European Urology Today Vol. 32 No.1 - January/February 2020 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology

Prof. M. Wirth says goodbye after 16 years EAU Executive responsible for Finance and Communications

Vol. 32 No.1 - January/February 2020

Urgency urinary incontinence in MS patients

The European robotic curriculum fellowship

The disease, urological treatment and therapeutic guidelines

How do you prepare to get the most out of it

Dr. S. Charalampous

Dr. J. Vicente

EAU20: Europe’s finest in urology premieres in Amsterdam Novel scientific updates to expect at the Plenary Sessions The upcoming 35th Annual EAU Congress (EAU20) will bring practice-changing updates to the forefront when it commences in Amsterdam this March. One of the exemplary elements of EAU20’s Scientific Programme is its Plenary Sessions. In this article, seven respected and prominent urologists, who will chair the sessions, offer a glimpse of the novel scientific content that constitute the Plenary Sessions.

New frontiers in infections

Modern PCa imaging in daily practice

Dr. John Heesakkers (NL), Plenary Session 1: New frontiers in infections, 21 March

Dr. Jochen Walz (FR), Plenary Session 3: Modern prostate cancer imaging in daily practice, 22 March

Views on the diagnosis and treatment of urinary tract infections (UTIs) substantially vary per country. In some, the use of antibiotics in UTI treatment is extensive and tailor-made to the patient. In others, disease management is based on the restriction of antibiotics usage to overcome antibiotic resistance.

Modern imaging is substantially changing the way how we diagnose and treat prostate cancer (PCa). Multiparametric MRI improved the detection of the disease but the new MRI pathways generate new problems, i.e. decisions to biopsy or whether to favour treatment or surveillance need to be adapted and put into context with regard to new developments such as biomarkers and genomics.

What are the consequences of these contrasting assessments? Is one better than the other? Is it possible to create guidelines on infections when local situations concerning bacteria load and antibiotic resistance differ from region to region? This Plenary Session will investigate to find the answers to these questions.

Testis cancer and surgical andrology

This Plenary Session will address these issues in detail and offer answers on how imaging can be integrated in new clinical pathways and clinical decision-making.

LUTS and storage symptoms

Prof. Jean-Nicolas Cornu (FR), Plenary Session 6: Bladder dysfunction, storage symptoms and benign prostatic disease, 23 March Lower urinary tract symptoms (LUTS) in men often include storage symptoms (e.g. overactive bladder) and/or nocturia. Whilst the underlying pathophysiology of non-neurogenic storage symptoms is more understood and mainly relying on bladder dysfunction, their management remains complex in clinical practice. This is especially so when benign prostatic obstruction is present. Mixed symptoms are also a major cause of persistent LUTS after surgery which are a daily challenge for the urologist.

The discussants will deliver key practical messages on how to identify the symptoms and rule out a neuroMoreover, molecular imaging provides substantial logical origin. Through real-life cases, panels will improvements in detection and location of recurrent discuss the best medical treatment for overactive disease. The challenge is how to integrate this bladder (OAB) in men; the best ablative surgical information into the clinical decision-making and risk option between resection, vaporization, enucleation stratification. Perhaps the use of artificial intelligence and aquablation in case of concomitant storage will be the solution in the future. The last presentation symptoms and proven obstruction; and an update will give answers to this hypothesis. about minimally invasive, day-case surgical strategies.

If complication cases came to court...

Challenges across the BCa spectrum

The role of innovation in stone management

Prof. Thomas Knoll (DE), Plenary Session 7 Stones: The role of innovation, 24 March The removal of stones, which is a daily business for most urologists, is driven by innovation. Treatment has shifted from open and shock wave lithotripsy to endoscopic approaches; and ureteroscopy and percutaneous nephrolithotomy became the standard. However, safety aspects have to be respected for the reduction of septic complications such as intrarenal pressure or antibiotic prophylaxis. Since fluoroscopy is used as a standard imaging modality, radiation safety includes both the patient and the surgical team. The second part of the Plenary Session will determine when and if new lasers, ballistic lithotripters, and scopes are required. This will be followed by a round-table deliberation among experts on a challenging stone case. Plenary Session 7 will raise your knowledge on stone intervention to the next level. Don’t miss it!

You are invited! Join us for the Opening Ceremony on Friday 20 March, 18.00-19.30, in eURO Auditorium 1*

Dr. Maarten Albersen (BE), Plenary Session 2: #Testis cancer and surgical andrology, 21 March Plenary Session 2 will kickstart with updates on surgical andrology and a review of the new 2020 EAU Guidelines on Peyronie’s disease. The session will also focus on diseases that result from the testicular dysgenesis syndrome, and review the links with fertility, carcinoma in situ, and invasive testicular cancer. In addition, the esteemed Prof. Kyle Orwig (US) will present pioneering research in fertility preservation. To reduce treatment burden in testis cancer, the Plenary Session will explore the promising role of micro RNAs in patient selection, and conduct a case-based discussion on the role of robotic-assisted complex retroperitoneal surgery.

Mr. Tim O’Brien (GB), Plenary Session 4: Nightmare on robotics, 22 March Plenary Session 4 will explore the complications of robotic surgery through the prism of the law courts. Leading medico-legal lawyer, Mr. Bertie Leigh (GB), is back for his fourth EAU congress and ready to hold urologists accountable for their decisions. The session will feature three scenarios: Should I proceed to perform open surgery after machine failure during robotic-assisted radical prostatectomy (RARP)? Was I ready for the transition to inferior vena cava (IVC) surgery in renal cell carcinoma? Who is responsible for table-side errors? The Plenary Session will be raw and likely, entertaining. It will challenge assumptions concerning decision-making, consent and safety during surgery.

January/February 2020

Prof. Morgan Rouprêt (FR), Plenary Session 5: Challenges across the spectrum of bladder cancer, 23 March The landscape for novelties in bladder cancer (BCa) has not changed as quickly as it did in the past few years. Molecular pathway, description of new biological mechanisms, markers in blood and urine, and several drugs in the pipeline make this topic extremely appealing. We aim to find more solutions to challenges in organ preservation, personalised medicine, proper usage of tools, a wise indication of cystectomy, follow-up schedule, and implementation of immunotherapy in the management of local and locally-advanced BCa. BCa is at the crossroads of endoscopic, open and minimally invasive surgery; the use of new generations of drugs such as immunotherapy; and medical strategy development.

*) Including prestigious EAU Awards The Opening Ceremony will be followed by a Networking Reception in the foyer of eURO Auditorium 1 until 21.00 hrs.

www.eau20.org More information on page 4-5 European Urology Today

New Seeding Grant Application now open! EAU RF supports highly innovative original research by a junior investigator 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 Last year, the EAU’s Research Foundation (EAU RF) release of funds. announced the availability of new grants for • Certification that approval has been given should short-term studies ‘seeding grants’. A final selection be forwarded with the application or as soon as from the 30 submissions was made during the Annual available. EMUC Congress in Amsterdam, last November, following personal interviews with candidates. Two The evaluation process were funded with € 25,000 each. Applications that are incomplete or do not comply with the requirements stated in this Call for The EAU RF is pleased to announce another Applications will not be accepted. opportunity for seeding grants, with the aim of supporting highly innovative and original research by a junior investigator. The call for applications is "If you miss deadlines 1 or 2, your currently open, with deadlines closing on Wednesday, application unfortunately cannot 19 February, 2020 (notification) and 26 February, 2020 (grant application). be accepted for evaluation at this Through a ‘seeding grant’, short-term, exploratory research projects can be supported. The results will determine the potential and long-term feasibility of the research. A seeding grant allows young colleagues with ideas for new research initiatives, that may be high-risk projects, to start working on their research project with a seeding grant.

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 younger than 40 at submission deadline. The total project period is one year. Successful projects will start in May 2020 and will end on May 2021.

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)

time." 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. 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. Second step The top 3-4 applicants will be invited to a personal meeting with the Review Panel, consisting of a brief

EAU Research Foundation

A farewell after 16 years

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 (as .docx file) (to be downloaded from: https://uroweb.org/research/ seeding-grant-application/) • 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. 2 pages) • Specification of the costs / budget using headlines: laboratory costs, travel costs, personal hours, other expenses. All details on submission can be found on the application form, link above. 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 19 February, 2020. 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. 2 pages) and sent to the EAU RF according to details on the form no later than Wednesday, 26 February, 2020 at 24.00 hrs. Central European Time by email (e.spieker@uroweb.org). All applicants will receive a message of receipt. 3) The top 2-4 applicants will be invited for a personal meeting with the Review Panel on Thursday/Friday, 19/20 March, 2020 prior to the Annual EAU Congress in Amsterdam.

VOLUM E 17 NO. 2 JUNE 2005

End of an era for European Urology Today

Euro pean Urology Tod ay

Official news letter of the European Asso ciation of Urolo News from the gy EAU Secretary-G eneral Prof. Pierre Teillac Secretary-General EAU

Dear friends,

Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL) J. Seesing, Arnhem (NL) EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680 F +31 (0)26 389 0674 EUT@uroweb.org

Editor-in-Chief Prof. M. Wirth, Dresden

Prof. Manfred Wirth EAU Treasurer and Executive Member responsible for Communication Dresden (DE) manfred.p.wirth@ gmail.com

Dear colleagues and friends,

Disclaimer

After having been responsible for communication on the EAU’s Executive Committee for almost 16 years, its Treasurer, and Editor-in-Chief of European Urology Today since 2005, the time has now come to say goodbye.

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.

It was always a pleasure working with the wonderful and dedicated people in the EAU’s Central Office. A special thanks goes to EUT Editorial Manager Hanneke Lurvink who really made this publication successful. My thanks also go out to all the editorial team members that help in the production of five editions every year.

Over the past 16 years, we’ve seen changes to the journal, but many things, including its medium have remained the same. I always felt that European Urology Today was a way for the EAU to directly reach its members. Its physical presence in members’ homes and offices sets it apart from the constant stream of e-mails and other digital information. I hope our readers have enjoyed, as I have, the ritual of reading EUT and finding out what our association is up to all over the globe. Looking back, it was my plan (and dream) from the very beginning to build a family of journals serving the different needs of our members. I am very happy to note that the EAU now has such a family of four scientific journals, each outstanding in its respective field, and also European Urology Today which publishes the latest news of our society. It is great to see that all journals and also the EUT have and always had an excellent editorial team and great leaders and I want to thank them all. It would really be impossible to name them all here. By finishing my time on the EAU’s Executive Committee, which I am proud to have been a part of, I can look back on having worked with the best European urologists, together making the EAU the number one international urological society in the world. My best regards, and see you at our events!

My special thanks also go to all the Section editors, most of who have served the Editorial Board for many years. Finally, a thank you also to everyone who has submitted articles and reports over the years. 2

European Urology Today

Manfred Wirth, MD Department of Urology University Hospital Carl Gustav Carus Technical University of Dresden

(D)

Section Editors Prof. A. Bjartell, Malmö (S) Dr. A. Cestari, Milan (I) Priv.Doz.Dr. O. Hakenberg, Dresden Dr. S. Larré, Paris (D) (F) Dr. Th. Roumeguèr e, Mr. D. Summerton Brussels (B) , Portsmouth (UK) Special Guest Editor Prof. C. Schulman, Brussels

(B)

It is a pleasure for me to address second issue you in this of European Urology Today. this moment in At time, already all has been put in motion for next year’s EAU annual meeting in Paris. This is unfortunate ly a logistical necessity but I should like to dwell a our XXth annual meeting in Istanbul, little on welcomed 6,440 where we delegates from all over the world. For those of you interested detailed information in more in this respect, the EAU website I (www.uroweb.org). refer to

EAU and I am confident, also for our gracious Turkish hosts. It was a unique meeting in many ways, and I hope that everyone used the oppor tunity to look around and see more than the congress hall and enjoy the many interesting locations one can visit in, and around, Missing out on the very spectacular Istanbul. would be a shame; taxi rides seeing the experts was rather exhilarating at work and I believe not quite a tardy that I am driver myself.

The secretary general Urological Association of the Indonesian prof. Doddy and prof. K.T. Soebadi Foo from the Asian Urological Association as well as professor K. Sasidharan and Dr. Rainy Umbas were present and the EAU in Istanbul pledged funds to purchase a cysto/TUR set, new a URS, a PCNI and a mobile ray C-arm. The Xcompany Karl Storz, Tüttlingen, Germany will be helping us Professor Sedat to successfully realize this and Tellaloglu, this Mrs. S. Storz graciously year’s president, and the Turkish urologists congress to arrange for offered the safe transportati tremendously have been supportive and badly needed on of these we cannot thank instruments to them enough the urological for all their help department of the in making the meeting a very Hospital in Indonesia. Banda Aceh General memorable event. enjoyed myself, I certainly and if one looks at the many photos taken, I believe the same This is only a start and we hope holds true for my esteemed colleague professor that the EAU will have the opportunity to Tellaloglu. provide aid in other areas as well. On a more sombre note, a meeting in Istanbul the EAU Executive had The General with our colleagues Assembly, our Asia and we feel from EAU ‘business meeting’, held very privileged on Wednesday that we have the opportunity March 16th, proved very interesting. to offer some help to our colleagues to By a landslide rebuild their 87.1% of the vote of departments EAU members restore medical and present the new “Statutes and care after the Bylaws” were Tsunami disaster of last December. approved. This also

Advisory Board Prof. C. Abbou, Paris (F) Prof. P. Abrams, Bristol (UK) Prof. W. Artibani, Verona Prof. G. Aus, Göteborg (I) This annual congress (S) Prof. T. Bjerklund-J was the only EAU history that meeting in ohansen, Porsgrunn had to be postponed Prof. T. Esen, Istanbul (N) reasons beyond due to (TR) anyone’s control, Prof. F. Hamdy, which makes its success even Sheffield (UK) more gratifying, Prof. D. Jacqmin, both for the Strasbourg (F) Prof. E. Jaurequizar , Madrid (E) Prof. U. Jonas, Hannover Prof. T. Loch, Flensburg (D) Continued on page 2 (D) Prof. H. Madersbach er, Innsbruck (A) Prof. M. Marberger, Vienna (A) Prof. L. Martínez-Pi ñeiro, Madrid (E) Prof. V. Mirone, Manfred Wirth Naples (I) European Urology Prof. F. Montorsi, Editor-in-Chief Today was never Milan (I) be a scientific intended to Prof. H. Van Poppel, Great attention publication, but Leuven (B) will be paid we do aim provide interesting Dr. H. van der to the topic Poel, Amsterdam scientific information to training in urology. of the form of (NL) For Prof. I. Romics, this in we have comments Residents' Section Budapest (HU) concise - but state-of-the on scientific papers, providing information the Prof. J. De la Rosette, training centres art - summaries on and programmes topics and problems Prof. J.A. Schalken, Amsterdam (NL) of hot scholarship but also on under discussion. Nijmegen (NL) and sections research opportuniti The new Prof. C. Schulman, implemented (EUSP). Regular Brussels (B) es internet information in the previous issue on information Dr. D. Schultheiss, included on the should be Hannover (D) relevant for available training (www.reviews) urologists Prof. I. Sinescu, programmes and summaries and their realization Dear reader of Bucharest (RO) of key articles European Urology from internationa in the various Prof. C. Stief, Munich countries since European l medical journals Today, (D) there are distinct continued. Both Prof. R. Tenaglia, will be and data on the differences of these sections After only one Chieti (I) situation of colleagues somewhat on issue may focus Prof. A. Tubaro, countries is often issues outside Francesco Montorsi under the editorship of Rome (I) in other scarce. Along mainstream urology but in I was given the the same lines, future we intend we should also to take over opportunity like to provide to also include as Editor-in-Ch information on Founding Editor a series on the ief of European working situation international Urology Today. urological key of The position articles. Prof. F. Debruyne, of Editor-in-Ch different European trained urologists in the for EUT became Nijmegen (NL) ief countries with vacant after promote understandi Francesco the aim to appointed as the new Editor-in-Ch was The various aspects ng and of course EUT EDITORIAL inform. European OFFICE surrounding ief of guidelines Urology, taking the EAU P.O. Box 30016 effort, methodolog over from Claude To come back Schulman at to the scientific y, evolution and the beginning future activities 6803 AA ARNHEM interest, another of next year. project may may be of means that I This readers be the inclusion will have the The Netherlands as well as material, interest to our help of a team summaries of of regular committed section information, com of basic scientific ments and discussions Phone: +31 (0) editors to turn issues - to all readers Urology Today 26 38 90 680 European related to the as well as discussions of interest into a worthwhile side of medicine Fax: political clinical +31 (0) 26 38 90 on disputed and urology or and meaningful publication affairs. 674 on professional providing and health care EUT@uroweb.org remuneration items and information a range of interesting in general. The current issue for its readers. Overall, the intention features an article by Luis Martínez Piñeiro is to continue trend set by the on the effect first issue of Europeanwith the of a European directive on working Today in 2005 Urology hours for junior and do our very doctors. best to improve the service to our readers.

News from the Editor-in-Ch ief

The front page of European Urology Today volume 17, no. 2, from June 2005. This was the first edition to be produced under Prof. Wirth’s leadership as Editor-in-Chief. Prof. Hakenberg was already serving as Section Editor, as he does today. In his first editorial, Prof. Wirth stressed that “European Urology Today was never intended to be a scientific publication, but we do aim to provide interesting scientific information in the form of comments on scientific papers, concise - but state-of-the art - summaries of hot topics and problems under discussion.” Much like in more recent editions of European Urology Today, “regular information should be included on the available training programmes and their realisation in the various European countries since there are distinct differences and data on the situation of colleagues in other countries is often scarce.” Some things never change! We thank our Editor-in-Chief for his dedicated and long-lasting tenure and wish him all the best. The EUT Editorial Team

January/February 2020

Update from the EAU Guidelines Office EAU20 Guidelines sessions and latest publications EAU20 Amsterdam March will see the publication of the full text and pocket versions of the 2020 European Association of Urology Guidelines. As always, the Guidelines will be available to collect - free for EAU full members - from the EAU Booth at EAU20, Amsterdam. European Association of Urology

Guidelines 2020 edition

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

Cell Carcinoma Guidelines Panel Fernández-Pello, S, et al, Eur Urol Oncol 2019, [ahead of print]. 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 Donaldson, J, et al. Eur Urol 2019 Sep;76(3):352-367.

• Benefits and Harms of Electrical Neuromodulation for Chronic Pelvic Pain: A Systematic Review Cottrell, A, et al. Eur Urol Focus 2019 Oct;. pii: S2405-4569(19)30287-1. • EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer-An International Collaborative Multistakeholder Effort: Under the Auspices of the EAU-ESMO Guidelines Committees Witjes J & Horwich A, et al. Eur Urol 2019, ahead of print & Ann Oncol 2019 Nov 1;30(11):1697-1727.

The Guidelines Office is pleased to announce that it will once again facilitate multiple interactive activities during EAU20, these include:

• EAU-EANM-ESTRO-ESUR-SIOG Prostate Cancer Guideline Panel Consensus Statements for Deferred Treatment with Curative Intent for Localised Prostate Cancer from an International Collaborative Study (DETECTIVE Study) Lam, T, et al. Eur Urol 2019 Dec;76(6):790-813.

• Two interactive workshop sessions on Guidelines Controversies – Saturday, 21 March, 14.30-16.30 hrs. and Sunday, 22 March, 14.00-16.00 hrs. These sessions will see pro and con presentations on areas within the EAU Guidelines which have highly conflicting evidence. Each set of presentations will be followed by a methodological comment/elaboration, and audience voting. Topics to be discussed include: • Small renal mass: Treat or observe? • Treatment options of bladder neck contracture and incontinence after radical prostatectomy: Does it change after adjuvant radiotherapy? • Flexible ureterorenoscopy or imaging for upper tract urothelial cancer? • Standard TURB or office fulguration or active surveillance for small papillary recurrence in the bladder? Are hospital urologists really necessary? • Haematuria: Always cystoscopy? • High-risk non-seminoma CS 1: 1x BEP or surgery?

Recent publications from Panels We are very pleased to announce that several papers from Guidelines Panels have recently been accepted for publication:

• A thematic session on the new EAU guidelines on Male Sexual and Reproductive Health: Challenges and Controversies – Monday, 23 March, 10.3012.00 hrs.

• Male life expectancy is still inferior to that of women: Urologists must refine and develop the concept of men’s health Tharakan, T, et al. Eur Urol. Focus 2019 Dec; 76(6): 712-713.

• Intraoperative Adverse Incident Classification (EAUiaiC) by the European Association of Urology ad hoc Complications Guidelines Panel Biyani ,CS, et al. Eur Urol 2019, [ahead of print].

• Management of Sporadic Renal Angiomyolipomas: A Systematic Review of Available Evidence to Guide Recommendations from the European Association of Urology Renal

• Antibiotic prophylaxis for the prevention of infectious complications following prostate biopsy: A Systematic Review and Meta-analysis Pilatz, A, et al. J. Urol 2019, [ahead of print].

• Three European School of Urology courses: • Updates and controversies: Incontinence, bladder/paediatric stones and Male LUTS – Friday, 20 March, 15.30-17.30 hrs. • Updated renal, bladder and prostate cancer guidelines 2020: What has changed? – Monday, 23 March, 8.30-11.30 hrs. • Prostate cancer challenges and controversies from guidelines to real world – Monday, 23 March, 12.00 – 15.00 hrs.

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

• EAU Guidelines Poster Walk – Friday, 20 March, 11.30-13.30 hrs. Take a guided tour through the best poster abstracts from the EAU Guidelines Panels and Committees. In addition to this exciting programme of events, the Guidelines Office will also have a presence at the EAU20 exhibition. We would encourage everybody to please stop by the EAU Publications booth and meet our Guidelines Office staff, who will be more than happy to answer any questions you may have regarding the many activities of the Guidelines Office. Systematic Review Training Workshop The Room Mate Aitana Hotel in Amsterdam was the venue for a well-attended Guidelines Office Systematic Review Workshop at the end of November 2019. The intensive two-day event saw established Guidelines Panel members, experienced associates and newer recruits participate in a packed programme of events, which featured presentations from the faculty in the morning and practical sessions in the afternoon.

• EAU/ESPU Guidelines on the Management of Neurogenic Bladder in Children and Adolescent Part I: Diagnostics and Conservative Treatment Stein, R, et al. Neurourol Urodyn. 2019 Nov 13, [ahead of print]. • EAU/ESPU Guidelines on the Management of Neurogenic Bladder in Children and Adolescent Part II: Operative Management Stein, R, et al. Neurourol Urodyn. 2019 Dec 3, [ahead of print]. • Practical Recommendations of the EAU-ESPU Guidelines Committee for Monosymptomatic Enuresis—Bedwetting Bogaert, G, et al. Neurourol Urodyn. 2019 Dec 2, [ahead of print].

• What Is the Prognostic and Clinical Importance of Urothelial and Nonurothelial Histological Variants of Bladder Cancer in Predicting Oncological Outcomes in Patients with Muscle-invasive and Metastatic Bladder Cancer? A European Association of Urology Muscle Invasive and Metastatic Bladder Cancer Guidelines Panel Systematic Review Veskimae, E, et al. Eur Urol Oncol 2019 Nov;2(6):625-642. • The Importance of Hospital and Surgeon Volume as Major Determinants of Morbidity and Mortality After Radical Cystectomy for Bladder Cancer: A Systematic Review and Recommendations by the European Association of Urology Muscle-invasive and Metastatic Bladder Cancer Guideline Panel Bruins, H.M., et al. Eur Urol Oncol 2019, [ahead of print].

