFR and death-censored allograft survival (both p < 0.001).

The authors found that the donor's age may serve as a simple reference for future graft function and that an organ with a low KDPI or from a young donor had an improved graft survival rate. Kidneys with a high Kidney transplant recipients are at high risk for donor-derived infections in the early post-transplant KDPI or from an older donor yielded an inferior period. Transplant preservation fluid (PF) samples are performance although they were still considered collected for microbiological analysis. In case of positive acceptable. The authors conclude that they would not encourage defining a distinct KDPI cut-off in the PF cultures, the risk for the recipient is unknown and prescribing prophylactic antibiotics is not standard. This decision-making process of accepting or declining a nationwide observational study was aimed to kidney graft.

Sci Rep. 2019 Aug 2;9(1):11234. doi: 10.1038/s41598-01947772-7.

Resistance to new generation hormone therapy may be linked to mutations of the Wnt-pathway Development of resistance to hormonal therapies invariably appears at the metastatic prostate cancer stage despite the use of new hormone drugs, such as abiraterone or enzalutamide. The androgen receptor (AR) drives the main signalling pathway but additional AR-independent mechanisms are also involved in tumour carcinogenesis and castration resistance. Wnt signalling pathway is physiologically responsible for many functions such as cell growth, organ formation, cell survival. Thus, mutations of the Wnt-pathway genes may be involved in tumour progression and resistance to anti-tumoural treatment which has been demonstrated in colorectal, breast, and lung cancers. In the present series, the authors have assessed the correlation between somatic Wnt-pathway activating mutations and responses to first-line abiraterone or enzalutamide. They included men who received new generation hormone therapy at the mCRPC stage between August 2009 and November 2018 at the Johns Hopkins Hospital. It is worthy to note that not all treated patients were analysed because the decision to perform genetic testing was taken at each physician’s discretion. Genes of interest were CTNNB1, RNF43, RSPO2, and ZNRF3. They were assessed by clinicalgrade next-generation DNA sequencing assays. Tumour DNA analysis was performed using archival primary cancer in 70 cases, metastatic biopsies in 52 cases, or circulating DNA samples in 24 cases.

Multivariable analysis showed that the presence of a Wnt-activating mutation was independently associated with increased hazard of PSA progression as well as the use of previous chemotherapy. Overall, 137 mCRPC patients were included and 11% of them harboured at least one Wnt-pathway activating mutation. Of the 15 Wnt-pathway mutations, 53% were detected from metastatic biopsy sites, 33% from the primary tumour, and 20% from circulating DNA. Two-thirds of the alterations were reported when tissue was collected at the CRPC stage. Patients with Wnt-activating mutations had fewer T3/T4 tumours and had received chemotherapy more frequently (73% versus 51%) than wild-type patients. No difference was seen between both groups regarding other demographic, clinical, and pathologic characteristics. Patients with Wnt-activating mutations had a median time to PSA progression of 6.5 versus 9.6 months in patients without Wnt mutations (HR 2.3, p = 0.003). Multivariable analysis showed that the presence of a Wnt-activating mutation was independently associated with increased hazard of PSA progression as well as the use of previous chemotherapy. Inactivating APC/RNF43 mutations were more likely to be correlated with PSA progression than activating CTNNB1 mutations. After adjusting for concurrent inactivating alterations in TP53, RB1, and PTEN, presence of Wnt-activating mutations remained independently predictive for outcomes. Regarding PSA > 50% responses to first-line abiraterone/enzalutamide treatment, Wnt-activated patients had numerically lower PSA responses than patients without Wnt mutations (53% vs 75%, p = 0.12). Median overall survival was poorer for men with Wnt-pathway mutations compared with those without mutations (23.6 versus 27.7 months). Wnt-pathway status was independently predictive for overall survival in multivariable analysis. The hypothesis is that Wnt-activating mutations confer an earlier AR-independent growth pathway to CRPC cells. To summarise, this study suggests a significant correlation between Wnt-pathway status and response to first-line abiraterone/enzalutamide in mCRPC patient. The impact on clinical practice remains debatable. Should the clinician change his

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August/September 2019


Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de first-line therapy decision in the 10% of men harbouring these mutations? Future studies are needed to confirm these preliminary findings, to assess the efficacy of drugs targeting the Wntpathway, and to prove that Wnt-pathway may play a role as a real theranostic factor guiding treatment decision-making.

Source: Wnt-pathway activating mutations are associated with resistance to first-line abiraterone and enzalutamide in castrationresistant prostate cancer. Isaacsson Velho et al.

Serious bleeding after aquablation appeared infrequently in the series. Nevertheless, a mean of 2.9 g/dl haemoglobin drop was reported, in line with previous publications. One patient experienced serious bleeding with the need for transfusion and reoperation. Indeed, no coagulation of the resection bed was performed after aquablation. Waterjet does the job for prostate tissue resection but does not offer adequate haemostasis. In that study, haemostasis was only obtained by the Foley catheter traction. Thus, the haemostasis strategy has to be improved in the future to secure the early postoperative course. Interesting outcomes are reported regarding ejaculatory and erectile function with the possibility of adapting the resection mapping to preserve more tissue and therefore offer better results in sexual function.

Source: Waterjet ablation therapy for treating benign prostatic obstruction in patients with small- to medium-size glands: 12-month results of the first French aquablation clinical registry. Misrai V et al.

Present and future of robotic surgery for paediatric ureteropelvic junction obstruction and vesicoureteral reflux The introduction of robotic surgical technology into urological reconstruction, specifically paediatrics, has introduced new horizons for reducing the morbidity and enhancing the efficacy of surgical repair of congenital conditions in children.

August/September 2019

serdartekgul@ gmail.com

future. Satyanarayan A, Peters CA. World J Urol. 2019 Apr 5. [Epub ahead of print]

The robot has well-known significant advantages intraoperatively, including providing high-resolution three-dimensional visualisation, tremor-filtered instrument control, and comparable manual dexterity to open surgery. The smaller size of the children, longer operating times and the cost have been the main limitations for robotic surgery in children.

Eur Urol 2019

With the evolution of the technique during the era of Eur Urol 2019 laparoscopic pyeloplasty, robotic pyeloplasty now has become a standard of care for older and larger FGFR3 as theranostic factor children, nearing 100% reported success rates in predictive for immunotherapy resolution of clinical symptoms and radiographic Waterjet ablation for benign indicators of obstruction. It is now considered to be prostatic obstruction: Results response in metastatic the most commonly performed robotic procedure bladder cancer among paediatric patients, although the overall from a prospective registry numbers of pyeloplasties in children have decreased and age at diagnosis shifted to younger ages. Aquablation may be a future option of treatment for Urothelial cells with fibroblast receptor 3 (FGFR3) However, the cost-to-benefit balance of robotic benign prostatic obstruction (BPO). It combines mutations expressed decreased T-cell infiltration and compared to open pyeloplasty remains equivocal, transurethral resection of the prostate by waterjet with could be less sensitive to PD-1/PD-L1 inhibition largely due to the need for additional operating robotic guidance. Randomised trials have already compared with wild type tumour tissue. In the present room staffing and equipment. The fairly clear assessed the efficacy and safety of aquablation in study, the authors have assessed the potential role of reduction in postoperative morbidity in older well-trained teams. The aim of the present series was FGFR3 mutation status as biomarker to resistance of children continues to drive its use. It is likely that to report the peri-operative and 1-y functional checkpoint inhibition in metastatic urothelial cancer. with further improvements in instruments and outcomes after intervention by three different surgeons greater standardisation of operative technique, without previous experience of the techniques. Data from a phase II trial exploring atezolizumab were robotic pyeloplasty will continue to be a mainstay of reviewed, including two separated cohorts of patients paediatric urology. The study FRANCAIS WATER is a prospective, (IMVigor 210). Mutations analyses were done using multicentre, single-arm clinical trial conducted at hybrid capture-based next-generation sequencing Although the gold standard for correction of VUR three centres to assess the safety and effectiveness of data in 274 patients. Overall, 49 FGFR3 mutations were remains open ureteral reimplantation, the use of Aquablation in men with prostate volumes between found in urothelial tumours. The FGFR3 mutation robotic ureteral reimplantation is slightly increasing 30 and 80 cc. The Aquabeam system was used. This status was not significantly correlated with overall from less than 1% in 2000–2012 to over 6% in 2016. device consists of three main components: the survival or with objective response rate. No difference While the intravesical and extravesical approaches conformal planning unit allowing the operator to map was found even when the two cohorts were analysed have been well described, much of the outcomes the contour of the prostate; the console which controls separately. depend on surgeon experience. Intravesical robotic the functionality of the high-pressure waterjet; and reimplantation has not been a popular approach, the robotic hand piece. Briefly, under real-time possibly due to the technical challenges posed and FGFR3 status does not help to sonography guidance, the surgeon defined the target limited workspace associated with working in an anatomic resection contour on a computer console insufflated bladder. The extravesical approach is predict response to checkpoint with limits of the resection which were automatically more widely accepted. Overall success rates from inhibitors suggested by the computer. However, it was the multiple reports (within a range of success rates surgeon's decision to maintain, extend or reduce the from 72 to 99%) are still far from the almost perfect resection area. In a second analysis, FGFR3 status was then explored results gained by open reimplantation. This is in the single-arm phase II trial CheckMate 275 possibly due to the variability of surgical practices Under robotic execution, prostate tissue was resected (nivolumab in metastatic urothelial cancer). Findings and experience and therefore its utility is yet with high-velocity waterjet that can move from a were comparable without any link between FGFR3 unclear. 220-degree side to another in a controlled manner mutation status and treatment responses. However, from the bladder neck to the apical part of the FGFR3 mutation was correlated with increased FGFR3 Although robotic pyeloplasty now prostate. Haemostasis was achieved using a urinary gene expression compared with wild type urothelial catheter, which was inflated with 20–80 ml of saline cancer, and negatively associated with a T-cell gene has become a standard of care for at the bladder neck with adequate traction using signature. older and larger children, the role sonography guidance. Constant pressure on the bladder neck was maintained using a catheter Then, the authors present hypothesis-generating data, of robot-assisted reimplantation tensioning device. and suggest that similar response rates may be remains unclear with varying rates explained by a “balancing out” of previously identified independent positive and negative predictors of check of success. Waterjet does the job for prostate point inhibitor sensitivity. Indeed, the tumour mutational burden did not differ between urothelial tissue resection but does not offer cancer with or without FGFR3 mutations. Tumours As robotic surgery becomes more customised to adequate haemostasis. with FGFR3 mutations had a lower expression of a paediatric populations, most urologists are becoming fibroblast TGF-B response and of the epithelial to more cognisant of the physiologic and anatomic mesenchymal transition/stromal signatures, as well as differences in children compared to adults. The None of the three surgeons had previous experience decreased expression of immune-related genes such with aquablation. They received two dedicated smaller working environment, more compliant as interferon response. Thus, tumours with FGFR3 courses and a cadaver-laboratory teaching session. abdominal walls of children, abdominal location of The primary endpoint was the change in the total IPSS mutations may gain checkpoint inhibitor sensitivity the bladder, more sensitive decreases in cardiac score at 6 and 12 months. The success was defined by due to this lower level of stromal-mediated immune output and development of crepitus require specific suppression, compared with wild type mutations. a change exceeding 10 points. Thirty patients were caution. In ureteral reimplantation, to have more included with a median age of 68 years. The median space for optimising surgical instruments, The quest for the optimal biomarker to guide treatment standardisation of techniques, and understanding operative time was 30.5 minutes with an overall decision-making continues in metastatic urothelial resection time of 4 minutes. A single pass of the patient selection are important for surgeons and cancer. The FGFR3 status does not help to predict probe was sufficient in 63% of the cases (mean 1.3 trainees. response to checkpoint inhibitors. Thus, immunotherapy passes). The mean duration of catheterisation and of should not be denied for these patients. Ongoing trials hospital stay was 43 hours and 2 days, respectively. These technologies are demonstrating their potential Mean change of IPSS score was 15.6 points. Qmax and combining checkpoint inhibition and FGFR3 inhibitors as well as the challenges of use in children and there are awaited and might help to better understand the post-void residual improved significantly after 12 is a steady evolution of capabilities. Practitioners complex relationship between FGFR3 mutation and months. The level of erectile function decreased should be aware of both the possibilities as well as antitumor immunity in a close future. slightly over time. the risks of such new technology in the interest of our patients. This requires thorough and open reporting Overall, 23 complications occurred in 20 patients Source: Fibroblast Growth Factor Receptor 3 of outcomes, the willingness to introduce change and (two-thirds). The 6-month rate of grade 3 adverse alterations and response to PD-1/PD-L1 integrate new findings into practice. events was 13% with re-operations for urethral stone, blockade in patients with metastatic urothelial meatal stenosis, and bleeding. No re-treatment for cancer. Wang L et al. Source: Advances in robotic surgery for Eur Urol 2019 BPO was reported after a 1-y follow-up. Ejaculatory pediatric ureteropelvic junction obstruction and dysfunction occurred in 27% of patients. vesicoureteral reflux: history, present, and Key articles

Prof. Serdar Tekgül Section Editor Ankara (TR)

Prevalence of hypospadias continues to increase internationally: ICBDSR Results, 1980–2010 Hypospadias is one of the most common congenital anomalies in male infants, its prevalence varies across and within different geographical settings globally. Hypospadias can have different degrees of clinical severity, as defined by the location of the urethral opening. Estimates of the prevalence of hypospadias vary. Moreover, there have been reports of increases in the prevalence of hypospadias in many countries, especially in the last decades of the 20th century. However, a number of countries have also reported that the prevalence has not increased in recent decades. Authors evaluated hypospadias data in 27 birth defect surveillance programmes participating in the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR) to understand prevalence trends in recent years across the world. For all programmes combined, there were 36, 127,500 births and 74,814 cases of hypospadias. The international total prevalence of hypospadias was 20.9 (95% CI: 19.2–22.6) per 10,000 births among 27 programmes of the ICBDSR during 1980–2010. For 2000–2010 specifically, the international total prevalence was 23.8 (95% CI: 22.1–25.5) per 10,000 births, showing an increase within the last decade. Arkansas, USA, had the highest total prevalence (39.1 cases per 10,000 births, 95% CI: 36.7–41.4), while Argentina had the lowest total prevalence (2.1 cases per 10,000 births, 95% CI: 1.1–4.8). The total prevalence in Europe is highly variable, ranging from 10.6 (France) to 37.4 (Lombardia, Italy) cases per 10,000 births. When prevalence is analysed according to severity, across all three degrees of severity, increasing trends were observed from the mid-1990s to the mid-2000s, confirming an overall increase rather than a specific group increasing.

Hypospadias prevalence continues to increase over the last 2 decades which may reflect increases in environmental and occupational exposure to hypospadias risk factors Observed prevalence increase might reflect increases in exposure to hypospadias risk factors over time. However, given the broad range of potentially relevant environmental and occupational exposures that could be responsible for the observed increase, as well as issues related to exposure dosage, timing, and other factors, it has been challenging to identify the main culprits. It is also possible that changes over time in the distribution of other parental factors associated with hypospadias risk (e.g. parity, body mass index, maternal age, and fertility treatments) may have influenced the prevalence over time, but data were not available to assess this possibility in this analysis. Further study of potential hypospadias risk factors, including genetic factors, endocrine disruptors, and other maternal and paternal exposures and characteristics may shed light on this possibility.

Source: Hypospadias Prevalence and Trends in International Birth Defect Surveillance Systems, 1980-2010. Yu X, Nassar N, Mastroiacovo P, Canfield M, et al. Eur Urol. 2019 Jul 9. pii: S0302-2838(19)30517-2. doi: 10.1016/j.eururo.2019.06.027. [Epub ahead ofprint] PubMed PMID: 31300237.

EAU EU-ACME Office

European Urology Today

11


Can we handle female SUI in a world without meshes? A comparison between synthetic slings and non-mesh procedures Prof. Elisabetta Costantini Chief Andrological and Urogynaecological Clinic, Terni-Perugia University of Perugia (IT) elisabetta.costantini@ unipg.it

Konstantinos Giannitsas Associate Professor of Urology Patras University Hospital Dept. of Urology Patras (GR) giannitsaskon@ yahoo.com Soon after their introduction in the 1990s1, surgery using mid-urethral synthetic slings became the most common type of surgery to correct SUI (stress urinary incontinence), because of their efficacy and minimally invasive nature.

involving lifting the tissues near the bladder neck and proximal urethra into the area of the pelvis behind the symphysis pubis, gained popularity in the 1980s after modification of the original technique by Tanagho in 197611. It became the first-line treatment for many women with SUI for many years. The efficacy of Burch colposuspension has been rigorously evaluated. In an extensive systematic review and meta-analysis of more than five thousand cases, overall cure rates were 68.9% to 88.0% for open retropubic colposuspension12. Such benefits were maintained over time with approximately 70% of women expected to be dry in five years post-surgery. Laparoscopic Burch Laparoscopic Burch is a less invasive alternative to the open Burch. Laparoscopy in general, as well as in the case of colposuspension, is associated with less postoperative pain, shorter duration of urethral catheterisation, shorter hospital stay and quicker time to return to normal activities13. Additionally, it is aesthetically superior to the open procedure. In terms of efficacy in treating stress incontinence, laparoscopic colposuspension is as good as open colposuspension, at least in the short term. Patient-reported incontinence rates at long-term follow-up showed no significant differences between open and laparoscopic retropubic colposuspension, however, there are wide confidence intervals13. Therefore, the place of laparoscopic colposuspension in clinical practice will become clearer when long-term results are available.

Figure 1: Annual rate of mid-urethral slings per 100,000 women aged 25+ years, Australia, 2008/09- 2017/186

synthetic mid-urethral slings)15. Too few randomised trials have reported long-term comparative efficacy of pubovaginal versus synthetic slings, making it very difficult to draw safe conclusions.

Burch versus autologous slings The non-mesh procedures, Burch and autologous slings, have been compared in the Stress Incontinence Based on industry estimates, approximately 250,000 Surgical Treatment Efficacy Trial (SISTEr) with slings were placed in 2010 in the USA. Reports from long-term results published17. The overall continence the US Food and Drug Administration (FDA) in 20082 Autologous pubovaginal sling 3 rates at five years were lower in the Burch and 2011 and from the European Commission Scientific The current autologous pubovaginal slings are based Committee on Emerging and Newly Identified Health on the work of Aldridge in the 1940s and McGuire and urethropexy group than in the fascial sling group: Risks (SCENIHR) in 20174 have drawn attention to Blaivas later in the 20th century. Most sling procedures 24.1% vs. 30.8%, respectively. Patient satisfaction at 5 urogynaecological mesh implants and their require a combined abdominal and vaginal approach, years was higher in women undergoing a sling procedure (83% vs. 73%). The two groups had similar complications, resulting in thorough scrutiny, even of and the sling material most commonly used is rectus mid-urethral synthetic slings for stress incontinence. fascia. In their more contemporary form, pubovaginal adverse event rates (10% Burch vs. 9% sling). slings may be placed under the mid-urethra instead of What to do... The fear of mesh-related complications and the under the bladder neck and the use of “sling on a The final decision on whether a surgical technique related publicity have inevitably led to a consistent string” minimises the amount of autologous tissue for treatment of stress incontinence should be drop in their use, with a nadir of 6,383 procedures in that needs to be harvested. recommended depends on the balance between its the UK in 2016-20175 and similar trends in other parts advantages and disadvantages. of the world (see figure 1)6. Furthermore, the litigation In a recent systematic review14 objective and costs to support the use of their products have led subjective success rates of 88% and 79%, manufacturers of mid-urethral mesh slings to respectively, have been reported with autologous It is true that the use of mesh slings introduced a risk withdraw from the market. pubovaginal slings. not present in traditional non-mesh surgery for SUI: mesh exposure. Exposure of mesh slings through the The scenario of slings becoming unavailable How do non-mesh procedures compare to synthetic vagina is the most commonly reported complication worldwide is anything but impossible and the mid-urethral slings? from SUI surgeries with mesh. Mesh exposures in POP question ‘can we handle female stress incontinence in Burch versus synthetic slings surgery may have a devastating impact on patient a world without meshes?’ becomes crucial. In a recently updated systematic review and well-being and even require multiple operations for meta-analysis of the literature aiming to evaluate the their removal. Indeed, an increasing number of efficacy and safety of mid-urethral slings (MUS) mid-urethral slings have been removed in recent years. “The scenario of slings becoming compared with other surgical treatments for female unavailable worldwide is anything stress urinary incontinence15, synthetic slings were Nevertheless, similarly to small and asymptomatic better than colposuspension in terms of overall POP repair mesh exposures which can be managed but impossible…” continence (82% vs. 74%, respectively) and objective expectantly18, midurethral sling-related exposures Return to the past cure rates (79.7% vs. 67.8%, respectively). There were may be small and require no intervention. This, combined with the fact that SUI treatment-related no significant differences in subjective cure rates. If synthetic materials are to be avoided, the most There was also some evidence of an effect in favour of mesh complication rate is relatively low - 1.8% and reasonable way to deal with stress incontinence is to 2.8% with retropubic and transobturator slings rely on procedures used before the introduction of synthetic MUS compared with laparoscopic Burch respectively15 - suggests that the fear for mesh sling mesh-slings; a return to the past. Indeed the most colposuspension as far as overall continence is prestigious urological guidelines, such as the National concerned, but it did not reach statistical significance. complications is probably disproportionate and not evaluated in the light of the advantages mid-urethral Institute for Health and Care Excellence (NICE) 2019 slings offer. guidelines7 and the American Urological Association/ In subgroup analyses limited to studies with a Society of Urodynamics, Female Pelvic Medicine and follow-up duration of five years, better objective cure Mid-urethral slings are equivalent or slightly more Urogenital Reconstruction (AUA/SUFU) 2017 rates for synthetic MUS were demonstrated and efficacious compared to non-mesh operations such as guidelines8 recommend the following alternative to statistically non-significant trends for overall Burch colposuspension and autologous pubovaginal continence and subjective continence rate. mesh-sling procedures: Burch colposuspension and slings and have comparable side-effect profiles. They autologous fascia pubovaginal slings. For other are, nevertheless, clearly superior in terms of As one can safely assume, the mid-urethral tape techniques used in the past (such as anterior avoiding prolonged hospitalisation, delay in return to colporrhaphy, needle bladder neck suspension, procedures had significantly shorter operating time, daily activities and sequela of harvesting autologous paravaginal defect repair, porcine dermis sling and hospital stay, and time for resuming normal activity, material from the abdominal wall. If we take into even compared to the less invasive laparoscopic the Marshall-Marchetti-Krantz procedure) the consideration that stress incontinence is a very colposuspension. As far as intraoperative European Association of Urology has not made any common condition carrying a 13.6% lifetime complications are concerned, differences between recommendation since 20119. The 2019 NICE cumulative risk for surgery19, the economic burden of synthetic slings and colposuspension were not guidelines advise not to offer them to patients with hospitalisations and loss of productivity for relatively stress incontinence; there is insufficient evidence of significant, with the exception of a higher bladder young women treated surgically for SUI would be perforation rate with retropubic slings, in particular, efficacy and safety to support their use. unbearable to society. and a higher reoperation rate with Burch16. Bulking agents are still considered a safe alternative The possible complications of mesh use for the to other surgical treatments of stress incontinence, but Autologus versus synthetic slings treatment of SUI are real and should be addressed their efficacy is short-lived and cannot be compared As far as autologous pubovaginal slings are accordingly. However, the abandonment altogether of directly to other surgical techniques10. New agents concerned efficacy is shown to be similar to that of mid-urethral slings seems to be a political-marketing promise better outcomes and have presented data of synthetic mid-urethral slings. However, there was decision and not a scientifically supported one. We head-to-head comparisons with mid-urethral slings some evidence of an effect in favour of MUS for can definitely treat incontinence with non-mesh in recent congresses, but data should mature before reoperation rates (3.9% for synthetic slings versus definite conclusions are made. 7.7% for autologous pubovaginal ones), but it did not operations in terms of efficacy, but otherwise this would be a huge step backwards in our efforts to meet levels of statistical significance15. Prevalence of Efficacy of non-mesh anti-incontinence procedures complications, including haematoma, vaginal erosion offer women efficient and well-tolerated treatments Open Burch and voiding lower urinary tract symptoms (LUTS), was for a benign condition such as incontinence. Synthetic Open Burch colposuspension or urethropexy, comparable between synthetic and autologous slings. slings as well as non-mesh procedures should remain available, giving physicians the ability to tailor Storage LUTS, nevertheless, were more frequent with treatment not only to condition characteristics but also EAU Section of Female and Functional Urology to informed patient preference. autologous pubovaginal slings (32% vs. 16% with 12