EURURO-8596; No. of Pages 28 E U R O P E A N U RO L O GY X X X ( 2 019 ) X X X – X X X

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

Bladder Cancer

EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer—An International Collaborative Multistakeholder Efforty

Under the Auspices of the EAU-ESMO Guidelines Committees

E U R O P E A N U RO L O GY 76 ( 2 019 ) 7 9 0 – 8 13

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

Review – Prostatic Disease – Editor’s Choice

EAU-EANM-ESTRO-ESUR-SIOG Prostate Cancer Guideline Panel Consensus Statements for Deferred Treatment with Curative Intent for Localised Prostate Cancer from an International Collaborative Study (DETECTIVE Study)

January/February 2020

New Seeding Grant Application now open! . . 2 A farewell after 16 years. . . . . . . . . . . . . . . . . 2 Update from the EAU Guidelines Office. . . . . . 3 EAU supports urology training in Tanzania. . . 6 Book review. . . . . . . . . . . . . . . . . . . . . . . . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . 8-11 Treatment of urgency urinary incontinence in MS patients. . . . . . . . . . . 12-13 ESUO: Sperm DNA fragmentation (SDF) . . . . 15 ESGURS: Penile transplantation programmes in Europe. . . . . . . . . . . . . . . . . 16 Myths and realities: The Pisa and Trento experiences. . . . . . . . . . . . . . . . . . . . 17 ESU section: A complete spectrum of clinical laser applications. . . . . . . . . . . . . . . . . . . . . . . . . 18 Masterclass explores new FT techniques and technologies . . . . . . . . . . . . . . . . . . . . . 19 EAU-CAU: Educational conduit for Europe & Latin America. . . . . . . . . . . . . . . . 20 Iraqi community to bring “scientificity to the forefront”. . . . . . . . . . . . . . . . . . . . . . 21 1st E-BLUS course in Mexico exceeds expectations. . . . . . . . . . . . . . . . . . . . . . . . . 22 ESU Boot Camp in Lisbon boosts residents’ skills. . . . . . . . . . . . . . . . . . . . . . . 23 1st SEA-UREP commences in Manila. . . . . . . 24 PUA 2019 unveils the “Best of EAU”. . . . . . . 24 ESU course imparts PCa & BCa essentials in Uzbekistan. . . . . . . . . . . . . . . . 24 Art in Flexible step 2 prepares for minimally invasive field . . . . . . . . . . . . . . . . 25 First GUA-CCA meeting secures future editions. . . . . . . . . . . . . . . . . . . . . . . 25 EAU RF sessions at EAU20 . . . . . . . . . . . . . . 26 YUO section: Getting ready for the European robotic curriculum fellowship. . . . . . . . . . . . . . . . . . 27 E-BLUS exam now in Poland. . . . . . . . . . . . 27 EBU Certification for Erasme Hospital in Brussel. . . . . . . . . . . . . . . . . . . . . . . . . . . 29 eUROGEN and ESSIC work together against interstitial cystitis. . . . . . . . . . . . . . . 30 Preparing for Horizon Europe. . . . . . . . . . . . 30

E U R O P E A N U RO L O GY 76 ( 2 019 ) 712 – 713

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

‘Magic Bratislava’: Stimulating inter-academic collaboration . . . . . . . . . . . . 31 ESUT20: 54 Cases on three screens over two days. . . . . . . . . . . . . . . . . . . . . . . . 33

Platinum Opinion

Male Life Expectancy is Still Inferior to That of Women: Urologists Must Refine and Develop the Concept of Men’s Health Tharu Tharakan a,b, Andrea Salonia c,d,y, Suks Minhas a,y,*,

Guidelines Office

EAU20: Europe’s finest in urology premieres in Amsterdam . . . . . . . . . . . . . . . . 1

on behalf of the European Association of Urology Working Group on Male Sexual and Reproductive Health

EAUN section: Healthy hormones: Support for men on hormone therapy. . . . . . . . . . . . . . . . . . . . . 34 Nurses and Doctor of Philosophy (PhD) education - part 2. . . . . . . . . . . . . . . . . . . . . 35

European Urology Today

#EAU18 Cutting-edge Science at Europe’s largest Urology Congress

Roma Intima: Pick up your copy at EAU20 Exploring the urological and sexual habits of Ancient Rome Johan J. Mattelaer and Bert Gevaert EAU members attending the EAU20 in Amsterdam can look forward to a new congress gift. EAU History Office expert Dr. Johan Mattelaer and classical historian Dr. Bert Gevaert have joined forces for the publication of Roma Intima: Love, Lust and the Human Body. The English translation of this book will be published by the EAU on the occasion of its 35th Annual EAU Congress. Roma Intima explores the sexual and urological habits, practices and attitudes of ancient romans through a new, critical look at primary and secondary sources. Here you can find an extract, as the authors present their work in their own words.

a Intima the authors answer questions at did the Romans think made a body ul? What turned them on, sexually? urned them off? What was their e towards love between people of me gender? Were they embarrassed by nd-toilet’ matters? Did the Romans rodisiacs? Or contraceptives? What othes did they wear? Did they have raphy? What obscene swear words y use to insult each other?

LOVE, LUST & THE HUMAN BODY

GEVAERT guides readers effortlessly h the many Roman texts – most m little known and uncensored – ove, sex and intimacy, while N MATTELAER opens the door to the f physiology and the physical of human sexuality. The wealth of ions that accompany the texts come oman archaeological sites and from f the world’s finest museums and collections.

Roma Intima can be collected by EAU Members at the EAU booth in the Exhibition from the morning of Saturday, March 21st. Dr. LOVE, LUST AND THE HUMAN BODY Mattelaer will be giving a presentation with highlights of the book during the History Office session on Saturday morning (Room G107, 11:00-13:30). Following the session, the authors will be present at a festive book launch and signing session, to be held in the vicinity of the EAU Booth and Historical Exhibition. This is a chance to meet the authors and get your copy of Roma Intima signed. johan mattelaer & bert gevaert

johan mattelaer & bert gevaert

ient Rome, orgies were an everyday , weren’t they? The place was a ise for people with a huge sexual e, wasn’t it? Ever since the discovery c images amongst the ruins of i and Herculaneum, this one-sided of a dissolute and debauched Rome n consistently presented in literature, and television. Bert Gevaert, in Classical Philology, and Dr. Johan er, urologist, now consign these o the dustbin of history.

Ancient Rome: a perverts’ paradise? When you organise today a “Roman dinner”, people will be interested to know whether this cena Romana (Roman evening meal) will be ‘decadent’. They will ask whether or not anything ‘saucy’ or ‘piquant’ is on the menu – and they weren’t talking about the food! Would there be slaves? Would they be naked? Might there even be a darkened room somewhere, where the more ‘unofficial’ parts of the programme could take place? Many of these questions were no doubt inspired by the countless literary works, comic books, TV series and films that continue to depict the Roman Empire as a den of iniquity, a perfect paradise for paedophiles, homophiles, necrophiles and every other type of -phile. Surely this was the empire ruled by sadistic madmen like Nero and Caligula, where blood (and other bodily fluids) flowed in torrents and men had a different concubine for every day of the week? Wasn’t it in Ancient Rome that sex and drugs and rock-’n-roll were first invented? ‘Sex sells!’ -or so the advertisers tell us Or are you looking for something a little more erudite and uplifting? Perhaps you really want to know more about the intricacies of the intimate life of Roman men and women? You do? Then you have come to the right place since this is the book you have been waiting for. This book focuses on the intimate life of the Romans. We concentrate on roughly three hundred years of Roman history, from the first century B.C. to the second century A.D. We have chosen these centuries deliberately, not only because it was a period for which many different sources have survived, but also because it corresponds with the

EAU Opening Ceremony & Networking Reception

Prestigious EAU Awards will also be handed out: the Willy Gregoir Medal, the Frans Debruyne Life Time Achievement Award, the Crystal Matula Award, the Innovators in Urology Award, the Ernest Desnos Prize, the Hans Marberger Award and the Prostate Cancer Research Award.

European Urology Today

A topic such as the intimate life of the Romans covers a wide range of subjects. Like most readers (we imagine), our thoughts turned first and foremost to what the Romans got up to ‘between the sheets’, but we soon realised that we needed to look much further than this. What did the Romans think made a beautiful body? What turned them on? What turned them off? This is the subject of our first chapter. The second chapter focuses on the male genitalia, which, with a urologist as one of the co-authors, is only to be expected. In the third chapter, love between people of the same gender is central, followed in the fourth chapter by a brief look at Roman marriage.

In between these main chapters, a number of ‘quickies’ have been inserted, which deal with other subjects associated with Roman love, sex and marriage: did the Romans use aphrodisiacs; what kind of underclothes did they wear; who were the real sex maniacs in the ancient world; did the Romans have pornography; what contraceptives did they use; what were the most popular Roman obscenities? We will even be looking at the theme of sex and death (eros and Thanatos).

After the Opening Ceremony you will have the chance to catch up with your colleagues from all over the world and make new contacts during the EAU Networking Reception. Join us at the eURO Auditorium 1 to celebrate the start of EAU20!

height of ‘the grandeur that was Rome’. It was during these centuries that many of Rome’s greatest and most important writers were active, such as the orator Cicero, the encyclopaedist Pliny the Elder, the historians Tacitus and Suetonius, the novelists Apuleius and Petronius, and the many remarkable poets like Catullus, Virgil, Ovid, Horace and Martial. It was also a period when the influence of Christianity on Roman culture had not yet made its impact meaningfully felt.

After this introductory foreplay comes the climax: chapter five is devoted to the many and varied bedroom activities of Roman men and women. After the heat of the sexual fray, most people can use a bath and a pee – and the Romans were no different. This therefore forms the subject of the sixth chapter. The book ends with a chapter that looks at some of the great works of art through the centuries that have depicted, often with great sensuality, the intimate life of people in Ancient Rome and have helped to shape our opinions about Roman society in general.

On Friday, 20 March the EAU launches the 35th Annual Congress with an official Opening Ceremony. During this festive opening, EAU Secretary General Chapple, will welcome everybody to Amsterdam and will announce the new EAU Honorary Members.

Friday, 20 March 2020 18.00 - 21.00 Orange Area: eURO Auditorium 1

Fresco in the fullonica of Veranius Hypsaeus in Pompeii, showing the fullones who stamp on the linen in fermented urine to clean and degrease it.

You are invited!

The problem with Roman sources To write a book like this one, you need to make use of numerous sources, which are essentially of two different kinds. The first are the primary sources, the sources written by the Romans themselves. The second are more recent texts written about the Romans by later authors and scholars: these are the secondary sources. We have also supplemented the various sections of the book with numerous images, which can range from works of high art (sculptures, frescos and mosaics) to ordinary everyday objects

that have a bearing on our theme. For us, the primary sources are by far the most important. Using primary sources to try and reconstruct the mentality of people who lived a long time ago is by no means an easy task, particularly when those sources are more than two thousand years old. Most of these sources (with the exception of grave inscriptions, graffiti and papyri) reflect the views of a very select and literate section of Roman society, who perhaps made up just one percent of the total population. This literate elite was largely male and conservative. They were also acutely aware that what they wrote would have to stand the test of time. They knew that their words would be published and handed down from generation to generation. As a result, they made every effort to present themselves in a positive light, particularly when writing about matters as personal as their own marriage. Roma Intima and Urology Beside their heterosexual relations, a different conception on homosexuality existed as active or passive sex (penetration or not). Romans also had a very special concept of the phallus and urologists will be interested in the social aspects of Roman latrines, as a place for discussion and information and a talks about politics and the events of the day. Urine was also very important to clean their laundry and was used by the ‘fullones’ to wash their togas. The Romans’ views on circumcision and castration is also discussed and the matula was used for uroscopy as a medical diagnostic tool. With all these caveats in the back of our mind we have tried to steer our way carefully through sources to create an illustrated text that paints a picture of the intimate lives of Roman men and women that is both nuanced and stimulating (in all senses of the word). Perhaps this picture differs dramatically from what you have always thought about the Romans until now. In fact, we would be surprised if it didn’t...

Back on Sale! On sale again, at the EAU Booth (D64), some classics from the collections of the EAU History Office. The following books (and more!) will be available in Amsterdam at heavily discounted prices. Leave some space in your luggage! • Urine: Urination, Catheterisation, Collection, The Liquid White Gold • From Ornamentation to Mutilation: Genital Decorations and Cultural Operations in the Male • Sexological and Other Less Logical Stories • Europe: The Cradle of Urology

January/February 2020

www.eau20.org

#EAU20

EAU20 beats EAU19’s abstract submission record Congress popularity leads to new record for most abstract submissions EAU19 didn’t hold the record for most abstract submissions for longer than a year: 5,703 abstracts were submitted for EAU20 in Amsterdam, surpassing EAU19 by 242 submissions. Although the number of video abstracts slightly decreased compared to last Prof. Albers year (465 versus 455), the amount of poster abstracts increased significantly (4,996 versus 5,248). 1,589 abstracts for poster presentations have been accepted, 107 video abstracts. This makes an acceptance rate of 30.28% and 23.52% respectively. 29.7% of the total abstracts submitted are accepted, a gentle decline of 2.34% compared to last year. “The number of abstracts submitted has been on the rise in the past years,” Prof. Dr. Peter Albers (DE), Chair-elect of the EAU Scientific Congress Committee, explains. “We already opened more spots for presentations. Altogether, we have more than one hundred poster sessions, and a lot of them are already in parallel. We cannot expand the congress more, because then the audience would not have enough time to see and discuss the scientific work.” The submissions came from more countries than ever. Urologists and other health care professionals from 83 countries sent their abstracts of which 52 countries made the cut. Europe (926) and Asia (431) provided the most accepted abstracts. “The overall

quality of the submitted abstracts was outstanding,” Prof. Dr. Albers continues. “All abstracts were selected after a thorough review by approximately 370 independent reviewers who had been selected themselves based on their CV and publication record. We work with a four-point rating system. Most of the abstracts selected had to have at least three points from at least four reviewers in order to get accepted. Sometimes even from six reviewers.” Prostate cancer most popular topic Prostate cancer was the most popular topic by far, the statistics show. The following top five presents the categories with the most accepted abstracts for poster presentations: • Prostate cancer – 443 accepted (1,367 submitted); • Urothelial cancer – 228 (808); • Benign lower urinary tract symptoms – 214 (582); • Renal tumour – 128 (574); • Urolithiasis – 105 (493).

However, the overall level of evidence with comparative trials is even higher, and scientists in the EAU should strive to get more of their work done in an investigator-initiated comparative trial on oncological and non-oncological topics.” Additional poster sessions After its successful inception at EAU18 in Copenhagen and continuation at EAU19 in Barcelona, EAU20 will again feature the interactive expert poster-guided tours next to the poster sessions — and with more tours than the previous two years. Members of the Scientific Congress Office and specialists in the field will act as dedicated moderators who will lead and inform groups on highlighted abstracts. Abstracts of particular interest, in terms of new insights,

Under Course Chair Prof. Eva Compérat (FR), the biennial ESU Course 16: Practical aspects of cancer pathology for urologists. The 2020 WHO novelties aims to improve the urologist-pathologist interaction, explore the diagnostic spectrum as a whole, and update urologists with the new World Health Organization (WHO) classification. Attendees will learn about the optimal handling of a pathology specimen, understand the pathology report, receive vital information on the novelties in uro-onco pathology and their applications. During ESU Course 42: Practical tips for laparoscopy of the pelvic floor, attendees will receive recommendations on patient positioning and trocar placement. They can expect tips and tricks on laparoscopic adenomectomy, radical cystectomy, radical prostatectomy, reconstructive surgery of the pelvic floor and sacrocolpopexy. Dr. Jose Maria Gaya Sopena (ES) will chair the must-attend course. Through the guidance of Course Chair Prof. Francisco Gómez Veiga (ES) and the speakers of ESU Course 56: Prostate cancer challenges and controversies from guidelines to the real world, January/February 2020

In total, sixteen expert tours are scheduled in Amsterdam. Check out the Scientific Programme on www.eau20.org.

“Overall, the abstracts reflect a lot of interesting scientific achievements all over Europe,” Prof. Dr. Albers said. “For the future, I hope that more comparative trials will be published in urology as this is done in oncology. Many research groups already produce very high-impact publications.

Novel courses at EAU20 and e-courses with CME credits

The ESU organised an impressive 56 courses for the upcoming 35th Annual EAU congress (EAU20) wherein 148 distinguished experts from 22 countries will oversee the courses and mentor attendees. Out of the 56, two courses are new and one is offered every other year.

Prof. Dr. Albers: “The expert tours provide a good opportunity to discuss an issue based on three to five abstracts. With a good moderator, the scientific content can be transmitted in a much better way compared to a short presentation with only one additional question. In the poster tours, we tried to get topics together for discussion in a larger format.”

And for video presentations: • Renal tumour – 18 accepted (66 submitted); • Uro-genital reconstruction – 15 (65); • Benign lower urinary tract symptoms – 15 (59); • Prostate cancer – 15 (42); • Urothelial cancer – 10 (50).

ESU introduces new and updated courses Side-by-side with the expanding field of urology, the European School of Urology (ESU) has been developing its educational activities since its inception twenty years ago. These ESU pursuits have increased in size and popularity among the young and seasoned healthcare professionals. This year, the ESU will introduce new ESU courses and e-courses.

best practices and prospective clinical role, will be presented by the authors and commented on by the moderators to participants in the poster tour.

attendees will learn how to optimally use the prostate-specific antigen (PSA), new biomarkers and MRI to minimise unnecessary biopsies. Course attendees will familiarise themselves with how to stratify factors for different approaches; select risk patients to diagnose and manage after local progression; diagnose and treat advanced tumours; and critically review new alternatives. Explore the EAU20 Scientific Programme to know more about all the ESU courses, then secure your place at your course(s) of choice by registering via https://eaucongress.uroweb.org/registration/ esu-courses/.

Metastatic Prostate Cancer”, “EAU Guidelines on Urological Infections”, and “EAU Guidelines on Urinary Incontinence”; and updated existing e-courses such as “EAU Guidelines on Prostate Cancer”, “EAU Guidelines on Renal Cell Carcinoma” and “Introduction to upper urinary tract endoscopy for stones”. After EAU20, all EAU Guidelines courses will be reviewed again and updated according to the new EAU Guidelines. For inquiries about the e-courses, please send an email to educationonline@uroweb.org.

New e-courses and updates Whether attending EAU20 or not, individuals interested in enriching and testing their knowledge can do so via the new and/or updated e-courses. And upon completion, participants will receive European CME credits (ECMEC®). This February, the ESU will introduce the new e-courses “EAU Guidelines on Chronic Pelvic Pain”, “EAU Guidelines on Renal Transplantation”, and the “Basis of ADT” which is the first of five sub-courses of the course series “Advanced prostate cancer”. Before EAU20 commences, the ESU will update the e-courses “Non-muscle-invasive bladder cancer” and “Risk profile-oriented management of BPE/ LUTS”. Stay tuned for these new e-courses and updates via www.uroweb.org/e-courses/

European Association of Urology

ESU Courses at EAU20 • 56 courses • 30 Hands-on training courses • Friday, Saturday, Sunday, Monday You are strongly advised to book in advance Full details at: www.eau20.org/scientific-programme/ esu-courses/

Download the NEW EAU App and install EAU20 for the most up-to-date info on the congress

When the previous EAU annual congress in Barcelona concluded, the ESU proceeded to publish new e-courses at that time which are namely, “EAU Guidelines on Muscle Invasive and European Urology Today

EAU supports urology training in Tanzania Residents enhance their theoretical and practical knowledge and understanding of modern urology Dr. Jacques Bogdanowicz Co-initiator IITP Moshi (TZ)

jack.bogdanowicz@ yahoo.co.uk Since 2015/16, with support from the Global Philanthropic Committee (GPC), Prof. Christopher Chapple (GB) as Secretary General of the EAU, and Mr. Reinhard Zentner (DE) as managing director of Olympus, the donor of the equipment, a major effort has been made to improve the urology training and health care delivery at the Institute of Urology at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. To facilitate this, Prof. Magnus Grabe (SE) and Dr. Jacques Bogdanowicz (NL, TZ) initiated and developed the Intensive Interactive Training Programme (IITP) designed to enhance theoretical and practical knowledge, oral presentation techniques, basic research methodology, and surgical skills by focusing intensively on the individual resident in training. KCMC is the major specialist health care provider in Northern Tanzania, supporting the needs of some 15 million people. Tanzania is a low-resource country

The group of residents of one of the IITPs, with Dr. Jacques Bogdanowicz and Prof. Magnus Grabe in the bottom row on the right

with many demands on these limited resources. The practice of modern urology is a high-tech area of surgery which in this situation depends on support from the international community. The role of KCMC as the premier training centre not only for Tanzania, but also for East Africa means that support for this unit plays a significant part in the improvement of urological health care for the whole region. Residents in training (approximately 10 - 15 per group) come from all over East and Central Africa; the majority from Tanzania, but also from Ethiopia, Kenya, Malawi, Madagascar, Namibia, Rwanda, and Uganda.

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

paul.meria@ sls.aphp.fr

The Business of Plastic Surgery Plastic surgery is a specialty far removed from urology. Nevertheless, there is common ground in some aspects of training and clinical practice, in private or academical institutions. The interest of a book such as this is to address all aspects and stages of a plastic surgeon’s career, from trainees to skilled and experienced practitioners. Consequently, the information is intended to help practitioners to plan their career. Many of the advices are useful no matter what the specialty is, other advices are specifically intended for plastic surgeons. Aspects of practice In this context, editors J.M. Korman and H.J. Furnas (with the help of more than 40 American experts) assembled a large amount of information and advice. The first part of the work is dedicated to career direction and begins with an overview of training aspects, including various tips to achieve certification. The choice of the clinical practice mode is addressed,

including the aspects of private and academic practices, and individual or group practice. The subsequent part addresses ‘marketing and monitoring’ aspects of the practice. The authors provide the reader with a great amount of advice to obtain media attention and how to succeed in journals or in front of a camera. Other aspects of marketing are covered, including blogs, social media, events, etc. They also provide information about the financial aspects of practices and the authors conclude this part with a chapter dedicated to money saving.

European Urology Today

To support these efforts, the endoscopic equipment has been modernised. A bipolar transurethral resection option was set up with the corresponding need for its introduction under careful individual supervision. In response to this need, the IITP was developed. This approach to education proved so successful that the programme was extended to include endoscopic stone treatment (facilitated by Dr. Aasem Chaudry, GB), shortly followed by programmes in urethra reconstructive surgery (Prof. Ruud Bosch, NL), and most recently in paediatric reconstructive surgery (Dr. Barbara Kortmann and Dr. Liesbeth De Wall, both NL). Up to the present, eleven IITPs have been held with the following main topics: transurethral resections, urethra reconstructions, endoscopic stone management, URS, PNL, paediatric reconstruction, uro-oncology, and neurogenic bladder dysfunction.

followed by practical hands-on surgery with close supervision and instruction provided by the experts. This approach to training brings the expertise to the trainee and avoids the necessity of travelling abroad which might lead to brain drain; a recurring issue for health care in Africa.

"This approach to training brings the expertise to the trainee and avoids the necessity of travelling abroad which might lead to brain drain..." Avoiding brain drain An IITP is structured around experts from abroad, most of whom are of high academic standing and/or possess expert practical experience in a specialised field. Typically, both visiting faculty and residents present and discuss various topics of importance,

Future plans This progress needs to be maintained. A goal for the short/medium-term is to restructure one of the operating theatres to make it suitable for X-ray use. Furthermore, modernisation of the ultrasound equipment is necessary. Other objectives are to set up flexible cystoscopy for use in out-patients and to further develop the IITP, making it available not only to our residents, but also to specialist urologists in the region as part of continuing medical education. The Institute of Urology at KCMC already plays a major role in the education of doctors and medical specialists, and it aims, with some ongoing financial support from GPC, to continue this into the future.

Prof. Magnus Grabe gives instructions during a transurethral resection

Prof. Magnus Grabe gives instructions on taking a prostate biopsy

The support of the EAU, GPC, and Olympus has greatly facilitated the improved educational quality at the Institute of Urology. Group discussions and personal one-to-one coaching have shown that residents are most enthusiastic about the format of the IITP and suggest extending it with further topics. Due to the upgraded endoscopic and surgical facilities and the intensive training programmes, the residents have obtained a better understanding of modern urology. The quality of both their theoretical knowledge and practical skills has improved.

The role of internet The third part is dedicated to the role of internet in the plastic surgeon’s practice. The authors discuss the aspects of website optimisation, video making and presentation and finally describe how to achieve digital marketing and advertising. The organisational and technical aspects are highlighted in the following parts. The authors focus on the development and the organisation of a successful centre, including accreditation and other special aspects of managing a surgical facility. Scientific publications and research A special chapter is dedicated to the optimisation of scientific publications and research. The development and funding opportunities for new devices are also addressed, including regulatory aspects. Contracts and medical practice relationships are detailed in the last part of the book, in which the authors consider various aspects of medical liability, wealth protection, burn-out and other issues. The concluding chapter is a panel discussion addressing various problems in plastic surgery practice. This textbook is undoubtedly a unique source of information, firstly intended for plastic surgeons practising in North America. However, many non-technical aspects of plastic surgery are comparable to that of other surgical disciplines, even in European practice. Therefore, several aspects of this book are useful for urologists.

Book reviews

Dr. Barbara Kortmann and Dr. Liesbeth De Wall perform surgery during the IITP in paediatrics

Global Philanthropic Fund The Global Philanthropic Committee (GPC) consists of multi-national urology organisations including the American Urological Association (AUA), European Urology Association (EAU), International Continence Society (ICS) and the Société Internationale d’Urologie (SIU), with the goal of supporting proposals for worthy projects to improve urologic care throughout the world. The GPC allows organisations to pool their resources to fund larger scale philanthropic projects as a collaborative effort. Urology organisations can support a project through monetary funds and/or in-kind donations, including volunteer time. The GPC’s mission is to provide philanthropic support to improve urological education in the developing world. The GPC strives to provide funding mainly for education and generally will not provide funds for purchasing expensive equipment. The GPC will selectively provide funds for educators to travel for the purpose of providing training in various regions of the world, within the parameters of an approved funding request.

Editors : Joshua M. Korman and Heather J. Furnas ISBN : 987-1-62623-972-2 eBook : 987-1-62623-973-9 Publication : 2019 Edition : 2nd Publisher : Thieme Publishers Cover : softback Pages : 512 Illustrations : 57 Website : www.thieme.com Price : h 79.99/89.99 January/February 2020

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

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

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 63

Case study No. 64 A 60-year-old otherwise healthy lady presents with recurrent episodes of febrile urinary tract infections which led to the diagnosis of a left pelvic kidney with a large staghorn calculus (CT scan, fig.1-3).

Discussion point: • What treatment is advisable?

A 50-year-old man had a ureteroscopy a year ago. Several weeks later he complained of dysuria. The urethrogram at the time showed a mild bulbar stricture. He underwent optical internal urethrotomy followed by monthly dilatation with hydrophilic sounds. However, he still has a weak urinary stream and a new urethrogram is done (Figure 1).

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

Figure 1

Best option is buccal mucosa ventral onlay Comments by Dr. Roland Dahlem, Hamburg (DE)

Figure 1

In the retrograde urethrogram you see a short stricture with a pre- and poststrictural reduction of the diameter as a sign of spongiofibrosis. In this case the best option is a buccal mucosa urethroplasty. In our institute we prefer the ventral onlay technique, because the bulbus is well-

vascularized and thick enough for covering the graft. In the dorsal inlay technique you would need more mobilisation and the risk for damaging erectile nerves is much higher.

“Non-transecting” procedure with or without buccal mucosa only Comments by Dr. Nicolas Morel-Journel, Lyon (FR) I would tell the patient that there are two options and would decide during the operation which is better for him.

The first and the best solution would be to do a modified “non-transecting procedure” with resection of the mucosa located at the narrowest part of the stenosis and re-anastomosis of the proximal with the distal part of the mucosa. If the width of the urethra is not sufficient to obtain a large diameter of the reconstructed urethra, I would put a buccal mucosa graft on the corpus cavenosum to be sure to have enough tissue for a wide diameter.

However, if the length of the tight stenosis is over 1 cm, the resection of the mucosa carries a high risk of recurrence because there would be too much tension on the mucosal suture. I would then prefer complete resection of the stenotic urethra and an end-to-end anastomosis. If the stenosis were longer, I would have done a two stage procedure with a buccal mucosa graft.

Case study No. 63 continued This patient had a ventral graft. A guidewire is inserted into the urethra and the bulb is opened ventrally over a 20F catheter until a big Clutton sound goes in easily into the bladder (Fig 1). A short buccal mucosa graft is harvested, defatted and anchored to the proximal healthy mucosa with 3 stitches at 5, 6 and 7 o’clock positions (Fig 2). The graft is anastomosed to the right margin of the urethral mucosa in a running fashion and a 18F catheter is inserted into the bladder (Fig 3). The anastomosis is completed between the graft and the left margin of the urethral mucosa. The thick spongiosum tissue is closed over the graft (Fig 4). No perineal drainage is needed.

Figure 2

Figure 3

Discussion point: • What treatment is advisable?

Case provided by Prof. Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany. email: oliver.hakenberg@med.uni-rostock.de

Figure 1

Figure 2

Figure 3

Figure 4

After 3 weeks, a urethrogram is done with a 6F pediatric sound, showing a wide urethra and no fistulation (Fig 5) and the 18F catheter is removed. Compared to an end-to-end anastomosis, this technique requires minimal urethral mobilization and does not jeopardize its vascularity.

January/February 2020

Figure 5

European Urology Today

Key articles from international medical journals Prof. Serdar Tekgül Section Editor Ankara (TR)

serdartekgul@ gmail.com

Does hyperbaric oxygen help radiation-induced cystitis? Late radiation cystitis is a chronic and progressive condition that is reported in 5–15% of patients after radiotherapy to the pelvic area (e.g. for prostate, rectal, or gynaecological cancers). Symptoms include haematuria, increased urinary frequency and urgency, incontinence and dysuria, which often progressively deteriorate over time. Treatment is challenging. Mild and moderate cases are usually treated with a combination of anticholinergic drugs and training of pelvic floor muscles (often with poor response), and sometimes with the addition of analgesics and incontinence pads. In serious cases, with debilitating symptoms and severe haematuria, blood transfusions and bladder irrigation to prevent urinary retention caused by blood clots maybe required. Interventions such as blood clot evacuation or coagulation of bleeding bladder vessels, using general or regional anaesthesia, are often necessary. Instillation of locally acting agents such as hyaluronic acid, alum, or formaldehyde solution are frequently tried in cases with diffuse recurrent bleeding. However, although these treatments can be helpful in the short term, recurrence and re-treatment rates are very high, and cystectomy and urinary diversion may become necessary.

Source: Antimicrobials: access and sustainable effectiveness 4. Exploring the evidence base for national and regional policy interventions to combat resistance. Osman A Dar, Rumina Hasan, Jørgen Schlundt, Stephan Harbarth, Grazia Caleo, Fazal K Dar, Jasper Littmann, Mark Rweyemamu,Emmeline J Buckley, Mohammed … efforts should be made to make Shahid, Richard Kock, Henry Lishi Li, Haydar this treatment more widely available Giha, Mishal Khan, Anthony D So, Khalid M Bindayna, Anthony Kessel, Hanne Bak Pedersen, Govin Permanand, Alimuddin Zumla, John-Arne Cystoscopic assessments done by urologists masked to Røttingen, David L Heymann. (95% CI 2.2–18∙1; p = 0∙013; 17∙8 points [SD 18∙4] in the hyperbaric oxygen therapy group vs.. 7∙7 points [15∙5] in the standard care group). A 9 points change is thought to be the minimum clinically significant difference.

treatment assignment were also significantly different in favour of the intervention group. 17 (41%) of 41 patients in the hyperbaric oxygen therapy group experienced transient grade 1–2 adverse events, related to sight and hearing, during the period of hyperbaric oxygen therapy. All patients in the standard care group were offered hyperbaric oxygen therapy after the final assessment. This paper is the first randomised controlled study to assess the role of hyperbaric oxygen therapy in late radiation cystitis to have assessed a broad range of symptoms associated with late radiation tissue injuries. The treatment was safe and well tolerated. Hyperbaric oxygen therapy seems to have a place among treatment options for radiation-induced organ complications, which until now has been limited to symptomatic modalities. Long-term follow-up is awaited but efforts should be made to make this treatment more widely available.

Source: Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): a randomised, controlled, phase 2-3 trial. Oscarsson N, Muller B, Rosen A, et al.

Lancet 2016; 387: 285–95. Published Online November 18, 2015. http://dx.doi.org/10.1016/S01406736(15)00520-6

GPIU study provides valuable evidence on infection control policies Health care associated urinary tract infections (HAUTI) is a common complicating factor in urological practice. It is unclear what the appropriate empirical antibiotic choices are and what the influence of infection control policies (ICP) is. The aim of this study was to determine the chances of coverage of empirical antibiotic choices in HAUTIs and their annual trends in Europe. In addition, the impact of departmental self-reported compliance with catheter management and regulated use of prophylactic antibiotics policies was tested. In this study a probabilistic approach was used.

Lancet Oncology. 2019; 20: 1602-14.

The estimated chances of coverage of antibiotics and further probabilistic calculations were carried out using the European data of the Global Prevalence of Global system to secure Infections in Urology (GPIU) annual surveillance accountability for control of study. In this analysis, the European cohort from Hyperbaric oxygen therapy is used for late radiation 2005 to 2015 was used. The estimated chance of antimicrobial resistance tissue injury in other organs such as the bowel and coverage for each antibiotic choice in HAUTIs was rectum, genital organs, and in the head and neck area The effectiveness of existing policies to control calculated using the Bayesian Weighted Incidence and might have a role in the management of radiation antimicrobial resistance is not yet fully understood. Syndromic Antibiogram (WISCA) approach. Annual cystitis. Patients undergoing hyperbaric oxygen A strengthened evidence base is needed to inform trends of the overall cohort and number of therapy breathe pure oxygen at an increased ambient effective policy interventions across countries with appropriate antibiotic choices were estimated. pressure in a hyperbaric chamber. It causes the serum different income levels and for the human health and Departments were compared according to their partial pressure of oxygen and tissue oxygenation to animal sectors. The authors of this paper examine three self-reported compliance to ICPs to determine if increase, creating a steep oxygen gradient from policy domains—responsible use, surveillance, and there was an impact on chances of coverage and healthy to hypoxic tissue in the radiated area. infection prevention and control—and conclude which appropriate antibiotic choices. Repeated therapy has been shown to stimulate stem will be most effective at national and regional level. cell mobilisation, increase neoangiogenesis, and …most single agent choices had There are many complexities in the implementation of reduce inflammation. Retrospective reports have such policies across sectors and in varying political suggested that hyperbaric oxygen therapy alleviates limited coverage for HAUTIs and and regulatory environments. Therefore, the authors symptoms of late radiation cystitis, but randomised combination choices had improved make recommendations for policy action, calling for controlled data is lacking. comprehensive policy assessments, using chance of coverage standardised frameworks of cost-effectiveness and RICH-ART [Radiation Induced Cystitis treated with generalisation. Such assessments are especially hyperbaric oxygen—A Randomised controlled Trial]) important in low-income and middle-income was run at five Nordic university hospitals. All adult Investigators found that in most study years less than patients, with pelvic radiotherapy completed at least 6 countries (LMIC), and in the animal and half of the single-agent antibiotics and all environmental sectors. They also advocate a ‘one months previously, a score of less than 80 in the combination options were appropriate for empirical health approach’ that will enable the development of treatment of HAUTIs. Departments with compliance to urinary domain of the Expanded Prostate Index sensible policies, accommodating the needs of each Composite Score (EPIC) and referred to participating both ICPs were estimated to have 66% (2006) to 44% sector involved, and addressing concerns of specific hyperbaric clinics because of symptoms of late (2015) more antibiotic choices compared to radiation cystitis, were eligible for inclusion. Patients countries and regions. departments with complete lack of compliance to the with indwelling catheters, urinary fistulas and ICPs. Departments with adherence to a single policy previous treatment with hyperbaric oxygen therapy were not superior to departments with complete lack The absence of progress is partly were excluded. After computer-generated 1:1 of adherence to ICPs. randomisation with block sizes of four for each due to an insufficient evidence base stratification group (sex, time from radiotherapy to It was concluded that most single agent choices had to inform policy makers inclusion, and previous invasive surgery in the pelvic limited coverage for HAUTIs and combination choices area), patients received hyperbaric oxygen therapy had improved chance of coverage. Optimum antibiotic (30–40 sessions, 100% oxygen, breathed at a pressure Several key messages from this study are relevant for selection decisions should be part of decision of 240–250 kPa, for 80–90 min daily) or standard care urologists: experiments and tested in local surveillance studies. • The effect of antimicrobial resistance policies with no restrictions for other medications or Departments with self-reported compliance to ICPs seems to be variable. The absence of progress is interventions. No masking was applied. The primary have more antibiotic choices and details of the partly due to an insufficient evidence base to outcome was change in patient-perceived urinary compliance should be evaluated in future studies. The inform policy makers. symptoms assessed with EPIC from inclusion to analysis showed that over a 10-year course there was • Stewardship programmes in secondary care can follow-up at visit 4 (6–8 months later), measured as no clear time trend in the chances of coverage of be effective in encouraging responsible use of absolute change in EPIC urinary total score. antibiotics (Bayesian WISCA) in European urology antibiotics and should be scaled up. departments. • Effective infection prevention and control 223 patients were screened, and 87 patients were interventions (IPCIs) can reduce the demand and Source: Appropriate empiric antibiotic choices in enrolled and randomly assigned to either hyperbaric need for antimicrobials, but evidence on health care associated urinary tract infections in oxygen therapy (n = 42) or standard care (n = 45). appropriate IPCI strategies in LMICs is inadequate. urology departments in Europe from 2006 to After excluding eight patients who withdrew consent • Evidence of the most cost-effective systems for 2015: A Bayesian analytical approach applied in directly after randomisation (1 in the hyperbaric surveillance of antibiotic use and resistance a surveillance study. Zafer Tandogdu, Evgenios oxygen therapy group and 7 in the standard care remains weak worldwide. T. A. Kakariadis, Kurt Naber, Florian group), 79 were included in the intention-to-treat • A global surveillance system should be created to Wagenlehner, Truls Erik Bjerklund Johansen. analyses (n = 41 in the hyperbaric oxygen therapy secure accountability for control of antimicrobial group, n = 38 in the standard care group). The PLoS ONE 14(4): e0214710. https://doi.org/10.1371/ resistance and improve between-country difference between change in group mean of EPIC journal.pone.0214710 comparisons. urinary total score at final assessment was 10∙1 points Key articles

Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

Sequencing enzalutamide and abiraterone- does it matter? Both enzalutamide (androgen receptor inhibitor) and abiraterone (inhibitor of CYP17A1, an enzyme essential in the process of androgen synthesis) have been shown to have benefit in the treatment of men with mCRPC. Whether patients treated with one androgen receptor pathway inhibitor benefit from treatment with the alternate drug at progression is uncertain because available data have consistently shown varying degrees of cross resistance. The proportion of patients with a 50% PSA response to enzalutamide who were previously given abiraterone plus prednisone has varied between 18% and 40%, whereas the proportion who respond with abiraterone plus prednisone after previous treatment with enzalutamide has not exceeded 10% in single institution, retrospective case series. This study updates an open-label phase 2 crossover trial recruiting men with newly diagnosed mCRPC without neuroendocrine differentiation and a performance status of 2 or less. Patients were randomly assigned (1:1) using a computer-generated random number table to receive either abiraterone acetate 1000 mg orally once daily plus prednisone 5 mg orally twice daily until PSA progression followed by crossover to enzalutamide 160 mg orally once daily (group A), or the opposite sequence (group B). Treatment was not masked to investigators or participants. Primary endpoints were time to second PSA progression and PSA response (≥ 30% decline from baseline) on second-line therapy, analysed by intention-to-treat in all randomly assigned patients and in patients who crossed over, respectively.

…the chance of any significant response to abiraterone after enzalutamide is slim and should be abandoned 202 patients were enrolled and randomly assigned to either group A (n = 101) or group B (n = 101). At the time of data cut-off, 73 (72%) patients in group A and 75 (74%) patients in group B had crossed over. Time to second PSA progression was longer in group A than in group B (median 19.3 months [95% CI 16.0–30.5] vs. 15.2 months [95% CI 11.9–19.8]; hazard ratio 0.66, 95% CI 0.45–0.97, p = 0.036), at a median follow-up of 22.8 months (IQR 10.3–33.4). PSA responses to second-line therapy were seen in 26 (36%) of 73 patients for enzalutamide and three (4%) of 75 for abiraterone (χ² p < 0.0001). The most common grade 3–4 adverse events throughout the trial were hypertension (27 [27%] of 101 patients in group A vs. 18 [18%] of 101 patients in group B) and fatigue (six [10%] vs. four [4%]). Serious adverse events were reported in 15 (15%) of 101 patients in group A and 20 (20%) of 101 patients in group B. There were no treatment-related deaths. The authors conclude that time to second PSA progression was better for the sequence of abiraterone followed by enzalutamide (group A) than for enzalutamide followed by abiraterone (group B; median 19.3 months vs. 15.2 months). This seemed to be driven by the second-line activity of enzalutamide, which was greater than that of abiraterone. However, the median time to PSA progression on second-line therapy in patients who crossed over was short (3.5 months of enzalutamide vs. 1.7 months for abiraterone), and there was no difference in overall survival. This combined with the recent CARD trial1 should make physicians consider alternative nonhormone-based treatments. It is clear the chance of any significant response to abiraterone after enzalutamide is slim and should be abandoned. Response to enzalutamide after abiraterone is more common but short-lived and of questionable clinical

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January/February 2020

Mr. Philip Cornford Section editor Liverpool (GB)

monitoring group, but it reduced gradually over time, related adverse events occurred in 19 (11%) patients with tivozanib and in 17 (10%) patients with sorafenib. reflecting ageing and different radical treatment received during follow-up. No treatment-related deaths were reported.

philip.cornford@ rlbuht.nhs.uk

value in the face of developing alternatives where available.

Source: Tivozanib versus sorafenib in patients with advanced renal cell carcinoma (TIVO-3): a phase 3, multicentre, randomised, controlled open label study. Rini BI, Pal SK, Escudier BJ, et al.

Source: Optimal sequencing of enzalutamide and abiraterone acetate plus prednisolone in Lancet Oncology. 2019. https://doi.org/10.1016/ S1470-2045(19)30735-1. metastatic castration resistant prostate cancer: a multicentre, randomised, open-label, phase 2, crossover trial. Khalaf DJ, Annala M, Taavitsainen S, et al. Ten-year outcomes of the Lancet Oncology. 2019; 20: 1730-9. 1 Cabazitaxel versus abiraterone or enzalutamide in metastatic prostate cancer. De Wit R, de Bono J, Sternberg CN, et al. N Engl J Med 2019; published online Sept 30. DOI: 10.1056/NEJMoa1911206.

Tivozanib in advanced RCC The treatment of renal cell carcinoma has been revolutionised with the advent of anti-angiogenic drugs targeting the VEGF receptor (VEGFR). However, all these drugs are associated with adverse events that commonly result in high rates of dose interruptions and reduction. Tivozanib is a novel VEGFR tyrosine kinase inhibitor that was designed to optimise the VEGF blockade while minimising off-target toxic effects. This results in improved efficacy and reduced need for dose interruptions and dose reductions, which led to a progression-free survival advantage when compared with sorafenib in a first-line setting. Increasingly, however, drug combinations that include immune check-point inhibitors have shown clinical benefit in the first-line treatment of renal cell carcinoma. But prospective data suggested that treatment with a VEGFR tyrosine kinase inhibitor after checkpoint inhibitor therapy can result in robust clinical efficacy. TIVO-3 was designed to compare the efficacy and safety of tivozanib versus sorafenib in patients with advanced renal cell carcinoma that had progressed after multiple systemic therapies.

This trial showed a significant improvement in progression-free survival in patients with highly refractory advanced renal cell carcinoma treated with tivozanib compared with sorafenib 350 adults with histologically or cytologically confirmed metastatic renal cell carcinoma and at least two previous systemic treatments (including at least one previous treatment with a VEGFR inhibitor), measurable disease according to the Response Evaluation Criteria in Solid Tumours version 1.1, and an Eastern Cooperative Oncology Group performance status of 0 or 1 were included. Patients were stratified by International Metastatic Renal Cell Carcinoma Database Consortium risk category and type of previous therapy and randomised (1:1) with a complete permuted block design (block size of four) to either tivozanib 1.5 mg orally once daily in 4-week cycles or sorafenib 400 mg orally twice daily continuously. Investigators and patients were not masked to treatment. The primary endpoint was progression-free survival by independent review in the intention-to-treat population. Safety analyses were done in all patients who received at least one dose of study treatment. 175 patients received tivozanib and 175 patients received sorafenib. Median follow-up was 19.0 months (IQR 15.0−23.4). Median progression-free survival was significantly longer with tivozanib (5.6 months, 95% CI 5.29–7.33) than with sorafenib (3.9 months, 3.71–5.55; hazard ratio 0.73, 95% CI 0.56–0.94; p = 0.016). Overall survival was assessed at 2 years and there was no difference between the groups. The most common grade 3 or 4 treatmentrelated adverse event was hypertension (35 [20%] of 173 patients treated with tivozanib and 23 [14%] of 170 patients treated with sorafenib). Serious treatmentKey articles

January/February 2020

Globally, the exploratory analyses comparing outcomes between groups defined by treatment received confirmed the initial findings reported with the intention-to-treat analysis. However, there was stronger evidence supporting a lower risk of prostate cancer-related deaths and metastasis after surgery and radiotherapy compared with active monitoring, when results of the randomisation and treatment choice cohorts were pooled. The absolute reduction of specific deaths remained low. Nevertheless, the development of metastasis (which were significantly reduced with radical treatments) may be considered as a good surrogate for specific death. Moreover, follow-up is continuing, and subsequent analyses may strengthen the trends reported here regarding cancer specific survival benefits with radical treatments.

ProtecT trial: analysis in men in randomised and treatment choice cohorts

Source: Ten-year Mortality, Disease Progression and Treatment-related side effects in men with localised prostate cancer from the ProtecT randomised controlled trial according to treatment received. Neal DE et al.

The ProtecT trial has randomised men aged 50-69 years with localised prostate cancer to be treated by active monitoring, radiotherapy or surgery. In the present series, the authors report outcomes according to treatment received in both randomised and treatment choice cohorts. The aim of the analysis by cohorts was to limit potential underestimation of group differences that could be caused by intentionto-treat analysis given the high proportion of patients (38%) who chose treatment and declined randomisation. Overall, it included 1,643 men (62%) who agreed to be randomised and 997 men who declined randomisation and chose treatment. Differences between cohorts were estimated with adjustment for known prognostic factors using propensity scores.

Eur Urol 2019

…stronger evidence supporting a lower risk of prostate cancer-related deaths and metastasis after surgery and radiotherapy compared with active monitoring, when results of the randomisation and treatment choice cohorts were pooled In the cohort of men who declined randomisation, 51% of men chose active monitoring, 26% surgery, 13% radiotherapy and 6% brachytherapy. Men with higher-risk grade and stage disease were more likely to undergo radical treatments than active monitoring. For men treated by active monitoring, similar rates of different radical treatments were observed (45% at 10 years) between the randomised and treatment choice cohorts. Although the risks of disease-specific and all-cause death remained low, there was evidence of increased metastatic disease, disease progression, and initiation of androgen deprivation therapy in the active monitoring group compared with surgery and radiotherapy groups. The rate of prostate cancer death per 1,000 person years was 1.5 in the randomised active monitoring group versus 0.75 and 0.92 in the randomised radiotherapy and surgery groups, respectively. Disease progression was also more common in the active monitoring group: 20.3% versus 5.9% in the surgery group, and 6.6% in the radiotherapy group. These findings were consistent in both randomised and treatment choice cohorts. Whereas the difference regarding death from prostate cancer remained consistent with chance in the randomised cohort (p = 0.08), statistical significance was reached in the exploratory analyses performed in the randomised plus treatment choice cohort. The risk of dying from prostate cancer was reduced by 68% (p = 0.026) and 66% (p = 0.034) in men undergoing surgery and radiotherapy, respectively, compared with active monitoring. The combined risk of developing metastasis or dying from prostate cancer similarly decreased by 60% to 67% with radical treatments. No difference was observed for all-cause mortality according to the treatment received. With regard to the treatment-related side effects, there were higher risks of sexual dysfunction and urinary incontinence after surgery, and of sexual and bowel dysfunction after radiotherapy compared with active monitoring. Only 15-30% of men reported being potent in the radiotherapy and surgery groups at 6 years. This proportion was significantly higher in the active

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

tebj@medisin.uio.no The safety profile was comparable with that previously reported. The most frequent high-grade side effect was anaemia, which occurred in 31% of men. Dose reduction was observed in 37% of 400 mg cohort patients and 12% of 300 mg cohort. The data from this TOPARP-B trial confirmed the antitumoral activity of olaparib in the population of men with metastatic, castration-resistant, already treated by chemotherapy, prostate cancer. Patients with BRCA1/2 mutations had a high, long-lasting, response rate. Other molecular aberrations such as ATM, APLB2, CHEK2 may also represent interesting targets with confirmed antitumoral activity. Thus, the future of castration resistance and advanced disease may be led by molecular stratification and genomicdriven treatment decision-making.