European Urology Today

References 1. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 1996;7(2):81-5. 2. Food and Drug Administration. FDA Public Health Notification: Serious Complications Associated with Transvaginal Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary Incontinence. 2008. 3. Food and Drug Administration. Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse. 2011. 4. Chapple CR, Cruz F, Deffieux X, et al. Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence. Eur Urol. 2017;72(3):424-431. 5. Zacche MM, Mukhopadhyay S, Giarenis I. Changing surgical trends for female stress urinary incontinence in England. Int Urogynecol J. 2019;30(2):203-209. 6. Elmer S, Brennan J, Mathieson R, Norris B, Carey M, Dowling C. Making surgery safer through adequate communication with the stakeholders: vaginal slings. World J Urol. 2019 Jul 4. doi: 10.1007/s00345-019-02859-8. 7. NICE Guidance - Urinary incontinence and pelvic organ prolapse in women: management: © NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management. BJU Int. 2019 May;123(5):777-803. 8. Kobashi KC, Albo ME, Dmochowski RR, et al. Surgical Treatment of Female Stress Urinary Incontinence: AUA/ SUFU Guideline. J Urol. 2017;198(4):875-883. 9. Thüroff JW, Abrams P, Andersson KE, et al. EAU guidelines on urinary incontinence. Eur Urol. 2011;59(3):387-400. 10. Siddiqui ZA, Abboudi H, Crawford R, Shah S. Intraurethral bulking agents for the management of female stress urinary incontinence: a systematic review. Int Urogynecol J. 2017;28(9):1275-1284. 11. Tanagho EA. Colpocystourethropexy: the way we do it. J Urol. 1976;116(6):751-3. 12. Lapitan MCM, Cody JD, Mashayekhi A. Open retropubic colposuspension for urinary incontinence in women Cochrane Database Syst Rev. 2017 25;7:CD002912. 13. Dean N, Ellis G, Herbison GP, Wilson D, Mashayekhi A. Laparoscopic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev. 2017 27;7:CD002239. 14. Blaivas JG, Simma-Chiang V, Gul Z, Dayan L, Kalkan S, Daniel M. Surgery for Stress Urinary Incontinence: Autologous Fascial Sling. Urol Clin North Am. 2019;46(1):41-52. 15. Fusco F, Abdel-Fattah M, Chapple CR, et al. Updated Systematic Review and Meta-analysis of the Comparative Data on Colposuspensions, Pubovaginal Slings, and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence. Eur Urol. 2017;72(4):567-591. 16. Novara G, Galfano A, Boscolo-Berto R, et al. Complication rates of tension-free midurethral slings in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of randomized controlled trials comparing tension-free midurethral tapes to other surgical procedures and different devices. Eur Urol. 2008;53(2):288-308. 17. Brubaker L, Richter HE, Norton PA, et al. 5-year continence rates, satisfaction and adverse events of burch urethropexy and fascial sling surgery for urinary incontinence. J Urol. 2012;187(4):1324-30. 18. Illiano E, Giannitsas K, Li Marzi V, Natale F, Manicini V, Costantini E. No treatment required for asymptomatic vaginal mesh exposure. Urol Int. 2019;21:1-5. 19. Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014;123(6):1201-6.

August/September 2019


#EAU20 Cutting-edge Science at Europe’s largest Urology Congress

Top 9 tips for submitting your abstract The Scientific Congress Office of the Annual EAU Congress receives thousands of abstract submissions from urologists and other medical professionals from around the world. At the previous congress held in Barcelona, nearly 5,500 abstracts were submitted in total with an acceptance rate of 31%: 1,593 abstracts and 93 video abstracts. Having your research accepted to be part of the EAU20 Scientific Programme is challenging. To help your abstract stand out from the rest, here are the top 9 tips in submitting your abstract: 1. Read the Rules for Abstract Submission very carefully. Most errors are made because submitters do not read the rules thoroughly. Check out the full list of rules by visiting https://eaucongress.uroweb. org/scientific-programme/abstracts then scroll down to see the link to the PDF. 2. Be straight to the point. Unnecessary words can cause confusion. Incorrect: The pending conclusions from the sub-study of FANTASE, a trial which started in 2000 wherein over 10,000 participants have joined with aims to provide evidence as to what is the best way of treating men with newly diagnosed advanced prostate cancer, will clarify and guide international practice within hormone naive mPCa.

Important dates

Correct: The pending conclusions from the FANTASE sub-study will clarify and guide international practice within hormone naive mPCa.

Congress days 20-24 March 2020

3. Adopt a neutral tone of voice to show objectivity.

Exhibition days 21-23 March 2020

Incorrect: We strongly feel that without a doubt in our minds, renal scarring is more linked to higher grades of reflux and urinary tract infections.

Registration opens 1 October 2019

Correct:  Renal scarring is more linked to higher grades of reflux and urinary tract infections.

Choose the appropriate topic in the new abstract submission feature

4. Check your facts and numbers, then check them again.

8. Familiarise yourself with the new abstract submission feature. It is very important that you choose the appropriate topic, subtopic, clinical step(s) and management tool(s) of your abstract from the dropdown menu.

5. Ask a trusted colleague(s) to proofread your work. Sometimes typos and grammatical errors are overlooked during the initial check. Your colleague can help spot mistakes you might miss. 6. Upload only one (1) high-resolution image in jpeg format. The image should contain only one figure/graphic. 7. If you are submitting a video, make sure it meets all the requirements. For example, your video should have narration explaining the procedure(s) in English, and should contain information such as title, authors’ names, production date, and running time.

9. Submit before the deadline. Submitting your abstract on the day of the deadline can be risky since technical errors may occur due to the high number of users at that time. Save the date of the abstract submission deadline: 1 November 2019 (23:59:59 CET).

Abstract submission deadline 1 November 2019 Awards submission deadline 1 November 2019 Early Bird deadline 16 January 2020 Late Fee deadline 13 February 2020

Check out the programme ove

www.eau20.org

rview at

You can submit your abstracts via abstracts.uroweb.org Best of luck!

A local’s guide to Amsterdam The Dutch capital is home to the nation’s historical and art treasures. Three essential museums are the Van Gogh, the Rijksmuseum and the Stedelijk Museum, each with a different approach to golden age masterpieces and more modern art. The Dutch masters are well-represented in the museum quarter, just to the south of the main canal belt.

Call for

ESUI Vision Award 2020 The EAU Section of Urological Imaging (ESUI) is calling for abstracts for the ESUI Vision Award 2020, which will be given to the first author of the most innovative imaging study published in urology during the last year. How to apply Send a PDF copy of the published study or of the published/accepted abstract together with a CV and publication list to esui@uroweb.org

If you have no time for museums, note that the city centre itself has UNESCO World Heritage status. Explore the 17th century canals on foot or organise a canal boat tour. These typically start just outside of Amsterdam Central Station. Amsterdam is the world capital of bicycling, and you will notice that every street has dedicated cycle paths (in red) or even that cars are banned outright in some areas. Please only try to cycle in Amsterdam if you’re an experienced and confident cyclist, or the locals won’t be shy to tell you what they think of your attempts.

stroopwafel are popular snacks. If you’re feeling adventurous, treat yourself to a typically Dutch brined herring from one of the fish shops. Amsterdam also offers the best Indonesian and Surinamese cuisine outside of those countries so seek out a restaurant for a unique experience. Dutch courage Of course the Netherlands in general and Amsterdam in particular is associated with world-conquering pilsner beers like Heineken and Amstel. For many decades, these brewing companies had a near-monopoly on the Dutch beer scene, leaving more specialised beer styles to small Belgian brewers.

If you want to drop by the Red Light District, please be aware that it will be extremely crowded in the evenings. If you visit during the day, you will enjoy Amsterdam’s oldest streets and canals without the distractions of the nocturnal economy.

Over the past ten years, dozens of small breweries have sprung up in and around Amsterdam, creating a rich tapestry of locally-brewed Dutch and international beer styles. While every Amsterdam bar will have Heineken or Amstel on draught, they will also offer bottled (or even on draught if you are lucky!) local beers. Many microbreweries have their own tap rooms. Particularly popular is the IJ Brewery, just outside the centre and situated at the base of a windmill.

Dutch cuisine hasn’t quite taken the world by storm like Chinese or Italian, but our cheese is world-class and our baked goods like apple pie or the

Whether it’s your first time to the city or you are a returning visitor, we hope you get a chance to enjoy Amsterdam when you attend EAU20.

Deadline: 21 January 2020 (23:59 CET) The award will be handed out at the 35th Annual EAU Congress in Amsterdam during the ESUI section meeting on Saturday, 21 March 2020. The award is supported by a grant worth € 1,500 by INVIVO, a Philips company.

August/September 2019

European Urology Today

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EAU Crystal Matula Award 2020

Send your nominations today!

For a young promising European urologist The EAU Crystal Matula Award 2020 is the most prestigious prize given to a young promising European urologist aged 40 or under who has the potential to become one of the future leaders in academic European urology. The award will be presented at the Opening Ceremony of the upcoming 35th Annual EAU Congress in Amsterdam from 20-24 March 2020. The list of previous awardees includes many M. Albersen (2019), S. Silay (2018), C. Gratzke (2017), A. Briganti (2016), M. Rouprêt (2015), S. Shariat (2014), P. Boström (2013), P. Bastian (2012), S. Joniau (2011), J. Catto (2010), M. Ribal (2009), V. Ficarra (2008), M. Michel (2007), A. De La Taille (2006), M. Matikainen (2005), P. Mulders (2004), B. Malavaud (2003), M. Kuczyk (2002), B. Djavan (2001), A. Zlotta (2000), G. Thalmann (1999), F. Montorsi (1998), F. Hamdy (1996). Nomination Process National Societies can nominate a candidate by supplying the following documents: • Letter of endorsement • Motivation letter • Complete curriculum vitae

• List of publications in the below sequence: 1. Peer reviewed papers (including the impact factors of the journals) • Original articles • Reviews • Case reports 2. Book chapters or editor of books • Overview of grants received from (inter-)national institutions or from the industry • List of received Awards • The deadline for nomination is 1 November 2019. Please note that eligible candidates can also apply for this award by contacting their national urological society directly. The candidate is then expected to supply his/ her national society with a CV and the above mentioned documents, requesting a letter of endorsement. How to apply Please send your nominations to the EAU Central Office at m.smink@uroweb.org and mention “EAU Crystal Matula Award 2020” in the subject line of your e-mail.

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

EAU Hans Marberger Award 2020 For the best European paper published on Minimally Invasive Surgery in Urology The EAU Hans Marberger Award will be handed out for the best European paper published on Minimally Invasive Surgery in Urology. The award, annually given since 2004, is named after Prof. Hans Marberger to honour his pioneering achievements and contributions to endourology and the development of urologic minimally invasive surgical procedures. The award will be handed over at the 35th Annual EAU Congress in Amsterdam, 20-24 March 2020 during the Opening Ceremony. Rules and Eligibility • All urologists and scientists are invited to send in papers. • The topic of the paper should deal with Minimally Invasive Surgery in Urology. • The paper must have been published or accepted for publication in a European Journal between 1 July 2018 and 30 June 2019.

LABORIE

Apply now!

• All papers must be submitted in English. • All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • Deadline for submission is 1 November 2019. A review committee, consisting of members of the EAU Scientific Congress Office, will select the winning paper. How to apply Please send your paper to the EAU Central Office at m.smink@uroweb.org and mention “EAU Hans Marberger Award 2020” in the subject line of your e-mail.

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

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European Urology Today

August/September 2019


Practical questions about nocturia Multifactorial aetiology, multiple targets for treatment Dr. Alekzander Khelaia Member EAU Section of Urologists in Office (ESUO) National Center of Urology Tbilisi (GE) alekoxelaia@gmail.com

Dr. Athanasios Zachariou Member EAU Section of Urologists in Office (ESUO) Dept. of Urology University of Ioannina (GR) zahariou@otenet.gr Nocturia is a common non-life threatening problem which becomes more prevalent with age. It affects the quality of sleep, causing daytime somnolence, fatigue, depression, and for those still working reduced work productivity. Below the key questions answered by ESUO Section Members Dr. Alekzander Khelaia (AK) and Dr. Athanasios Zachariou (AZ). What is the prevalence of nocturia and how does it influence the quality of life? AK: Nocturia is one of the most common symptoms in the practice of office urologists. The causes of nocturia vary and include both urological and non-urological conditions. There is an increasing role for multidisciplinary teams in managing nocturia in collaboration with urologists. Nocturia may also be the initial symptom of chronic kidney disease (CKD), congestive heart failure (CHF), diabetes mellitus (DM) and sleep disorders. The International Continence Society (ICS) defines nocturia as “waking at night to void, > 1 void per night”, provided that a person awakens before voiding and falls asleep right after. By contrast, nocturnal enuresis is voiding at night while asleep. It is difficult to estimate the prevalence of nocturia, but in all epidemiological studies nocturia was observed to increase dramatically with age. Undisturbed sleep is necessary for the maintenance of physical, mental, and emotional well-being. In patients with nocturia, sleep deprivation may be a cause of serious health risks (for example, falls and bone fractures). Also, quality of life (QoL) is negatively affected in the majority of individuals who experience nocturia. In general, the causes of nocturia fall into three categories; global (diurnal) polyuria, nocturnal polyuria, and low bladder capacity (bladder storage disorders) (see fig.1). Which diagnostic tools are necessary for the clinical assessment of nocturia? AK: Evaluation of nocturia includes determining a patient’s history of sleep patterns, cardiac problems with medication (diuretics, antihypertensives, glycosides), fluid intake habits including alcohol and caffeine consumption and other comorbidities that can account for excessive output of urine at night or bladder overactivity. Physical examination should also include an evaluation of the lower extremities for oedema. A frequency volume chart (FVC) – voiding diary (for a 72-hour period) - has primary importance as a diagnostic tool for nocturia. Patients must receive clear instructions on how to keep a voiding diary. The diurnal pattern of voids, including any episodes of incontinence, must be documented, as well as the volume of urine voided and fluid intake. Nocturia is the number of voids recorded during a night’s sleep – each void is preceded and followed by sleep. The first morning void after a night’s sleep is seen as daytime (diurnal) frequency rather than nocturia, as it is not followed by sleep. Thus, the calculation of nocturnal frequency or nocturnal urine volume excludes voids when people are awake in bed. The nocturnal urine volume (NUV) is defined as the total volume of urine passed between the time the EAU Section for Urologists in Office (ESUO)

August/September 2019

patient went to bed (with the intention of sleeping) and the time he/she wakes. It excludes the last void before going to bed but includes the first void of the morning. For analysis, the first void of the morning should be included in the NUV, but should not be considered as a nocturia event. Can insomnia be a reason for nocturia/frequent voiding during the night? AK: Yes, we don’t forget sleep disturbances. Sometimes it is challenging to assess the reason why patients wake up to pass urine. Either the patient awakes for another reason and then needs to void, or the need to void is the reason for waking. It may prove difficult to get a reliable answer from the patient. Obstructive sleep apnoea causes nocturnal polyuria due to increased secretion of atrial natriuretic peptide, which induces a natriuresis. What is pharmacologically induced nocturia? AK: Some drugs contribute to nocturia (diuretics, antihypertensives), and that is a vital issue. For example: selective serotonin reuptake inhibitors (SSRI), which are very often prescribed by urologists for premature ejaculation and also very common to manage depression, can result in increased urine output.

"Obstructive sleep apnoea causes nocturnal polyuria due to increased secretion of atrial natriuretic peptide, which induces a natriuresis." Fig. 1: Classification of nocturia

There is a 2-fold increased risk of developing urinary incontinence and nocturia after SSRI medication. The possible mechanism associated with these drugs is thought to be mediated through activation of neuronal 5-HT4 receptors located in the detrusor muscle, potentiating cholinergic neuromuscular transmission and detrusor muscle activation. What is your take-home message? AK: Nocturia is a multifactorial problem requiring comprehensive assessment. A few take-home messages: 1. global polyuria presents with diurnal and nocturnal frequency of good voided volumes; 2. nocturnal polyuria presents with nocturnal frequency of good voided volumes; 3. bladder storage disorder/low bladder capacity presents with diurnal and nocturnal frequency of poor voided volumes, other LUTS may be present; 4. sleep disturbance presents with nocturnal frequency of varied volumes. Of course, in some patients a mix of symptoms is seen. Overall, it is surmised that a decreased nocturnal bladder capacity generally underlies nocturia in younger patients (mostly female) and nocturnal polyuria predominates in older patients of both genders. Should the first step in nocturia treatment be behaviour modification? AZ: Urologists consider behavioural modifications as first-line therapy. The main reasons are the concern for polypharmacy in the ageing population and the increasing prevalence of nocturia as patients get older. Decreasing the intake of fluids at least 4 hours before going to bed, voiding before going to bed and avoiding alcohol and caffeine, primarily during the afternoon can provide benefit. The use of compression stockings and leg elevation above the heart level in the early evening may decrease nocturnal urine volume. Changing the time of diuretic medication administration to 6 hours before going to sleep may prove helpful. Nocturia is often associated with LUTS/BPH and OAB. How effective are drugs administered for BPH or OAB in patients who also suffer from nocturia? AZ: 5-ARIs do not reduce nocturnal voids in men < 70 years old with LUTS. There is some evidence that men over 70 with bothersome nocturia may benefit from ARI administration. Most selective alpha-1 adrenergic antagonists (alfuzosin, doxazosin, tamsulosin, and silodosin) are more effective than placebo in decreasing nocturia in men with BPO suffering from nocturia. Approximately 30% of patients with nocturia also report OAB symptoms. Antimuscarinics, as well as

mirabegron, demonstrate a significant reduction of nocturnal micturition in OAB patients. These agents give poor results in patients suffering from nocturnal polyuria. Several studies have shown advantages with combination treatments. The combinations currently in use are antimuscarinic medication plus alpha-1 adrenergic blockade, 5-ARI and alpha-1 adrenergic antagonist, and alpha-1 adrenergic antagonist and phosphodiesterase-5 inhibitor. Level 1 evidence exists for the combination of 5-ARI and alpha-1 adrenergic antagonists for the treatment of LUTS including nocturia. In a similar way, data support that antimuscarinic agents plus alpha-1 adrenergic blockers significantly reduce nocturia, when compared to placebo. The treatment of choice should target the main underlying cause. In this case, it should aim primarily at increasing bladder capacity by counteracting detrusor overactivity. Surgical treatments for BOO may reduce nocturnal voids. They should not be proposed to patients before an extensive evaluation of the cause of nocturia has taken place. Urologists should advise patients that surgery is not always successful and nocturia may persist after surgery. Is reduction of excessive nocturnal urine production the cornerstone of treating nocturia? AZ: We can roughly assume that most patients with nocturia do have nocturnal polyuria. Nearly 72-85% of women and 79-90% of men screened for inclusion in nocturia studies suffer from nocturnal polyuria. By reducing nocturnal urine production, there is a decrease in the overall urine volume presented in the

bladder, and the patient suffering from nocturia is relieved. Desmopressin has, for a long time, been in clinical use for the treatment of diabetes insipidus and paediatric nocturnal enuresis. In 2017, the FDA approved desmopressin nasal spray for the treatment of nocturia and nocturnal polyuria in adults who wake at least two times per night to void. An oral desmopressin lyophilisate formulation requiring no concomitant fluid intake is currently the most widely used DDAVP preparation. Why isn’t desmopressin used more commonly for treating nocturia? AZ: The International Consultation on Incontinence has given desmopressin a Level 1 evidence and Grade A recommendation for the treatment of nocturia and nocturnal polyuria in adults < 65 years old. The reason desmopressin acetate has not been used more commonly for the treatment of nocturia is the risk of hyponatraemia. Except for the older patients (> 65 years old) and women, desmopressin side effects are most likely experienced by patients with lower body mass, higher urine output, lower basal serum sodium level and lower creatinine clearance at baseline. Conclusions The causes of nocturia are often multifactorial and a full examination is crucial to exclude any treatable underlying cause. In most cases, behavioural intervention is the first step of management. While providing benefits for the treatment of nocturia in many patients, the risk of adverse events associated with some of the available medication requires careful selection to optimise the therapeutic effect.

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

European Urology Today

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EAU Best Papers published in Urological Literature Awards

Apply now!

To be awarded at the 35th Annual EAU Congress in Amsterdam, 20-24 March 2020 The two EAU Prizes for Best Paper published in Urological Literature are tools through which the EAU encourages young and promising urological scientists to continue their work and to communicate their achievements to the European urological community. Two awards of € 5,000 each will be made available for the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers have to be published or accepted for publication between 1 July 2018 and 30 June 2019. The awards will be handed out at the 35th Annual EAU Congress in Amsterdam, 20-24 March 2020. Rules and Eligibility • Eligible to apply for the EAU Best Paper published in Urological Literature are urologists, urologists-intraining or urology-related scientists. All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • The paper must be written in English (or translated into English).