Although a minority of patients with metastatic castration-resistant disease who exhibited DDR gene aberrations has been considered as the ideal population for receiving this drug in this trial, some data from other phase 2 combination strategy trials have highlighted that a broader population might Metastatic castration-resistant prostate cancer exhibits benefit from PARP inhibitors. a number of genomic aberrations that increases with Source: Olaparib in patients with metastatic the metastatic dissemination of the disease and the castration-resistant prostate cancer with DNA number of treatment lines received. Loss-of-function alterations in DNA repair genes have been reported in repair gene aberrations (TOPARP-B): a 20-25% of metastatic cases. Aberrations in BRCA2 are multicentre, open-label, randomised, phase 2 trial. Mateo J et al. the most common alterations. Olaparib is a PARP Lancet 2019 inhibitor which plays a key part in DNA damage response. It has demonstrated antitumoral activity in other cancers such as ovarian cancer associated with BRCA1 or BRCA2 mutations.

New treatment line in metastatic castrationresistant prostate cancer

In the present article, the authors report the results from a phase 2 study assessing olaparib in metastatic castration-resistant disease. Patients had received at least one but no more than two taxane-based chemotherapy treatments, regardless of prior exposure to novel hormonal drugs. All patients had previously received docetaxel and 90% had also been treated with abiraterone or enzalutamide. Two doses of olaparib were tested (300 mg or 400 mg twice a day). The primary endpoint was confirmed response defined by a radiological objective response (RECIST criteria), a decrease in PSA of 50% or more from baseline, or conversion of circulating tumour cells.

…the future of castration resistance and advanced disease may be led by molecular stratification and genomic-driven treatment decisionmaking Overall, 711 patients have been screened for DDR gene aberration, 161 patients had confirmed DDR gene aberration (27% of the 592 patients with evaluable tissue samples) and finally, 98 patients were included and randomly assigned: 300 mg versus 400 mg dose. The most frequent DDR gene aberrations were BRCA2 mutation in 31% of cases, ATM and CDK12 in 21%. BRCA1 mutations were found in only 7% of cases. The distribution of gene aberration was similar in both cohorts, except for CDK12 (31% in the 300 mg versus 12% in the 400 mg cohort). Median follow-up was 25 months.

No oncological differences between open and laparoscopic surgery in radical cystectomy The benefit of minimally invasive surgery for the management of muscle-invasive bladder cancer remains unproven. No prospective trial has demonstrated the superiority of laparoscopic approach (pure or robot-assisted) compared with the open standard approach. In the present series, the authors report the 5-year oncological outcomes of the CORAL trial, comparing open, laparoscopic, and robot-assisted radical cystectomy. A previous publication suggested reduced blood loss and shorter hospital stay with the minimally invasive approaches without significant difference regarding the 90-day complications rate. A total of 60 patients were randomised to undergo one of the 3 surgeries. Only 38 men had muscle-invasive bladder cancer. Ileal conduit was performed in 89% of cases and the vast majority of patients did not receive neoadjuvant chemotherapy. No correlation between surgical arm and positive surgical margin was found. The lymph node yield was 19 in the open group versus 16 in the laparoscopic and robot-assisted groups. Disease recurrence was noted in 39% of patients during follow-up. The location of recurrence (local, distant) did not differ among surgical arms. The surgical procedure did not affect recurrence or bladder cancer-specific death when using Cox regression models. Additional assessments of competing risks did not reveal any other associations.

A confirmed composite response was observed in 54% of 400 mg cohort patients, and 39% of 300 mg cohort patients (p = 0.14). Radiological response was reported in 16-24%, PSA response in 30-37% and CTC conversion in 48-53% of cases. Median overall survival was 14 months in the 400 mg cohort versus 10 months in the 300 mg cohort.

… this trial confirmed the findings from the RAZOR trial with a longer follow-up, but with several limitations

The analysis per gene subgroup showed that the BRCA1/2 subgroup had the highest number of responses for the composite endpoint of confirmed responses, also across all its component outcomes. Ten patients in the BRCA1/2 subgroup remained on treatment for more than 1 year. Conversely, no confirmed PSA or radiological responses were observed in the CDK12 subgroup.

This trial confirmed the findings from the RAZOR trial with a longer follow-up. Minimally invasive techniques achieved equivalent oncological outcomes to the standard open procedure. No increased risk of local/distant recurrence or positive margins has been reported with laparoscopic surgery. Thus, the advantages obtained for peri-operative outcomes by minimising the morbidity of cystectomy are not

EAU EU-ACME Office

European Urology Today

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de counter-balanced by a potential risk of poorer oncological outcomes. The risk of tumour cell spillage seemed negligible after laparoscopic surgery in this series, given that no peritoneal or port metastasis has been reported after 5 years of follow-up. Nevertheless, several limitations need to be highlighted. The study only included patients from a single institution. The sample size was small, and few events occurred limiting the power of the statistical analyses. The randomisation was not well adhered to; there were some cases of conversion from the laparoscopic/robot groups to open surgery and from laparoscopy to robot-assisted surgery because the laparoscopic surgeon was unavailable. The recurrence rate was relatively high whereas 36% of patients underwent surgery for non-muscle invasive bladder cancer. This may also be explained by the low proportion of patients receiving neoadjuvant chemotherapy (< 15%).

Source: Long-term Oncological Outcomes from an Early Phase Randomised Controlled Threearm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL). Khan et al. Eur Urol 2020

Transfusion rates after aquablation using various haemostasis methods Many studies have evaluated the bleeding complication profile post-operatively for TURP and report a range of up to 7% of patients requiring a blood transfusion, but with typical limitations in treating prostates up to 80 ml in size. For larger prostates (> 80 ml), open prostatectomy and Holmium laser enucleation of the prostate (HOLEP) are the global reference standard surgical options with reported transfusion rates of up to 24% and 4%, respectively. The aquablation procedure is a new surgical resection alternative for BPH. While several techniques for haemostasis following aquablation have been utilised, the optimal strategy has not been fully vetted across different prostate sizes. The current commercial AQUABEAM robot that performs aquablation therapy was first used in 2014. The objective was to determine if a-thermal methods are as effective in preventing blood transfusions as the use of cautery across various prostate volume sizes.

…while the a-thermal subgroup with robust traction with a catheter tension device had comparable transfusion rates for smaller prostates, the risk increased significantly as prostate volume increased

prostates, the risk increased significantly as prostate volume increased. With standard traction methods and selective bladder neck cautery, the risk of transfusion is reduced to a 1.9% across all prostate sizes.

Source: Transfusion Rates After 800 Aquablation Procedures Using Various Haemostasis Methods. Elterman D, Bach T, Rijo E, Misrai V, Anderson P, Zorn KC, Bhojani N, El Hajj A, Chughtai B, Desai M. BJU Int. 2020 Jan 4. doi: 10.1111/bju.14990. [Epub ahead of print]

Trends and patterns of testosterone therapy in the older US male population The authors investigated the United States Medicare database (1999-2014) to provide a comprehensive assessment of testosterone therapy (TT) patterns in the older US male population. They estimated annual age-standardised incidence (new users) and prevalence (existing users) of TT according to demographic characteristics, comorbidities, and potential indications. There were 392,698 incident TT users during 88 million person-years. TT users were predominantly younger, white non-Hispanic, and located in South and West US Census regions. On average, TT dramatically increased during 2007-2014 (average annual percent change = 15.5%), despite a decrease in 2014. In 2014, the most recorded potential indications for any TT were hypogonadism (48%), fatigue (18%), erectile dysfunction (15%), depression (4%), and psychosexual dysfunction (1%). Laboratory tests to measure circulating testosterone concentrations for TT were infrequent, with 35% having had at least one testosterone test in the 120 days preceding TT, 4% had the recommended two pre-TT tests, and 16% at least one pre-TT test and at least one post-TT test.

…testosterone therapy (TT) remains common in the older US male population… The investigators conclude that testosterone therapy (TT) remains common in the older US male population, despite a recent decrease. Although TT prescriptions are predominantly for hypogonadism, a substantial proportion appear to be for less specific conditions. Testosterone tests amongst men prescribed TT appear to be infrequent.

Source: Trends and Patterns of Testosterone Therapy Among US Male Medicare Beneficiaries, 1999-2014. Zhou CK, Advani S, Chaloux M, Gibson JT, Yu M, Bradley M, Hoover RN, Cook MB. J Urol. 2020 Jan 13:101097JU0000000000000744. doi: 10.1097/JU.0000000000000744. [Epub ahead of print]

Effect of intensive blood pressure treatment on erectile function in hypertensive men

The effect of intensive blood pressure control on erectile function in men with hypertension, but without diabetes, is largely unknown. The authors aimed to examine the effects of intensive systolic 801 patients were treated with aquablation therapy blood pressure (SBP) lowering on erectile function in a multi-ethnic clinical trial of men with hypertension. from 2014 to early 2019 in several countries. The They performed subgroup analyses from the Systolic average prostate volume was 67 ml ± 33 ml (range 20-280 ml) where 31 (3.9%) transfusions were Blood Pressure Intervention Trial ([SPRINT]; reported. The largest contributing factor to transfusion ClinicalTrials.gov: NCT120602, in a sample of 1,255 risk was prostate size and method of traction. There men aged 50 years or older with hypertension and increased cardiovascular disease risk. Participants was an increasing risk of transfusions in larger were randomly assigned to an intensive treatment prostates when robust traction using a catheter group (SBP goal of < 120 mmHg) or a standard tensioning device without cautery was used ranging from 0.8% to 7.8% in prostates ranging from 20 ml to treatment group (SBP goal of < 140 mmHg). 280 ml. However, when standard traction (taping the The main outcome measure was change in erectile catheter to the leg, gauze knot synched up to the function from baseline, using the 5-item International meatus) was used and when the surgeon only performed bladder neck cautery when necessary, the Index of Erectile Function (IIEF-5) total score, and risk of transfusion was 1.4% to 2.5% in prostates erectile dysfunction ([ED]; defined as IIEF-5 score ≤ ranging from 20 ml to 280 ml. 21) after a median follow-up of 3 years. The authors conclude that, while the a-thermal subgroup with robust traction with a catheter tension device had comparable transfusion rates for smaller Key articles

At baseline, roughly two-thirds (66.1%) of the sample had self-reported ED. At 48 months after randomisation, they determined that the effects of

more intensive blood pressure lowering were significantly moderated by race-ethnicity (p for interaction = 0.0016), prompting separate analyses stratified by race-ethnicity. In non-Hispanic whites, participants in the intensive treatment group reported slightly, but significantly better change in the IIEF-5 score than those in the standard treatment group (mean difference = 0.67; 95% CI = 0.03, 1.32; p = 0.041). In non-Hispanic blacks, participants in the intensive group reported slightly worse change in the IIEF-5 score than those in the standard group (mean difference = -1.17; 95% CI = -1.92, -0.41; p = 0.0025). However, in non-Hispanic whites and non-Hispanic blacks, further adjustment for the baseline IIEF-5 score resulted in nonsignificant differences (p > 0.05) according to the treatment group.

The investigators conclude that the effect of intensive treatment of blood pressure on erectile function was very small overall and likely not of great clinical magnitude The investigators conclude that the effect of intensive treatment of blood pressure on erectile function was very small overall and likely not of great clinical magnitude.

Source: Effect of Intensive vs Standard Blood Pressure Treatment Upon Erectile Function in Hypertensive Men: Findings From the Systolic Blood Pressure Intervention Trial. Foy CG, Newman JC, Russell GB, Berlowitz DR, Bates JT, Burgner AM, Carson TY, Chertow GM, Doumas MN, Hughes RY, Kostis JB, Buren PV, Wadley VG; SPRINT Study Research Group. J Sex Med. 2019 Dec 17. pii: S1743-6095(19)31779-5. doi: 10.1016/j.jsxm.2019.11.256. [Epub ahead of print]

Emergency department visits after urinary stone treatment with SWL, URS and PCNL compared There is a wide heterogeneity of the outcomes reported in studies on urinary stones interventions. Most of them are mere quantitative measurements of the stone-free rates according to different definitions, complication rates and other surgical parameters. Very few studies provide results centred on patients’ experiences, although modern medicine is moving more and more in this direction. Moreover, in stone disease there is a lack of patient-reported outcomes and health-related quality of life tools, which may make it even more difficult to identify patients’ satisfaction about the type of treatment they have undergone. In order to provide more meaningful insights into a patient’s treatment journey for urinary stone disease, authors have recently published results of a large cohort of patients undergoing SWL, ureteroscopy or PCNL in several USA states, based on the number of visits to the emergency department (ED). Although the study was prompted by the wish to better define costs associated with the relevant treatments, it ended up giving a larger scale picture of the impact of the intervention undertaken on the immediate aftermath.

…this is one of the first studies with an outcome that may clearly reflect the impact of the intervention undertaken on the patients’ quality of life Patients’ data was pulled out of national databases (the Agency for Healthcare Research and Quality’s (AHRQ) Healthcare Cost and Utilisation Project (HCUP)). The data was cross-matched with the International Classification Codes to identify the intervention undertaken, the patients’ comorbidities burden (defined as chronic condition > 12 months limited self-care or required long-term treatments), and the number of ED access within 30 days from the intervention. Furthermore, they could estimate other variables, such as patients’ urban-rural type of residence and mean patients’ incomes. Subsets of outcome analyses were carried out by comparing the ED admission rates of the patients undergoing URS with/without ureteric

stent, and – in the case of patients with indwelling stents - according to the type of stent (JJ or tethering string) inserted. A total of 321,899 patient data were evaluated, including 128,040 (39.8%) SWL, 151,006 (46.9%) URS and 42,853 (13.3%) PCNL. Overall, the authors found that PCNL had the highest rate of ED visits at 30 days post-intervention compared to URS and SWL (13.2 vs. 10.6 vs. 7.5%, p < 0.0001). At multivariate analysis, after adjusting for baseline clinical parameters and socio-demographic characteristics, both PCNL (OR = 1.62, 95% CI:1.561.69) and URS (OR = 1.33, 95% CI:1.30-1.37) were associated with a significantly higher risk of ED visits compared to SWL. As usual in this study’s setting, no data were available with respect to the stone burden and complexity of the required intervention, which obviously limited the robustness of the outcomes reported. The more challenging the clinical situation, the higher the chance that a more invasive procedure was undertaken. Although the authors could not control for many other confounding factors, this is one of the first studies with an outcome that may clearly reflect the impact of the intervention undertaken on the patients’ quality of life. Surely, in the era of personalised medicine, research should also move to a patient-centred reporting of outcomes.

Source: Postoperative Emergency Department Visits After Urinary Stone Surgery: Variation Based on Surgical Modality. Khanna A, Fedrigon D 3rd, Monga M, Gao T, Schold J, Abouassaly R. J Endourol. 2019 Dec 18. doi: 10.1089/end.2019.0399. [Epub ahead of print]

COLD multicentric registry: 2 years follow-up of Salvage Focal Cryotherapy According to the EAU and NCCN guidelines, salvage treatment for biochemical failure after radiotherapy of prostate cancer may involve radical prostatectomy, prostate ablation or brachytherapy, as long as patients show a negative metastatic work-out with a long life expectancy, in order to fully benefit from a potentially radical salvage treatment. The choice of the treatment may depend on the balances of pros and cons for each of them, after appropriate patient counselling. When salvage radical prostatectomy is the treatment providing the best oncological outcomes, prostate ablation with cryotherapy, HIFU or other sources of energy have been described to give the lowest risk of toxicity. Focal salvage treatment is an emerging option introduced to further minimise the patient’s risks of complications, although evidence is limited to a few retrospective studies. The largest one is an industryfunded registry from several centres in North America, collecting prospective data of patients undergoing cryotherapy, the COLD (Cryo On-Line Database) registry.

The only difference in favour of the focal treatment was a significantly lower rate of post-treatment and transient urinary retention… Recently, outcomes comparing focal versus total salvage cryotherapy have been published in literature in order to better investigate the potential advantages of focal treatment versus whole gland ablation. Preliminary outcomes were previously published by other authors using the same database, although the cohort of patients analysed was quite heterogeneous. 385 patients receiving salvage cryotherapy were recruited from 37 sites between 1992 and 2017 for biopsy-proven, localised recurrence/persistency of prostate cancer after prostate radiotherapy. There was a predominance of patients undergoing total salvage cryotherapy versus those undertaking focal treatment (n = 313 vs. 72, consisting of 81.3% vs. 18.7% of the cohort). Selection criteria were at the discretion of operators and no information was provided about how the focal treatments were performed. Moreover, the COLD registry lacks entry-data for multiparametric MRI, making it more difficult to distinguish what type of focal treatment was undertaken (i.e. hockey-stick, hemi-ablation, or purely focal).

EAU EU-ACME Office

European Urology Today

January/February 2020

Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ hotmail.com To reduce the heterogeneity of the patient characteristics, patients with PSA level >10 ng/ml and > 80 years of age were excluded from the statistical analysis. Furthermore, a propensity score was performed to compare outcomes with a subgroup of patients with matching baseline data. At a median follow-up of 24 months and after propensity score weighting oncological and functional outcomes were comparable between focal and total salvage cryotherapy. The rates of progression-free survival were 76.98% vs. 79.8% (p = 0.11), the de-novo incontinence rates were 9.3% vs. 15.1% (p = 0.19), and the de-novo impotency occurred in 52.6% vs. 59.6% (p = 0.47) of the cases, respectively. Rectal fistula were observed in 1.4% vs. 3.8% of patients (p = 0.30). The only difference in favour of the focal treatment was a significantly lower rate of post-treatment and transient urinary retention, happening in 5.6% vs. the 22.4% of patients (p < 0.001). Although much more robust data is needed, this is a further example of the slowly but steadily growing evidence of the feasibility and safety of focal salvage treatment after failure of prostate radiotherapy.

Source: Salvage Focal Cryotherapy Offers Similar Short-term Oncologic Control and Improved Urinary Function Compared With Salvage Whole Gland Cryotherapy for Radiationresistant or Recurrent Prostate Cancer. Wei Phin Tan, Ahmed ElShafei, Alireza Aminsharifi, Ahmad O. Khalifa, Thomas J. Polascik.

CT scan; the supra-costal access was always performed above the 12th rib and never further above. A JJ stent was inserted in all cases. To assess possible post-operative thorax complications, a thorax X-ray was performed peri-operatively at the bed site, and at the 1st day post-op. After 3 years of recruitment (December 2013-2016), a total of 75 patients were enrolled in the study. The trial was subsequently closed because it was difficult to recruit more patients, so the study was underpowered. Nevertheless, the statistical analyses were carried out according to the study design, showing a large benefit of the tubeless PCNL over the standard procedure. Hydrothorax events were significantly more frequent in the latter group than in the tubeless group, and this outcome was the same in both ITT and PP analysis (37.8% vs. 15.8%, p = 0.031; 38.4% vs. 13.8%, p = 0.016). The null-hypothesis was rejected as the difference was larger than the expected 20%. Interestingly, only one patient had the indication changed during the procedure (i.e. from tubeless to standard PCNL), so no differences were found in the ITT vs. PP outcomes in the analyses. At multivariate analysis the only factor significantly associated with a higher risk of hydrothorax was again the insertion of the nephrostomy tube (OR:3.628, 95% CI:1.073-12.265). The authors explained the phenomenon based on the proven effect of fluid drainage outside the nephrostomy tube that, in the presence of even a small discontinuation of pleural space, may perpetuate its accumulation inside the pleural cavity. They also found that the clinical impact of such a complication was minimal, as only 1 patient per arm needed the insertion of a pleural tube for drainage of the hydrothorax. No cases of lung injury or haemothorax were recorded. Overall, despite the limitations of the RCT, this is the first evidence suggesting that an uneventful supracostal PCNL on the 12th rib should preferably be undertaken without the insertion of a nephrostomy tube.

Clinical Genitourinary Cancer, in press. doi.org/10.1016/j. clgc.2019.11.009 Source: Tubeless supra-costal percutaneous

Changing paradigms: Tubeless PCNL is safer than standard PCNL Several studies on tubeless PCNL have demonstrated its benefit in reducing patients’ post-operative pain and the length of the hospital stay. The main issue is the selection of patients: those undergoing an uneventful PCNL for the treatment of a relatively low-burden renal stones are the best candidates.

… this is the first evidence suggesting that an uneventful supra-costal PCNL on the 12th rib should preferably be undertaken without the insertion of a nephrostomy tube Supra-costal access to the renal cavities is a potentially more morbid type of PCNL, because of the intrinsic higher risk of pleural or lung injuries. Therefore, its use is limited to highly experienced centres. Such centres have significant advantages. They are more experienced, e.g. in better targeting staghorn stones or large lower pole or proximal ureteric stones. Traditionally, a post-PCNL supra-costal nephrostomy tube insertion is deemed compulsory to reduce the risk of hydrothorax, due to the supposedly better drainage of urine. This belief is challenged by a randomised controlled trial undertaken in a single-centre/single-surgeon setting, in order to address the clinical question: does a nephrostomy tube post supra-costal PCNL increase the risk of pulmonary complications? The design of the study was methodologically sound. The calculated sample size consisted of 124 patients, 62 per arm. The aim was to demonstrate a difference of < 20% lower risk of hydrothorax in the tubeless group compared to the standard supra-coastal PCNL; an intention to treat and per protocol analysis were both planned. The patient selection was based on the characteristics of baseline stone(s) present at baseline Key articles

January/February 2020

nephrolithotomy is associated with significantly less hydrothorax: a prospective randomised clinical study. Goldberg H, Nevo A, Shtabholtz Y, Lubin M, Baniel J, Margel D, Ehrlich Y, Lifshitz D. BJU Int. 2019 Nov 13. doi: 10.1111/bju.14950. [Epub ahead of print]

Parental decision making about surgery on their child’s genitals Genital surgery is known to be surrounded by arguments suggesting surgery may compromise sexual function and sensation and create lifelong health issues. There is a great deal of controversy about timing, evidence, necessity and indications for genital surgery in infancy, adolescence or adult age, linked to issues of consent. Recently, genital surgery in infants and children is increasingly being questioned by patient groups and human rights institutions, as such interventions are seen as a human rights issue. Therefore, the basis and necessity of any intervention in early childhood should be thoroughly discussed with the parents, including all aspects such as possible future psychological issues. Many parents who choose hypospadias repair for their son experience decisional conflict and regret. Even though this decision-making process is extremely important, so far there is no structured model or guideline about how both parents and physicians should be involved in this shared process. The authors conducted semi-structured interviews with parents of children with hypospadias. The aim was to explore their role as proxy decision-makers by inquiring about their emotions/concerns, informational needs, and external/internal influences. The interviews were conducted until no new themes were identified. The interviews were analysed iteratively using open, axial, and selective coding. The iterative approach entailed a cyclical process of conducting interviews and analysing transcripts while the data collection process was ongoing. This allowed the researcher to adjust the interview guide, based on preliminary data analysis in order to explore themes that emerged from previous interviews with parents.

Grounded theory methods were used to develop an explanation of the surgical decision-making process. Sixteen mothers and one father of seven preoperative and nine postoperative patients (n = 16) with distal (8) and proximal (8) meatal locations were interviewed. Four stages of the surgical decision-making process were identified: (1) processing the diagnosis, (2) synthesising information, (3) processing emotions and concerns, and (4) finalising the decision (Extended Summary Figure). Core concepts in each stage of the decision-making process were identified. Primary concerns of parents included anxiety/fear about the child not waking up from anaesthesia and their inability to be present in the operating room. Parents incorporated information from the internet, medical providers, and their social network as they sought to relieve confusion and anxiety while building trust/ confidence in their child's surgeon.

Shared decision-making process for genital surgery in children is much more complex than initially recognised and requires a wellstructured methodology to avoid any future consequences The findings of this study contribute to our understanding of decision making about hypospadias surgery as a complex and multifaceted process. This study provides an initial framework of the parental decision-making process about hypospadias surgery. It gives information which may enable the development of a decision aid. Future stages of decision aid development will focus on recruitment of fathers, minorities, and same-sex couples in order to enrich the perspectives of this work.

Source: Parental perspectives on decisionmaking about hypospadias surgery. Chan, K.H. et al. Journal of Pediatric Urology, Volume 15, Issue 5, 449.e1 - 449.e8

Transplantectomy in the first 3 months after renal transplantation Sometimes, complications in renal transplantation require early transplantectomy and this is mostly due to vascular complications with an incidence of 1-5%. In the literature, it has been reported that early surgical intervention in such cases with graft salvage by removal, reperfusion and re-transplantation can save grafts which otherwise had to be removed. The authors of this study retrospectively analysed factors that led to early transplantectomy (within 3 months), with the emphasis on vascular complications. 770 kidney transplants performed between June 2011 and June 2017 were analysed of which 3.9% underwent early graft removal. Logistic regression was applied to study the relationship between independent variables and the occurrence of early transplantectomy.

Graft salvage in cases of early vascular complications should be attempted Regarding the recipient, it was verified that age over 65 years, body mass index, time on dialysis, previous transplant and several comorbidities (obesity, hypertension, diabetes mellitus, dyslipidemia, peripheral arterial disease and history of a thrombotic episode were not predictive factors. Neither were the use of expanded criteria donors, their age, or cause of death predictive factors. Similarly, the use of a right renal graft or grafts with multiple arteries, the duration of surgery, the performance of surgery at dawn, the need for transfusion, cold ischemia time and hemodynamic parameters at reperfusion (central venous pressure, systolic or diastolic blood pressure) were not predictive factors. The only significant predictive factors found were recipient age (p < 0.015; B = -0.059; Exp(B) = 0.943 [0.899-0.988]) which increased the risk of transplantectomy, while reoperation within the first 10 days (p < 0.002; B= -2.574; Exp(B) = 0.076 [0.028-0.210]) was a protective predictive factor reducing the risk of early transplantectomy.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com Thus, the authors concluded that reoperation in the first 10 days after transplantation decreased the risk of early transplantectomy, supporting their hypothesis that graft salvage by early intervention in cases of vascular complications is beneficial and should be attempted. Their finding that the lower the age of the recipient the higher the risk of early transplantectomy may be explained by declining immunity with increasing age.

Source: Transplantectomy in the First 3 Months After Renal Transplantation: Experience of a Reference Center. Marinhox A, Tavares da Silva E, Moreira P, Roseiro A, Parada B, Marconi L, Nunes P, Simões P, Santos L, Rodrigues L, Romãozinho C, Bastos CA, Figueiredo A. Transplant Proc. 2020 Jan 8. pii: S0041-1345(19)31009-7. doi: 10.1016/j.transproceed.2019.10.023. [Epub ahead of print]

Burden and timeline of infectious diseases in the first year after solid organ transplantation The burden and timeline of post-transplant infections are not comprehensively documented in the current era of immunosuppression and prophylaxis. The authors undertook to assess this in a prospective study nested within the Swiss Transplant Cohort Study (STCS). All clinically relevant infections were identified by transplant-infectious diseases physicians in persons receiving solid organ transplant (SOT) between May 2008 and December 2014 with ≥ 12 months of follow-up. Among 3,541 SOT recipients, 2761 (1,612 kidney, 577 liver, 286 lung, 213 heart, and 73 kidney-pancreas) had ≥ 12 months of follow-up. 1,520 patients (55%) suffered 3,520 infections during the first year after transplantation. Burden and timelines of clinically relevant infections differed between transplantations. Bacteria were responsible for 2,202 infections (63%) prevailing throughout the year, with a predominance of Enterobacteriaceae (54%) as urinary pathogens in heart, lung, and kidney transplant recipients and as digestive tract pathogens in liver transplant recipients. Enterococcus spp (20%) occurred as urinary tract pathogens in kidney transplant recipients and as digestive tract pathogens in liver transplant recipients, and Pseudomonas aeruginosa (9%) in lung transplant recipients.

Transplant recipients experience a high burden of infections throughout the first year Among 1,039 viral infections, herpesviruses predominated (51%) in kidney, liver, and heart transplant recipients. Among 263 fungal infections, Candida spp (60%) prevailed as digestive tract pathogens in liver transplant recipients. Opportunistic pathogens, including Aspergillus fumigatus (1.4%) and cytomegalovirus (6%), were rare, scattering over 12 months across all SOT recipients. In the current era of immunosuppression and prophylaxis, SOT recipients experience a high burden of infections throughout the first year after transplantation, with rare opportunistic pathogens and a predominance of bacteria.

Source: Burden and Timeline of Infectious Diseases in the First Year After Solid Organ Transplantation in the Swiss Transplant Cohort Study. Van Delden C, Stampf S, Hirsch HH, Manuel O, Meylan P, Cusini A, Hirzel C, Khanna N, Weisser M, Garzoni C, Boggian K, Berger C, Nadal D, Koller M, Saccilotto R, Mueller NJ; Swiss Transplant Cohort Study. Clin Infect Dis. 2020 Jan 9. pii: ciz1113. doi: 10.1093/cid/ ciz1113. [Epub ahead of print]

EAU EU-ACME Office

European Urology Today

Treatment of urgency urinary incontinence in MS patients Urologists should be involved in setting up an individualised treatment plan Dr. Stavros Charalampous Institute of Functional & Reconstructive Urology Limassol (CY) dr.charalampous@ cyprusurology.com Multiple sclerosis (MS) is a progressive, demyelinating disease of the central nervous system. MS is a chronic and potentially highly disabling disorder with considerable social impact and economic consequences. It is the major cause of non-traumatic disability in young adults1. The total estimated prevalence rate of MS for the past three decades is 83 per 100,000 with higher rates in northern countries and a female: male ratio around 2.0. Prevalence rates are higher for women for all countries considered. The highest prevalence rates have been estimated for the age group 35-64 years for both sexes and for all countries. The estimated European mean annual MS incidence rate is 4.3 cases per 100,000. The median global incidence of MS is 2.5 per 100,000 (range: 1.1–4) and the median prevalence of MS is 30 per 100,000 (range: 5–80)2,3. Bladder dysfunction Vesicourethral dysfunction is very frequent in multiple sclerosis (MS) and has functional consequences for patients' quality of life. It also has an organic impact following complications of the neurogenic bladder on the upper urinary tract4. The US-based National MS Society estimates that 80% of MS patients have some sort of bladder dysfunction5. Pelvic floor dysfunction includes bladder, bowel and sexual dysfunction. Bladder dysfunction in MS can be socially disabling, have negative psychological and economic consequences, and impair patients’ quality of life1. Symptomatic voiding dysfunction occurs in 50% to 80% of patients with MS during the disease course and may include urinary retention and/or incontinence. Neurogenic detrusor overactivity (NDO) is the most common lower urinary tract complaint in men and women with MS (60%) and is defined by urgency, urge incontinence, urinary frequency and nocturia. Increased storage pressure can put the upper urinary tract at risk of deterioration; reducing this risk is a primary aim of therapy6. Urinary incontinence is viewed by many people with MS as being their worst symptom7,8,9. Evaluation Although only 2 to 2.5% of patients present with urological symptoms, MS should be suspected in any young patient with unexplained voiding dysfunction, even without neurological symptoms10. Patients with unexplained voiding dysfunction who fit the demographic parameters for MS should be questioned about fatigue, heat intolerance (Uhthoff’s phenomenon)11, sensory dysfunction, motor weakness and periods of waxing or waning symptoms. A history of visual disturbance (diplopia, oscillopsia12) or dizziness may indicate pontine pathology with concomitant bladder and sphincter effects. Gastrointestinal disturbances, usually constipation, may be reported. The association between cranial nerve findings and urinary tract abnormalities is not well established12. Neurogenic detrusor overactivity (NDO) is a urodynamically measured bladder dysfunction caused by a lesion in the brain. NDO is a lower urinary tract dysfunction (NLUTD) and can cause urinary symptoms such as frequency, urgency and urinary Incontinence13. Detrusor sphincter dyssynergia The type of bladder dysfunction depends on the site, extent and evolution of the lesion. Patients with suprapontine lesions may have UI due to NDO or disinhibition of the micturition reflex. They usually have reflex contractions of the detrusor but may lose cerebral contributions to lower urinary tract control, such as control over the timing of emptying, inhibition of bladder contractility, and the conscious filling and emptying sensation. Sphincter activity is synergic with EAU Section of Female and Functional Urology

European Urology Today

the bladder. Patients with suprasacral spinal cord lesions may have UI due to NDO, and this can be accompanied by urinary retention due to detrusor sphincter dyssynergia (DSD). DSD leads to impaired voiding, elevated residual urine, and in some cases prolonged detrusor contractions, structural bladder damage and vesicoureteric reflux. In the MS patient population, the incidence of abnormal urodynamic findings may be as high as 100%14. Detrusor hyperreflexia, defined as bladder overactivity due to a disturbance of nervous control mechanisms, is the most common urodynamic abnormality in MS15. Urodynamic investigation Urodynamic investigation is the only method that can objectively assess the function and dysfunction of the LUT. In neuro-urological patients, invasive urodynamic investigation is even more challenging than in general patients. Fig. 1: Preparation set for botox injections

The EAU guidelines state that NLUTD is the only method that can objectively assess the (dys)function of the LUT (Evidence 2a) and urodynamic investigation is the only method that can objectively assess the function and dysfunction of the LUT. In neuro-urological patients, invasive urodynamic investigation is even more challenging than in general patients, with grade of recommendation STRONG16. The EAU guidelines statement for NLUTD is that urodynamic investigation is the only method that can objectively assess the (dys)function of the LUT. (Evidence2a) In neuro-urological patients, invasive urodynamic investigation is even more challenging than in general patients with grade of recommendation STRONG16.

“In MS and spinal cord injury (SCI) patients, with very short follow up, mirabegron has not demonstrated any significant effect on detrusor pressure or cytometric capacity, despite the reported improvement in LUTS16.” In the management of NDO the primary aims for treatment of neuro-urological symptoms are the protection of the upper urinary tract (UUT); achievement (or maintenance) of urinary continence; restoration of LUT function and improvement of the patient’s QoL17,18. Urological treatment and therapeutic guidelines Conservative therapy for bladder storage disorders Primary management of NDO should incorporate behavioural approaches such as increasing the frequency of micturition, limiting fluid intake in the evening, limiting intake of diuretics including caffeine and alcohol, and using absorbent undergarments and bed pads19. The UK consensus recommended that physical interventions such as Pelvic Floor Muscle Training (PFME) should be offered to MS patients with mild disability (recommendation grade B)20. The EAU guidelines do not have a recommendation grade for PFME, they do emphasise that this treatment could have some benefit in selected patients21. The results of a systematic review of the management of LUT dysfunction in MS recommended pelvic floor rehabilitation together with neuromuscular electrical stimulation. This increased the success rate of symptomatic treatment22. The next phase in managing this condition consists of pharmacologic approaches. Anticholinergic medications can be tried, as in theory they decrease the detrusor muscle activation by antagonising the cholinergic muscarinic receptors. Symptoms of frequency, urgency, nocturia and incontinence comprise the most common cause for urological consultation. As nearly two-thirds of patients have detrusor hyperreflexia, treatment involves pharmacological therapy to suppress uninhibited bladder contractions. Various drugs can be used. Dosages may be titrated to therapeutic response until anticholinergic side effects become intolerable23.

Antimuscarinic drugs are the first-line choice for treating NDO. They increase bladder capacity and reduce episodes of urinary incontinence secondary to NDO by the inhibition of parasympathetic pathways. Antimuscarinic drugs have been the first-line choice of treatment for many years for patients with NDO. The responses of individual patients to antimuscarinic treatment are variable17. Anticholinergic medications are prescribed to 27.5% of patients. Oxybutynin chloride is among the most widely prescribed of these medications and has demonstrated fair to good responses in 67 to 80% of MS patients. Because anticholinergic side effects, such as decreased salivation, blurred vision and constipation, occur in 57 to 94% of patients, long-term compliance is a problem. If a patient experiences a side effect with the use of oxybutynin, another ACM should be prescribed. Higher doses or a combination of antimuscarinic agents may be an option to maximise outcomes in neurological patients24. However, these drugs have a high incidence of adverse events, which may lead to early discontinuation of therapy25. New selective muscarinic receptor blockers may hold promise for relieving these symptoms with a lower incidence of anticholinergic side effects. Trospium, tolterodine and propiverine are established, effective and well tolerated treatments even in long-term use26. Anticholinergic therapy is frequently prescribed in higher doses than in overactive bladder (OAB); this can lead to an increased incidence of adverse events27. Darifenacin and solifenacin have been evaluated in NDO secondary to SCI and MS with results similar to other antimuscarinic drugs27. Combination of anticholinergics is suggested by the EAU, but this may also lead to increased adverse events28. A further complication of the use of anticholinergics in NLUTD is their adverse events in the central nerve system. In the cognitively impaired, anticholinergics should be prescribed with a warning about possible deterioration in memory or the onset of confusion29.

The way of action of the new agent mirabegron (Beta-3-adrenergic receptor agonists) in neurourological patients is still unclear. In MS and spinal cord injury (SCI) patients, with very short follow up, mirabegron has not demonstrated any significant effect on detrusor pressure or cytometric capacity, despite the reported improvement in LUTS16. There is therapeutic efficacy of low dose (25mg) mirabegron therapy for patients with mild to moderate overactive bladder symptoms due to central nervous system diseases35. Combination therapy with mirabegron and desmopression in MS patients has shown promising results; however, clinical experience is still very limited in neuro-urological populations36. The EAU guidelines state that the use of antimuscarinic agents as first-line medical treatment for neurogenic detrusor overactivity is strongly recommended. If patients are refractory to pharmacological treatment of NDO or cannot tolerate the side effects, the behavioural modifications and pelvic floor physical therapy are unsuccessful, then intradetrusor injection of botulinum toxin-A (OnaBotA; Botox Allergan, Dublin, Ireland) is a highly effective option. Intradetrusor injection of botulinum toxin-A. Given the risk to the upper urinary tract of NDO and DSD, urodynamic criteria are more important indicators of treatment success in NLUTD than in OAB. In this context, a patient refractory to oral therapy may be defined as a patient in whom the storage pressure in the bladder is not normalised with such therapy. Compared with OAB, the risk for the upper urinary tract in NDO means there is a more immediate need to identify these patients and move to minimally invasive therapy. In such patients, options include onabotulinumtoxinA, which is supported by the greatest weight of evidence and is considered by the EAU to be the most effective (LE 1a, GR Strong).

Injection of BoNT-A into the detrusor muscle is an effective treatment modality for intractable NDO in patients with MS. A recommendation with an evidence It is well known that adherence to and persistence with level 1 was issued by the UK consensus for intravesical anticholinergics is poor in OAB, but there is scant BoNT-A treatment in patients with MS and NDO37. evidence on this subject in NDO. Among 26,922 patients with NLUTD analysed in a retrospective claims The toxin injections are mapped over the detrusor in a dosage that depends on the preparation used. database, 38% discontinued oral therapy within 1 Traditionally, 300 units (U) of Onabotulinum Toxin A year30. (Bot-A) was used to control NDO in MS patients38. In some patients clean intermittent catheterisation may Exclusion criteria were OAB symptoms due to bladder be combined with anticholinergic therapy; this may be outlet obstruction, recurrent urinary tract infections, cognitive impairment, pregnancy, anticoagulant especially beneficial in those with storage and emptying failure. In these patients, urinary retention is therapy, psychoactive agents modulating bladder function (venlafaxine, amitriptyline), aminoglycosides promoted by anticholinergics, thus alleviating storage and other drugs thought to interfere with bladder problems, while emptying is provided solely by function and patients with radiculopathy and intermittent catheterisation31. peripheral neuropathy39. BoNT-A has been proven To avoid anticholinergic side effects from oral effective in patients with neuro-urological disorders medications, intravesical verapamil, lidocaine and due to MS, SCI and PD in multiple RCTs and metaoxybutynin have been tested for treatment of detrusor analyses40. Urodynamic studies might be necessary after treatment in patients with a maximum filling hyperreflexia32. Oxybutynin, the most used single pressure of > 40 cm H2O in order to monitor the effect Intravesical agent, has demonstrated an 86% of the injections on bladder pressure41. BTX-A bladder therapeutic response in MS patients in selected studies. However, the inconvenience of this route of injection therapy was effective to treat refractory NDO administration has contributed to a high attrition rate in MS patients, with an overall efficacy of 77%, in and has tempered enthusiasm33. Nevertheless, in a terms of clinical and urodynamic results42. Volumes for select group of patients who are already on first, normal and strong desire significantly increased, intermittent catheterisation, intravesical oxybutynin and detrusor overactivity disappeared after BoNT/A may lead to a significant improvement in continence injection39. The efficacy of repeated injections was well sustained in terms of improving OAB symptoms and but with fewer side effects. Currently, the use of these QOL. However, 95% of the patients needed IC after substances is not indicated since they are not licensed BoNT-A treatment. for intravesical treatment34. January/February 2020

IC treatment It is important to explain to patients, during counselling before treatment, they may need IC treatment after BoNT-A treatment. Repeated detrusor botulinum neurotoxin type A injection for refractory neurogenic detrusor overactivity in patients with MS have a consistent effect on bladder control, resulting in sustained improvement in quality of life43. The most frequently occurring side effects are UTIs and elevated PVR42. Intermittent catheterisation may be necessary. EAU guidelines state that botulinum toxin A has been proven effective in patients with neuro-urological disorders due to MS or SCI in multiple RCTs and meta-analyses (LE 1A, GR Strong)16. Neuromodulation Neuromodulation has been tried in patients with MS and LUTS. Several sites have been studied for neuromodulation including the sacral, pudendal, tibial and genital nerves, but the most widely reported area for the treatment of overactive bladder (OAB) is the third sacral nerve root (S3)44. Neuromodulation most probably causes rebalancing of inhibitory and excitatory impulses that control bladder function in the CNS and inhibits bladder activity by depolarising somatic sacral and lumbar afferent fibres. Tibial nerve stimulation (TNS) and transcutaneous electrical nerve stimulation (TENS) might be effective and safe for treating neurogenic LUT dysfunction. However, more reliable evidence from well-designed randomised controlled trials (RCTs) is required to reach definitive conclusions. Electrical stimulation of the pudendal nerve afferents strongly inhibits the micturition reflex and detrusor contraction45. The tibial nerve is a mixed nerve containing L4-S3 fibers. It originates from the same spinal segments as the

the course of the underlying neurological disorder is considered stable or slowly progressive and patients are not likely to require repeated magnetic resonance scans51. Bladder augmentation Surgical augmentation for detrusor dysfunction is usually reserved for the patient in whom all other conservative options have been exhausted. As the course of MS is by nature dynamic and progressive, permanent procedures using intestinal segments should be performed only after careful consideration of the course of disease (relapsing or progressive) and overall prognosis. Patients undergoing augmentation cystoplasty should be assessed for manual dexterity as most will continue to require some intermittent catheterisation. For most patients, long-term management plans should be based on a life expectancy of 20 to 30 additional years. Thus, short-term solutions may need to be dismissed in favour of a more comprehensive long-term approach. Surgical options include suprapubic cystostomy, sphincterotomy, sphincteric stents, augmentation cystoplasty - with or without a catheterisible limb and incontinent vesicostomy. Augmentation cystoplasty is a frequently used surgical option to obtain adequate bladder capacity and low intravesical pressure. The indication for augmentation ileocystoplasty is low capacity. Augmentation cystoplasty resulted in a significant improvement in bladder capacity, compliance, reflex volume and maximum detrusor pressure from the preoperative to the follow-up values52. Auto-augmentation This method has proved effective in lowering bladder pressure, increasing bladder capacity and improving

Fig. 2: Botox A = before

innervations to the bladder and pelvic floor. The idea of stimulating these nerves was based on the traditional Chinese practice of using acupuncture points over the common peroneal or posterior tibial nerve stimulation (PTNS) to affect bladder activity. The ankle region of stimulation used in PTNS is close to the Sanyinjiao (SP6) used in Chinese acupuncture46. PTNS The results of a large multicentre study evaluating the effect of Transcutaneous Posterior Tibial Nerve Stimulation (TPTNS) on refractory OAB in MS shows it significantly relieved clinical symptoms and the related psychosocial burden. While TPTNS appears effective in improving the more bothersome symptoms, urgency in more than 80% of the patients, it also appeared to reduce frequency and urge urinary incontinence and had a positive impact on QoL. The efficacy of TPTNS appears in the first week and remains stable when applied daily for 3 months. A 20-minute session seems enough to allow a persistent effect for the entire day. The outcome of this study argues the indication should be considered for inclusion in first-line treatment in patient presenting with OAB without risk of urinary tract damage due to high detrusor pressure47,48. PTNS is a minimally invasive neuromodulation technique that has been shown to be an effective treatment for patients with neurogenic and nonneurogenic LUTS unresponsive to medical treatment49. Sacral neuromodulation (SNM) may be beneficial in a patient with a history of urge incontinence which does not respond to oral agents50. Sacral neuromodulation for the treatment of detrusor disorders has been used since the 1960s and it has been approved by the Food and Drug Administration (FDA) since the 1990s for refractory voiding dysfunction, urgency incontinence, urgency-frequency syndrome and nonobstructive urinary retention. Patients suffering from MS should be carefully evaluated and, although there is a lack of randomised controlled trials, SNM is usually offered if January/February 2020

4. Nortvedt M, Riise T, Myhr KM et al: Reduced quality of life among multiple sclerosis patients with sexual disturbance and bladder dysfunction. Mult Scler 2001; 7: 231. 5. Ruffion A, Castro-Diaz D, Patel H, et al. Systematic review of the epidemiology of urinary incontinence and detrusor overactivity among patients with neurogenic overactive bladder. Neuroepidemiology 2013; 41:146–55. 6. National Multiple Sclerosis Society. Bladder dysfunction. Available at: http://www.nationalmssociety.org/ about-multiple-sclerosis/what-we-know- about-ms/ symptoms/bladder-dysfunction/index.aspx. 7. Hemmet L, Holmes J, Barnes M, et al. What drives quality of life in multiple sclerosis? QJM. 2004; 97:671–676.   8. Borello-France D, Leng W, O’Leary M et al: Bladder and sexual function among women with multiple sclerosis. Mult Scler 2004; 10: 455. 9. Bradley, W. E.: Urinary bladder dysfunction in multiple sclerosis. Neurology, 9 52, 1978. 10. Fowler, C. J.: Bladder dysfunction in multiple sclerosis: causes and treatment. Int. MS Journal, 1:4,1996 11. JA Opara,* et al Uhthoff`s phenomenon 125 years later - what do we know today? J Med Life. 2016 Jan-Mar; 9(1): 101–105. 12. Blaivas, J. G., et.al.: Multiple sclerosis bladder, Studies and care. Ann. N.Y. Acad. Sci., 436328,1984. 13. Drake M, Apostolidis A, Emmanuel A, et al. Neurologic urinary and faecal incontinence. In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence (5th Ed). ICUD-EAU; 2013. p 827–1000 14. de Seze, M., et al. The neurogenic bladder in multiple sclerosis: review of the literature and proposal of management guidelines. Mult Scler, 2007. 13: 915. 15. Blaivas, J. G. The neurophysiology of micturition: a clinical study of 550 patients. J. Urol., 127: 958, 1982 16. EAU Guidelines :https://uroweb.org/guideline/ neuro-urology/#note_40.2019

Fig. 3: Botox B = after the injection

related symptoms in many patients. Patients who demonstrate poor bladder compliance, but no severely reduced capacity are good candidates to achieve continence, decrease hydronephrosis, and lower bladder storage pressure. Patients with severe bladder hyperreflexia, uncontrolled with medications, have also benefited greatly from autoaugmentation procedures. Auto-augmentation involves removing the detrusor from at least one half of the bladder. As the procedure progresses the epithelium should begin to bulge distinctly53. Bladder augmentation is an effective option to decrease detrusor pressure and increase bladder capacity, when all less-invasive treatment methods have failed, according to the EAU guidelines (LE 3, GR strong) Conclusions MS is a devastating disease, affecting 0.1% of the population in the prime of life. During this disease nearly all patients have lower urinary tract symptoms and/or sexual dysfunction. Although these symptoms are rarely life threatening, they have a significant impact on quality of life. Consequently, the urologist may be asked to assist in the care of these patients. To treat these problems effectively and intelligently the urologist must have a fundamental working knowledge of the disease process and its effects on the genitourinary system. With this knowledge a logical and individualised treatment plan can be formulated, thus making the urologist an integral part of the MS management team. References 1. Noseworthy JH, Lucchinetti C, Rodriguez M et al: Multiple sclerosis. N Engl J Med 2000; 343: 938 2. Pugliatti, M., et al. The epidemiology of multiple sclerosis in Europe. Eur J Neurol, 2006. 13: 70 3. World Health Organization. Atlas: Multiple sclerosis resources in the world. 2008. Available at: http://www. who.int/mental_health/neurology/ Atlas_MS_WEB.pdf.