Apply now!

• The subject of the paper must be urological or urology related. • The deadline for submission is 1 November 2019. How to apply • Please send your paper by e-mail to m.smink@uroweb.org, indicating clearly the category in the subject line: “EAU Best Paper on Clinical Research” or “EAU Best Paper on Fundamental Research”. • Include a copy of your curriculum vitae. • Supply a list of all authors who have significantly contributed (if relevant). • Mention any financial support by companies, government or health organisations. • A publisher’s letter of acceptance has to be submitted along with your paper. A review committee consisting of members of the EAU Scientific Congress Office will review all submitted papers and select the winner of the two EAU awards for Best Paper published in Urological Literature.

EAU Prostate Cancer Research Award 2020 For the best paper published on clinical or experimental studies in prostate cancer With the goal to encourage innovative, high-quality research in prostate cancer, the EAU has launched the EAU Prostate Cancer Research Award. Supported by the Fritz H. Schröder Foundation, an expert jury will select the best paper dealing with clinical or experimental studies in prostate cancer. The award will be handed over at the 35th Annual EAU Congress in Amsterdam, 20-24 March 2020 during the Opening Ceremony.

• The paper must have been published or accepted for publication in a high-ranking international journal between 1 July 2018 and 30 June 2019, and submitted in English. • Applicants must be a member of the EAU. • The submitting author must be the first author of the paper or, by exception, the corresponding senior last author. • Applicants should only submit one paper. • Deadline for submission by e-mail is 1 November 2019.

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

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

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

How to apply Inquiries and correspondence should be addressed to the EAU Central Office, at m.smink@uroweb.org, with “EAU Prostate Cancer Research Award 2020” in the subject line of your e-mail.

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

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European Urology Today

August/September 2019


EAU RF PRECISION study: MRI ± targeted biopsy superior Results lead to changes in international prostate cancer diagnosis guidelines Dr. Veeru Kasivisvanathan Specialist Registrar University College London & UCLH (UK) PRECISION Study Coordinator veeru.kasi@ucl.ac.uk Twitter: @veerukasi The PRECISION Trial is a landmark study evaluating MRI and MRI-targeted biopsy compared to standard TRUS biopsy in men with suspected prostate cancer who have not had a biopsy before. The study was published in the New England Journal of Medicine and was awarded the Fritz Schröder EAU Prostate Cancer Research Award in 2019. The work has helped to influence the EAU 2019 guidelines for prostate cancer diagnosis. Authorship of trial Veeru Kasivisvanathan, Antti S. Rannikko, Marcelo Borghi, Valeria Panebianco, Lance A. Mynderse, Markku H. Vaarala, Alberto Briganti, Lars Budäus, Giles Hellawell, Richard G. Hindley, Monique J. Roobol, Scott Eggener, Maneesh Ghei, Arnauld Villers, Franck Bladou, Geert M. Villeirs, Jaspal Virdi, Silvan Boxler, Grégoire Robert, Paras B. Singh, Wulphert Venderink, Boris A Hadaschik, Alain Ruffion, Jim C. Hu, Daniel Margolis, Sébastien Crouzet, Laurence Klotz, Samir S. Taneja, Peter Pinto, Inderbir Gill, Clare Allen, Francesco Giganti, Alex Freeman, Stephen Morris, Shonit Punwani, Norman R. Williams, Chris Brew-Graves, Jonathan Deeks, Yemisi Takwoingi, Mark Emberton, Caroline M. Moore, for the PRECISION Study Group Collaborators

without prior biopsy, were randomised to either standard 12-core TRUS biopsy or a MPMRI arm. In the MPMRI arm, areas of the prostate were scored according to the PIRADsv2 scoring system. Areas scoring 3, 4 or 5 underwent targeted biopsy only. Up to three MRI-suspicious areas were targeted with a maximum of 4 cores per target, leading to a maximum of up to 12 cores per patient in the MRI arm. Visual registration or software-assisted registration were permitted.

The potential implications of this trial • Introduction of an alternative prostate cancer diagnostic pathway in biopsy naive men • An increase in the number of patients with clinically significant cancer diagnosed • A reduction in the over-diagnosis of clinically insignificant prostate cancer • A reduction in the number of patients undergoing prostate biopsy • A reduction in the number of biopsy cores taken per patient • A reduction in biopsy-related sepsis, pain and other side effects

Outcomes Primary Outcome: Proportion of men with clinically significant cancer (Gleason 3 + 4 or greater) detected Secondary Outcomes included: 1. Proportion of men with clinically insignificant cancer (Gleason 3 + 3) detected 2. Proportion of men with negative MPMRI who avoid biopsy 3. Maximum cancer core length of most involved biopsy core

Key patient inclusion criteria 1. Men at least 18 years of age referred with clinical suspicion of prostate cancer who have been advised to have a prostate biopsy 2. Serum PSA ≤ 20ng/ml 3. Suspected stage ≤ T2 on rectal examination (organ-confined prostate cancer) Key patient exclusion criteria 1. Prior prostate biopsy 2. Prior treatment for prostate cancer 3. Contraindication to MRI or prostate biopsy

"The PRECISION (PRostate Evaluation for Clinically Important disease, Sampling using Imageguidance Or Not?) study is an international study that was reported in 2018." Changes in international guidelines As a result of the PRECISION trial and a number of other high-profile studies5-8, the 2019 European Association of Urology and 2019 UK National Institute for Health and Care Excellence Guidelines in Prostate Cancer now recommend performing an MRI before prostate biopsy in biopsy-naive men. The information from the MRI should be used to influence how the prostate biopsy is performed by the addition of MRI-targeted prostate biopsy. Both organisations recommend considering avoiding a biopsy in men with low clinical risk of prostate cancer who have a non-suspicious MRI after an informed discussion with the patient.

Background Funding The PRECISION (PRostate Evaluation for Clinically The EAU Research Foundation provided its web-based Important disease, Sampling using Image-guidance Areas scoring 3, 4 or 5 underwent targeted biopsy only. Up to three MRI-suspicious areasdatabase were management system for collection of patient Key findings Or Not?) study is an international study that was 1,2 maximum of 4 cores per target leading to a maximum of up to 12 cores per patient targeted with a One third of men (71/252, 28%) avoided biopsy in data and provided all sites with patient recruited reported in 2018 . Prior to the publication of the the MRI arm. registration Clinically significant cancer was funding. We would particularly like to acknowledge role ofregistration multiparametric in inPRECISION the MRI study, arm.the Visual orMRI software-assisted were permitted. Wim Witjes, Christien Caris and Joke van Egmond the diagnosis of prostate cancer in biopsy-naïve men detected in 95 (38%) of 252 men in the MRI ± TB arm compared to 64 (26%) of 248 men randomised from the EAU Research Foundation for their important was uncertain, with national3 and EAU4 guidelines Outcomes: contribution. to TRUS-biopsy on the intention-to-treat analysis. only recommending its use in men with a prior Adjusting for centre effects, the absolute difference negative prostate biopsy and ongoing suspicion of Primary Outcome: (MRI ± TB vs. TRUS-biopsy) in the proportion of men Veeru Kasivisvanathan was funded by a UK NIHR cancer. PRECISION aimed to assess whether Proportion of men 3+4 orclinically greater)significant detectedprostate cancer diagnosed with Doctoral Research Fellowship (DRF-2014-07-146) and multiparametric MRIwith and aclinically targetedsignificant biopsy onlycancer (MRI (Gleason UK sites were funded by the NIHR Clinical Research ± TB) is non-inferior to transrectal ultrasound guided was 11.7% (2-sided 95% CI 3.6 to 19.8; p = 0.005). Secondary Outcomes The lower bound of the 95% CI for the difference is Network. (TRUS) biopsy in the detectionincluded: of clinically significant 1. Proportion men with clinically (Gleason 3+3) detected greater than -5% therefore MRI ± TB was nonprostate cancer inofbiopsy-naive men. insignificant cancer inferior to TRUS biopsy. Furthermore, these results Participating centres: 2. Proportion of men with negative MPMRI who avoid biopsy also indicated Argentina StudyMaximum design cancer core length of most involved biopsy 3. core that MRI ± TB was superior to • Centro de Urologia The study is an international multi-centre randomised TRUS-biopsy. MRI ± TB also diagnosed fewer men with insignificant cancer than TRUS biopsy (23/252 Belgium controlled trial, in which 500 men, who had been (9%) vs. 55/248 (22%), p < 0.001). • Ghent University Hospital referred with clinical suspicion of prostate cancer Study Schema Canada • Jewish General Hospital Finland Man with no prior biopsy referred with clinical suspicion of prostate cancer • Helsinki University Central Hospital • Oulu University Hospital France • Bordeaux University Hospital Registration (n=470) • CHU Lille, University Lille Nord de France • Lyon HEH and Lyon Sud

Italy • Sapienza University of Rome, Italy • San Raffaele Hospital, Milan Germany • University Hospital Heidelberg • Martini Klinik, Hamburg Netherlands • Erasmus University Medical Centre • Radboud University, Nijmegen Medical Centre Switzerland • University Hospital Bern United Kingdom • Basingstoke and North Hampshire Hospital • Northwick Park Hospital • Princess Alexandra Hospital • Royal Free Hospital NHS Foundation Trust • University College London Hospitals • Whittington Health Trust USA • Chicago University Hospital • Mayo Clinic Rochester • Weil Cornell Medical Centre References 1. Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. N Engl J Med. 2018;378:1767-77. 2. Kasivisvanathan V, Jichi F, Klotz L, Villers A, Taneja SS, Punwani S, et al. A multicentre randomised controlled trial assessing whether MRI-targeted biopsy is non-inferior to standard transrectal ultrasound guided biopsy for the diagnosis of clinically significant prostate cancer in men without prior biopsy: a study protocol. BMJ Open. 2017;7:e017863. 3. NICE. Prostate cancer: diagnosis and management [CG175], 2014, accessed 24 May 2019. 4. Mottet N, Bellmunt J, Bolla M, Briers E, Cumberbatch MG, De Santis M, et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2017;71:618-29. 5. Ahmed HU, El-Shater Bosaily A, Brown LC, Gabe R, Kaplan R, Parmar MK, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet. 2017;389:815-22. 6. Rouvière O, Puech P, Renard-Penna R, Claudon M, Roy C, Mège-Lechevallier F, et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study. The Lancet Oncology. 2019;20:100-9. 7. van der Leest M, Cornel E, Israël B, Hendriks R, Padhani AR, Hoogenboom M, et al. Head-to-head Comparison of Transrectal Ultrasound-guided Prostate Biopsy Versus Multiparametric Prostate Resonance Imaging with Subsequent Magnetic Resonance-guided Biopsy in Biopsy-naive Men with Elevated Prostate-specific Antigen: A Large Prospective Multicenter Clinical Study. European Urology. 2018. 8. Panebianco V, Barchetti G, Simone G, Del Monte M, Ciardi A, Grompone MD, et al. Negative Multiparametric Magnetic Resonance Imaging for Prostate Cancer: What's Next? Eur Urol. 2018;74:48-54.

1:1 Randomisation Arm 1 (n=235)

Arm 2 (n=235)

Multi-parametric MRI

MpMRI score 1,2 No biopsy

Results given Treatment Decision Questionnaire

10-12 core trans-rectal biopsy of the prostate

MpMRI score 3,4,5

Rese Foun

MRI-targeted biopsy of the prostate

Results given Treatment Decision Questionnaire

Results given Treatment Decision Questionnaire

EAU Research Foundation is looking for investigators from basic urology research laboratories Interested? http://eaurfbslist.uroweb.org/

Figure 1: Study Scheme

Key patient inclusion criteria 1.August/September Men at least 18 2019years of age referred with clinical suspicion of prostate cancer who have been advised to have a prostate biopsy 2. Serum PSA ≤ 20ng/ml

European Urology Today

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www.esuerectile19.org

www.esukidneytransplant19.org

ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie’s disease

ESU-ESTU Masterclass on Kidney transplant 24-25 October 2019, Madrid, Spain An application has been made to the EACCME® for CME accreditation of this event

3-4 October 2019, Leuven, Belgium An application has been made to the EACCME® for CME accreditation of this event

www.esulasers19.org

www.esufocal19.org

ESU-ESUT Masterclass on Lasers in urology

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

21-22 November 2019, Barcelona, Spain An application has been made to the EACCME® for CME accreditation of this event

28-29 November 2019, Paris, France An application has been made to the EACCME® for CME accreditation of this event

18

European Urology Today

August/September 2019


Report

Mastering stone management A recap and review of the 3rd ESU-ESUT Masterclass on Urolithiasis Dr. Iason Kyriazis General University Hospital of Patras Dept. of Urology Patras (GR)

jkyriazis@gmail.com

Prof. Evangelos Liatsikos Chair, EAU Section of Uro-Technology Patras (GR)

liatsikos@yahoo.com

Enthusiastic participants of the masterclass

“What prompted me to apply was the masterclass’ scientific programme; it included live surgeries and lectures on PCNL, a procedure that I aimed to be more familiar with, such as supine PCNL,” said Dr. Angelica Grasso (IT).

Organised by the European School of Urology (ESU) and the EAU Section of Uro-Technology (ESUT), the “I was drawn to the whole programme especially 3rd ESU-ESUT Masterclass on Urolithiasis commenced because of the live surgeries. I wanted to learn and from 14 to 15 June in Patras, Greece. perfect my techniques of PCNL and flexible ureteroscopic lithotripsy,” shared Dr. Alexandros Drivalos (GR). The masterclass centred on the metabolic evaluation of urolithiasis, indications, new technologies, and tips “I applied because the masterclass offered hands-on training. I wanted to try new devices in stone surgery. and tricks for the most commonly employed operations. Through interactive lectures, live and Also as my interests lie in PCNL and retrograde intrarenal surgery (RIRS), I was glad to know that pre-recorded surgeries and hands-on training, 10 experts offered 40 delegates comprehensive theoretical there were many topics covering these in the scientific and practical training in stone management. programme,” said Dr. Sven Nikles (HR). The live surgeries included a supine Endoscopic Combined Intrarenal Surgery (ECIRS) performed by Dr. Cesare Marco Scoffone (IT) and Assoc. Prof. Andreas Skolarikos (GR); prone percutaneous nephrolithotomy (PCNL) by Dr. Panagiotis Kallidonis (GR); flexible ureteroscopic lithotripsy by Prof. Dr. Olivier Traxer (FR); and single-use ureteroscopic lithotripsy by Dr. Esteban Emiliani (ES). The pre-recorded surgeries were comprised of flexible ureteroscopic lithotripsy by Prof. Bhaskar Somani (GB); single-use ureteroscopy (URS) by Prof. Athanasios Papatsoris (GR); and bladder stone lithotripsy by Dr. Iason Kyriazis (GR). The hands-on training involved the use of endoscopic stations so that delegates could employ a wide range of low and high power lasers. The delegates also received training in PCNL, semi-rigid and flexible ureteroscopy. In this article, we also included the feedback received from four delegates who shared their impressions, experiences during the masterclass, and their motivations for applying. According to Dr. Ralf Veys (BE), “Joining the masterclass was the ideal opportunity to increase what I know about urolithiasis. The masterclass had broad coverage of flexible URS, ECIRS, PCNL and medical management of urolithiasis. And renowned speakers shared their valuable insights and expertise.”

“It was also great to know about the pros and cons of different approaches from the experts. I was amazed to see how they defended these stone treatment approaches with great conviction. Prof. Traxer had an excellent lecture on the various types of stones and the ways to treat them and this led to lively discussions,” added Dr. Nikles. Aside from the scientific programme loaded with stone management essentials, the participants had specific techniques in mind they wanted to enhance. Dr. Veys stated, “I wanted to evaluate my knowledge as compared to what is current and what the faculty knows.” Personal highlights “My masterclass highlights included the live surgeries and excellent lectures,” shared Dr. Grasso shared. To Dr. Drivalos, the best parts of the masterclass were the live demonstrations of the ECIRS, PCNL and flexible ureteroscopic lithotripsy procedures, and coverage on endourological complications. “On day two, I enjoyed the panel discussions on endourological complications which was moderated by Prof. Liatsikos,” stated Dr. Nikles. “Another highlight for me was the live surgery on supine ECIRS performed by Dr. Scoffone and Prof. Skolarikos who both gave key points and tips and tricks.” According to Dr. Veys, the state-of-the-art lectures in combination with live and pre-recorded surgeries gave participants the opportunity to test and compare their knowledge and daily practice to those of the faculty’s.

Dr. Achilles Ploumidis (GR) demonstrates and gives instructions

www.esunmibc20.org

ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer 20-21 February 2020 Prague, Czech Republic An application has been made to the EACCME® for CME accreditation of this event

“The intimate setup provided participants the opportunities to discuss with the experts, including subjects which do not have a lot of evidence yet. The hands-on training was also good; it gave participants the chance to discuss clinical cases with the faculty in an atmosphere conducive to learning. This, in combination with the facilities in Patras (including the weather) make this masterclass a must-attend,” said Dr. Veys. “I look forward to new ESU masterclasses in the future because I really enjoyed this one. I met great new people and learned a lot along the way,” concluded Dr. Nikles.

Dr. Kyriazis mentors a delegate during the hands-on training

August/September 2019

Join us in the next edition Interested in taking part in this masterclass’ fourth edition? Join us from 19 to 20 June 2020 in picturesque Patras, Greece. Would you like to participate in other ESU masterclasses? Feel free to explore www.esu-masterclasses.uroweb.org. European Urology Today

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ESU Event Calendar Date

Event name

Location

11-13 21 28-29

ESU-ERUS courses during the 17th Meeting of the EAU Robotic Urology Section (ERUS) ESU course on Modern BPH surgery and Endourology (PCNL and RIRS) during the national congress of the Russian Society of Urology E-BLUS during SET-UP Programme

SEPTEMBER 2019 Lisbon (PT) Rostov-on-Don (RU) Shanghai (CN)

OCTOBER 2019 2 2-5 3-4 4 10 10-11 10-12 11 12 17 24-25 31-1/11

ESTs1 during the 5th Meeting of the EAU Section of Urolithiasis (EULIS) 6th Confederación Americana de Urologia Residents Education Programme (CAUREP) ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie's disease ESU course on The treatment of muscle-invasive bladder and metastatic bladder cancer during the Caucasus Central Asia meeting ESU course on New challenges and unmet needs in basic science and histopathology to address the clinical management of renal malignancies during the 26th Meeting of the EAU Section of Urological Research (ESUR) ESTs2 during SET-UP Programme 3rd EAU Update on Prostate cancer (PCa19) ESU course on Update on prostate and bladder cancer during the national congress of the Turkish Urological Association ESU course on Prostate cancer during the national congress of the Hungarian Urologic Association ESU course on Controversies on the treatment of urological tumours during the national congress of the Czech Urological Society 2nd ESU-ESTU Masterclass on Kidney transplant ESU-ESFFU Masterclass on Functional urology at the European Lower Urinary Tract Symptoms meeting (ELUTS19)

Milan (IT)

ESU course on Prostate and bladder cancer; Insight into research and lecturing during the national congress of the Scientific Society of Urologists of Uzbekistan ESU courses on Oligometastases in Genito urinary cancers and Immunotherapy for urological tumours during the 11th European Multidisciplinary Meeting in Urological Cancers (EMUC) 6th ESU-ESUT Masterclass on Lasers in urology ESU course on Prostate cancer imaging during the national meeting of the Lithuanian Association of Urology 1st South East Association Resident Programme (SEAREP) in collaboration with the European School of Urology E-BLUS during the Philippine Urological Association (PUA) 60th Annual Convention 4th ESU-ESUT Masterclass on Focal therapy for localised prostate cancer ESTs1 during SET-UP Programme

Improve your skills: e-learning at your own convenience

EAU Education Online introduces 2 new courses:

Guidelines on Urological Infections

Buenos Aires (AR) Leuven (BE) Tbilisi (GE)

Porto (PT) Bangkok (TH) Prague (CZ)

Guidelines on Urinary Incontinence Get a complete view on clinical aspects, diagnoses and treatments of Urological Infections and Urinary Incontinence:

Antalya (TR) Eger (HU) Prague (CZ) Madrid (ES)

• Understand the diverse natures of Infections and Urinary Incontinence • Arrive at the right diagnoses • Make risk assessment of cases • Decide on a treatment and follow-up strategy

ESU course on Endourology during the national congress of the Egyptian Association of Urology ART in Flexible - Step 2 ESU course on Kidney cancer and the infertile couple during the national congress of the Algerian Association of Urology

11-12 17-19

ESTs1/ESTs2 during SET-UP Programme ESU course during the occasion of the 16th meeting of the EAU Section of Oncological Urology (ESOU)

11-13 20-21

Hands-on training skills programme on Laparoscopy and Endourology ESU-ESOU Masterclass on Non muscle invasive bladder cancer

20-24

35th Annual EAU Congress

9 tbd tbd 16-18

ESU course on Prostate cancer during the National meeting of the Urological section of the Serbian Medical Association E-BLUS during SEP-UP Programme, UROFAIR ESTs2 during SET-UP Programme URO Berlin Skills Teaching and Training (UROBESTT)

7-8 22-23

5th ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction ESU course on PCNL during the 7th Baltic Meeting in conjunction with the EAU

redits

Dr. Panagiotis Kallidonis, Prof. Gernot Bonkat Dr. Tom Marcelissen, Dr. Arjun Nambiar Tashkent (UZ)

Vienna (AT) Barcelona (ES)

uroweb.org/education

Vilnius (LT) Manila (PH)

EAU Edu Platform

Manila (PH) Paris (FR) Lukan Township (TW)

The online learning platform for Lower Urinary Tract Symptoms

DECEMBER 2019 4 4-5 6

2 CME c

Prague (CZ)

NOVEMBER 2019 11 14-17 21-22 23 27-28 27-30 28-29 30-1/12

Education Online

Cairo (EG) Berlin (DE) Algiers (DZ)

JANUARY 2020 Beijing (CN) Dublin (IE)

FEBRUARY 2020 Caceres (ES) Prague (CZ)

MARCH 2020 Amsterdam (NL)

APRIL 2020 Vrnjacka Banja (RS) Singapore (SG) Bangkok (TH) Berlin (DE)

MAY 2020 Heilbronn (DE) Minsk (BY)

JUNE 2020 17-19 19 19-20 28-4/7

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ART in Flexible – step 1 ESU course on Trauma in urology and reconstructive urology during the national congress of the Ukrainian Urological Association 4th ESU-ESUT Masterclass on Urolithiasis ESU – Weill Cornell Masterclass in General urology

European Urology Today

uroluts.uroweb.org

Berlin (DE) Kyiv (UA) Patras (GR) Salzburg (AT)

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August/September 2019


ESU Update

MRI knowledge: A crucial key competence for urologists HOT course to offer MRI-reading benefits and info on pitfalls By Erika De Groot “Throughout the years, magnetic resonance imaging (MRI) has evolved into an element essential in the diagnosis and management of prostate cancer (PCa). For this very reason, a urologist must be able to read and interpret prostate MRI images to acquire as much reliable information to optimise treatment strategy,” said Dr. Jochen Walz (FR), one of the esteemed tutors of the ESU/ESUI Hands-on Training Course in prostate MRI reading for urologists.

fusion biopsy. There is already broad knowledge of traditional ultrasound, which is the most used diagnostic tool in daily urologic practice. Therefore, knowledge of MRI advantages, reading, interpreting, and awareness of the pitfalls are crucial.”