17. Apostolidis, A., et al., Neurologic Urinary and Faecal Incontinence, In: Incontinence 6th Edition,P. Abrams, L. Cardozo, S. Khoury & A. Wein, Editors. 2017. 18. Pannek J, Sto€hrer M, Blok B, et al. EAU guidelines on neurogenic lower urinary tract dysfunction. 2011. Available at: http://www.uroweb.org/gls/pdf/ 17_ Neurogenic NLUTS.pdf. 19. Yonnet et.al Advances in the Management of Neurogenic Detrusor Overactivity in Multiple Sclerosis Gael J. Int J MS Care. 2013;15:66–72 20. Fowler CJ, Panicker JN, Drake M, Harris C, Harrison SC, Kirby M, et al. A UK consensus on the management of the bladder in multiple sclerosis. J Neurol Neurosurg Psychiatry 2009;80(5):470–7. 21. www.uroweb.org/gls/pdf/19_Neurogenic_LR%20II.pdf. 22. Cetinel B, Tarcan T, Demirkesen O, Ozyurt C, Sen I, Erdogan S, et al. Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis. A Systematic Review and Turkish Consensus Report. Neurourol Urodyn 2013;32(8):1047–57. 23. Yes im Akkoç et.al:Overactive bladder symptoms in patients with multiple sclerosis: Frequency, severity, diagnosis and treatment The Journal of Spinal Cord Medicine 2015 24. Bennett N1 Can higher doses of oxybutynin improve efficacy in neurogenic bladder? J Urol. 2004 Feb;171(2 Pt 1):749-51. 25. Amend, B., et al. Effective treatment of neurogenic detrusor dysfunction by combined high-dosed antimuscarinics without increased side-effects. Eur Urol, 2008. 53: 1021. 26. Nicholas RS, Friede T, Hollis S, Young CA. Anticholinergics for urinary symptoms in multiple sclerosis. Cochrane Database Syst Rev 2009;(1):CD004193. 27. Amarenco, G., et al. Solifenacin is effective and well tolerated in patients with neurogenic detrusor overactivity: Results from the double-blind, randomized, active- and placebo-controlled SONIC urodynamic study. Neurourol Urodyn, 2015. 29: 29. 28. Nardulli R, Losavio E, Ranieri M, et al. Combined antimuscarinics for treatment of neurogenic overactive bladder. Int J Immunopathol Pharmacol 2012;25:35S–41S.

29. Drake M, Apostolidis A, Emmanuel A, et al. Neurologic urinary and faecal incontinence. In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence (5th Ed). ICUD-EAU; 2013. p 827–1000. 30. Manack A, Motsko SP, Haag-Molkenteller C, et al. Epidemiology and healthcare utilization of neurogenic bladder patients in a US claims database. Neurourol Urodyn 2011;30:395–401. 31. Kurze, I., et al. Intermittent Catheterisation and Prevention of Urinary Tract Infections in Patients with Neurogenic Lower Urinary Tract Dysfunction - Best PracticeAn Overview. [German]. Aktuelle Neurologie, 2015. 42: 515. 32. Madersbacher, H. and Jilg, G.: Control of detrusor hyperreflexiabytheintravesicalinstillationofoxybutyninhydrochloride. Paraplegia, 29: 84, 1991. 33. Weese, D. L., Roskamp, D. A., Leach, G. E. and Zimmern, P. E.: Intravesical oxybutynin: experience with 42 patients. Urol- ogy, 41: 527, 1993. 34. Phe, V., et al. Intravesical vanilloids for treating neurogenic lower urinary tract dysfunction in patients with multiple sclerosis: A systematic review and meta-analysis. A report from the Neuro-Urology Promotion Committee of the International Continence Society (ICS). Neurourol Urodyn, 2018. 37: 67. 35. Chen, S.F., et al. Therapeutic efficacy of low-dose (25mg) mirabegron therapy for patients with mild to moderate overactive bladder symptoms due to central nervous system diseases. LUTS: Lower Urinary Tract Symptoms, 2018. 36. Zachariou, A., et al. Effective treatment of neurogenic detrusor overactivity in multiple sclerosis patients using desmopressin and mirabegron. Can J Urol, 2017. 24: 9107. 37. Fowler CJ, Panicker JN, Drake M, Harris C, Harrison SC, Kirby M, et al. A UK consensus on the management of the bladder in multiple sclerosis. J Neurol Neurosurg Psychiatry 2009;80(5):470–7. 38. Chowdhury S.A. Decreasing the dose of onabotulinum toxin A from 300 units to 200 units in multiple sclerosis patients – does it matter? Eur Urol Suppl 2014;13; e698 39. Antonella Conte et.al: Intradetrusorial Botulinum Toxin in Patients with Multiple Sclerosis: A Neurophysiological Study Toxins 2015, 7, 3424-3435; doi:10.3390/ toxins7093424 40. Yuan, H., et al. Efficacy and Adverse Events Associated With Use of OnabotulinumtoxinA for Treatment of Neurogenic Detrusor Overactivity: A Meta-Analysis. Int Neurourol J, 2017. 21: 53. 41. Koschorke, M., et al. Intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity incontinence: do we need urodynamic investigation for outcome assessment? BJU International, 2017. 120: 848. 42. S. Deffontaines-Rufin et.al: Botulinum Toxin A for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients International Braz J Urol Vol. 37 (5): 642-648, September - October 2011 43. Khan S, Game X, Kalsi V, Gonzales G, Panicker J, Elneil S, et al. Long-term effect on quality of life of repeat detrusor injections of botulinum neurotoxin-A for detrusor overactivity in patients with multiple sclerosis. J Urol 2011;185(4):1344–9. 44. Bartley J, Gilleran J and Peters K. Neuromodulation for overactive bladder. Nat Rev Urol 2013; 10: 513–521 45. Del Popolo, G., et al. Neurogenic detrusor overactivity treated with english botulinum toxin a: 8-year experience of one single centre. Eur Urol, 2008. 53: 1013. 46. Vodusek, D.B., et al. Detrusor inhibition induced by stimulation of pudendal nerve afferents. Neurourol Urodyn, 1986. 5: 381. 47. Marianne de Se`ze et.al:Peranscutaneous Posterior Tibial Nerve Stimulation for Treatment of the Overactive Bladder Syndrome in Multiple Sclerosis: Results of a Multicenter Prospective Study Neurourology and Urodynamics 30:306–311 (2011) 48. V. Vandoninck et.al Posterior Tibial Nerve Stimulation in the Treatment of Voiding Dysfunction: Urodynamic Data Wein, A. J. (2005). The Journal of Urology, 174(3), 1008–1008. 49. Rahnama’i, M. S. (2019). Neuromodulation for functional bladder disorders in patients with multiple sclerosis. Multiple Sclerosis Journal, doi:10.1177/1352458519894714,20 50. Uzunköprü C Invasive Therapies in Multiple Sclerosis Noro Psikiyatr Ars. 2018;55(Suppl 1):S21-S25. doi: 10.29399/ npa.23362 51. Puccini, F., Bhide, A., Elneil, S., & Digesu, G. A. (2015). Sacral neuromodulation: an effective treatment for lower urinary tract symptoms in multiple sclerosis. International Urogynecology Journal, 27(3), 347–354. doi:10.1007/ s00192-015-2771-0 52. Krebs, J., Bartel, P., & Pannek, J. (2014). Functional outcome of supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction. Neurourology and Urodynamics, 35(2), 260–266. doi:10.1002/nau.22709 53. ow, B. W., & Cartwright, P. C. (1996). BLADDER AUTOAUGMENTATION. Urologic Clinics of North America, 23(2), 323–331. doi:10.1016/s0094-0143(05)70314-1

European Urology Today

EUREP20 18th European Urology Residents Education Programme 4-9 September 2020, Prague, Czech Republic

www.eurep20.org A unique and exclusive training opportunity General information Participation and contribution This teaching programme has been developed and created exclusively for all European urological residents. The EUREP provides an almost complete update and overview of modern urological practice presented by a distinguished European faculty. The EUREP is an initiative of the European School of Urology (ESU) in collaboration with the European Board of Urology. The written part of the FEBU exam (Fellow of the European Board of Urology) will take place at a later date in different cities throughout Europe. Further information will be available on www.ebu.org. Format The format is a full six-day course comprising of five modules. Each day is made up of two sessions that last around seven hours. Morning sessions feature state-of-the-art lectures, while afternoon sessions offer interactive case discussions, video, and test-your-knowledge sessions. The hands-on-training sessions will take place around the modules. The training which is sponsored by Olympus helps the participants sharpen their skills and offers hands-on interaction with state-of-the-art equipment. Venue The EUREP will be organised in Prague, Czech Republic. The venue at the Clarion Congress Hotel provides excellent facilities and the four-star hotel has all the necessary facilities needed for both the scientific programme and social activities. Travel Arrival date: Thursday, 3 September Departure date: Wednesday, 9 September after the modules end at 12.30.

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

Preliminary programme 2020

Registration information

Module 1 Urological cancer

Important dates Online registration opened on 6 January 2020. The selection process will be made after registration closes on 1 May 2020. A total of 360 participants will be selected. Participants will be notified by email if they have been selected. If selected, the deadline for cancellation is 1 August 2020. After this time a cancellation fee of €500 will be charged.

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

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

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

Additional criteria 1. EAU membership. Priority is given to those who are or become a member before the registration deadline 2. Year of training. Priority is given to residents in their final year of training (i.e. training should be finished before September of the following year based on the information received from the proof of status) 3. It is required to obtain CME credits by completing European Urology multiple choice questions (MCQ’s). For further information please check www.eurep20.org 4. First-come, first-served basis 5. English skills 6. Target per country 7. It is only allowed to attend the EUREP course once

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

The courses in laparoscopy are specifically designed for individuals with minimal or no prior experience in laparoscopic suturing. Tutors will, of course, gladly adapt tasks for more experienced individuals. Basic techniques will be trained in a dedicated step-by-step programme including intracorporeal suturing depending on individual skill level. Scientific secretariat ESU Office 14

European Urology Today

A. Merseburger (DE)

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

S. Joniau (BE), Chair

S. Ahyai (DE)

N. Mottet (FR)

T. Steuber (DE)

C. Scoffone (IT)

A. Skolarikos (GR)

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

Module 3 Andrology, stones and upper tract endourology

For further detailed information regarding the registration rules for the 18th EUREP course we strongly recommend that you visit www.eurep20.org

Andrology Physiopathology diagnosis and treatment of erectile dysfunction Penile curvature Priapism and metabolic syndrome Male infertility diagnosis and treatment Surgery for male infertility and vasectomy Male hypogonadism

Registration non-European residents If you are a non-European resident that is interested in taking part in the 18th EUREP course please go to www.eurep20.org for the rules and regulations regarding participation.

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

I. Moncada (ES), Chair

S. Minhas (GB)

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

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

Sharpening Your Skills: TUR, URS, and Laparoscopy

The workshop provides the participants with a unique opportunity to learn the basic techniques using complex training models under expert supervision. Thanks to the intense tutoring scheme -with a personal tutor per training station- optimal learning is warranted.

K. Bensalah (FR) M. Hora (CZ)

Module 2 Prostate cancer and male voiding LUTS

Hands-on-training workshops

Intensive hands-on training is offered as an essential part of EUREP. This year's programme consists of practical activities with state-of-the-art equipment in laparoscopy, ureteroscopy (URS) and transurethral resection (TUR) -all of which are sponsored by Olympus.

F. Liedberg (SE), Chair

The training curriculum for the ureteroscopy workshop is designed by Prof. Olivier Traxer of Tenon Hospital, Paris. Residents will learn about the proper use of flexible ureteroscopes using a variety of stone disposables in order to remove kidney stones.

Paediatric urology Essentials of obstructive uropathy Congenital malformations of the external genitalia Infections Urinary tract infections

Participants can only participate in one session optimal learning is warranted.

H. Abol-Enein (EG), Chair

B. Burgu (TR)

Y.F. Rawashdeh (DK) Z. Tandogdu (GB)

Trauma Diagnosis and management of kidney, bladder and urethral trauma

For more information on the different training modules, please visit www.eurep20.org.

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

K. Sievert (DE)

Module 5 Paediatric urology, trauma and infection

The course in transurethral resection of the prostate gives residents the great opportunity to learn more about the basics of high-frequency surgery, the instruments needed, as well as, tips and tricks for daily surgery.

The hands-on-training workshops are sponsored by an unrestricted educational grant from:

J. Heesakkers (NL), A. Giannantoni (IT) G. Karsenty (FR) Chair

“If you meet the criteria, we would encourage you to register for this opportunity," - Prof. Palou, Course Director

eurep@uroweb.org January/February 2020

Sperm DNA fragmentation (SDF) Where does it occur and how can it be avoided? Dr. Alekzander Khelaia Member ESUO National Centre of Urology Ass. Prof. of European University Tbilisi (GE) alekoxelaia@gmail.com

Dr. Evangelos Symeonidis 1st Dept. Urology, G. Gennimatas General Hospital, Aristotle University of Thessaloniki (GR) evansimeonidis@ gmail.com

Ass. Prof. Fotios Dimitriadis ESUO board member ESAU associated board member 1st Dept. of Urology G. Gennimatas General Hospital, Thessaloniki (GR) helabio@yahoo.gr Over 15% of married couples worldwide experience fertility problems. Males contribute to approximately 50% of infertility cases. DNA damage, via fragmentation and denaturation, can have adverse effects on fertilisation and embryo development, causing subsequent infertility. Recently, sperm DNA fragmentation (SDF) testing has emerged as a valuable complementary semen analysis tool for the infertility specialist. Sperm DNA fragmentation represents a multifactorial disorder with genetic, environmental and lifestylerelated factors being dominantly incriminated. A concise summary of the available evidence regarding the possible aetiology and different mechanisms of action is cited in Table 1. Effect of oxidative stress It is well documented that oxidative stress (OS), via the pathway of reactive-oxygen species (ROS)-induced infertility, reflects on both mitochondrial and nuclear DNA, thus altering the structure and functionality of spermatozoa. High levels of DNA fragmentation, chromosomal microdeletions and mitochondrial DNA mutations are among the most noticeable deleterious effects of OS on sperm DNA.

Table 1: Summary of the available evidence regarding the possible aetiologic and different mechanisms of action of SDF Reason Smoking1

Air pollution2 Pesticides3

Exposure to high temperatures4

How Cadmium, radioactive polonium, benzopyrenes, dimethylbenzanthracene, naphthalene, methylnaphthalene of the gaseous cigarette smoke SO2, NOX, CO, O3, PAHs Nematocide dibromochloropropane (DBCP), endosulfan, toxaphene, dieldrin, o,p’-DDT, b-HCH, methoxychlor, chlordecone (Kepone), dimethoate Sedentary position (drivers) exhausts the testicular heat regulation; chimney sweepers; ceramic and steel industry

Varicocele10 Spinal cord injury (SCI)11

Selective serotonin reuptake inhibitors (SSRIs)12 Obesity13

Coffee consumption14 Vitamin C, vitamin E, β-carotene, zinc, and selenium15

Sperm aneuploidy, structural chromosome aberrations, chromatin structure anomalies, DNA breaks, and higher frequency of mutations

Sperm DNA damage; DNA strand breaks and inhibition of DNA repair

BPA acts primarily by mimicking antiandrogenic and estrogenic effects; DNA methylation and the effects of epigenetics; significant increase in sperm DNA fragmentation favouring double-strand breaks caused by BPA mimic effects of 17β-oestradiol (E); direct genotoxicity to sperm from BPA exposure in vitro Hyperglycaemic and hypo-insulinemic states Sperm DNA denaturation, base pair oxidation, changes in both quality and quantity of nuclear chromatin condensation and sperm DNA fragmentation Oxidative stress, toxic metabolites, excessive heat Abnormal chromatin packaging, sperm DNA damage; increased levels of abnormal mitochondrial membrane potential Alteration in the epididymal autonomic innervation, and sperm Altered nuclear chromatin/DNA structure in spermatozoa is implicated as accumulation in the cauda epididymis for a long period of time, a possible cause of increased DNA fragmentation resulting in ageing Binding to sulfhydryl groups of sperm membrane is important Interaction with sperm cell membrane and inner mitochondrial for the spermicidal activity; alterations in hormonal membrane, causing inhibition of ATP synthesis; impairment in sperm homeostasis transport may cause alterations in sperm DNA integrity High levels of IL-6 in vitro decreased zinc finger protein 637 Overexpression of Zfp637 promotes cell differentiation and activates the (Zfp63) expression; alterations in hormonal levels expression of specific haploid cell markers (TH2B and protamine 1); aberrant protamine ratio increased DNA damage and decreased sperm quality Three cups or more of caffeine per day (caffeine with its Quenching effect on the production of hydroxyl radicals, as well as on catabolic products theobromine and xanthine) oxidative DNA breakage by hydroxyl radicals. Daily oral antioxidant treatment consisting of vitamins C and E Decrease in DNA fragmentation but unexpected increase on sperm (400 mg each), β-carotene (18 mg), zinc (500 μmol) and decondensation. Possible opening of interchain disulphide bridges in selenium (1 μmol) protamines, such as antioxidant vitamins, especially vitamin C, can open the cystin net, thus interfering with paternal gene activity during preimplantation development16].

Secondly, administration intervals and specified follow-up protocols are still missing, and all current follow-up schemes seem arbitrary.

Studies investigating sexual development in male children with simple obesity have demonstrated that their testicular volume, size, serum luteinizing hormone (LH), follicle stimulating hormone (FSH), To overcome this type of stress and its negative impact inhibin β and testosterone levels are reduced on fertility potential, antioxidants have arisen as an compared with the control groups. extrinsic asset to redox state regulation. Nowadays, many urologists prescribe these reducing agents, Inflammatory cytokines aiming at an amelioration of sperm quality. Inflammatory cytokines can also affect the Nevertheless, the risk of over-the-counter development and function of testes in obese supplementation remains unambiguous. There is individuals. IL-6, a multi-functional proalways the threat of ‘reductive’ stress with adverse inflammatory cytokine secreted by adipose cells effects on fertility status comparable to those of its and macrophages, has both inflammatory and oxidative counterpart. Reductive stress derives from anti-inflammatory functions. The effects of IL-6 the inability of the human body to maintain a correlate with its concentration in the tissue and physiologic balance, moving the redox equilibrium can damage the structure of the testicular tissue towards reduction. Of note, Silver et al. examined 87 – with direct inhibition of testosterone secretion in healthy volunteers taking various antioxidant Leydig cells. formulations. Males with moderate β-carotene intake had an increase in sperm DNA fragmentation The value of sperm DNA integrity compared with participants with low intake. Ménézo Sperm DNA integrity is vital for successful fertilization et al. treated 58 infertile men with daily vitamin C, and embryo development. Notably, sperm’s DNA vitamin E, β-carotene, zinc, and selenium at precise repair capacity diminishes with age. Of the four DNA doses. They noticed a paradoxical effect, namely an bases, guanine is the most susceptible to oxidation. increase in sperm decondensation (+ 22.8%, p < Significant correlations have been observed between 0.0009). the levels of 8-hydroxy-2’-deoxyguanosine (8-OHdG) expression by human spermatozoa and DNA Lack of universal tests fragmentation. The latter represents a major oxidative Various useful points must be taken into consideration compound, which causes fragmentation and has a in order to avoid potential deviation to uncontrollable mutagenic effect. It is, therefore, essential for 8-OHdG redox states and subsequent SDF. Firstly, it is evident lesions to be removed from DNA-damaged that there is a lack of universal tests to measure the spermatozoa. oxidative status of body and semen precisely. Therefore, it seems logical that every treatment 8-OHdG, like other ROS-induced lesions, is repaired approach should be explicitly individualised. primarily via the DNA base excision repair (BER) pathway with excision of the damaged base by 8-oxoguanine-DNA glycosylase (OGG). The DNA EAU Section for Urologists in Office (ESUO) strand breaks, resulting from such attacks, will January/February 2020

Reaction of the metabolites with sperm DNA to form adducts; increased DNA fragmentation Damage of spermatogonia causes irreversible impaired sperm production; Sertoli cells’ functional impairment, damage, or destruction

Higher temperatures lead to an increase of testicular metabolism that results in sperm damage; negative correlation between high scrotal temperature and sperm output, with a 40% decrease per 1o C increment of median daytime scrotal temperature Cell phones, microwave ovens, laptops and Wi-Fi (850 MHz-2.4 DNA strand break in sperm cells after exposure of the testes for 2 h/day GHz) for 60 days (the antenna position of 3G cell phone kept near rat testis)

Electromagnetic radiation – non-ionizing radiations5 Ionizing radiation X-rays, Ionizing radiation occurs in the form of an atomic or subatomic particle or an electromagnetic wave with very high kinetic γ-rays and α-particles6 energy, which has an ability to ionize the nucleus of a substance. Bleomycin, etoposide, and cis platinum (BEP) (alkylating agents Chemotherapy7 have more chance for prolonged azoospermia) Environmental endocrine toxicants used mainly in the Bisphenol A (BPA) and production of polycarbonate plastics and epoxy resins phthalates8

Diabetes mellitus (DM)9

Mechanism of action Decrease in the level of sperm mitochondrial activity and damage to the chromatin structure of both nuclear and mitochondrial sperm DNA

prevent transcription and replication and could also trigger apoptosis. However, in the presence of a comparable amount of apurinic endonuclease (APE1), the specific activity of OGG1 was increased ~5-fold17. Thus, OGG1 may provide a protective function until APE1 and other components required for subsequent steps of the base excision repair pathway are recruited. But all these processes are familiar for somatic cells. It is therefore essential that 8OHdG lesions are removed from DNA-damaged spermatozoa, but how? APE1 was not detected in human spermatozoa using immunocytochemistry or western blot analysis. Detailed examination of the base excision repair pathway in human spermatozoa has revealed only the presence of an enzyme critical to this pathway, 8-oxoguanine DNA glycosylase 1 (OGG1)17 Response to oxidative stress These results emphasise the limited capacity of mature spermatozoa to mount a DNA repair response to oxidative stress. They highlight the importance of such mechanisms in the oocyte in order to protect the embryo from paternally mediated genetic damage. Damaged spermatozoal DNA is normally repaired to completion following fertilization, at a time that precedes the S-phase of the first mitotic division in the one-cell embryo. Future studies should thoroughly evaluate SDF and further define its role in the field of male infertility. Furthermore, there is an eminent need for new adjunctive diagnostic techniques, given the fact that basic semen analysis might sometimes prove inadequate in the complete evaluation of the infertile male. References: 1. Sharma R, Harlev A, Agarwal A, Esteves SC. Cigarette Smoking and Semen Quality: A New Meta-analysis Examining the Effect of the 2010 World Health Organization Laboratory Methods for the Examination of

Human Semen. Eur Urol.2016 Oct;70(4):635-645. 2. Rubes J, Selevan SG, Sram RJ, Evenson DP, Perreault SD. GSTM1 genotype influences the susceptibility of men to sperm DNA damage associated with exposure to air pollution. Mutation Res. 2007;625:20–28. 3. Roeleveld N, Bretveld R. The impact of pesticides on male fertility. Curr Opin Obstet Gynecol. 2008 Jun;20(3):229-33. 4. Hjollund NH, Storgaard L, Ernst E, Bonde JP, Olsen J. Impact of diurnal scrotal temperature on semen quality. Reprod Toxicol 2002;16:215–21. 5. Kumar S, Nirala JP, Behari J, Paulraj R. Effect of electromagnetic irradiation produced by 3G mobile phone on male rat reproductive system in a simulated scenario. Indian J Exp Biol. 2014;52:890–897. 6. Saghaei H, Mozdarani H, Mahmoudzadeh A. Sperm DNA damage in mice irradiated with various doses of X-rays alone or in combination with actinomycin D or bleomycin sulfate: an in vivo study. Int J Radiat Res. 2019; 17(2):317-323. 7. Ioannis Vakalopoulos, Petros Dimou, Ioannis Anagnostou, Theodosia Zeginiadou. Impact of cancer and cancer treatment on male fertility. Hormones 2015, 14(4):579-589. 8. BISPHENOL A (BPA) CONFERS DIRECT GENOTOXICITY TO SPERM WITH INCREASED SPERM DNA FRAGMENTATION. D. H. Wu, Y.-K. Leung, M. A. Thomas, R. Maxwell, S.-M. Ho. Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH; Environmental Health, University of Cincinnati, Cincinnati, OH. Fertility and Sterility. September 2011, Volume 96, Issue 3, Supplement, Pages S5–S6. 9. Agbaje IM, Rogers DA, McVicar CM, McClure N, Atkinson AB, Mallidis C, Lewis SE. Insulin dependent diabetes mellitus: implications for male reproductive function. Hum Reprod. 2007 Jul;22(7):1871-7.