The participants enrich their knowledge in determining the quality criteria for prostate MRI scans, and using systems such as the Likert The growing importance of MRI in the biopsy and scoring system and active surveillance settings will result to an increased version 2.0 of the demand for such courses. This will also underscore Prostate Imaging the importance of urologists developing basic and Reporting and Data reliable abilities of MRI interpretation and knowledge. System (PI-RADS).

According to Dr. Walz, the ability to read MRI scans will be a key competence and a prerequisite for all urologists dealing with PCa in the near future.

“MRI reading is not easy; it requires further education and training. Hence, the inception of the course,” said Dr. Walz.

“Various well-designed studies such as the PRECISION trial demonstrated the impact of MRI on the early detection of PCa, patient selection for active treatment, and prevention of overdetecting low-risk cancers,” stated fellow-tutor Dr. Lars Budäus (DE).

What the HOT course offers Organised by the European School of Urology (ESU) and the EAU Section of Urological Imaging (ESUI) which is chaired by Prof. Dr. Georg Salomon (DE), the hands-on training (HOT) course will take place on 15 November during the 11th European Multidisciplinary Congress on Urological Cancers (EMUC19) in Vienna, Austria.

He added, “Therefore, MRI knowledge should be more widespread among urologists and readily available to them, especially for tumour diagnosis by

The course's intimate setup is conducive to learning

Under the tutelage of the expert faculty, course participants will work with imaging workstations. They will also learn about the basic concepts/principles behind different MRI sequences such as e.g. T2-weighted imaging, diffusion-weighted imaging (DWI), and dynamic contrast-enhanced (DCE) imaging to familiarise themselves with different sequences of prostate MRI interpretation.

Afterwards, they will read and assess the scans on their laptops, followed by discussions with expert radiologists. Participants work on course exercises on their laptops

Feedback from previous attendees “Previous course participants enjoyed and appreciated the hands-on aspect of the MRI reading using the picture archiving and communication system (PACS), and the real-time feedback they received from the faculty,” shared Dr. Walz. “For them the best part was the individual MRI interpretation. This allowed them to interpret MRIs similar as to how radiologists would. And if lesions were scored differently, the faculty and radiologists checked and discussed the results and interpretations with the participants,” stated Dr. Budäus. Complementary course and the future Another HOT course at EMUC19, ESU/ESUI Hands-on Training Course in MRI Fusion biopsy led by Dr. Budäus, will critically review and discuss diverse prostate biopsy approaches. During the second half of this course, the participants will further boost their skills using fusion biopsy machines. This course will complement the MRI-reading course, and vice versa.

And as for new MRI-related HOT courses in development, Dr. Walz disclosed that a masterclass on prostate biopsy is underway. Limited seats available Attending EMUC19 and interested in signing up for the in-demand courses mentioned? Register by simply adding the courses during the registration process. Please note that there are only limited seats available. Register via www.emuc.org/registration/. If you already have an EMUC registration, send an email to our Registrations Department via registrations@congressconsultants.com to join the HOT courses. To know more about EMUC19 and to explore its Scientific Programme, please visit the congress’ official website at www.emuc19.org for more information.

Are you the ultimate Challenger to beat at UROBESTT20? More demanding competition, real-world insights, and expert tutors Are you searching for mentors to help guide you in the next stage in your career? Are you ready to challenge fellow young urologists and seasoned experts with your innovative research? The second edition of the at the URO Berlin Skills Teaching and Training (UROBESTT20) programme could be the ideal platform you are looking for. UROBESTT is designed to expand the capabilities of promising urologists such as yourself who are eager to learn and upgrade their skills. Every aspect of this programme is tailored towards your educational and professional needs. In this article, we interviewed Prof. Dr. Olivier Traxer (FR), a respected faculty member and mentor of the UROBESTT programme. For eight productive years, Prof. Traxer dedicated his expertise and served as a valued board member of the European School of Urology (ESU). Together with the ESU, he was integral in developing the UROBESTT programme where he will remain as one of its esteemed contributors. “As a UROBESTT20 delegate, you will enjoy its dynamic programme; from the practical Hands-on Training (HOT) courses to in-depth discussions on patient cases and state-of-the-art lectures,” said Prof. Traxer.

Check the selection criteria here: urobestt.uroweb.org/application/ Application deadline: 1 February 2020 What’s waiting for you at UROBESTT20 UROBESTT20 aims to offer you insights and lessons learned from real-life situations. You will also have the opportunity to familiarise yourself with approaches and methodologies of colleagues across Europe. According to Prof. Traxer, this second edition of UROBESTT promises you more interaction with key opinion leaders and peers, as well as, more August/September 2019

demanding Challengers sessions where you can showcase what you know and what you do. “The Challengers sessions can be nerve-wracking but definitely exhilarating for participants. You will stand on the podium, present your research results and defend it to the expert panel. As a faculty member and a mentor, it is truly rewarding to witness to see a young Challenger expound upon their research and give arguments to demonstrate their thoughts,” shared Prof. Traxer. In addition, on UROBESTT20’s day one ESU Chair Dr. Joan Palou (ES) will also impart information on how to give a lecture, how to teach, and how to reach your audience. This will be followed topics on laparoscopic renal surgery such as evaluation and treatment through pyeloplasty; indications and technique of endopyelotomy; and limitations of radical nephrectomy. Day two will continue with more Challengers sessions and HOT courses interspersed with lectures on laparoscopy focusing on reconstructive surgery, and endo-urology centred on devices. You can expect coverage on ureteral reimplantation, catheters and guidewires.

View the Scientific Programme here www.urobestt.uroweb.org. “The general atmosphere of UROBESTT20 will be informal, lively and engaging as the first edition was. You will learn tips and tricks that will benefit your practice. You will contribute to the education of your fellow delegates as well. You will brainstorm with the best of the best,” stated Prof. Traxer. How to apply for UROBESTT20 To join this exclusive programme, you must be a certified urologist and an EAU member who is or younger than 41 years old. You are required to submit a clinical case related to topics such as laparoscopy, robotic urology and endoscopy. The selection will be on a first-come, first-served basis as the UROBESTT20 programme will only accommodate a maximum of 90 delegates. Selected delegates will be granted a complimentary hotel accommodation for two nights.

How to be a challenger If you are selected as a UROBESTT20 delegate, you have the opportunity to participate in the Challengers sessions. The candidate must have three published works of his/her own research and data, and a letter of recommendation from the head of the department. A total of six challengers will be selected based on a certain criteria. If you are selected as a challenger, you are required to submit your publication list, the recommendation letter, and the titles of three lectures on the topic of choice. Each lecture should have a duration of 10 minutes. For more information about the application and challenger criteria, the UROBESTT20 Scientific Programme and important dates, please visit www.urobestt.org. UROBESTT20 will take place from 16 to 18 April 2020 in the vibrant German capital, Berlin.

After a hearty lunch, you will know more about lymphadenectomy in prostate cancer, as well as, the origins and evaluation of ureteroscopy. And what better way to conclude the third and final day of UROBESTT20 than with a wrap-up of this special programme and a much-awaited award ceremony for the best challenger of them all? UROBESTT20 vibe UROBESTT20 will offer you three days of a well-rounded Scientific Programme and riveting peer interactions under the mentorship of a knowledgeable faculty.

16-18 April 2020, Berlin, Germany

European Urology Today

21


Report

My impressions of the ESU-Weill Cornell masterclass Enriching my practice, making new friends, getting expert insights Dr. Abisola Oliyide Stepping Hill Hospital Dept. of Urology Manchester (UK)

aquaaby@ yahoo.co.uk Attending the ESU-Weill Cornell Masterclass in General Urology marked the first time I visited Austria. The masterclass, which was organised by the European School of Urology (ESU) and the Weill Medical College of Cornell University, took place from 23 to 29 June 2019 in Salzburg. In this report, I have collated activities, personal anecdotes, and my overall impression of the masterclass. Day one: Hello, Austria I commend the organisers for the clear and easy-tofollow directions to the venue, Schloss Arenberg. Coincidentally, I noticed a man walking in the same direction as I was. I asked if he was attending the masterclass and he said yes. We continued the walk together and that was when I made my first friend. At the welcome reception, Medical Director of the Open Medical Institute (OMI) Prof. Wolfgang Aulitzky (AT) gave us a brief overview on what to expect in the coming days. He was joined by the rest of the faculty members: Course Director Prof. Peter Schlegel (US), Co-Course Director Prof. Hein van Poppel (BE), Dr. Scott Tagawa (US) and Dr. Rafael Sanchez-Salas (FR). We, the delegates, consisted of 33 fellows from 26 countries; a group who provided an exciting mix of cultures and topics of interests.

Day two: Initial lectures Monday morning began with a 30-minute pre-test which helped me determine my level of knowledge of genitourinary cancers. I felt reassured that the masterclass lectures will address questions and knowledge gaps. The series of lectures began with coverage on Stages I, II and III of testis cancer. We were provided with handouts which we also used for noting salient points. The lectures that followed covered renal cancer management. The discussions from all these lectures were rich with diverse insights and experience of both the faculty and the fellows. The last session of the day consisted of case presentations by the fellows. The presentations were very enlightening as these showed that although management of the same condition may differ per country (based on expertise, technology and experience available), the overall goal was to achieve the best possible outcome for the patient. I was the 8th fellow to present a case. I was quite shy and nervous but in the end, I gained valuable tips that would improve my current practice. We had a bit of time in the evening, so 16 of us headed into the city which gave us the opportunity to bond, exchange ideas and talk about non-academic topics as well. Day three: Fascinating cases On Tuesday morning, the lectures covered classification of renal tumours, nephron sparing surgery, and the controversy surrounding lymph node dissection in renal tumours presented in an easy-to-understand manner. I found the lecture “Ablative therapies for renal cancer” interesting as these therapies are not

routinely offered at the centre back home. I was able to gather a lot of information based on the expertise of the faculty. Following the lunch break, we had 10 more case presentations from fellows; a few of which were unusual and complex which I found very interesting. The most fascinating case for me was the one about a “burned out” testicular tumour as a metastatic prostate germ cell tumour. After the day’s lectures, I decided to visit the Mirabell Palace and Gardens as I am an avid fan of the film “The Sound of Music”. It was a surreal experience. I found myself humming the song “Do-Re-Mi” throughout my tour of the Mirabell Gardens. Day four: Very useful to my practice We started the day with lectures on magnetic resonance imaging (MRI) prostate imaging, the use of positron emission tomography (PET), and treatment options for high-risk localised cancer of the prostate. The coffee break was in perfect timing; it gave me an extra boost for the lecture I had been looking forward to: “Management of men with persistently elevated PSA”. The lecture is very useful to my practice as it can get quite challenging especially when managing the expectations of the patient. This lecture was followed by other lectures about the prostate and the hands-on training (HOT) course in laparoscopy. Day five: Demonstrations This day was full of interesting lectures on andrology and penile cancer such as those by Dr. James Kashanian (US) and Mr. Suks Minhas (GB) whose informative slides generated a lot of discourse.

Afterwards, there were five training points for 17 participants which took us through four basic and essential skill models under the supervision of Prof. Sanchez-Salas and Dr. Theodoros Tokas (GR) during the HOT course. They made it look easier than it actually was! They were very helpful and patient, and shared numerous useful tips and ergonomic tricks. Day six and closing remarks I am grateful for the opportunity to be in Salzburg, gain new friends, and improve my clinical practice with insights one cannot simply find in just any literature. I highly commend the faculty and staff for the seamless organisation of the masterclass. I have learned a lot from the highly-experienced faculty who were willing to share their knowledge, tips and tricks. I look forward to further collaboration with OMI and I hope to participate in future programmes beneficial to my clinical practice. Please see page 27 for other masterclass reports and testimonials by Dr. Rodrigo Suarez-Ibarrola (DE) and Dr. Nelson Morales Palacios (ES).

Together with the esteemed faculty of the masterclass

Report

ART in Flexible: Training the pathway for surgeons 2nd edition’s step 1 commences in Berlin By Erika De Groot ART in Flexible (AiF) step 1 kick-started on 15 July in Berlin, Germany where it welcomed 48 enthusiastic and promising delegates. Organised by the European School of Urology (ESU), the two-day novel programme delivered hands-on training and lectures on the history of stone treatment; overview of the instruments and handling; patient selection and positioning; set up selection; and the latest technologies in endoscopic diagnostics. “The tendency is to believe that the outcome of a surgery depends on a procedure itself and comorbidities. In my opinion, the outcome is determined by the training pathway of a surgeon. Thanks to initiatives such as AiF, we have the opportunity to standardise. I hope that the results from the programme will help encourage standardisation at residency centres worldwide,” stated AiF Coordinator Dr. Domenico Veneziano (IT). In this article, Dr. Veneziano, together with delegates Dr. Yu-Chen Chen (TW) and Dr. Mateusz Czajkowski (PL) recount their experiences at AiF and talk about the future of the programme. Noteworthy highlights “My personal AiF highlight was the final evaluation. We, the faculty, used the Performance improvement (Pi)-score algorithm to analyse the improvement of each delegate. That was the moment when we learned more about the extent of our efforts and the effectivity of our teaching,” shared D. Veneziano. “My AiF highlights were the demonstrations from experts in the field, and learning tips and tricks from them. As an Asian urological resident, it was great for me to know more about the techniques, methodologies and technologies used in Europe,” stated Dr. Chen. 22

European Urology Today

She added, “At AiF, I learned how to properly handle the flexible ureteroscope. I learned about the complications that may result from the procedure so these can be prevented; and how to choose the best ergonomic set up.” “For me, the main highlight of AiF was the programme’s focus on the hands-on training under the supervision of experienced tutors,” said Dr. Czajkowski. “I also valued learning about the efficient handling of flexible cystoscopy; Endoscopic Stone Treatment step 1(EST 1); and endoscopic treatment tips and tricks that I can apply to my daily work.” Reasons for applying “What attracted me to apply was the hands-on training courses which I found fantastic! I was so pleased that the setup of the course was two residents per tutor. This helped me learn from my mistakes and truly improve,” said Dr. Chen. She continued, “I aimed to learn all about flexible as much as I could, especially in the wet lab. In Taiwan, it’s difficult for a resident to learn flexible ureteroscopy because it’s easily broken and costs a lot to repair. That’s why I cherished the opportunity given to me at AiF.”

Dr. Veneziano imparts expert insights

Enthusiastic AiF delegates with dedicated tutors and course organisers

According to Dr. Czajkowski, he applied because of the hands-on training as well. He said that he developed his skills in flexible cystoscopy and Retrograde Intrarenal Surgery (RIRS). “I’m pleased that I had the opportunity to practise because those techniques are only available to a very small extent for young residents in Poland.” Next steps “During AiF, the participants undergo over three hours of technical-skills training. We collect data in real time then use an algorithm to determine who learned the most within the given timeframe. This challenge is also to push each delegate to show his/ her best. The top performers will proceed to AiF’s step 2,” said Dr. Veneziano. AiF is comprised of three steps in total. Step 1’s top 16 delegates will be invited to participate from 4 to 5 December 2019 in Berlin for ART in Flexible step 2. From the 16, four of the most skilled delegates will be invited for ART in Flexible step 3 in February 2020 in Caceres, Spain.

“We have had residents from Malaysia and Taiwan, which confirms that the word is spreading about the quality of AiF. Now the programme is effective and well-balanced. One of the plans is to increase the number of seats available to meet the growing demand. The 48 seats were filled just one week after the application page on the AiF website went live! So stay tuned for 2020!” concludes Dr. Veneziano. Check out the AiF report from another participant, Dr. Pablo Abad-López (ES), on page 26. About AiF The AiF programme is designed for third-year residents. An EAU membership for interested parties is mandatory. Selected applicants for AiF step 1 will receive a complimentary one-night accommodation inclusive of meals. For step 2, the top performers will receive accommodation for two nights with meals and a travel-fee compensation of a maximum of €250. For more information about the programme, visit www.artinflexible.uroweb.org. August/September 2019


Report

ESU course: A great success at ROMURO 2019 Kidney laparoscopic approach and non-muscle invasive bladder tumours highlighted Prof. Catalin Pricop Chairman of Romuro 2019 University of Medicine and Pharmacy Iassy (RO) bobopricop@ yahoo.com The course "Kidney laparoscopic approach and Non muscle invasive bladder tumours" by the European School of Urology (ESU) was organised on the third day of the 35th Romanian National Congress of Urology (ROMURO 2019). It was an excellent opportunity to experience the benefits of ESU's support, generously offered to member associations first-hand. The course was held in Bucharest, Crowne Plazza Hotel, on 7 June 2019 and was attended by 312 delegates. Recommendations for renal tumour treatment In the first part of the course, Prof. Francesco Porpiglia from Torino (IT) gave a presentation on the advantages of this type of scientific event, of which all participating urologists could benefit. He then

presented, in a very didactic manner, the recommendations regarding the surgical treatment of renal tumours. The lecture was followed with great interest, as it referenced the EAU Guidelines viewed from the perspective of a highly-experienced surgeon.

The presentation of laparoscopic complications in the surgical approach of renal tumours was particularly useful for the surgical teams at the beginning of their journey in this field, but also for those who work in more high volume centres.

Partial laparoscopic nephrectomy Partial laparoscopic nephrectomy is a procedure that is getting more attention because imaging investigations can detect renal tumours at an early stage. Prof. Porpiglia's lecture has repeatedly emphasised investigating and treating the minimally invasive lesions without neglecting oncological principles.

I would like to especially mention the interactive case discussion presented by our colleagues from Romania; the cases aroused vivid interest and provoked interesting discussions from which all participants could learn.

From discussions with colleagues from other centres, I learned that Prof. Porpiglia's lectures, in which both the advantages and the possible risks, as well as the complications of the method were clearly presented, have inspired colleagues with little experience with a laparoscopic approach of the kidney. Laparoscopic approach The programme was followed by lectures delivered by Dr. Tiago Ribeiro De Oliveira from Lisbon (PT), who focused on the laparoscopic approach of large kidney tumours and upper urothelial cancer (TTC upper tract). The lectures were followed with great interest.

Second programme part In the second part of the programme, Prof. Georgio Gakis from Würzburg (DE) gave a very useful review of the current treatment of non-muscular invasive bladder tumours. We have all noticed the earnestness of the presentation, with direct references to the proportion of urologists who apply various recommendations of the EAU Guidelines, especially because not all European urologists have access to similar technological facilities. The lecture on transurethral resection of bladder tumour (TURBT) classic resection versus en-block resection for bladder tumours, accompanied by edifying video images, was exciting and encouraging for many participants.

Prof. Porpiglia combined EAU Guidelines with longstanding experience

In conclusion, I would say that the ESU Course organised was a great success, due to both the selected topics and the manner of presentation, as well as the liberal, sincere, amicable discussions on subjects that highly interested the audience. Finally, I sincerely thank the ESU and the distinguished panel of the course for this successful event.

Also the role of bladder instillations after TURBT was objectively and thoroughly discussed. Prof. Gakis’ personal experiences may turn out to be a good guide for young urologists.

Prof. Gakis (DE) gives his lecture on non-muscle-invasive bladder tumours

The ESU course had a high attendance and evoked much discussion

Interactive case discussion The second part of the course ended with an interactive case discussion, during which three colleagues from Romania presented cases of patients with non-invasive bladder tumours, with an atypical clinical course.

Dr. Ribeiro De Oliveira speaking on the laparoscopic approach of large kidney tumours

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

2020 Japanese Tour The JUA/EAU International Academic Exchange Programme will send both Japanese faculty to Europe and European faculty to Japan. The programme aims to promote international exchange of urological medical skills, expertise and knowledge. For 2020 the JUA/EAU International Exchange Programme will provide grants to enable two EAU members to travel to Japan. The tour should take place from 13-25 April 2020 starting with visits to urological facilities in Japan, culminating with participation in the 108th JUA Annual Meeting, which will be held in Kobe (23-25 April). Eligibility criteria • Less than 42 years of age • Minimum academic rank of assistant professor • Letter from the departmental chairman of the applicant’s commitment to academic medicine • Membership of the EAU • Availability to travel around two weeks at the earlier mentioned time

• • • •

Curriculum Vitae (C.V.) Personal statement (300 words or less) describing how participation in the Programme will benefit him/her both personally and professionally Statement of your primary and secondary area of academic and/or clinical interest Applications should include a letter of support from department chair (must be signed and on letterhead of the institute/department)

Information and application forms For all further information and programme application forms please visit http://uroweb.org/about-eau/our-partners/ and scroll down to Exchange Programmes and click on Japanese programme. Additionally you can contact Angela Terberg at the EAU Central Office, +31 26 389 0680, a.terberg@uroweb.org

Application deadline: 1 October 2019

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

August/September 2019

European Urology Today

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You too can take part in

Brushing your teeth takes a lot longer. A prostate check only takes a few minutes and it can save your life. #UROLOGYWEEK

Squeezing is good for oranges, not your bladder! Having an enlarged prostate or benign prostatic hyperplasia (BPH) adds pressure on your bladder. Ease your discomfort. Consult your urologist to know more about BPH.

Size does matter… to your prostate!

YUO leadership course

How big is a normal-sized prostate? Are you at risk of benign prostatic hyperplasia (BPH)? Know more about the symptoms. Talk to your urologist.