References 10-17 of this article are available from the EUT Editorial Office. Please send an e-mail to: EUT@uroweb.org with reference to the article “Sperm DNA fragmentation” by Dr. Khelaia, January/ February 2020. European Urology Today

Penile transplantation programmes in Europe Multidisciplinary transplantation team to include urological surgeon Prof. Ignacio Moncada Member of ESGURS Board Hospital Universitario La Zarzuela Dept. of Urology Madrid (ES) ignacio@moncada. name

Dr. Javier RomeroOtero Member of ESGURS Board Hospital Universitario 12 de Octubre Dept. of Urology Madrid (ES) jromerootero@ hotmail.com In the past, penile transplantation was a theme for jokes, more than a medical reality. But now the Vascularised Composite Allotransplantation (VCA) has become a viable alternative for some complex defects (face, hands…), penile transplantation is considered a possibility. Total phalloplasty can be a solution for transgender patients or patients suffering from congenital defects. However, frequent complications and less-than-perfect cosmetic results do not make it the best option for male patients who lost their penis due to trauma or penile cancer. Recent publications Two recent publications attracted the attention of the urological reconstructive surgeons’ community. One was a letter published in NEJM announcing a ‘total penis, scrotum, and lower abdominal wall transplantation’1. The second was a publication in Transplant International about ‘The Baltimore criteria for an ethical approach to penile transplantation: a clinical guideline’ in September 20192. Both articles came from Johns Hopkins institute, where a penile transplant programme was established recently3. Important considerations There are a few important considerations that need to be made regarding penile transplantation; from ethical considerations to social acceptance, from patient selection to technical aspects, including surgical issues and prevention, but also management of rejection. All these concepts were discussed in an article published in Nature Reviews4, highlighting the lack of guidelines to address the ethical concerns of this form of VCA. This paper establishes a hierarchy of steps which need to be taken for the success of a penile transplantation programme. The base of the pyramid should be formed by the ethical aspects. Normal part of human existence No question that male genital tissue loss can have devastating effects on self-image, on sexual and reproductive function as well as on the psychosocial wellbeing of the patient. This kind of transplantation is widely criticised, because it is supposed to be all about appearance and vanity, not life-saving5. But it is not about getting an ‘enhancement’ of the penis for whim, it is the only way to allow individuals to recover a normal part of human existence6. Transplantation reports The letter in NEJM describes the fifth report of a penile transplantation to date. There have been four previous reports: the first in Guangzhou, China in 20067, the next two in South Africa in 2014 and 20168, and the fourth at the Massachusetts General Hospital in 2017. This was done by a team led by Curtis Cetrulo9, a plastic surgeon whom we had the opportunity to meet in Italy on two different occasions. One was in Rome in 2018, during a meeting organised by Salvatore Sansalone with the support of ESGURS. The other, which was very recent, was in Florence (see Picture 1). D-day It was very encouraging to listen to Prof. Cetrulo and hear from him directly which difficulties he encountered and the excitement of accomplishing such a huge task. It was amazing to hear about the training and rehearsals sessions before ‘D-day’. There EAU Section of Genito-Urinary Reconstructive Surgeons (ESGURS)

European Urology Today

was an immense group of people involved; not only surgeons but a multidisciplinary team which included plastic surgeons, urologists, radiologists, pathologists, psychiatrists, transplant coordinators, nurses, social workers, dieticians and financial coordinators. Injured war veteran In the Johns Hopkins case, not only the penis was transplanted but also the scrotum and the lower abdominal wall. The donor was a young, agematched donor. The recipient was an injured war veteran who suffered a traumatic penile loss caused by a bomb blast. He also lost both legs above the knee, part of the lower abdominal wall, the scrotum and both testicles. The surgery started with urethral anastomosis followed by corporal anastomosis, going from the ventral side of the penis to the dorsal aspect. The donor dorsal arteries and veins were anastomosed to the recipient’s deep inferior epigastric arteries and veins. Both recipient dorsal nerves were approximated and anastomosed to those of the graft. The technique was very similar to that of the Massachusetts General Hospital case.

Prof. Ignacio Moncada (left) and Prof. Curtis Cetrulo meet in Rome

alemtuzumab and glucocorticoid induction therapy, and tacrolimus maintenance monotherapy10.

"It has been reported that the onset and severity of rejection can be significantly reduced through tacrolimus treatment."

Viable and feasible alternative One paper published in the Journal of Sexual Medicine about the attitudes toward penile transplantation among urologists and health professionals states that penile transplantation is accepted by most health professionals surveyed, albeit less than visceral organ transplantation11. Anticipated limitations include the risk of immunosuppression, lack of available donors, and the effect on healthcare utilisation.

Both had a very similar and successful evolution recovering near-normal erections and the ability to achieve orgasm and normal sensation in the glans. Both patients urinate while standing, with excellent stream, and low post-void residuals.

The current opinion is that penile transplantation is a viable and feasible alternative for male patients who have lost their penis due to trauma or cancer.

Urological surgeons should be part of the multidisciplinary teams involved in penile Tacrolimus treatment transplantation programmes. These programmes that It is well known that the penis is a complex organ should be implemented in Europe, assuming our role composed of many different tissue types, including as leaders in reconstructive genital surgery. skin, connective tissue, vascular sinuses, extensive innervation and urothelium. It is unclear how these References tissues reject, how rejection affects function, how to 1. Redett RJ 3rd, Etra JW, Brandacher G, Burnett AL, Tuffaha best monitor the penis for rejection and which SH, Sacks JM, Shores JT, Bivalacqua TJ, Bonawitz S, immunosuppression regimen is optimal. It has been Cooney CM, Coon D, Pustavoitau A, Rizkalla NA, Jackson reported that the onset and severity of rejection can AM, Javia V, Fidder SAJ, Davis-Sproul J, Brennan DC, be significantly reduced through tacrolimus Correspondence Sander IB, Shoham S, Sopko NA, Lee WPA, Cooney DS. treatment. The Johns Hopkins patient received

B Dorsal penile arteries, vein, and nerves

Proximal end of penile graft

Corpus spongiosum and urethra

Corpus cavernosum

Femoral artery and vein

External pudendal artery

External pudendal artery Femoral artery and vein

Saphenous vein

Day 8

Day 15

Day 340

Figure 1. Transplantation of a Penis, Scrotum, and Lower Abdominal Wall. Panel A shows a preoperative computed tomographic reconstruction of the extent of the injury in the transplant recipient. A small penile stump is visible, with loss of the lower abdominal wall, the entirety of penile shaft, and the scrotum and testes. Panel B shows the graft after explantation from the donor. The graft included the right and left external pudendal artery, a segment of the femoral artery, and the saphenous veins on both sides. Dorsal arteries can be seen on the deep, proximal portion of the penile graft. Panel C shows the graft before the procedure along with clinical images from postoperative day 8, day 15, and day 340. The graft has been incorporated without evidence of rejection. Biopsy sites (arrows) are visible on the skin of the abdomen and groin.

From N Engl J Med, RJ Redett III et al., Total Penis, Scrotum, and Lower Abdominal Wall Transplantation, 381:1876-1878 Copyright © 2019, Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

the Pressure-Specified Sensory Device (AxoGen) reveals that the glans has recovered to nearnormal sensibility for the one-point moving touch and has recovered to lower (better) thresh-

Total Penis, Scrotum, and Lower Abdominal Wall Transplantation. N Engl J Med. 2019 Nov 7;381(19):18761878. doi: 10.1056/NEJMc1907956. 2. Ngaage LM, Elegbede A, Sugarman J, Nam AJ, Cooney CM, Cooney DS, Rasko YM, Brandacher G, Redett RJ. The Baltimore Criteria for an ethical approach to penile transplantation: a clinical guideline. Transpl Int. 2019 Oct 24. doi: 10.1111/tri.13545. 3. Hawksworth DJ, Cooney DS, Burnett AL, Bivalacqua TJ, Redett RJ. Penile Allotransplantation: Pushing the Limits. Eur Urol Focus. 2019 Jul;5(4):533-535. doi: 10.1016/j. euf.2019.08.004. 4. Campbell JD, Burnett AL. Surgery in 2017: Moving towards successful penile transplantation programmes. Nat Rev Urol. 2018 Feb;15(2):75-76. doi: 10.1038/ nrurol.2017.204. 5. Patel HD. Human Penile Transplantation: An Unjustified Ethical Dilemma? Eur Urol. 2018 Sep;74(3):246-247. doi: 10.1016/j.eururo.2018.05.026. 6. Van der Merwe A. In response to an argument against penile transplantation. J Med Ethics. 2019 Feb 8. pii: medethics-2018-104795. doi: 10.1136/ medethics-2018-104795. 7. Zhang LC, Zhao YB, Hu WL. Ethical issues in penile transplantation. Asian J Androl 2010;12:795-800. 8. van der Merwe A, Graewe F, Zühlke A, et al. Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up. Lancet 2017;390:1038-47. 9. Cetrulo CL, Li K, Salinas HM, et al. Penis Transplantation: First US Experience. Ann Surg 2018;267:983-8. 10. Lough DM, Sopko NA, Matsui H, Miller D, Swanson EW, Bluebond-Langner R, Brandacher G, Burnett AL, Bivalacqua TJ, Redett RJ. The Urogenital Epithelium and Corporal Tissues Are the Primary Targets of Rejection in Penile Vascularized Composite Allotransplantation: A New Real-Time Tissue-Based Monitoring System. Plast Reconstr Surg. 2019 Mar;143(3):534e-544e. doi:10.1097/ PRS.0000000000005377 11. Najari B, Flannigan R, Hobgood J, Paduch D. Attitudes Toward Penile Transplantation Among Urologists and Health Professionals. Sex Med. 2018 Dec;6(4):316-323. doi: 10.1016/j.esxm.2018.06.003.

thresholds than that in the glans. The patient urinates while standing, without straining, frequency, or urgency, with the urine discharged in a strong stream.

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 May. For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website www.uroweb.org/ education/scholarship/

January/February 2020

Myths and realities: The Pisa and Trento experiences Infectious complications after endoscopic surgery of urinary stones Dr. Riccardo Bartoletti Dept. of Translational Research and New Technologies University of Pisa (IT) riccardo.bartoletti@ hotmail.com

Dr. Tommaso Cai Urology Unit S. Chiara Regional Hospital Trento (IT)

tommaso.cai@ apss.tn.it

Dr. Jacopo Durante Dept. of Translational Research and New Technologies University of Pisa (IT)

jacopodurante@ live.it Over the last 20 years, the minimally invasive approach has been the gold standard in the management of patients affected by urinary stones. Ureteroscopy (URS), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotripsy (PCNL) have been successfully introduced in clinical practice, although severe complications - such as the risk of bleeding and uncontrolled infections with an increased rate of urosepsis - have been described1,3. New recent and rapid technological progress in surgical instruments and devices allowed a higher patient compliance with earlier hospital discharge. Management is challenging However, the rate of infectious complications after endourological procedures is still considerable and its management still challenging. Urinary tract infections (UTI) are now the most common complications after urinary stone management with several severe clinical scenarios, from postoperative fever (4.4%) to urosepsis (0.7%), despite adequate perioperative antimicrobial prophylaxis4. The high incidence of infectious complications could be due to both an increased risk of infected stones and a risk of extended spectrum beta-lactamase (ESBL) and/or multi-drug resistant bacterial strains. The most likely pathogenetic mechanism for infectious complications is that stones containing bacteria enter the urine with systemic transudation, resulting in symptomatic UTI or sepsis5. To reduce the risk of developing infections, the American Urological Association (AUA) guidelines recommend to perform lithotripsy only in patients with sterile urine. Thus, the need for urine culture and adequate prolonged antibiotic treatment prior of any surgical approach was introduced6. Moreover, some recommendations, such as low-flow irrigation while checking the continuous outflow should not exceed 2 hours’ operation time and patients should be carefully observed in the first 6 hours, have also been included as appropriate recommendations for the treatment of urinary stones6. EAU guidelines Conversely, the European Association of Urology (EAU) guidelines on preoperative antibiotic prophylaxis recommend administering antibiotics only in case of a high risk of infections related to stone size or stone location, bleeding and surgeon’s experience7. Hsieh et al. compared the use of antibiotic prophylaxis versus no treatment in 212 candidates for ureterorenoscopic lithotripsy. They demonstrated that antibiotic prophylaxis significantly reduces the risk of postoperative pyuria, bacteriuria and febrile urinary tract infection8. However, some authors recently stated that indications regarding appropriate antibiotic treatment could be obtained from urine collected directly from the upper urinary tract before the endoscopic treatment or from the irrigation fluid during the lithotripsy. Moreover, other authors stressed the need to obtain valuable information from renal stone culture after PCNL to January/February 2020

prevent sepsis episodes by using appropriate antibiotic therapy9,10,11. Cultured bacteria Boeri et al. compared cultured bacteria taken from the urine of 71 consecutive candidates for endourological procedures at different times during surgery. Bladder urine and selective renal pelvis urine (behind or around the stone) were taken before lithotripsy, irrigation fluid samples were taken during stone fragmentation and stone fragments were collected and cultured after lithotripsy. They found that stone culture is the best predictor for infection but concordance between stone culture and irrigation fluid samples were found in 93.3% of cases12. Stone culture represents a good method to confirm the presence of antibiotic-resistant bacteria. Other authors confirmed this data by showing a discordance of bacterial strains between preoperative urine culture in urine taken from the bladder and stone culture in at least 52% of 224 candidates for urethroscopy and lithotripsy10. Similarly, Korets et al. found that renal pelvis urine and stone culture should be considered useful to identify causative pathogens and the appropriate antimicrobial treatment to prevent significant infections after PCNL13.

Multicentre experience Taking these considerations into account, we planned a prospectively longitudinal cohort study to define different aspects of urinary tract infections. This was in line with the multi-institutional minimally invasive approach to urinary stones and characterises the type of antibiotic treatment used in the course of the disease and when administering antibiotic prophylaxis. From January 2017 to December 2018, 63 consecutive patients were enrolled. 45 patients underwent RIRS, 4 ureteroscopy plus lithotripsy and 14 PCNL. Urine samples were taken from all patients before the procedure and a perioperative prophylaxis was administered according to the EAU guidelines. If a urine culture was positive for the presence of bacteria, targeted antibiotic therapy was administered, and urine samples checked again until the culture was negative. Renal pelvis urine was collected before the endourological procedure by using a renal calix puncture in the case of PCNL and a ureteral open-end catheter in the case of URSL and RIRS. Irrigation fluid samples were collected before, during and after the procedure. Urinary stone fragments were also collected for culture.

"…the rate of infectious complications after endourological procedures is still considerable and its management still challenging…"

Fig. A: Cisanello University Hospital Pisa; Fig. B: PCNL ultrasound stone fragmentation; Fig. C: Galilei's bending tower

variables, such as the irrigation fluid volume and the increased risk of high intrarenal pressure, may be considered a risk factor for developing symptomatic infection. However, in our experience no significant correlation between irrigation fluid volume and symptomatic UTI was found. Moreover, irrigation fluid volume may impact with significant intrarenal content dilution and reduce the probability of bacterial strain identification during the procedure. Regarding the antibiotic type used for perioperative prophylaxis, no significant differences were found between patients who received fluoroquinolones and those who received beta-lactams or other compounds.

Interesting aspects In conclusion, our multicentre experience underlines Symptomatic infectious complications were recorded some interesting aspects regarding opportunities to and correlated with microbiological and clinical data. prevent infective complications in the course of the endourological approach of urinary stones: Bladder urine infection was found in 13 cases. These were adequately treated before the surgical 1) patients should pre-operatively be diagnosed for the presence of bacteria in bladder urine and procedure. Renal pelvis urine infection and bacteria in the irrigation fluid were found in 52.3% and 30% of adequately treated with antibiotics; cases respectively. Positive stone culture was found in 2) perioperative antibiotic prophylaxis should be adopted with adequate timing and dosage and 92% of cases, although postoperative symptomatic infection with fever was only found in 14 out of 63 repeated in the course of prolonged procedures according to EAU Guidelines; patients. 3) renal pelvis urine samples as well as stone Main findings and clinical applications fragments should be taken for microbiological investigations, despite perioperative antibiotic Our findings confirmed that additional information prophylaxis. The culture results will be available regarding identification of potentially causative within the following days. They may give relevant pathogens may be easily obtained from the stone information regarding the possible options for the fragments and the renal pelvis urine culture, but less likely from the intraoperative irrigation fluid. best antibiotic treatment choice in case of sepsis; 4) Postoperative optimal drainage of the kidney through ureteral stents or nephrostomy tubes The evolution of symptomatic infectious should always be maintained to avoid obstruction complications during endourological treatment of or other risk factors involved in the potential urinary stones may have multiple reasons, such as development of infections. the presence of infected stones (the stone may be a hidden source of bacteria; the fragmentation process may increase the risk of infectious Because of the recent antibiotics crisis and the high complication due to micro-fragments that hurt the rate of infectious complications after urological procedures, all urologists should improve their calix/pelvis mucosa) and inadequate perioperative adherence to antimicrobial stewardship and to the antibiotic prophylaxis due to the presence of multi-drug resistant bacteria. EAU guidelines. The spreading of bacteria in the irrigation fluid has been suggested by different authors in the past, but in our experience no correlation was found between a laboratory-proven symptomatic UTI and the presence of bacteria in the irrigation fluid. Some

References 1. Ganpule AP, Vijayakumar M, Malpani A, Desai MR : Percutaneous nephrolithotomy (PCNL) a critical review. Int J Surg. 2016 ; 36:660-664. 2. Zheng C Xiong B, Wang H, Luo J, Zhang C, Wei W, Wang

Y. : Retrograde intrarenal surgery versus percutaneous nephrolithotomy for treatment of renal stones >2 cm: a meta-analysis. Urol Int. 2014;93(4):417-24. 3. Ghosh A, Oliver R, Way C, White L, Somani BK : Results of day-case ureterorenoscopy (DC-URS) for stone disease: prospective outcomes over 4.5 years. World J Urol. 2017 Nov;35(11):1757-1764. 4. Berardinelli F., De Francesco P., Marchioni M et al.: Infective complications after retrograde intrarenal surgery: a new standardized classification system. Int. Urol. Nephrol. 2016;48:1757-62 5. Wollin DA, Joyce AD, Gupta M, Wong MYC, Laguna P, Gravas S, Gutierrez J, Cormio L, Wang K, Preminger GM. Antibiotic use and the prevention and management of infectious complications in stone disease. World J Urol. 2017;35(9):1369-1379. 6. Wolf JS, Bennett CJ, Dmochowski RR, et al. : Best practice policy statement on urologic surgery antimicrobial prophylaxis. https://http://www.auanet.org/common/ pdf/education/clinical-guidance/AntimicrobialProphylaxis.pdf2014. 7. EAU European Association of Urology guidelines on urological infections, update 2018. http://uroweb.org/ guideline/urological-infections/. 8. Hsieh CH, Yang SSD, Lin CD, Chang SJ: Are prophylactic antibiotics necessary in patients with preoperative sterile urine undergoing ureterorenoscopic lithotripsy? BJU Int.2014; 113:275-280. 9. Walton-Diaz A., Vinay JI, Barahona J et al. : Concordance of renal stone culture: PMUC,RPUC,RSC and post-PCNL sepsis- a non-randomized prospective observation cohort study. Int Urol Nephrol 2017 Jan;49(1):31-35. 10. Yoshida S., Takazawa R., Waseda Y., Tsujii T.: The significance of intraoperative renal pelvic urine and stone culture for patients at high risk of post-ureteroscopy systemic inflammatory response syndrome. EAU 2019 Congress. Poster 408 11. Bolomytis S, Harding R, Timoney A, Keeley F et al. : PCNL SIRS risk increasing in patients with positive stone culture and suboptimal renal drainage. EAU 2018 Congress. Poster 325 12. Boeri L, De Lorenzis E, Gallioli A, Fontana M, et al. : Clinical relevance of the bacteria spread into the irrigation fluid during endourological procedures: a novel tool to guide appropriate postoperative antibiotic management? EAU 2018 Congress. Poster 337. 13. Korets R, Graversen JA, Kates M, Mues AC, Gupta M: Post-percutaneous nephrolithotomy systemic inflammatory response: a prospective analysis of preoperative urine, renal pelvic urine and stone culture. J.Urol. 2011; 186: 1899-1903

European Urology Today

Report

A complete spectrum of clinical laser applications: Masterclass delivers insights on contemporary laser systems Set in the historic Sant Pau Recinte Modernista in Barcelona, the ESU-ESUT Masterclass on Lasers in Urology provided a complete spectrum of clinical laser applications in the treatment of benign prostatic obstruction, bladder and upper tract urothelial carcinoma, renal stones, and urinary tract strictures.

Despite gentle attempts, Dr. Scoffone decided to abort the surgery. He positioned an 18Fr Foley catheter to slowly dilate the urethra instead, with the plan to have the patient come back for the surgery in two weeks. The audience and the moderators appreciated his decision, and a very interesting discussion on ethics took place afterwards. I would like to stress that the patient’s advocate, as well as, the moderators strictly followed the rules of the EAU live surgery ethics, and that both parties agreed with Dr. Scoffone’s decision to abort the surgery.”