#UROLOGYWEEK

#UROLOGYWEEK

urologyweek.org

urologyweek.org

urologyweek.org

Become an ambassador for Urology Week. Download the posters, tell us your story, organise an event and share it on social media. Register your event now on the website!

urologyweek.org

Sunday, 22 March 2019 08.30-12.30, room G109 RAI Amsterdam Application deadline: 1 February 2020 www.eau20.org

#urologyweek

3rd ADRIATIC UROLOGY FORUM

Main topics: KIDNEY TUMOURS UROLITHIASIS Poster and Video sessions

UUCG

Udruženje Urologa Crne Gore

Združenje urologov Slovenije

Hotel Budva, Budva, Montenegro September 20-21, 2019 More info at www.zus.si or contact: dperovic@t-com.me or marko.zupancic@sb-sg.si

24

European Urology Today

August/September 2019


Baltic19 focuses on onco-urology

BALTIC 19

A report on vital topics and relevant updates for the region Dr. Rauno Okas Urology Resident, Tartu University East-Tallinn Central Hospital (EE)

okas.rauno@ gmail.com

Dr. Andres Kotsar Chairman, Estonian Society of Urology Tartu University Hospital (EE)

andres.kotsar@ kliinikum.ee From 24 to 25 May 2019, the 6th Baltic Urology Meeting (Baltic19) took place in Tallinn, Estonia and welcomed 319 participants from 24 countries.

cystoprostatectomies at the Lithuanian National Cancer Institute. The laparoscopy session was followed by the traditional Young Urologist Competition wherein four promising urologists shared and defended their research results. Dr. Priit Veskimäe (EE) discussed the role of PSMA PET/CT in prostate cancer management. The competition winner, Dr. Janis Berzins (LV), gave an overview of the management principles (i.e. early initiation of antibiotic treatment accompanied by surgical debridement) in his lecture “Fournier gangrene is still a challenge”. He concluded that despite great advances in urology, the mortality rate for Fournier gangrene patients is still high. Dr. Minija Cerškute’s (LT) presentation was about the factors influencing postoperative results of nephron sparing surgery. Dr. Sergei Goldytski (BY) spoke about high dose brachytherapy in prostate cancer treatment. In the course organised by the European School of Urology (ESU) entitled “New Perspectives in the management of upper tract tumours”, Dr. Joan Palou (ES) and Dr. Shahrokh Shariat (AT) shared their expertise such as with regard to the POUT trial, which shows that perioperative systemic therapy is needed to treat micro-metastases and improve survival. Also, patients with papillary high-risk upper tract urothelial

Baltic19 commenced with the session dedicated to the use of laparoscopic surgery in urology. Prof. Günter Janetschek (AT) gave a thorough lecture on the history, current state, future perspectives of laparoscopic method and its possibilities. Within a short period of time, laparoscopy became the gold standard of treatment in some areas of urology (e.g. laparoscopic nephrectomy in case of T2 kidney cancer when nephron sparing surgery is not a feasible option). Dr. Mihhail Žarkovski (EE) gave an overview of the results of laparoscopic radical prostatectomies performed at the Tartu University Hospital from 2015 to 2018. Then Dr. Paulius Bosas (LT) Dr. Palou talks about ESU activities introduced the initial results of laparoscopic

Award winners review Baltic19 In recognition for their scientific contributions, three promising and talented urologists were given prestigious awards during the 6th Baltic Meeting. Dr. Arnas Bakavicius (LT) is recipient of the Berlin-Chemie Best Poster award; Dr. Janis Berzins (LV) is winner the Young Urologist Competition; and Dr. Aliaksei Ryndzin (BY) is first-prize awardee of the Karl Storz Award.

Preparations and topics Dr. Ryndzin shared “Working at the tertiary referral oncological hospital, we often have to deal with suboptimal results of muscle-invasive bladder cancer treatment. A national database of radical cystectomies was created to study this problem, analyse and compare the outcomes of radical cystectomy in various hospitals in the country in order to improve the results. The analysis of the database was the focus of my Baltic19 presentation.”

Overall impressions “Baltic19 had fantastic speakers and an excellent scientific programme,” said Dr. Bakavicius. “Meetings like these increase the quality of urological care in the region significantly.” “This is a very important meeting as young urologists from the Baltic States get the opportunity to present their research data, attend expert lectures, gain practical skills in laparoscopy and endoscopy. The scientific programme and organisation of the meeting met my expectations,” said Dr. Ryndzin.

Dr. Berzins (centre) receives the Young Urologist Competition Award

Dr. Berzins stated “It was my first Baltic meeting. I was impressed, from the venue, number of participants, quality of the scientific work presented, organisational aspects and so on. I look forward to Baltic20 in Minsk.”

“I was able to prepare well for my presentation on Fournier gangrene through the support and guidance of Dr. Linards Redmanis (LV), supervising doctor for my study; Assoc. Prof. Vilnis Lietuvietis (LV), head of the clinic; and my colleague Dr. Arvis Freimanis, previous winner of the Young Urologist Competition,” said Dr. Berzins.

Baltic19 highlights According to Dr. Ryndzin, his meeting favourites were the course “New perspectives in the management of upper tract tumours” organised by the European School of Urology; the “Laparoscopic urological surgery” session; and the Young Urologists Competition.

On the podium Dr. Bakavicius said “I like going outside my comfort-zone. Defending my work enables me to learn more and gives me extra motivation to move forward.”

Dr. Bakavicius’ highlights included topics on molecular markers changing the diagnostics of prostate cancer; local treatment becoming more common in upper urinary tract urothelial carcinoma; and consideration of neoadjuvant systemic treatment before radical nephroureterectomy.

August/September 2019

I was excited and anxious at first, but once I started talking and saw the support from my colleagues, delivering my presentation came easy. After my talk, I felt truly honoured by Prof. Jens Sønksen’s kind words. I'm glad my speech moved him. It was encouraging for me to keep studying and talking about Fournier gangrene,” shared Dr. Berzins.

24-25 May 2019 Tallinn, Estonia

carcinoma (UTUC) planned for radical nephroureterectomy (RNU) should receive neoadjuvant cisplatin-based chemotherapy. Additionally, with cases in which previously mentioned neoadjuvant cisplatin chemotherapy was not received, platinum-based adjuvant chemotherapy should be offered for pT2-4 Nx/0 or for all N+ UTUC patients. Dr. Shrariat also emphasised the role of adequate lymphadenectomy when performing RNU because it reduces recurrence. RNU alone is not sufficient treatment for UTUC in most patients. ESU’s hands-on trainings were scheduled on both days. Experienced laparoscopic surgeons led by Dr. Petr Macek (CZ) helped young urologists prepare for the European training in basic laparoscopic urological skills (E-BLUS) exams and endourology specialists led by Dr. Achilles Ploumidis (GR) introduced the first steps in cystoscopy and ureteroscopy. They also shared their complicated cases and treatment options during the tips-and-tricks sessions. The second day of the meeting started with a session dedicated to andrology and office urology. Dr. Oskars Jakušenoks (LV) gave a comprehensive overview of benign penile lesions. Later on, Assoc. Prof. Margus Punab (EE) and Dr. Titas Simaška (LT) debated on the role of prostate massage in case of acute prostatitis or deterioration of chronic prostatitis. Both concluded that it has a role in properly selected cases. A novel session for the Baltic meetings was the multidisciplinary analysis of a complicated case when ureteral stent was not removed at the right time and had caused the patient multiple problems. In addition to urologists describing the case from a medical point of view, lawyers commented the juridical aspects of the matter. During the poster sessions, 83 abstracts were presented. Dr. Ned Kinnear (AU) shared the results of a systematic review and meta-analysis on the use of

Drs. A. Kotsar and M. Jievaltas chair the session "Urologist faces the court (legal matters – session with lawyers)"

intraoperative cell salvage in urological surgery. He concluded that the results in 14 studies on prostate, bladder and kidney cancer surgeries with 4,536 patients involved suggested that the use of perioperative autologous blood transfusion reduced postoperative allogenic blood transfusion rates and did not increase tumour recurrence nor increase complications rate. Therefore, the limited data on the topic suggests that the use of cell savers on urooncological cases when a huge blood loss is expected has more benefits than hazards. The winners of the poster session were Dr. Aliaksei Ryndzin (BY) who won the first prize of the Karl Storz Award for his poster “Radical cystectomy in Belarus: Current status” wherein he shared his insights in bladder cancer surgery; and the multinational team led by Dr. Arnas Bakavicius (LT) won the first prize of the Berlin-Chemie Best Poster award for their poster “Predicting abiraterone acetate treatment resistance from blood-circulating androgen receptor variants in castration resistant prostate cancer.” To sum up, Baltic19 was a successful meeting where local urologists shared the results of their work; EAU experts gave overviews on the latest developments in urology; and young urologists had a chance to improve their skills.

Baltic20: New exciting changes are underway in Minsk By Dr. Alexander Minich (BY) and Prof. Aliaksandr Strotski (BY) Minsk will host the 7th Baltic meeting (Baltic20) in conjunction with the EAU which is a first for the Belarusian capital. Scheduled for May 22-23, 2020, the two-day event will deliver progress updates on the latest research, and offer relevant discussions to those who aspire to keep learning for the benefit of their patients. The annual Baltic meeting was traditionally held in the Baltic capital cities Vilnius, Riga and Tallinn. A few years ago, Belarus joined the meeting through the support of the EAU and urological associations of the Baltic states. And now, Minsk will host this reputable event. Baltic20 will provide the perfect opportunity to discuss the latest diagnosis and treatment-related developments achieved in the field of urology. The event programme will comprise of lectures by leading European and local experts on uro-oncology, functional urology, infections and other areas of urology. The meeting agenda will also include the Young Urologist Competition, ESU Course on percutaneous nephrolithotomy (PCNL), training courses in laparoscopy and ureterorenoscopy. As it has been, young colleagues can present their latest research results during the poster sessions. Abstracts will be accepted before April 1, 2020 and published in the European Urology Supplements. Meeting participants will have the privilege to discover the beauty of modern Minsk, which recently gained popularity as a tourist attraction. Learning about the glorious

past of being part of the Grand Duchy of Lithuania, and challenging heroic times of the last century which made Minsk a Hero City, today’s image of the capital as the Silicon Valley of Eastern Europe will leave a lasting impression. Luxurious greenery enveloping the eye-catching Soviet-time architecture, friendly citizens and unique Belarusian cuisine will cordially welcome all the participants of the 7th Baltic meeting. Visiting Belarus is now easier than ever. Citizens from more than 40 countries can visit the country visa-free for 30 days when they cross the border through the Minsk National Airport. It is important to mention this just in case you enter Belarus by car or by train as you still need to get an entrance visa to Belarus. The Belarusian Consulate or Embassy in your area can assist you with this. Detailed information regarding visa will be available at the meeting website soon at www.baltic.uroweb.org. On behalf of the EAU, Belarusian Association of Urology, Lithuanian Society of Urologists, Latvian Urological Association and Estonian Urological Society, we look forward to welcoming you in Minsk at Baltic20. See you in Belarus!

BALTIC20 7th Baltic Meeting in conjunction with the EAU 22-23 May 2020 Minsk, Belarus Abstract deadline: 1 April 2020

www.baltic20.org

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Young Urologists/Residents Corner Urological volunteering in Uganda Urologists are invited to take part in urological campaign Dr. Jose QuesadaOlarte University Hospital La Paz Dept. of urology Madrid (ES) Jose.quesada@ salu.madrid.org

Dr. Juan Antonio Mainez University Hospital La Paz Dept. of urology Madrid (ES) drmainez@ gmail.com “Service to others is the rent you pay for your room here on Earth.” - Muhammad Ali The idea of volunteering or donating money to Africa has probably crossed your mind at least once. I would like to share my experience as a volunteer in Africa with you.

Dr. Quesada-Olarte and Dr. Mainez enjoyed working with local staff

IDIWAKA Dr. Vives, a colleague and third-year thoracic surgery resident, introduced me to IDIWAKA, a non-profit organisation (NPO) for doctors. They collaborate with other NPOs in hospitals in north-western Uganda, run by the servants of Mary, a religious congregation. IDIWAKA and the servants of Mary are doing an excellent job attending to many patients and developing different projects, both medical and educational. To date, numerous campaigns have been carried out in ophthalmology, paediatrics, thyroid surgery - all of them with great success. Dr. Vives told us about her medical experiences in AFRICA, feeding our desire to contribute to this commendable cause. Large refugee community Dr. Mainez, a young urologist, and me - a third-year urology resident from Madrid (ES) - decided to participate in a urological campaign in a hospital centre in north-western Uganda. Congo and South Sudan have social conflicts and Uganda is a country that hosts a large community of refugees. IDIWAKA is an organisation that aids projects in this area of the country. So, we planned several surgical activities that we could perform in Lodonga hospital. This hospital is equipped with 1 operating room, 1 delivery room and Dr. Quesada-Olarte and Dr. Mainez at work in the Lodonga around 60 beds for patients. health centre Medical team Dr. Mainez and I met with eight other IDIWAKA volunteers and made a team of 10 volunteers consisting of doctors and nurses. We set out to collect donations of medical supplies necessary to complete our surgical activities. Our medical team consisted of 2 nurses, 2 general surgeons, 2 gynaecologists, 1 radiologist, ourselves (Dr. Mainez and Dr. QuesadaOlarte) and a thoracic surgery resident from our hospital. Our activities upon arriving at the hospital centre were to organise the surgical activities based on the centre's material, medical health personnel and urological pathologies of the community. We performed approximately 100 medical consultations, 20 urological surgeries and assisted in 80 nonurological surgeries. Our surgeries consisted of circumcisions, hydrocèlectomies, removal of epididymal cysts, undescended testicle repair surgery and suprapubic tube placement. In the medical consultations we were able to clinically diagnose

some cases of prostate cancer, primary hypogonadism, cryptorchidism, BPH and prune belly syndrome. We instructed local health care providers on how to perform urethral catheterisation.

The medical team consisting of doctors and nurses

“If our hopes of building a better and safer world are to become more than wishful thinking, we will need the engagement of volunteers more than ever.” — Kofi Annan

Please volunteer The main goal of sharing our experiences is to motivate the European urological community to volunteer in vulnerable populations. I strongly believe that the best influence we can have on the African population is done by using our professional talents for humanitarian causes. I keep the best memories of Uganda - my first experience in Africa – and would love to return if my next vacation allows it. By the end of my volunteer period, I realised two things: firstly, few experiences are as enriching as this one; secondly, there is still much work to be done.

The team ‘in action’

A wonderful hands-on training for 3rd year trainees ART in Flexible: advanced training on endourology and urolithiasis for selected residents Dr. Pablo Abad-López 12 de Octubre University Hospital Dept. of Urology Madrid (ES)

pablo.abad@ salud.madrid.org

programme full of endourology and urolithiasis. The programme included HOT (hands-on training) and theoretical speeches and was presented to two different groups on 15-16 and 16-17 July 2019.

"I firmly believe this consolidated event is a ‘must’ for 3rd year trainees who want to improve their endoscopic skills."

Last July, Karl Storz`s visitor centre in Berlin (DE) hosted ART in flexible – 2nd Edition Step 1, a 2-day ESU event designed to improve endourology skills of third year trainees all over the world. ART stands for Advanced Resident Training.

I had the chance to join the selected group of residents and take part in this programme. We met Professor D. Veneziano (IT), who has developed this programme, and the other faculty members: S. Biyani (GB), P. Kallidonis (GR), K. Ahmed (GB), N. Macchione (IT), A. Ploumidis (GR), B. Schoensee (DE), T. Tokas Programme full of endourology and urolithiasis The successful first edition of this event was organised (AT). Prof. Veneziano also designed the Endoscopic Stone Treatment-Step 1 (EST-s1), a training curriculum in 2018. This year, ESU continued to gather residents validated by ESU and the basis of this meeting. from different nationalities for an educational

Participants and faculty of ART in Flexible

During the course we listened to lectures focused on stone treatment (from history to current options) and endourology: instruments (optics, guidewires, operative channels, stents, sheaths, etc.), patient selection and positioning, set-up, latest technologies… We also had two time blocks of 1.5 hour each for benchmark assessment by one faculty member, prior to the final exam. Endoscopy exercises The hands-on training consisted of four endoscopy exercises (flexible cystoscopy, rigid cystoscopy, rigid ureteroscopy, flexible ureteroscopy), as designed for EST-s1, in order to achieve a better performance and reduce time spent.

Two participants during hands-on training

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European Urology Today

Prof. Veneziano explaining the set-up of the AiF meeting

However, the time was not only spent on academical activities. We could also enjoy a fantastic official

dinner and used the breaks to do some networking and share impressions with colleagues. And of course, we couldn´t leave Berlin without visiting the main city attractions. Finally, we performed the 4 exercises exam (as planned for EST-s1). The sixteen most skilful trainees are invited to come back to Berlin in December for the second step of this course. I firmly believe this consolidated event is a ‘must’ for 3rd year trainees who want to improve their endoscopic skills. Check out more ART in Flexible impressions on page 22. For further information about this event please visit: https://artinflexible.uroweb.org/

August/September 2019


Young Urologists/Residents Corner ESU-Weill Cornell Masterclass in Urology in Salzburg Strengthening unity among young urologists worldwide Dr. Rodrigo SuarezIbarrola University of Freiburg - Medical Centre Dept. of Urology Freiburg (DE) rodrigo.suarez@ uniklinik-freiburg.de

Dr. Nelson Morales Palacios University Hospital Príncipe de Asturias Dept. of Urology Alcalá de Henares (ES) nelmop@gmail.com The ESU-Weill Cornell Masterclass in Urology, a collaborative programme of the European School of Urology and Weill Medical College of Cornell University, was held from 23 to 28 June 2019 in Salzburg (AT). The week-long masterclass is a high-level programme about general urology, designed for young urologists with an active academic profile.

Schloss Arenberg meeting venue The meeting was held in Schloss Arenberg, a 19th century palace within walking distance of the centre of Salzburg, and coordinated by Dr. Wolfgang Aulitzky, Medical Director of the American Austrian Foundation (http://www.aaf-online.org/open-medical-institute. html). It was purchased in 2001 by the Salzburg Foundation of the American Austrian Foundation to serve as a state-of-the-art conference centre and currently hosts medical seminars for physicians from over 100 countries. For this particular seminar, thirty-five urologists from 27 different countries were selected to receive up-to-date lectures by 9 highly Participants and faculty members of the Masterclass in Salzburg experienced faculty members. Lectures were held daily from morning to early afternoon and covered the most recent findings on each of the discussion topics. The faculty complemented their presentations with expert opinions, and tips and tricks from their own medical practice. The talks stimulated questions from the entire spectrum of the audience and triggered engaging discussions. An early morning break provided participants the opportunity to mingle and engage in conversations with the faculty on academic and personal subjects over coffee and apricot cake.

This year´s programme covered topics on renal cell carcinoma, penile cancer, prostate cancer, testicular cancer, and infertility/andrology. A test took place before and after the Masterclass to assess the participants´ progress.

Salzburg and musicians However, it was not only urology that we were instructed in; in Salzburg, city of music, classical music was also part of the programme. Everyone greatly enjoyed a chamber concert by an Austrian violin and viola duet who played works by Franz Schubert and Wolfgang A. Mozart. The musicians shared stories with us which illustrated the longstanding relationship between Salzburg and some of the greatest musicians and composers of all time.

Hands-on training with Dr. Sanchez-Salas

For three days, the late afternoons were dedicated to presentations, where each participant presented a case report treated in their home institution. The topics ranged from rare diseases, to innovative treatment modalities and procedure-related complications. The discussions following each case presentation were highly illustrative and complemented the subjects covered in the morning lectures. The other two days were assigned to hands-on laparoscopy training with Dr. Christian Wagner, Dr. Rafael Sanchez-Salas and Dr. Theodor Tokas. Fellows tested their abilities on laparoscopic modules with three exercises involving tissue cutting,

passing a needle through small metallic loops, suturing and tying knots. Most original case reports At the end of the last dinner, prizes were awarded to the most original and best presented case reports. Recognition was also given to the participant who achieved the highest score on the final exam and to the individual who showed the greatest improvement at the end of the week.

The lectures on the latest updates in urology require full attention

Participating in this Masterclass was a privilege. It gave us a satisfying opportunity to enrich our everyday medical practice and vision of the world. We are sincerely grateful to the course organisers, Prof. Hendrik Van Poppel (BE) and Prof. Peter Schlegel (US), and the rest of the faculty for dedicating their time to us for an entire week, sharing their knowledge and making this seminar into an unforgettable experience. Read the masterclass experience of another enthusiastic participant, Dr. Abisola Oliyide (UK), on page 22.

Prof. Van Poppel, one of the dedicated organisers of the Masterclass

Fellowship Programme European Association of Urology Nurses

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

even worse case yourself? If so…

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

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

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

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

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

Please send the details of your personal Nightmare Case and photos to: Dr. David Karsza, eut@uroweb.org

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 31 January 2020

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

www.eu-acme.org

• Only EAUN members can apply • Host hospitals in Belgium, Denmark, France, the Netherlands, Sweden, Switzerland and the United Kingdom • A great way of widening your horizon For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

August/September 2019

European Association of Urology Nurses

European Urology Today

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www.gua-cca19.org

www.eulis19.org

GUA-CCA19

EULIS19

1st Georgian Urological Association Caucasus Central Asia Meeting

5th Meeting of the EAU Section of Urolithiasis

4-5 October 2019, Tbilisi, Georgia

3-5 October 2019, Milan, Italy An application has been made to the EACCME® for CME accreditation of this event

In conjunction with the European Association of Urology (EAU)

Register now!

www.esur19.org

ELUTS19

ESUR19 26th Meeting of the EAU Section of Urological Research

European Lower Urinary Tract Symptoms meeting

10-12 October 2019, Porto, Portugal

31 October - 2 November 2019 Prague, Czech Republic

In collaboration with the Society for Basic Urologic Research (SBUR) and the EAU Section of Uropathology (ESUP)

By

www.eluts19.org

In collaboration with

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European Urology Today

August/September 2019


Update from the EAU Guidelines Office Latest publications, guidelines training and the appointment of Prof. Maria Ribal analysis from the European Association of Urology/European Society For Paediatric Urology Guidelines Panel. Eur Urol 2019 75(3)448.

• Management of sporadic renal angiomyolipomas: A systematic review of available evidence to guide recommendations from the European Association of Urology Renal Cell Carcinoma Guidelines Panel. Eur Urol Focus 2019, prior to print.

E U R O P E A N U RO L O GY 7 5 ( 2 019 ) 4 4 8 – 4 61

• Updated European Association of Urology guidelines on renal cell carcinoma: Immune checkpoint inhibition is the new backbone in first-line treatment of metastatic clear-cell renal cell carcinoma. Eur Urol 2019 76(2)151.

Platinum Priority – Review – Pediatric Urology Editorial by Jack Elder on pp. 462–463 of this issue

Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel Mesrur Selcuk Silay a[1_TD$IF],*, Lisette Hoen b, Josine Quadackaers c, Shabnam Undre d, Guy Bogaert e, Hasan Serkan Dogan f, Radim Kocvara g, Rien J.M. Nijman c, Christian Radmayr h, Serdar Tekgul f, Raimund Stein i

E U RO P E A N U R O L O GY 76 ( 2 019 ) 151 – 15 6

Prof. Maria Ribal, new Vice-chairman Guidelines Office Board

available at www.sciencedirect.com journal homepage: www.europeanurology.com

a

available at www.sciencedirect.com journal homepage: www.europeanurology.com

Division of Pediatric Urology, Department of Urology, Istanbul Medeniyet University, Istanbul, Turkey; b Department of Urology, Erasmus MC, Rotterdam,

The Netherlands; c Department of Urology and Pediatric Urology, University Medical Centre Groningen, Groningen, The Netherlands; d Department of Pediatric and Adult Urology, East and North Herts NHS Trust, Stevenage, UK; e Department of Urology, University of Leuven, Leuven, Belgium; f Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey; g Department of Urology, General Teaching Hospital and Charles University 1st Faculty of [2_TD$IF]Medicine in Praha, Prague, Czech Republic; h Department of Urology, Medical University of Innsbruck, Innsbruck, Austria; i Department of Pediatric, Adolescent

And “Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel” will be published shortly and has been selected as a CME (Continuing Medical Education) article and, as such, will be accompanied by six multiple-choice questions based on the article content. and Reconstructive Urology, University of Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

Brief Correspondence

New Vice-Chairman of the Guidelines Board We are delighted to announce that Prof. Maria Ribal, Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Spain has been appointed to be the Vice-Chairman of the Guidelines Office Board. Professor Ribal is also the Vice-Chairman and active member of the Muscle-Invasive and Infiltrative Bladder Cancer Guidelines Panel. We wish her every success in her new appointment. Recent publications from Panels We are very pleased to announce that several papers from Guidelines Panels have recently been accepted: • Time to adapt our practice? The European commission has restricted the use of fluoroquinolones since March 2019. Eur Urol 2019 76(2)151. • Greetings from Africa: The emergence of tropical urological diseases in Europe. We had better be prepared! Eur Urol 2019 76(2)140. Guidelines Office

Updated European Association of Urology Guidelines on Renal Cell Carcinoma: Immune Checkpoint Inhibition Is the New Backbone in First-line Treatment of Metastatic Clear-cell Renal Cell Carcinoma Laurence Albiges a, Tom Powles b, Michael Staehler c, Karim Bensalah d, Rachel H. Giles e,f, Milan Hora g,h, Markus A. Kuczyk i, Thomas B. Lam j,k, Börje Ljungberg l, Lorenzo Marconi m, Axel S. Merseburger n, Alessandro Volpe o, Yasmin Abu-Ghanem p, Saeed Dabestani q, Sergio Fernández-Pello r, Fabian Hofmann s, Teele Kuusk t, Rana Tahbaz u, Axel Bex v,w,x,* a

Department of Cancer Medicine, Gustave Roussy, Université Paris-Saclay, Villejuif, France; b The Royal Free NHS Trust and Barts Cancer Institute, Queen Mary

University of London, London, UK; c Department of Urology, Ludwig-Maximilians University, Munich, Germany; d Department of Urology, University of Rennes, Rennes, France; e Patient Advocate, International Kidney Cancer Coalition (IKCC), Duivendrecht, The Netherlands; f Department of Nephrology and Hypertension, Regenerative Medicine Center, University Medical Centre Utrecht, Utrecht, The Netherlands; g Department of Urology, University Hospital Plze n, Plze n, Czech Republic; h Faculty of Medicine in Plze n, Charles University, Plze n, Czech Republic; i Department of Urology and Urologic Oncology, Hannover Medical School, Hannover, Germany; j Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK;

k

Academic Urology Unit, University of Aberdeen, Aberdeen, UK;

• Benefits of empiric nutritional and medical therapy for semen parameters and pregnancy and live birth rates in couples with idiopathic infertility: A systematic review and meta-analysis. Eur Urol 2019 75(4)615. l

Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden;

m

Department of Urology, Coimbra University

Hospital, Coimbra, Portugal; n Department of Urology, University Hospital Schleswig-Holstein, Lübeck, Germany; o Division of Urology, Maggiore della Carità

Hospital, University of Eastern Piedmont, Novara, Italy; p Department of Urology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel; q Department of

Article info

Abstract

Article history: Accepted September 24, 2018

Context: The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial. Objective: To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents. Evidence acquisition: A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion. Evidence synthesis: Of 1550 articles identified, 98 articles including 16 130 patients (7–21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52 ml, 95% confidence interval [CI] 0.73–2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84–38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non–lymphatic sparing surgery (p = 0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates. Conclusions: Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown. Patient summary: In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear. © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Associate Editor: James Catto Keywords: Varicocele Children Adolescent Recurrence Hydrocele Paternity

Please visit www.eu-acme.org/europeanurology to answer questions on-line. The EUACME credits will then be attributed automatically.

Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö, Sweden; r Department of Urology, Cabueñes Hospital, Gijón, Spain; s Department of

Urology, Sunderby Hospital, Sunderby, Sweden; t Department of Urology, Royal Free Hospital, Pond Street, London, UK; u Department of Urology, Elbe Kliniken

* Corresponding author. Division of Pediatric Urology, Department of Urology, Istanbul Medeniyet University, Doktor Erkin Caddesi, 34722, Kadikoy, Istanbul, Turkey. Tel. +90 505 6454005; Fax: +90 212 4530453. E-mail address: selcuksilay@gmail.com (M.S. Silay). E U RO P E A N U RO L O GY 76 ( 2 019 ) 3 5 2 – 3 6 7

Stade, Stade, Germany; v Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; w Specialist

Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK; x UCL Division of Surgery and Interventional Science, London, UK

Article info

Abstract

Article history: Accepted May 15, 2019

Recent randomised trials have demonstrated a survival benefit for a front-line ipilimumab and nivolumab combination therapy, and pembrolizumab and axitinib combination therapy in metastatic clear-cell renal cell carcinoma. The European Association of Urology Guidelines Panel has updated its recommendations based on these studies. Patient summary: Pembrolizumab plus axitinib is a new standard of care for patients diagnosed with kidney cancer spread outside the kidney and who did not receive any prior treatment for their cancer (treatment naïve). This applies to all risk groups as determined by the International Metastatic Renal Cell Carcinoma Database Consortium criteria. © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Associate Editor: James Catto

Keywords: Renal cell carcinoma Metastatic Immune checkpoint inhibitors Ipilimumab Nivolumab Sunitinib Pazopanib Cabozantinib Guidelines

• Effectiveness and harms of using kidneys with small renal tumours from deceased or living donors as a source of renal transplantation: A systematic review. Eur Urol Focus 2019 5(3)508.

* Corresponding author. Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands. Tel. +31 205 122 553; Fax: +31 205 122 554. E-mail address: a.bex@nki.nl (A. Bex).

https://doi.org/10.1016/j.eururo.2019.05.022 0302-2838/© 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.

available at www.sciencedirect.com https://doi.org/10.1016/j.eururo.2018.09.042 0302-2838/© ofpUrology. Published j o u r n a l h o2018 m e European p a g e : wAssociation ww.euro eanuro l o g y . c by o mElsevier B.V. All rights reserved.

Those invited will include new Guidelines Panel members and young urologists enrolled on the Guidelines Office associates programme. As usual, those attending the training workshop will come from across Europe. The intensive two-day event will see attendees participate in a packed programme of events. The training workshop will be led by members of the EAU Guidelines Office’s Methods Committee, who will give a series of presentations and lead participants in a series of practical sessions. The training will cover a diverse range of subjects aimed at underlining the importance of evidence synthesis methodology for young urologists. Topics covered will include the development of a search strategy, abstract and full text screening, assessing risk of bias, data abstraction, and data analysis and interpretation. Panel Meetings Once again, the autumn months mark a burst of activity in the Guidelines Office as Panels meet to finalise their Guidelines texts for 2020. The Paediatric Urology Panel met in Amsterdam at the end of August. September meanwhile sees meetings from the Non-muscle-invasive Bladder Cancer Panel in Prague, the Renal Cell Carcinoma Panel in Orto San Giulio and the Urological Trauma Panel in Berlin. The Guidelines Office Chairmen’s meeting will be held this October in Prague.

Review – Stone Disease

Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel James F. Donaldson a,*[25_TD$IF], Yasir Ruhayel b, Andreas Skolarikos c, Steven MacLennan d, Yuhong Yuan e[1_TD$IF], Robert Shepherd f, Kay Thomas g[2_TD$IF], Christian Seitz h, Aleš Petrik i, Christian Türk j,k, Andreas Neisius l a

Department of Urology, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK; b Department of Urology, Skåne University Hospital, Malmö, Sweden; c Second

Department of Urology, Sismanoglio Hospital, Athens Medical School, Athens, Greece;

d

Academic Urology Unit, University of Aberdeen, Scotland, UK;

e

Division of Gastroenterology & Cochrane UGPD Group, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, Canada;

f

European Association of Urology Guidelines Office, Arnhem, The Netherlands; g Department of Urology, Guy's Hospital, London, UK; h Department of Urology,

Medical University of Vienna, General Hospital of Vienna, Vienna, Austria; i Department of Urology, Charles University, First Faculty of Medicine, Prague,

• Are EAU/ESPU paediatric urology guideline recommendations on neurogenic bladder well received by the patients? Results of a survey on awareness in spina bifida patients and caregivers. Neurourol Urodyn 2019 38(6)1625. • Treatment of varicocele in children and adolescents: A systematic review and meta-

Czech Republic; j Department of Urology, Hospital of the Sisters of Charity, Vienna, Austria;

k

Urologische Praxis mit Steinzentrum, Vienna, Austria;

Systematic Review Training Workshop Following the success of the last Guidelines Office Systematic Review Workshop, held in Amsterdam at the end of April, another workshop has been organised for the Autumn. Once again, the training session will take place in Amsterdam and will be held on 22 and 23 November. Attendance at the workshop is by invitation of the Guidelines Office. l

Department of Urology, Hospital of the Brothers of Mercy Trier, Johannes Gutenberg University Mainz, Trier, Germany

Article info

Abstract

Article history: Accepted June 18, 2019

Context: Bladder stones (BS) constitute 5% of urinary stones. Currently, there is no systematic review of their treatment. Objective: To assess the efficacy (primary outcome: stone-free rate [SFR]) and morbidity of BS treatments. Evidence acquisition: This systematic review was conducted in accordance with the European Association of Urology Guidelines Office. Database searches (1970–2019) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and nonrandomised studies (NRSs) with 10 patients per group. Quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Evidence synthesis: A total of 2742 abstracts and 59 full-text articles were assessed, and 25 studies (2340 patients) were included. In adults, one RCT found a lower SFR following shock wave lithotripsy (SWL) than transurethral cystolithotripsy (TUCL; risk ratio 0.88, p = 0.03; low QoE). Four RCTs compared TUCL versus percutaneous cystolithotripsy (PCCL): meta-analyses demonstrated no difference in SFR, but hospital stay (mean difference [MD] 0.82 d, p < 0.00001) and procedure duration (MD 9.83 min, p < 0.00001) favoured TUCL (moderate QoE). Four NRSs comparing open cystolithotomy (CL) versus TUCL or PCCL found no difference in SFR; hospital stay and procedure duration favoured endoscopic surgery (very low QoE). Four RCTs compared TUCL using a nephroscope versus a cystoscope: meta-analyses demonstrated no difference in SFR; procedure duration favoured the use of a nephroscope (MD 22.74 min, p < 0.00001; moderate QoE). In children, one NRS showed a lower SFR following SWL than TUCL or CL. Two NRSs comparing CL versus TUCL/PCCL found similar SFRs; catheterisation time and hospital stay favoured endoscopic treatments. One RCT comparing laser versus

Associate Editor: James Catto

Keywords: Bladder stones Transurethral cystolithotripsy Percutaneous cystolithotripsy Open cystolithotomy Adults Children Stone-free rates Endoscopic treatments

Please visit www.eu-acme.org/europeanurology to answer questions on-line. The EUACME credits will then be attributed automatically.

The Paediatric Urology Panel Meeting in Amsterdam at the end of August

* Corresponding author. Assistant Guidelines Office, European Association of Urology, Mr. E.N. van Kleffenstraat 5, Arnhem 6842 CV, The Netherlands. Tel. +31 0263890680. E-mail address: james.donaldson6@nhs.net (J.F. Donaldson).

https://doi.org/10.1016/j.eururo.2019.06.018 0302-2838/© 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Laurent Managadze “Urology is my whole life” 1944 - 2019

Professor Laurent Managadze’s career in urology coincided with a very difficult time for Georgia, politically as well as financially. Nonetheless, he undoubtedly was the most successful urologist in the history of the country: an innovator, progressive, and a reformer.

In 2000, Prof. Managadze founded the Georgian Urological Association (GUA) and became its first president. His activities in this position were directed at incorporating Georgian urology in the western world… and he succeeded. The GUA became an active member of the EAU and thus derived much benefit from its educational and other activities in the country. In 2002, Prof. Managadze was awarded the title Honorary Member of the EAU.

In 1972, soon after graduation from the First Medical Institute of Moscow, Prof. Laurent Managadze returned to Tbilisi. From the beginning, his professional interest was kidney transplantation. In 1976, he performed the first 6 cases of cadaver kidney transplantation in Georgia, together with a team of surgeons from Moscow. It was the first step towards the realisation of his lifelong wish: to establish a renal transplantation programme in Georgia. A wish that came true later in his life. Profs. Rudolf Hohenfellner and Peter Alken, to Georgia. Both of them became close friends and contributed In 1985, Prof. Managadze became Director of the greatly to the development of urology in Georgia. Institute of Urology in Tbilisi, the largest and oldest urological hospital in Georgia. This was a Eventually Georgian urology started progressing very turning point towards progress and development fast. Transurethral surgery, oncourology, for Georgian urology. All of Prof. Managadze’s reconstructive urology, kidney transplantation, enthusiasm, knowledge and professional activity endourology and many other disciplines developed was aimed at the evolution of urology. As he said under the leadership of Prof. Managadze. He was the in one of his interviews: “Urology is my whole first in the former Soviet Union who performed life”. radical prostatectomy, radical cystectomy, continent urinary diversions, nephron sparing surgery, etc. He Although he was educated in Russia, he realised and his colleagues developed the original technique that progress wasn’t possible without close of continent urinary diversion called “Tiflis Pouch”. cooperation with the western world. In 1986, he Publications about this technique appeared in 7 invited two German urology professors, different languages.

August/September 2019

In 1998, Prof. Managadze called me into his office and told me he wanted to start a living kidney transplant programme. He asked me to go abroad to be trained in transplantation surgery. This was followed by a 4-year training period in Israel, Italy and Germany after which I returned to Georgia. In 2000 we started a living kidney transplant programme in the country, the biggest and most successful programme so far.

Apart from his clinical and scientific activities, Prof. Managadze was a dedicated mentor for students and young urologists. He was a rector of the Tbilisi State Medical University and Chairman of the Department of Urology of the Ivane Javakhishvili State University. Under his mentorship several generations of successful urologists were raised. Many of them are now chairmen of different urological departments in the country.

Prof. Managadze was awarded numerous prizes and awards: the Alexander Tsulikidze Medal, Medal of Honour, the Order of Excellence, etc. He is the founder and Editor of the “Georgian Medical News”, the only PubMed-cited Georgian medical journal. Prof. Managadze had a strategic view on progress and With his passing, Urology in Georgia has lost an development: sending young urologists abroad for extremely talented scientist, a superb doctor, an training and supporting their activities after their excellent mentor and a humble person, whose return. USA, France, England, Germany, Netherlands, whole life was dedicated to urology. Austria, Italy, Switzerland, Sweden, Hungary, Poland, Turkey… this is the incomplete list of countries where Archil Chkhotua Prof. Managadze sent his fellows for training. Secretary General, Georgian Urological Association

European Urology Today

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“Gatekeepers of the prostate cancer patient” EAU’s flagship PCa meeting now in its third year of interactive excellence Participants of PCa19 can expect two days of immersion in all the latest treatment options for prostate cancer, says Prof. Steven Joniau (Leuven, BE), member of the PCa19 Scientific Assoc. Prof. Steven Committee and one of Joniau, PCa19 Scientific the faculty members. Committee member Now in its third edition, EAU Update on Prostate Cancer is the longest-running flagship of the EAU’s Oncology Update meetings. Uniquely, registration for PCa19 includes free accommodation in Prague if you book before October 2nd. We spoke to Prof. Joniau about the upcoming meeting, the EAU’s goals for the meeting and the hottest topics that will be discussed this autumn. This marks the third occasion of the EAU’s PCa update. How do you think this meeting has been received in the past years, and has it developed since its launch? “The EAU PCa update meetings have a unique, highly interactive format which resembles the EUREP course but is fine-tuned to a more experienced audience. What sets these meetings apart is that they focus uniquely on all aspects of PCa management and may be considered true PCa Master Classes. The past two meetings were very positively received and were attended by 250-300 urologists, radiation oncologists, medical oncologists, onco-nurses and PCa researchers from all over the world.”

Register now for the late fee! Deadline: 13 July – 2 October 2019 “The format consists of concise, introductory state-of-the art lectures by European key opinion leaders in the main auditorium, followed by

For the complete Scientific Programme visit www.pca19.org interactive case discussions in separate break-out rooms. The faculty members are scored by the attendees and only the highest-scoring faculty are invited for the next meeting! In summary, the EAU’s PCa update meetings are a must for all practitioners dealing with PCa patients.” At the recent National Societies Meeting in Noordwijk, the EAU reiterated its commitment to familiarising urologists with oncological treatment options and to make sure that urologists remain the primary carer for urological cancer patients. How does PCa19 fit into this strategy? “As urologists, we are the gatekeeper of every single PCa patient. We follow and guide patients from diagnosis until (sometimes) full-blown metastatic disease and do so as leaders of a multidisciplinary team in which we work closely together with onco-nurses, general practitioners, radiologists, pathologists, radiation oncologists and medical oncologists. The EAU PCa update meetings perfectly fit in the multidisciplinary care of PCa patients, as experts from all these disciplines are welcome in the faculty as well as in the audience!

from the past two meetings reinforces that this is the best strategy to learn as much as possible in a two-day meeting.” What do you think participants will be taking away from this meeting? How will they improve as urologists?

“As all lectures and case discussions are built upon the latest EAU Guidelines on PCa, participants will be fully updated on the current developments in diagnosis and treatment of PCa. Undoubtedly, the knowledge gained from the PCa19 Update will help all individual participants in treating their patients in the most up-to-date way.”

EAU Update on Prostate Cancer

11-12 October 2019 Prague, Czech Republic

Includes FREE accommodation

www.pca19.org

What are some topics that you are looking forward to at PCa19 this year? “I personally look forward to learning about the latest developments in diagnostic imaging, such as mpMRI and PSMA PET/CT. Another hot item is focal treatment of localised disease and metastasisdirected therapy in oligometastatic disease.” This meeting is heavily case-based. How do you think participants learn from these? “A case-based meeting with voting questions and direct interaction with European key opinion leaders is undoubtedly a unique and very practice-based way of learning. The very positive feedback we got

ESUI19: Take part in the evolution of urological imaging Pros and cons of new technologies, practical applications and artificial intelligence By Prof. Georg Salomon Chairman, EAU Section of Urological Imaging (ESUI) Radioguided surgery as a therapeutic procedure was once deemed improbable until a few years ago when it was already administered in selected centres. The significance and popularity of radioguided surgery are gaining momentum. But as benefits go hand-in-hand with innovations, so do concerns about the limitations. Another notable innovation is multiparametric magnetic–resonance tomography (mpMRT). Recent reliable publications show that mpMRT has an indispensable position in the diagnosis of prostate cancer, especially before biopsy. The question remains whether a single mpMRT is sufficient prior to biopsy or is it even necessary. And when only targeted biopsies are performed, what is the appropriate number of biopsy cores that should be taken from magnetic resonance imaging (MRI)conspicuous areas? How far does mpMRT help detect extracapsular extension? Ultrasound technology is also advancing. Computerbased procedures or increased resolutions in transrectal ultrasound are promising methods for better detection of prostate cancer. Is transrectal ultrasound redundant or are there innovations to expect? The multiparametric ultrasound (mpUS) seems promising but can it be a cheaper alternative to mpMRT? What will be the role and/or importance of ultrasound microscopy? And what about the ultrasound devices in mobile format? Will these provide sufficient performance for the low price? The upcoming 8th EAU Section of Urological Imaging (ESUI19) meeting aims to address these questions and more. The theme and focus of this year’s ESUI meeting is “Less is more: What's really needed in imaging”. Good imaging may deliver positive changes in treatment; however at the moment, it is also economically 30

European Urology Today

challenging to implement. ESUI19 explores what is necessary, what is irrelevant in current urological imaging. Through state-of-the-art lectures and how-I-do-it sessions, delegates will also know more on what to prepare for in the future. ESUI19 will examine the role of imaging in urological diagnostics and intraoperative visualisation. It will highlight how modern imaging influenced the diagnostics of urological pathologies, and how it became a helpful tool. The meeting will also evaluate situations where contemporary imaging methods can be most useful, and determine what kind of standardisation of reporting of different urological cancers might be expected. It will assess the role, performance and limits of emerging technologies in relation to image-guided approaches in detail. Moreover, ESUI19 will provide detailed clinical knowledge regarding the application and use of these technologies. These analyses will help close the gap between preliminary experiences in selected centres and the early, broad application of these technologies in daily practice. How will artificial intelligence (AI) affect MRI findings in the future? AI will aid in the analysis of different imaging modalities which will help radiologists and urologists interpret the images. Improved imaging will make focal therapy a more serious method as diagnostic uncertainties are reduced. And these are just a few of the changes. The question is not if but when will machine learning reach the same level of human performance. This is one of the developments that urologists might confront in the near future. It is in our hands as urologists to be part of the evolution in urological imaging. Its role does not solely lie in therapy planning and follow-up, but in the decision-making in drug therapy as well. Let us

For the complete Scientific Programme visit www.esui19.org familiarise ourselves of which technologies and methodologies to embrace, and which ones to push for further advancement and more expansive application. About ESUI19 ESUI19 will take place on 14 November 2019 in Vienna, Austria and will precede the 11th European Multidisciplinary congress on

Urological Cancers (EMUC19), an annual event which brings together experts from diverse specialties such as radiology, urology, nuclear medicine, pathology and medical oncology for a critical examination of multidisciplinary approaches in urological cancers. Three Best Abstract prizes will be handed out at the ESUI19 meeting, courtesy of ANNA/C-TRUS GmbH. For more information about the ESUI19 Scientific Programme and other meeting essentials, please visit www.esui19.org.

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

Less is more: What’s really needed in imaging

August/September 2019


EMUC19: Presented trials have “guideline-changing potential” Latest results will guide the practising onco-urologist in his or her treatment decisions “Uro-oncology is a rapidly evolving field. Next to classical systemic therapies such as androgen deprivation in prostate cancer or chemotherapy, immunotherapeutical approaches or newer, more potent antiandrogens are increasingly incorporated in the armamentarium of medical urooncologists,” says urologist Dr. Tobias Maurer (Hamburg, DE). “It is up to well-designed prospective studies to determine their exact indication and place in the landscape in the treatment of metastatic urooncology patients. But established therapies and treatment regimens also need to be re-evaluated, for instance the duration of androgen deprivation in primary radiotherapy for localised high-risk prostate cancer.” Dr. Maurer is co-chairing the ‘New Trials Update’ session at EMUC19, the 11th European Multidisciplinary Congress on Urological Cancers. This session will give participants an update on upcoming and currently running trials in oncourology. Maurer: “The presented studies and data all serve to guide the practising urooncologist in their treatment decisions.”

Register now for the late fee! Deadline: 25 October 2019 EMUC19 is a collaboration between the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU). Other chairs of the session are radiation oncologist Dr. Carl Salembier (Brussels, BE) and medical oncologist Prof. Aristotelis Bamias (Athens, GR). Dr. Maurer currently serves on the Faculty of the Martini-Klinik Prostate Cancer Center at the University of Hamburg-Eppendorf, having joined in July 2018. His current main focus is staging, surgical and medical treatment of prostate cancer.

EMUC19 will take place in Vienna (AT) on 14-17 November, also featuring the 8th Section Meeting of the EAU Section of Urological Imaging, courses by the European School of Urology and many more optional sessions and meetings. The annual EMUC congress is unique in its multidisciplinary approach to urological cancers, featuring speakers from a huge variety of oncology-related disciplines in an attractive and focused scientific programme. Anticipating results The New Trials session on Saturday morning (Plenary Session 7) will cover new and ongoing trials like SPCG4, ARAMIS and KEYNOTE 057. Each trial will be presented by a specialist from one discipline and then discussed with another specialist, highlighting the multidisciplinary approach that is favoured for onco-urological conditions. Results of these trials are hotly anticipated by oncologists and urologists alike, according to Dr. Maurer: “Although some of the presented studies have recently been presented at other meetings or published in full, updated data will be presented at EMUC19. In this respect, medical oncologists, but also radiation oncologists and urologists who treat onco-urology patients should clearly take the chance to attend this careful selected session to confirm and update their knowledge.” “For example, in mRCC patients, the longer life expectancy makes sequential therapy likely. In this case the first-line treatment already strongly influences and guides sequential therapy, due to several approved classes of agents in metastatic renal cell cancer. Thus, several considerations have to be taken into account when choosing the initial therapy regime. The introduction of immunotherapy opened a whole new field of therapeutics especially in bladder cancer. For instance, Pembrolizumab could add a new potent option in BCG-refractory non-muscle-invasive bladder cancer.”

“Within the last years we can observe an everincreasing cooperation between the different medical disciplines in daily practice within interdisciplinary and even molecular tumour boards. Due to the increasing complexity of multimodal treatment regimens this is on the other hand a prerequisite for successful modern onco-urology.”

Late breaking abstract submission Deadline: 30 September 2019

Dr. Maurer feels that the EMUC congress sets a great example: “It has been a great success since its introduction as a platform for mutual exchange “These findings will likely soon impact daily treatment between medical oncologists, urologists, radiation in this specific patient cohort. But, as mentioned experts as well as (not to forget!) imaging specialists. The ESUI’s annual meeting has recently become a above, the other presented studies also have guideline-changing potential.” valuable ‘pre-congress’ to EMUC. As specialists, I think that we can all agree that multidisciplinary A multidisciplinary approach management of onco-urological patients is integral to As the EMUC congress represents the medical world’s our success!

14-17 November 2019, Vienna, Austria

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

www.emuc19.org

A not-to-be-missed opportunity

ESOU20

By Dr. Domenico Veneziano, Reggio Calabria (IT) The interest of the EAU in education is evident: several courses and workshops are arranged worldwide to provide training to all interested members. Less well known is the visiting professorship programme, provided by the EUSP (European Urological Scholarship Programme), chaired by Prof. Vincenzo Mirone.

17th Meeting of the EAU Section of Oncological Urology 17-19 January 2020, Dublin, Ireland An application has been made to the EACCME® for CME accreditation of this event

Deadline 1 November 2019

commitment to multidisciplinary approach, oncourological trials also reflect the cooperation of the involved disciplines.

Visiting Professorship

www.esou20.org

Register for the early fee!

One example of a trial that will have an impact on daily treatment is the ARAMIS trial. Maurer: “It not only showed significantly increased metastasis-free survival with darolutamide compared to placebo in non-metastatic CRPC patients, but also significant advantages for overall survival, time to pain progression and time to symptomatic skeletal events. These are all relevant endpoints for men suffering from nmCPRC. At the same time an increase in incidence for adverse events was not observed.”

The opportunity is indeed incredible: after you submit a well-defined request, the EUSP board may decide to provide funding to support the visit of a renowned urologist to your hospital for a dedicated course. Prof. Jens Rassweiler in Reggio Calabria After a brief talk with my mentor and friend Prof. Jens Rassweiler, he agreed to come visit our centre, the Grande Ospedale Metropolitano in Reggio Calabria, from 9 to 14 July 2019. Aim of the visit was to improve knowledge of the urology staff about extraperitoneal laparoscopic and robotic-assisted approaches. A dedicated local event was arranged, named ‘Heilbronn meets Reggio Calabria’, to underline the existing collaboration with our guest and the will to share knowledge. Before the visit, four patients who had to undergo radical prostatectomy and partial nephrectomy were selected, in order to analyse both extraperitoneal pelvic and retroperitoneal surgery. During his stay, Prof. Rassweiler reviewed the cases with our team and discussed the approaches. He provided us with some additional tools derived from his daily armamentarium: a rectal balloon dilator and space makers, critical to open the early access before port positioning.

approaches and demonstrated their pros and cons in comparison with the available alternatives. The lectures were given to our internal unit staff, but some colleagues from hospitals nearby joined us on invitation. In the last days, me and two other urologists from my team performed surgery on different patients. An extraperitoneal radical nephrectomy was performed following the retrograde robot-assisted approach, which allows the physician to reconsider the peri-prostatic anatomy. This provided us with some definitely interesting points of view and enriched our daily practice. Partial nephrectomy The partial nephrectomy of a left, 5 cm upper pole tumour was approached laparoscopically. Me and Prof. Rassweiler interchanged our positions on the camera and instruments several times, in order to ensure our audience fully comprehended the technique so they may be able to repeat it in the future. In our centre we are performing transperitoneal kidney surgery since the late 90s and this occasion provided us with new insights into our next kidney posterior-face cases. Early post-operative follow-up results were regular for all patients. Me as well as my team and our chief Dr. Pietro Cozzupoli are definitely grateful to EUSP and our guest for having supported this enriching educational opportunity.

Pros, cons and available alternatives In the past, our team had performed the extraperitoneal pelvic approach, which was stopped in favour of the intraperitoneal approach when a Da Vinci Xi platform was acquired in 2016. During the visit, our guest gave lectures about the different European Urological Scholarship Programme Office

August/September 2019

Prof. Rassweiler and Dr. Veneziano performing a partial nephrectomy during the visit

European Urology Today

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ESUT20: Get to know the latest in in endourology Prof. Liatsikos sets out ambitions for the Uro-Technology Section Following a well-attended and innovative meeting in Modena last year, the EAU Section of Uro-Technology (ESUT) has its sights set on Leipzig for 2020. On 23-24 January, ESUT and the German Working Groups of Endourology, Laparoscopy and RoboticAssisted Surgery will host a not-to-be-missed, surgery-focused scientific meeting. Recently, ESUT Chairman Prof. Liatsikos (Patras, GR) gave us a sneak preview of what to expect from ESUT20.

Register now for the early fee! Deadline: 24 October 2019 The importance of reaching out “ESUT has always had the ambition of getting to know all of Europe's endourologists,” explains Prof. Liatsikos. “Starting from two years ago, we decided to host our Biannual Meeting in collaboration with the different Endosopic and Laparoscopic Societies of the various European countries that we visit.” “This way, we really reach out to the maximum number of people that are doing the same job as we are within these different countries and gives excellent visibility of both the ESUT and the EAU to all the different people that maybe cannot afford to attend our larger meetings. For example, a lot of residents cannot afford to come to the Annual EAU Congress every year, and so we reach out to them.” “I think it is very important that we do this meeting in collaboration with different local working groups or national societies. It is a nice way of getting closer to the people, and in turn of getting the EAU well-known and established in the endoscopic surgery scene.” New technology Naturally, demonstrating new endoscopic and laparoscopic technology is at the forefront of every ESUT event. Liatsikos: “We aim to show different procedures performed by different surgeons but also

cases. People come to our meeting in order to watch live surgeries, listen the surgeon to explain the procedure step by step and give them the tips and tricks that they have to know.”

Prof. Evangelos Liatsikos, ESUT Chairman

using the best technology available. This meeting is going to showcase all the different lasers that are currently available, and the high-power lasers that are coming out, and also different techniques for BPH treatment, like aquablation. New robotic platforms like the AVATERA Robotic system will also be shown as part of a live case during our meeting.” “Every medical technology company will be showing off its new products: new lasers, new endoscopes, stone-breaking devices, 3D equipment, different kinds of BPH treatments. All these will be demonstrated at ESUT20, and people can also get a taste of this progress when they leave the auditorium and head into the exhibition.”

Naturally, live surgery is constantly evolving on a technical level: “The ESUT is trying to experiment by using the latest internet technology to facilitate the live transmission from different continents to our venue.”

For the complete Scientific Programme visit www.esut20.org “Clearly, in the near future live surgery is going to be shifting to technologies of long-distance transmission. ESUT, as a section that is always at the forefront of developments, will try to experiment with all of these technologies as we did in Modena. It is very

Live Surgery This meeting will feature three screens that will be used simultaneously, as premiered in Modena in 2018. Two of these are dedicated to live cases from the University of Leipzig and the third is going to show pre-recorded cases and intercontinental live transmissions from China, Russia and Canada.

interesting for our attendees to watch how our colleagues from all across the world are operating in their own theatres.” Professional Advancement Prof. Liatsikos is also looking at the future of the Section: “We are trying to reach the younger surgeons. We want to have as many residents as possible coming to our meetings and contributing to the Section. We are travelling around Europe and other countries of the Middle East and Africa trying to persuade the young people to come to our activities and see how we can help them out with their training.” “This is something that ESUT has as a major goal, this is the work that we have been doing for a long time, and our meeting is one of the main of the platforms that we have to be able to help these people with a professional advancement.”

www.esut20.org

ESUT20 7th Meeting of the EAU Section of Uro-Technology in conjunction with the German Working Groups of Endourology, Laparoscopy and Robotic Assisted Surgery

Incl. Live Surgery

23-24 January 2020, Leipzig, Germany

“A major goal for ESUT is reaching out to young urologists and helping with their training.” Liatsikos: “The meeting is mainly based on surgical demonstrations. We try to minimise the talks because it has been shown over the years that our audiences are mainly interested in seeing live and pre-recorded

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

Arbeitskreis Endourologie

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

2020 Canadian Tour The European Association of Urology (EAU) and the Canadian Urological Association (CUA) are pleased to announce the 2020 Canadian tour! The CUA/EAU International Exchange Programme will send Canadian faculty to Europe and European faculty to Canada. The programme aims to promote international exchange of urological medical skills, expertise and knowledge.

Information and application forms For all further information and programme application forms please visit uroweb.org/canadaexchange or contact Angela Terberg at the EAU Central Office, +31 (0)26 389 0680, a.terberg@uroweb.org. Application deadline: 1 October 2019

For 2020 the CUA/EAU International Exchange Programme will provide grants to enable three Junior EAU Members to participate in the Canadian Tour. The tour should take place from 13-29 June 2020 starting with visits to different urological centres in Canada, culminating with participation at the CUA Annual Meeting in Victoria, BC, from 27-29 June 2020. Eligibility criteria • Less than 42 years of age • Minimum academic rank of assistant professor • Letter from the departmental chairman of the applicant’s commitment to academic medicine • Membership of the EAU • Availability to travel around 2.5 to 3 weeks at the earlier mentioned time

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Canadian Urological Association (CUA)

August/September 2019


The inception of EAUN & ANZUNS collaboration To promote the professional development of nurses world-wide Kath Schubach President ANZUNS Scientific Advisory Committee ANZUP Melbourne (AU)

enthusiasm and passion suggesting that “evidence is evidence” and this evidence can be shared amongst urology nurses. I then proceeded to make contact with EAUN and sought permission to use their guidelines with some minor changes to encompass the Australian and New Zealand landscape. This was the beginning of our collaboration.

develop an educational framework for urology nurses (EFUN) worldwide. This project was consolidated at ANZUNS Annual Scientific Meeting this year where we had the opportunity to deliver the World Café to our members. This data is currently being analysed to provide the perspective of Australian and New Zealand urology nurses.

kathschubachnp@ gmail.com

Collaborative support Currently the EAUN executive have agreed to provide access to their guidelines for our ANZUNS members. This is a perfect example of collaborative support from EAUN. In the future ANZUNS would also like to contribute to the development of guidelines at an international level.

International input ANZUNS has recently endorsed a position statement on distress and psychosocial care for men with prostate cancer. This document will form part of the assessment process for nurses managing the distress experienced by men living with a diagnosis of prostate cancer. It has been produced by the lead author, Professor Suzanne Chambers, and has had international input from a number of key stakeholders. EAUN were invited to endorse this statement and we are delighted that they have agreed to do so.

In March 2015, I attended the EAUN conference in Madrid. It was my first international urology conference and I was very impressed with the high standard of presentations and workshops delivered by the nurses in Europe. I was delighted to be in attendance when the EAUN intravesicle guidelines were released. Guidelines update In 2016, I was given the role of updating the intravesicle guidelines of the Australian & New Zealand Urological Nurses Society (ANZUNS). Feeling very daunted and not knowing where to start I reached out to my dear friend Bente Thoft Jensen who was a great facilitator and assisted me in making these valuable connections. She shared her

With the use of the internet, teleconferencing and accessibility to air travel, the world is more open for opportunities to collaborate and share our information. Sometimes the term “the right place at the right time” is very apt. It is particularly relevant given one of ANZUNS strategic goals is to improve our profile internationally. Educational framework Fast-forward to 2018: Andrea Nixon (ANZUNS Immediate Past President) was invited to join a very exciting collaboration with EAUN and BAUN to

As urology nurses we are living and working in exciting times. The opportunities we have to collaborate are endless and we at ANZUNS look forward to continuing a strong collegial association with EAUN and continuing to promote the professional development of urological nurses world-wide.

Kath at the EAUN Meeting in Barcelona in March

10th anniversary post-EAUN meeting in Aarhus, Denmark Denmark hosts international speakers on a wide variety of topics once again Susanne Vahr Lauridsen, PhD EAUN chair Copenhagen (DK)

s.vahr@eaun.org

Paula Allchorne, MBA, RGN, Dip. EAUN chair-elect London (UK)

p.allchorne@ eaun.org The first post-EAUN meeting was initiated by Bente Thoft Jensen, former chair of the EAUN in 2010. The volcanic eruptions of Eyjafjallajökull in Iceland during the 11th EAUN meeting in Barcelona (ES) caused enormous disruption in air traffic across Europe. As a result the majority of the Danish urology nurses could not travel to Barcelona, and this inspired Bente to start the tradition of a Danish post-EAUN meeting. This year both the EAUN chair and EAUN chair elect participated in the celebration of the 10th anniversary, together with Franziska Geese who is an active EAUN member in the EAU Patient Information group. International speakers The programme featured international speakers and focused on patients with bladder problems, bladder cancer and prostate cancer. At the end of the meeting local urology nurses presented developmental projects to update and inspire each other on improve-ment in urology nursing care. The concept of prehabilitation became a focus in urology cancer surgery, because patients who are elderly, malnourished, anxious and have a low physical function before surgery are likely to have suboptimal recovery from cancer surgery. Celena Scheede-Bergdahl, a PhD from McGill University, Montreal (CA) introduced us to a practical prehabilitation ap-proach, with special focus on physical activity and nutrition. Her presentation was followed by that of Elke Rammant, PhD student from Ghent University Hospital (BE). She pre-sented part of her PhD study which focuses on how to promote an active lifestyle in pa-tients with bladder cancer before August/September 2019

and after radical cystectomy. Influence of mental stress Stress is something everyone experiences and despite being unpleasant, stress in itself is not an illness. For immediate, short-term situations, stress can even be beneficial to your health. Yet if your stress response doesn’t stop and stress levels stay elevated far longer than is necessary, it can have an impact on your health. Veronika Geng, Manfred-Sauer-Stiftung, Heidelberg (DE) explained the consequences of mental stress on bowel and bladder incontinence. Nihal Muhamed, Research Assistant Professor, Mount Sinai Hospi-tal, New York (US) elegantly shifted the topic from bladder cancer to prostate cancer by addressing care planning for patients with prostate cancer on active surveillance. She highlighted both the challenges and the potential solutions. Benefits of physical training in prostate cancer Patients with metastatic prostate cancer having androgen deprivation therapy often have sideeffects such as diabetes and coronary heart disease. Many androgen deprivation therapy-related complaints appear to be counteracted by exercise interventions. Brigitta Villumsen presented the latest news about the benefits of physical training in patients with prostate cancer. Finally EAUN chair elect Paula Allchorne gave a presentation with the challenging title ‘Prostate cancer in the UK – are you simply better?’ highlighting recent advances in prostate cancer nursing with a focus on nurse-led diagnostics, the 28-day pathway, survivorship and living with and beyond cancer. She concluded with the message that the EAUN and EAU guidelines are widely used in the UK as they are of high quality and exceedingly useful for UK urology nurses and medical teams.

"Mrs. Allchorne’s take-home message for anyone reading this: if you have been doing something for longer than 5 years, ‘stop’ and think! Have things changed, has practice changed globally? Is this pathway best practice, patientfocused and centred? If not, how can it be improved?" Prostate cancer pathway in the UK In her talk, Mrs. Allchorne wonders what the title suggests and whether anyone globally got it right yet? Can anyone say their pathways are purely patientfocused and centred or are we driven by hospital and national targets?

International faculty and organisers of the post-EAUN Meeting in Aarhus, Denmark, in June

In the UK the Recovery Package has been implemented which has encapsulated four key areas of ‘Survivorship - Living With and Beyond Cancer’. She discussed these four areas in great detail during the presentation and what impact the survivorship pathway has on the nurses. If implemented with management support it can make the patient’s pathway more efficient to both the patient and the hospital (streamlining services) and improve patient outcomes. Follow national guidelines She noted: “With meetings like this being so globally diverse, one cannot say ‘their pathway is better’. As nurses we all do very different roles and need to follow our own national guidelines. Nevertheless, what is important, and I think was clear throughout the meeting, nurses do feel empowered to change practice that has been implemented for many years.” All the talks were about how pathways have been redesigned to improve patient experi-ence and outcome, based on best practice and research. This was a clear theme throughout the day - nurses were recognising where patient care could be improved, particularly post-surgery with rehabilitation programmes. Mrs. Allchorne also discussed the UKs 28-day prostate cancer diagnostic pathway which is nationally driven, and the impact this has on the patients and nurses.

Some hospitals in the UK are now performing transperineal (TP) template biopsies instead of transrectal (TRUS) biopsies (or doing both). This pathway has pushed boundaries once again in the UK, particularly for nursing, as some nurses who were performing the TRUS biopsies have now trained to do TP biopsies. Take-home message Mrs. Allchorne’s take-home message for anyone reading this: if you have been doing something for longer than 5 years, ‘stop’ and think! Have things changed, has practice changed globally? Is this pathway best practice, patient-focused and centred? If not, how can it be improved? She added: “From the post EAUN meeting it was evident that nurses are looking for solutions to problems and the importance of the patient’s recovery back to better health was evident in all the talks.” Globally we have come a long way; nurses are now sharing practice which was clearly demonstrated in the 10th anniversary of post-EAUN meeting. It really was an international meeting with a platform provided for nurses from all over the world to share their evidence-based practice and research with other urology nurses. The EAUN are proud to see a satellite meeting being hosted for urology nurses! European Urology Today

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Prostate Cancer Specialist Nursing Role in Brisbane How to provide cancer care in remote areas – Australia deals with the challenge Deirdre Kiernan Prostate Cancer Specialist Nurse SIG Prostate Group Member Mater Hospital Brisbane (AU) deirdre.kiernan@ mater.org.au Prostate cancer is the most commonly diagnosed male cancer in Australia. Approximately 20,000 new cases are diagnosed each year. Australia is the sixth biggest country in the world with a population of 25 million. Approximately 30% of the population live in regional or remote areas. Prostate cancer services span across both public and private sectors which are located mainly in metropolitan areas. For those affected by prostate cancer, navigating the healthcare system can be complex due to the treatment options and the care provided across different services. Prostate cancer care in remote areas Prostate cancer care in Australia for men from regional or remote areas is one of many disparities compared to their metropolitan counterparts. These include late diagnosis, poor access to treatment due

to distance, financial implications and social isolation because of time spent away from work, partners and family while undergoing treatment. It is known that men in regional and remote areas are less likely to be diagnosed with prostate cancer, however, those diagnosed are more likely to die from their disease.

services based in metropolitan and regional areas. Approximately 20% of our patients are from metropolitan Brisbane and 80% are from nominated regional and remote areas of Queensland. These regional and remote areas are without a local public urological service.

In 2012, the Prostate Cancer Foundation of Australia (the peak national body for prostate cancer) launched a programme which involved implementing dedicated Prostate Cancer Specialist Nurse’s (PCSN) across Australia in various health care settings. Initially twelve PCSN positions were developed in conjunction with existing prostate cancer services. The PCSN’s operate through an agreed practice framework and according to national competency standards. The framework outlines the role and purpose which includes the coordination of care, education and support to those affected by prostate cancer. The programme has increased to 44 nurses across Australia with additional federal funding secured to further expand the programme in 2019.

Many challenges arise for men and their families when consultations or treatments are required at our department. To attend our department, patients can be required to travel many hundreds of kilometres and regularly need overnight accommodation. Multidisciplinary consultations are incorporated where possible to assist men regarding treatment decision making. Telehealth specialist consultation is used where possible to avoid unnecessary travel.

Strong multidisciplinary team Since 2012 I have held the position as PCSN within the urology department at the Mater Hospital Brisbane, Queensland. Our urology team has a strong multidisciplinary approach to care, with wellestablished networks with oncology and allied health

A voice for prostate cancer patients As the PCSN within our service, my aim is to ensure all men receive reliable, accurate information to allow them to understand their diagnosis and treatment options. Newly diagnosed men are prioritised, however, all men affected by prostate cancer can access the service throughout their cancer journey. Face to face consultations and telephone support is provided to men, their partners and family members. Men experience significant distress at the time of diagnosis. The role provides a point of contact, continuity of care and ease of access to advanced

nursing knowledge of prostate cancer care. A key aspect of the role is advocating on behalf of men both within our multidisciplinary team and with external stakeholders; this gives men a voice and assists in tailoring treatment to individual needs. Coordination of care is provided to help men navigate the health care system, avoid delays in treatment and prevent men getting lost in the system. Safe and effective care During and after treatment ongoing support is provided to help deal with the effects of treatment. Through patient assessment onward supportive care referrals are made when required. PCSN-led telephone follow-up consultation is routine in the post treatment setting, which results in reduced need to travel to the urology department and continuity of care. Patients can easily access the PCSN service via telephone or a face to face consultation. As a member of the multidisciplinary team the PCSN strives to contribute to the delivery of safe and effective care, regardless of geographical location of the men affected by prostate cancer. Recently, I joined the EAUN Special Interest Group Prostate Cancer. In this way, I hope to be able to share my experience with the EAUN members. Don’t hesitate to contact me if you have any queries or suggestions!

Prostate SIG group encompasses role diversity The essential multidisciplinary approach to prostate cancer acknowledged through its SIG members

Radiographer in Prostate Radiotherapy

SIG Prostate Group Member Clatterbridge Cancer Centre Wirral (UK)

I have been a member of the EAUN since 2009 and recently joined the EAUN Prostate Cancer Special Interest Group (SIG). My professional development has led me to the field of prostate cancer and I would like to use my expertise to benefit urology nurses and more specifically all the EAUN members. The special interest groups support the EAUN in any way they are able, such as putting together scientific programmes and courses, writing guidelines and articles.

of consultant therapeutic radiographers therefore is only going to grow. Four domains Guidance dictates that the four domains of nonmedical consultant practice1 are followed, which are defined as: 1) Expert clinical practice 2) Professional leadership 3) Practice and service development, research and evaluation 4) Education and professional development

It is therefore important for my role that I am not only clinical but I am able to hone my skills in research and education. As such I have completed a masters degree in prostate cancer care. I teach regularly to both under and post-graduate students, which has allowed me to develop my research and educational skills. I do have a good clinical understanding of prostate cancer. However, to become an expert clinical practitioner I looked to my clinician colleagues I qualified as a therapeutic radiographer in 1999 from and other consultant radiographers in the the University of Liverpool and commenced my career development of a training package. Therefore I have followed an adapted version of the educational at Auckland Hospital in New Zealand, then moved across The Tasman to work in Australia. I moved back standards set out by the Fellowship of the Royal College of Radiologists (FRCR) for clinical oncologists to the UK in 2002, settling at Guy’s and St Thomas in London. After years of being a treatment radiographer allowing me to become competent to practice. I moved into treatment review in 2005 and developed Become an independent practitioner the review service for urological patients, becoming I now have the scientific knowledge and the advanced urology practitioner. This role allowed me to combine my technical skills with a more holistic understanding of prostate cancer and its treatment, which allows me to review new patients in clinic to approach. Therefore allowing me to deal better with discuss non-surgical options of treatment, consent the side effects of treatment whilst also providing and plan and prescribe their radiotherapy. I have also support for both patients and their families been trained to undertake prostate biopsies both throughout treatment as well as developing my transrectally and template, which has also allowed clinical understanding of prostate cancer. me to insert gold seed fiducial markers into the prostate to aid in the accuracy of radiotherapy. Consultant radiographer For the last eighteen months I have been one of two newly appointed consultant radiographers in prostate I have also undertaken extra MSc modules in radiotherapy at The Clatterbridge Cancer Centre in the non-medical prescribing, clinical assessment and diagnostics; all of which have allowed me to become northwest of England. an independent, autonomous practitioner. It is now commonplace for a prostate cancer patient to never The nurse consultant role was originally established meet an oncologist on their cancer journey through in 1999 with allied health professional posts outlined radiotherapy. by the Department of Health in 20011 with the aim of improving clinical outcomes2, reducing wait times whilst allowing senior experienced staff to remain in I have a specialist interest in improving clinical practice3. This led to the first consultant communications between clinicians and patients radiographer post in oncology being established in undergoing hormone radiotherapy for prostate 20034. cancer. I discuss erectile/sexual dysfunction and its management and have set up specialist clinics in my It has also been well documented that there is a hospital and educated staff to be able to have these shortage of oncologists in the UK. The workforce upfront conversations to offer pre-rehabilitation and census compiled by The Royal College of earlier intervention for these patients. Radiologists in 20185 estimates that there could be a shortfall of 272 fulltime oncologists by 2023. If the EAUN members have any proposals or queries Although small in number, around 30, the number in the field of prostate cancer or the role of consultant 34

European Urology Today

radiographer, our SIG group will be happy to assist. Just contact us through the EAUN’s central email address eaun@uroweb.org or directly. Should you be interested to join the group then please send your CV and motivation to our Chair, Mr. Lawrence DrudgeCoates at ldrudge-coates@nhs.net. We hope to hear from you soon! References 1. Department of Health. Advanced Letter PAM (PTA) 2/2001. Arrangements for Consultant Posts e for Staff Covered by the Professions Allied to Medicine PT ‘‘A’’ Whitley Council. London: Department of Health; 2001. 2. J. Kelly, K. Piper, J. Nightingale Factors influencing the development of advanced and consultant radiographer

practice – a review of the literature Radiography, 14 (2008), pp. e71–e78. 3. F. Kennedy, A. McDonnell, K. Gerrish, A. Howarth, C. Pollard, J. Redman Evaluation of the impact of nurse consultant roles in the United Kingdom: a mixed method systematic literature review J Adv Nurs, 68 (2012), pp. 721–742. 4. J. Kelly, P. Hogg, S. Henwood The role of a consultant breast radiographer: A description and a reflection Radiography, 14 (2008), pp. e2-e10. 5. Clinical Oncology UK workforce census report 2018 https://www.rcr.ac.uk/system/files/publication/field_ publication_files/bfco192-co-workforce-census-2018.pdf [Accessed June 2019]

HYPERLINKS

The International Journal of

Urological Nursing

- the official Journal of the BAUN International Journal of

Urological Nursing the journal of the baun

ISSN 1749-7701

Volume 10 • Issue 2 • July 2016

Editor Rachel Busuttil Leaver Associate Editor Jerome Marley

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

wileyonlinelibrary.com/journal/ijun

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

Subscription Offer to EAUN members

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Call for papers Visit: bit.ly/2jgOqQj

Visit: www.wileyonlinelibrary.com/journal/ijun

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Philip Reynolds Consultant

August/September 2019


10th Anniversary Hong Kong College of Urological Nursing EAUN representative visits urological care units in Hong Kong hospitals Crystal Li Suk Yin Nurse Consultant Urology Prince of Wales Hospital Hong Kong (HK)

lsy160@ha.org.hk Co-Authors: Cherry Chau, Nurse Consultant Urology at the Pedder Clinic (HK); Hoi-chu To, Nurse Consultant Urology in the Queen Elizabeth Hospital (HK); Corinne Tillier, Nurse Practitioner Urology, Antoni Van Leeuwenhoek Hospital (NL) The Hong Kong College of Urological Nursing has organised its 10th annual scientific meeting in Hong Kong on 6 and 7 July 2019. The programme of this scientific meeting was very varied and included lectures about urological cancers as well as functional urology and was attended by nurses from Hong Kong and Macau. Keynote speaker Ms. Corinne Tillier, who represented the EAUN, was proud to be invited and gave several lectures that were very well received. Nursing association The Hong Kong College of Urological Nursing is a very active association for nurses working in urology or who have an interest in urology. Part of its mission (it is impossible to include all its objectives) is to promote the interest in and better understanding of urology and urology nursing in Hong Kong and to represent and promote the interests of nurses particularly of those practising in urology nursing. Furthermore, the College encourages/promotes the education of nurses and improves the standard of urological nursing care in Hong Kong. The College’s council includes 8 councillors with different tasks. The president is Mr. Chink Lok San. All nursing staff in all grades and ranks (public sector or private sector, hospital setting or nursing home) who are interested in urological nursing can become member of the Hong Kong College of Urological Nursing. Registered nurses in Hong Kong have a high level of education/training which is comparable to the UK education system. Since 2010, all registered/enrolled nurses can declare to the Nursing Council that they have obtained the Continuing Nursing Education (CNE) points over the past 3 years as prescribed (a minimum of 45 CNE points for a registered nurse and a minimum of 30 CNE points for an enrolled nurse).

Registered nurses possessing a valid Practising Nurse certificate by the Nursing Council of Hong Kong can follow a specialisation course in urology. To specialise nurses must have more than 24 months postregistration experience. As a guest of the Hong Kong College of Urological Nursing, Ms. Corinne Tillier (EAUN Board Member from Amsterdam (NL)) was invited to visit several colleagues in different hospitals. Prince of Wales Hospital Ms. Crystal Li Suk Yin, Urology Nurse Consultant, works in a public hospital, the Prince of Wales Hospital (PWH). The hospital was officially opened in 1984. The PWH urology unit, part of the department of surgery, is one of the main academic and clinical urology centres in Hong Kong. Under the division of urology, the Lithotripsy & Uro-investigation Centre (LUC) offers services in uro-oncology, andrology, reconstructive surgery, renal transplantation, stone management etc. Services in the LUC include ESWL, transperineal prostate biopsy, flexible cystoscopy, urodynamic investigation and a nurse clinic. The unit has prostate and bladder cancer protocols to ensure the cancer management standard is met. Also a cancer patient support group was set up to facilitate psychosocial support among patients and caregivers and to improve their understanding of the disease and its self-care management. Urology ward The urology ward is a very busy, mixed gender ward. Nurses and urologists are working together to provide the best care to patients. A digital patient file system will become available very soon. Until then, nurses must read written orders from the urologist and file nursing reports in a paper file.

Board Members of the Hong Kong College of Urological Nursing, posing with the participating urologists and Ms. Corinne Tillier (standing middle)

All urology beds in the ward are arranged in a cubic shape consisting of several boxes (6 patients in each box). This means: boxes for male patients on one side and boxes for female patients on the other side. The doctors’ and nurses’ station is located in the centre of the ward. This facilitates caring for the patients conveniently and supervising the entire ward from the best point of view. Nurses are working in 3 shifts, 07.00 am until 2.00 pm, 2.00 pm until 9.00 pm and the night shift from 09.00 pm to 07.00 am. Queen Elizabeth Hospital Mr. To Hoi Chu, Nurse Consultant Urology in the Queen Elizabeth Hospital, explains that in this hospital all patients with bladder cancer are following the ERAS pre-rehabilitation programme before cystectomy. He collects all data for research purposes.

world. The Hong Kong College of Urological Nursing wants to stimulate nursing research, proposes education for nurses and is aware of the importance of knowledge in urology nursing practice. A high level of education/knowledge allows nurses working in urology to deliver a high level of patient care. The Hong Kong College of Urological Nursing’s goals are similar to the goals and objectives of the EAUN and we hope this meeting in Hong Kong is the beginning of a long and successful collaboration between both associations!

Private clinics Dr. Bill Wong Tak Hing and Nurse Consultant Urology Ms. Cherry Chau provide care to patients with urological diseases in Pedder Clinic, one of Hong Kong’s private clinics. The advantage of a private clinic is that patients do not have to wait for a consultation with the urologist. The role of the nurse is mostly counselling and planning of patients for e.g. TRUS prostate biopsies. The disadvantage is that patients have to pay for access to this private practice.

On the picture Ms. Cherry Chau , Ms. Corinne Tillier, Ms. Miu Ling Ll and Ms. Crystal Ll Suk Yin

Nursing research Every year the EAUN receives poster abstracts from Hong Kong and the submissions are often successful. Research is part of the work of Hong Kong-based urological nurses and they are happy to share the results of this research with nurses from all over the

Patient information on lithotripsy renal stones

An ESUN course in your own language: It is possible! Dutch national society successful in organising ESUN courses in Dutch Jeannette Verkerk, RN Nurse practitioner Chair V&VN – Urology Board Member, EAUN Nieuwegein (NL)

j.verkerk@xs4all.nl The EAUN organises ESUN (European School of Urology Nurses) courses since 2015; the first course was about UTI and was held in Amsterdam. In the Netherlands, the English language is a barrier and thus in 2016 the Dutch national society for Urology Nurses (V&VN - Urologie) organised the Dutch version of the ESUN UTI course. That way, it is easier for the nurses to follow and understand the course. The course was a great success; immediately afterwards nurses asked when it would be repeated. This year the course is organised for the second time. How was the course organised? The Dutch society contacted the EAUN and they organised a meeting during the EAUN congress in 2015. The EAUN has formulated several rules for the national societies to follow if they want to copy a course. They are free to translate it into their own language and host it in their own country. Some of the rules are that it has to be organised by the August/September 2019

national society and that the high standard of the programme should be maintained. The programme and the presentations are available for the national society to use for their own programme. The Dutch society chose to make a copy of the course and change as little as possible. They invited the Dutch speakers from the ESUN course to give a lecture during the Dutch course. Instead of inviting foreign speakers they looked for national urologists to give presentations. One-day programme The EAUN ESUN course was given on a Friday afternoon and Saturday morning, to allow participants to fly in in the morning and return in the late afternoon, requiring only one hotel night. In the Netherlands the course was organised in 1 (long) day, because the driving distance in the Netherlands allows it to be organised in only one day. Thus, it was not necessary to book hotels and so the costs of the course dropped. The sponsors of the Dutch annual symposium were recruited to sponsor the course. Several sponsors reacted positively and wanted to support the course financially. The course took place more than a year after the original one, in September 2016. Networking dinner After the course a networking dinner was organised, for which the participants could apply separately with additional costs. This way they could meet each other informally and skip traffic jams. The motivation form

was translated into Dutch and used to select nurses who wanted to join the course. This stimulates nurses to think about why they would like to do this course, and they can also use it to apply for financial support from their employer. All applicants who were admitted received a confirmation letter by email with the literature they had to study beforehand. After the course the participants received a survey for evaluation and they rated the course with very good grades and remarks. The only ‘negative’ remark was that it is a long day!

holistic care for patients with prostate cancer was held last June. The UTI course will be repeated in September 2019 and the other courses will follow; there is now a fixed annual scheme of one new course and one course being repeated. It is very rewarding to organise the courses in cooperation with the EAUN. The positive reactions of the participants and the interesting subjects of the courses are an inspiration to continue organising them!

Organising board The board of the Dutch society and the symposium committee of the society organised the course. They do everything in their free time, besides their work. It is quite a lot of work, but it was very rewarding.

EAUN Board

Immediately after the course, the board of the Dutch society decided to organise the next ESUN courses in the Netherlands as well, and so they did. The second course about neurogenic and detrusor overactive bladder was organised about a year later, in September 2017, almost a year after the original ESUN course was held in Italy. This course was also fully booked.

Chair Chair Elect Board member Board member Board member Board member Board member Board member

Regular activity Nowadays the Dutch society regularly organises the ESUN course for its members and other urology nurses in Dutch. The fourth ESUN course about

Susanne Vahr (DK) Paula Allchorne (UK) Jason Alcorn (UK) Jerome Marley (GB) Tiago Santos (PT) Corinne Tillier (NL) Jeannette Verkerk (NL) Giulia Villa (IT)

www.eaun.uroweb.org

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Workshop improves skills of nurses in Pakistan Simulation-based workshop on urosepsis: A new form of education Sajida Chagani Nurse Manager Nephrology & Urology Service Line Aga Khan University Hospital Karachi (PK) sajida.chagani@ aku.edu Co-authors: Zohra Sutria, Nurse Specialist, and Dr. Wajahat, Aziz Senior Instructor Urology, Dr. Nuzhat Faruqui, Ass. Prof. Urology and Service Line Chief. Nephrology and Urology Service Line, Aga Khan University Hospital, Karachi, Pakistan Last March, at EAUN20 in Barcelona, our department presented a quality improvement project by Skype and were honoured to receive the 2nd Prize for Best Poster Presentation in the category Practice Development. Simulation-based training has become an integral part of medical education and is a useful pedagogical approach. The effectiveness of

simulation-based teaching has been recognised in several publications. It provides opportunities for nurses to practise their clinical and decisionmaking skills in real-life situations. The benefits of simulation-based educational interventions include: learning to provide immediate feedback, debriefing, hands-on practice sessions and improving psychomotor and communication skills. The emphasis is on giving patients accurate and safe care. Evaluation of improvements The objective of this study was to evaluate the improvement in knowledge and skills of participants after introduction of a new training methodology, namely a Simulation Based Workshop. In the workshop a the high-fidelity SimMan 3G® simulator is used to reduce practice gaps in clinical care management for the benefit of the patient. The Cause and Effect Tool (fishbone diagram method) was used to identify challenges urology nurses face while providing patient care. All 04 domains, man, material, methods, and measurement affect several areas that need attention. Management of urosepsis was identified as a learning topic, as it has direct impact on identifying and managing early warning

Figure 1: Cause and effect analysis

Figure 2: Graphic representation of the project Figure 03

signs in patients suffering from sepsis. The timeline was set and a PDSA (Plan Do Study Act) tool was applied to improve services provided by urology nurses and improve outcomes. SWOT analysis Our tertiary care university hospital revamped its biannual traditional training course for urology nurses and developed a Simulation Based Workshop. Multiple Choice Questions (MCQs)-based pre and post-tests were conducted. The effectiveness of the workshop was assessed via a Strengths, Weaknesses, Opportunities, Threats (SWOT) Analysis.

Nursing staff was acquainted with the sepsis protocol and performed focused assessments of patients with urosepsis and their initial management on the high-fidelity SimMan 3G® simulator. The simulationbased workshop significantly improved the knowledge and skills of urology nurses. Participants have shown a positive attitude toward this new method of training that induces significant improvements in the knowledge domain.

Simulation Based Workshop on Urosepsis improves Knowledge and skills of Urology Nurses Presenter: Sajida Chagani, MScN, Nurse Manager,

Staff quotes: • “Simulation based-training has shown us a new educational aspect. A platform that enriches individual experience” • “We learn hands-on skills and gain confidence while providing care to the patients”

Zohra Sutria , Nurse Specialist, Dr. Wajahat. Aziz Senior Instructor Urology, Nephrology and Urology Service line , Aga Khan University Hospital Karachi, Pakistan (# ABN20-0080)

The project was presented in the EAUN19 Poster Session in Barcelona

Figure 3: Strengths & Weaknesses, Opportunities & Threats

Figure 4: Various steps of the process

EAUN20: Cycling through urology nursing highlights Scientific Programme to offer key updates on nursing management Amsterdam will host the 21st International EAUN meeting (EAUN20) from 21-23 March 2020, and as part of the EAUN’s objective to provide top-quality meeting updates, the members of the Scientific Congress Office have prepared an exciting, surprising and highly educational programme. Confirmed speakers “Delegates can expect a comprehensive nursingoriented programme in Amsterdam,” says Jeannette Verkerk, Chair of the EAUN Scientific Congress Office. “For instance, Dr. Stefan Haensel’s doctor’s perspective talk on collaboration between nurses and doctors is particularly interesting for our target audience.” “Also of note are two talks on rare diseases: Postural Orthostatic Tachycardic Syndrome (POTS) (Prof. M. Drake, GB) and sleep-related painful erections (J. Verkerk-Geelhoed, NL). Ms. Veronika Geng (DE) will discuss the importance of practical experience for the indwelling catheterisation guidelines update. The Continence Special Interest Group has three confirmed speakers for Thematic Session 7, S. Holroyd (UK), S. Terzoni (IT) and E. Wallace (IE), presenting new innovative strategies for promoting patient education in urology.” Prizes To build on the success of previous EAUN congresses, Verkerk said regular features such as the Poster

Abstract submission now open! Deadline: 1 December 2019 Difficult Case Submission now open! Deadline: 1 December 2019 Research Plan Submission now open! Deadline: 1 December 2019 36

European Urology Today

Sessions will be part of the programme again with recognition and cash prizes for the top four best posters (€500 and €250 for the two best scientific and the two best practical posters). The expert-guided poster session, for which presenters do not have to present slides on stage (and no prizes attached), has a slightly different submission format this year. Submitters can choose themselves whether they prefer to take part in this session or in the regular Poster Session. The session is aimed at the less experienced nurses who are looking to gain experience in presenting.

Travel grant application now open! Deadline: 1 November 2019 The Nursing Research Competition, which aims to support and encourage innovative work, will offer a €2,500 prize. To be accepted, a detailed research project plan is required and to support nurses with this major work, advice is offered by research mentors. Details on how to contact the research mentors can be found on the submission page.

that is relevant for urology nursing are welcome. Participation in the research competition, however, is exclusively for members. Start preparing now! The criteria and rules for all submissions can be found on our congress website at: www.eaun20.org Travel grant application open The EAUN has travel grants available for a selected number of motivated members. Application is now open and will close on 1 November. Don’t hesitate and apply! Full details on the ‘Registration’ section of the congress website.

For the complete Scientific Programme visit www.eaun20.org The congress in Barcelona saw a significant increase in submissions from all over the world, and we hope to receive a record number of submissions and participants for EAUN20 again. See you in Amsterdam! Visit the website for more information: www.eaun20.org

21st International EAUN Meeting

Join us in Amsterdam! 21-23 March 2020, Amsterdam

Also to be featured at EAUN20 are the well-attended Video and Difficult Cases sessions. “We look forward to meeting our colleagues from across Europe and beyond to exchange experiences and share our expertise in all fields of urology,” Verkerk said. Submission open Submission is now open for poster abstracts, video abstracts, nursing research plans and difficult cases. Puzzled by an unusual case? Was your team finally able to find the right approach? Share your insights! Submitters who are invited to present in the Difficult Cases and Video sessions will receive a complimentary registration, as part of the EAUN’s efforts to promote promising work. in conjunction with

Submission of abstracts is not only open for nurses and EAUN members: all abstracts dealing with a topic

www.eaun20.org August/September 2019

Profile for European Association of Urology (EAU)

European Urology Today Vol. 31 No.4 - Aug/Sept 2019  

European Urology Today is the official newsletter of the European Association of Urology

European Urology Today Vol. 31 No.4 - Aug/Sept 2019  

European Urology Today is the official newsletter of the European Association of Urology

Profile for uroweb
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