From 21 to 22 November 2019, the frontline masterclass offered insights on the applications of contemporary laser systems such as the Holmium laser, 532-nm laser, Thulium laser, Diode laser, Neodymium and more. The masterclass was organised through the collaborative effort of the European School of Urology (ESU) and the EAU Section of Uro-Technology (ESUT). In this article, participant Dr. Kurdo Barwari (NL) and masterclass faculty members Dr. Alberto Breda (ES) and Prof. Andreas Johannes Gross (DE) look back on their experiences for the masterclass and share their aspirations for future editions. “Laser application is versatile and possesses great potential, particularly in urology. I think it’s of utmost importance to master laser techniques. That’s why I applied to this masterclass to learn as much as I could,” shared Dr. Barwari. Impressed by a presentation on Holmium laser enucleation of the prostate (HoLEP) at an event, Dr. Barwari was pleased to know that the ESU-ESUT masterclass offered video sessions of several techniques of laser-prostate enucleation, and numerous discussions with experts. Impressions For six years now, Dr. Breda has been the local organiser for the masterclass. “We have had a total of 17 faculty members who oversaw 11 live- and 6 semi-live surgeries, six presentations and one

Prof. Palou enumerates the goals of the masterclass

roundtable discussion. The overall impression was very positive. All the live surgeries went well with no intra- and postoperative complications recorded so far, and the presentations generated interesting discussions.” Prof. Gross added, “I agree. This masterclass was well organised by our colleagues in Barcelona, and we were certainly spoiled to have used the incredible facilities of our host, the Fundació Puigvert hospital.”

Future editions “The interest on this masterclass is very high. I foresee The eager and enthusiastic masterclass delegates some game changers in the field of lasers in the near future. I hope that we will be able to present early data on these new lasers soon,” disclosed Prof. Gross. and progression of laser science in our field. My hope is that more urologists will be involved with this “My main aspiration for this masterclass is that it will incredible technology. To generate more interest for continue to evolve and contribute to the dissemination the masterclass, I believe that more semi-live surgeries are needed. I noticed that participants were more engaged and asked more questions to the presenters,” stated Dr. Breda. Thank you Dr. Breda expressed his appreciation for the collaborative efforts provided. “I would like to personally thank the EAU, the ESU and the industry partners that have made this masterclass possible. Furthermore, I would like to thank Prof. Joan Palou and Prof. Evangelos Liatsikos for being a fundamental part of the organisation of the masterclass. And finally, to the Fundació Puigvert staff – Dr. Oriol Angerri Feu, Dr. Javier Ponce De León, the anaesthesia and nursing teams – for their tremendous effort and dedication.”

Dr. Barwari said, “The faculty members had excellent surgical and presentation skills. They were down-toearth and open for interactive discussions. There were plenty of video sessions with educational comments, and the astonishing venue provided a motivating environment for all participants.” Ethics and live surgery Dr. Breda shared an anecdote of what was one of his most memorable moments at the masterclass. “Dr. Cesare Scoffone was about to perform HoLEP on an intermediate-sized prostate. At the time of urethrocystoscopy, it was impossible to enter the very narrow urethra and consequently, the bladder.

One of the live surgeries streaming

For more information on the upcoming edition of the masterclass, please visit https://esu-masterclasses. uroweb.org/masterclass/esu-esut-masterclass-onlasers-in-urology/.

www.esubpo20.org

www.esuurolithiasis20.org

ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction

ESU-ESUT Masterclass on Urolithiasis 19-20 June 2020, Patras, Greece An application has been made to the EACCME® for CME accreditation of this event

4-5 June 2020, Heilbronn, Germany An application has been made to the EACCME® for CME accreditation of this event

European Urology Today

January/February 2020

Report

Masterclass explores new FT techniques and technologies A knowledge exchange of focal therapy developments and hands-on training By Erika de Groot

Dr. Belba shared, “I decided to apply for the masterclass to improve my knowledge on each different FT option. I was interested in improving my skills in performing the fusion biopsy of the prostate. The multidisciplinary panel of international experts and the hands-on training sessions were my other reasons for joining the masterclass. I must say, the masterclass completely satisfied my expectations.”

New focal therapy (FT) techniques, rationale for FT, treatment modalities such as hemiablation to ultrafocal, tools, and development of new energies were the core of the ESU-ESUT-ESUI Masterclass on Focal Therapy for Localised Prostate Cancer’s programme. Organised by the European School of Urology (ESU), the EAU Section of Uro-Technology (ESUT), and the EAU Section of Urological Imaging (ESUI), the masterclass welcomed 37 delegates from around the globe from 28 to 29 November 2019 in Paris. The masterclass was led by its esteemed Course Director Dr. Eric Barret. In this article, internationally-known faculty members Prof. Caroline Moore and ESUI Chair Prof. Georg Salomon, together with promising delegates Dr. Arben Belba and Dr. Marc Hofmann, share their masterclass experience and impressions. “It was great to see so many people engaged in the masterclass, sharing their own experiences from across the world, and discussing the challenges that we face in clinical practice. The masterclass was well run and the delegates were very engaged during the lectures and discussions,” said Prof. Moore. Prof. Moore shared her expert insights on the use of high intensity focussed ultrasound (HIFU) and photodynamic therapy as treatment modalities for FT. In her lectures, she also spoke about treatment planning: How to assess men for FT for prostate cancer (PCa); how to choose the right FT for each man; and what treatment plan to create based on MRI, histology and the patient's priorities.

Masterclass delegates

“I commend the excellent organisation of the masterclass,” said Prof. Salomon, who shared his expertise and developments on biomarkers and TULSA (Transurethral Ultrasound Ablation). “The masterclass was packed with key opinion leaders and delegates who were eager to explore the potential of FT. The FT methods were presented in a promising yet critical way as FT is still in its infancy.” He added, “I was pleased that industry partners were present during the hands-on training. Events such as this masterclass are the best way to promote promising techniques and emerging technologies.” Masterclass highlights “My top masterclass highlights were the high-quality lectures and productive discussions between experts and delegates. Lectures presented by radiologists, pathologists and radiotherapists were very stimulating, too. And the clinical cases help better understand the rationale for focal therapy, as well as, help establish the best treatment per patient with fewer adverse effects involved compared to radical therapies,” stated Dr. Belba.

He added, “The hands-on training was also a must-do activity which was divided into two sessions. The first session focused on diagnosis such as ultrasound and fusion biopsy, transrectal or transperineal; the second gave us opportunities to familiarise ourselves with the tools and the software interface for each focal therapy.” To Dr. Hofmann, his masterclass highlights included highly-informative presentations such as those by Prof. Moore, the hands-on training, meeting other delegates from all over the world and discussing with them how they apply FT in local practice.

Dr. Hofmann aimed to know about the latest FT developments straight from the experts. “I signed up for this masterclass because I wanted to know how they apply the FT techniques. I also wanted to learn about the current FT options and technologies as research and application of FT is progressing.” Plans and hope for future editions “I was truly pleased and appreciative of how the discussions turned out. The masterclass was highly interactive and productive; the delegates posed questions and brainstormed together with the faculty. A successful masterclass couldn’t be more ideal than this,” said Prof. Salomon. “Perhaps in future editions, the hands-on training will be scheduled on both days.”

Prof. Moore aspires to see the attendance continue to increase, and to have all FT groups across the world represented on the faculty. In future masterclass Reasons for joining editions, she thinks case debates among According to Dr. Belba, radical therapy and active multidisciplinary faculty members on primary, redo surveillance in low-volume disease are mainly and salvage treatments would further enrich the considered for PCa management at present. In the last masterclass experience. An interactive workshop on decade, literature has increased with regard to the HIFU treatment planning would be a great addition to role of focal therapy as a valid option for localised PCa this EAU masterclass.” management due to multiparametric MRI. The literature on the combination with fusion biopsy The next edition of the ESU-ESUT-ESUI leading to accurate diagnosis and tumour localisation Masterclass on Focal therapy will take place in has also expanded. 2021. Stay tuned!

www.esusalzburg20.org

www.esuerectile20.org

ESU - Weill Cornell Masterclass in General urology

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

29 June - 3 July 2020, Salzburg, Austria

1-2 October 2020, Leuven, Belgium An application has been made to the EACCME® for CME accreditation of this event

January/February 2020

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

European Urology Today

ESU Update

EAU-CAU: Educational conduit for Europe & Latin America Upcoming collaborations in Amsterdam and Ecuador By Erika De Groot To facilitate the educational pipeline between Europe and Latin America, the Confederación Americana de Urología (CAU) and the European Association of Urology (EAU) have organised joint sessions and specialised programmes during their annual congresses. The latest of which will be a joint session that take place from 8.45 to 12.15 on 20 March, 2020 during the 35th Annual EAU Congress (EAU20) in Amsterdam. Session attendees can expect relevant updates on MRI/Ultrasound fusion biopsies; lymphadenectomy for MIBC (muscle invasive bladder cancer); alternatives to BCG (Bacillus Calmette-Guerin), and more. The session will also include case discussions on always transrectal or perineal with regard to prostate biopsy, and better HIFU (high intensity focused ultrasound) or TOOKAD® for focal therapy in prostate-cancer treatment.

The programme is a joint initiative of the EAU and the CAU held annually during the CAU’s annual congresses. CAUREP is modelled after European Urology Residents Education Programme (EUREP), the popular flagship programme of the ESU for final-year residents. “Through the years, CAUREP has become the most attended session of our congress. Language was never a barrier as sessions are presented in English with simultaneous Spanish translations,” stated Dr. Rodriguez. “Since its inception, we have reviewed all urology topics relevant to the region,” said Prof. Palou. “The CAUREP faculty changes every year to guarantee wide-ranged coverage and expertise, and timely and suitable topics.” This year, the CAUREP faculty will comprise of Prof. Albers, Dr. Oriol Angerri (ES), Prof. Andreas Gross (DE), Prof. Palou, and Prof. Hein Van Poppel (BE). “Through the programme, CAU members became more acquainted with what the EAU is about and its aims. In the past, the EAU was known only by a few CAU members who either participated in fellowship trainings in Europe, or attended EAU congresses. Now through the CAUREP programme, more and more CAU members learn about the EAU and the urological advances in Europe. Having said this, these members become EAU members who use the EAU Guidelines as part of their daily urology practice.”

The EAU-CAU joint session is one of the most popular "Urology Beyond Europe" sessions at the EAU congress

“The session has been meticulously prepared, resulting to a faculty of key opinion leaders and an excellent programme. The synergy of the expertise of urologists from Europe and Latin America anticipates fruitful endeavours,” stated Prof. Joan Palou (ES), Chair of the European School of Urology (ESU). According to Secretary General of the CAU, Dr. Alejandro Rodriguez (US), the participants will have the opportunity to partake in debates on established and contemporary approaches. He said, “Experts in the field will give state-of-the-art lectures in the management of erectile dysfunction and urinary stress incontinence after prostate cancer therapy, and many other essentials.” “Session participants will receive detailed insights in current uro-oncological developments and controversies,” added Prof. Peter Albers (DE), Chair of the EAU’s Scientific Congress Office. “The quintessential collaboration between the CAU and the EAU will bring people together; stimulate more knowledge exchange; and help optimise urological care in the region.” Residents’ programme in Ecuador Another notable EAU-CAU link is this year’s 7th edition of the Confederación Americana de Urología Residents Education Programme (CAUREP), a programme which offers the Hispanic urological community learning opportunities and updates pertinent to the region.

Every year, two residents from the CAU participate in the EUREP programme. Prof. Palou said, “Through lectures, clinical cases and hands-on trainings at EUREP, the interactions among residents and the faculty contribute to the enrichment of the residents’ knowledge on diverse clinical practices. At the end of the programme, the residents can decide how their newfound knowledge and skills can benefit their daily practice in their home country.” According to Prof. Palou, there are plans to incorporate an MRI course into the CAUREP programme. The course has been has been established together with the ESU and the EAU Section of Urological Imaging (ESUI). The 7th CAUREP will take place on 21 October 2020 at the Hotel Hilton Colón in Guayaquil, Ecuador. Topics will include prostate, urothelial and testicular cancers; stones; and benign prostatic hyperplasia. The programme will consist of state-of-the-art lectures and point-counterpoint deliberations that are overseen by leading experts. “CAUREP’s scientific programme is evidence-based and follows the guidelines and standards of contemporary care in urology. These are the reasons why its scientific programme has a huge impact on those who attend. What’s new in the upcoming CAUREP? This year, we’ll offer the best of the EAU,” said Dr. Rodriguez. For more information on the joint EAU-CAU session and EAU20, feel free to explore www.eau20.org. To know more about CAUREP and CAU 2020, please visit www.cau2020guayaquil.com/programa-cientifico/.

ESU Event Calendar Date

Event name

Location

FEBRUARY 2020 10-12 20 20-21

Hands-on training skills programme on Laparoscopy and Endourology ESU course on Endourology at its best! during the national congress of the Moroccan Urological Association ESU-ESOU Masterclass on Non muscle invasive bladder cancer

Caceres (ES) Rabat (MA) Prague (CZ)

MARCH 2020 20-24

35th Annual EAU Congress

Amsterdam (NL)

APRIL 2020 4 9 tbd 16-18 18 23-25

ESU course on Diagnostic and therapeutic management of male infertility during the national congress of the Cyprus Urological Association ESU course on Treatment of oligometastatic prostate cancer during the national congress of the Urological section of the Serbian Medical Association ESTs2 during SET-UP Programme URO Berlin Skills Teaching and Training (UROBESTT) ESU course on Prostate cancer: Treatment for biochemical recurrence (BCR) after local therapy and for oligometastatic disease during the CEM meeting E-BLUS during SEP-UP Programme, UROFAIR

Limassol (CY)

Vrnjacka Banja (RS) Bangkok (TH) Berlin (DE)

Vienna (AT) Singapore (SG)

MAY 2020 7-9 23 26-28 29

ESU EST workshop - step 2, Prague (CZ) ESU course on Percutaneous nephrolithotripsy (PCNL) during the 7th Baltic Meeting in conjunction with the EAU Minsk (BY) ART in Flexible – step 1 Berlin (DE) ESU course on Chronic pelvic pain and surgical treatment of benign prostatic hyperplasia during the national congress of the 8th Slovenian Urology Association Ljubljana (SI)

JUNE 2020 4-5 10 17 19 19-20 26-28 29-3/7

ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction ESU course during the Nevsky urological forum of the Russian Society of Urology ESU course on Tips and tricks in challenging surgeries during the national congress of the Spanish Urological Association ESU course on Trauma in urology and reconstructive urology during the national congress of the Ukrainian Urological Association ESU-ESUT Masterclass on Urolithiasis, Patras (GR) EAU Update on Bladder cancer (BCa20) and Renal cell cancer (RCC20) ESU - Weill Cornell Masterclass in General urology

Heilbronn (DE) St. Petersburg (RU)

Burgos (ES)

Kyiv (UA)

Frankfurt (DE) Salzburg (AT)

SEPTEMBER 2020 4-9 11-12 13 25

18th European Urology Residents Education Programme (EUREP) EAU Update on Prostate cancer (PCa20) ESU course during the national congress of the Russian Society of Urology ESU course on New technologies in urology during the national congress of the German Association of Urology

Prague (CZ) Madrid (ES) Kazan (RU) Leipzig (DE)

OCTOBER 2020 1-2 2 22 29-30

ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie's disease ESU course during the national congress of the Hellenic Urological Association 7th Confederación Americana de Urologia Residents Education Programme (CAUREP) ESU-ESFFU Masterclass on Functional urology at the European Lower Urinary Tract Symptoms meeting (ELUTS20)

Leuven (BE) Thessaloniki (GR) Guayaquil (EC) Lisbon (PT)

NOVEMBER 2020 5-7 12-15 19-20 26-27

ESU-ERUS courses during the 17th Meeting of the EAU Robotic Urology Section (ERUS) ESU courses during the 12th European Multidisciplinary Meeting in Urological Cancers (EMUC) ESU-ESUT Masterclass on Lasers in urology ESU-ESUI Masterclass on Prostate biopsy

Dusseldorf (DE) Athens (GR) Barcelona (ES) Marseille (FR)

DECEMBER 2020 2-4

ART in Flexible - Step 2

Berlin (DE)

Prof. Rafael Sanchez-Salas presents at the packed EAU-CAU joint session at EAU19

European Urology Today

January/February 2020

Report

Iraqi community to bring “scientificity to the forefront” An ESU course roundup of impressions and PCa topics By Erika De Groot The course “A unique possibility for urological education" organised by the European School of Urology (ESU) was incorporated in the programme of the 8th Scientific Congress of the Iraqi Urology Association held in Baghdad from 20 to 22 November 2019. Presenter Dr. Lütfi Tunç (TR) shared, “In a country that has gone through a history of chaos and challenges, I came across a community that wants to bring scientificity to the forefront. They have shown tremendous respect for science and for the acquisition of knowledge. They have expressed gratitude to those who came to teach them.” In his presentation “Robot-assisted laparoscopic radical prostatectomy with bladder neck sparing technique”, Dr. Tunç emphasised the significance of anatomical details. He said, “We need to use our experience in endoscopic surgery in anatomy education.”

watch laparoscopy videos as much as possible,” stated Dr. Tunç. He also underlined that the basis of performing a procedure well is to learn it correctly in the first place. Dr. Tunç advised: “If your interests lie in laparoscopy and refining your skills, learn from the right surgeons and at centres with sufficient experience. Then amplify that newfound knowledge and skills with ESU activities such as courses, masterclasses, and programmes to name a few.” According to fellow presenter, Prof. Theo De Reijke (NL), attendance at the course surpassed expectations despite ongoing demonstrations that took place en route to the venue. “The delegates were very eager to learn. Dr. Tunç and I were approached to discuss various topics; the level of interaction was high,” shared Prof. De Reijke. Dr. Tunç agreed, “We were showered with questions evident in their enthusiasm and willingness to learn.” Prof. Al-Hamdani (left) with Prof. De Reijke (right)

In Prof. De Reijke’s presentation “Diagnosis nowadays in prostate cancer”, he stated that diagnosis of Dr. Tunç mentioned that observation is highly prostate cancer should be individualised while taking important in adopting the colour differences of tissues into account risk factors. He said to make use of risk in laparoscopy learning. “I encourage colleagues to calculators, explained the benefit of pre-biopsy

prostate magnetic resonance imaging (MRI) and how to obtain biopsies via the transperineal route. Prof. De Reijke mentioned that in case of upper tract urothelial cancer, kidney-sparing surgery still lacks the accuracy in determining patients with real low-risk tumours. “Enhanced imaging using optical coherence tomography (OCT), narrow-band imaging (NBI), and confocal laser endomicroscopy (CLE) could be helpful imaging modalities excluding high-risk tumours,” stated Prof. De Reijke.

Delegates demonstrate enthusiasm and willingness to learn throughout the course

According to Prof. De Reijke, multidisciplinary team discussions are essential

As for an individual patient, other factors and comorbidity could determine which is the best approach and therefore, multidisciplinary team discussions are essential. The President of the association and fellow presenter at the congress, Prof. Nibbras Al-Hamdani (IQ). was impressed with the turnout at the course, the quality of the lectures and coverage of the scientific materials. “We might have future ESU courses set up for a full day, with more lecturers and an assessment for the delegates at the end of the course accordingly,” said Prof. Al-Hamdani.

In his other lecture entitled “EAU Guidelines recommendations on prostate cancer”, Prof. De Reijke said that these guidelines are helpful in deciding what Interested in attending an ESU course in your city? Visit www.uroweb.org/events/calendar/ and tick the investigations or treatments should be advised. However, these guidelines can only guide the clinician. boxes “2020” and “ESU” to view the full list.

EAU Edu Platform

Education Online

The online learning platform for Lower Urinary Tract Symptoms

Improve your skills: e-learning at your own convenience

EAU Education Online introduces 2 new courses:

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

2 CME c

redits

Dr. Panagiotis Kallidonis, Prof. Gernot Bonkat

uroluts.uroweb.org

Dr. Tom Marcelissen, Dr. Arjun Nambiar

uroweb.org/education January/February 2020

European Urology Today

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1st E-BLUS course in Mexico exceeds expectations Course impressions during the SMU congress Dr. Alexander Heinze Rodríguez American British Cowdray Medical Center Mexico Mexico city (MX)/ Hamburg (DE) alexander@ heinzemg.com For the first time in Mexico, the official European training in basic laparoscopic urological skills (E-BLUS) took place in the city of Merida in Yucatan, Mexico during the LXX National Congress of the Sociedad Mexicana de Urología (SMU). The E-BLUS course was a success. Organised through the collaboration of the European School of Urology (ESU) and the SMU, the course was offered to both residents and urologists who would like to learn, develop or improve their laparoscopic skills. Thanks to the support of Committee President Dr. Alfredo Medina Ocampo and Education Secretary Dr.

Ricardo Castillejos, three workshops sessions were held wherein participants learned theoretical knowledge and practical tasks of basic laparoscopy. In addition, laparoscopic experts including Dr. Jesus Javier Torres, Dr. Arnaldo Jose De Carvalho, Dr. Carlos Alberto Brugiati, and Dr. Alexander Heinze formed a group of local and international tutors led by Prof. Ali S. Gözen of the EAU Section of Uro-Technology (ESUT). Under the guidance of the trainers, the participants carried out their tasks within the define time limits and aimed to reduce errors to a minimum. The participants were very excited to receive the tips and tricks, and were able to monitor their progress throughout the course. Prior to the practical hands-on-training part, the course had a theoretical part consisting of an e-learning module which participants must complete via an EAU webpage. Before the course, Prof. Gözen gave a presentation on the EAU online learning courses and training programmes. Videos about the E-BLUS steps with tips for the trainees were shown. Detailed information of each task was given.

A high number of participants attended the first E-BLUS Course in Mexico

At the end of the training sessions, participants could request to take an exam to obtain the valued official certificate issued by the EAU. The trainees who have successfully completed both the theoretical part with the online course, and the practical part with the completion of the four exercises in the stipulated time and without errors, can receive the certificate. It is important to mention that all the exams were recorded on video.

An international faculty guided participants and share tips and tricks with them

More than 120 urologists enrolled in the course and 40 examinations applied

These videos and test materials were sent to a committee that reviews the assessment once more before granting the certificate.

and offer standardization in the surgical training for urologists. The next goal will be that these universal programmes are adopted by countries in Central and South America under the same rigorous control that guarantees favourable results in the training, but above all, in patient safety.

"The next goal will be that these universal programmes are adopted by countries in Central and South America under the same rigorous control that guarantees favourable results in the training, but above all, in patient safety." Huge interest in the first E-BLUS course resulted to exceeded expectations as we received more than 120 registrations for the training sessions. Around 40 participants took the certification exam. The exam was extended into the evening due to the high number of participants and an extraordinary evaluation session was required the following day. Undoubtedly, these types of programmes extend beyond Europe; these strengthen ties among societies

We also shared the benefits of being an international member of the EAU to the Mexican urologists: Opportunities for fellowships, scholarships, and short-visit programmes; free download of the latest EAU Guidelines; access to the scientific journals such as European Urology, EU Focus, and EU Oncology; special rates to EAU events; advanced access to 60,000 items of scientific content via UROsource, and more. Through education and training, potential ways of collaboration were explored during the E-BLUS course to bring the SMU and the EAU closer. We expect more and stronger collaborations in the training programmes in the near future e.g. through offering intermediate and advanced laparoscopy courses, as well as, academic exchange programmes.

www.baltic20.org

BALTIC20

EAU Update on Prostate Cancer

7th Baltic Meeting in conjunction with the EAU

12 -13 September 2020 Madrid, Spain

22-23 May 2020, Minsk, Belarus

EAU onco-urology series

www.pca20.org An application has been made to the EACCME® for CME accreditation of this event

European Urology Today

January/February 2020

ESU Boot Camp in Lisbon boosts residents’ skills Essential trainings in open surgery, endoscopy and laparoscopy Dr. Tiago Oliveira Dept. of Urology Armed Forces Hospital Lisbon (PT)

tiagoribeirooliveira@ sapo.pt Co-authors: Mr. Chandra Shekhar Biyani (GB), Mr. Sunjay Jain (GB), and Dr. Ben Van Cleynenbreugel (BE) In the past decades, the number and variety of diagnostic and therapeutic urological techniques have been increasing. In fact, the modern urologist needs to be skilled not only in open surgery, but also in endoscopy and laparoscopy. In many cases, the learning curve to master these techniques can be quite steep. For this reason, the training of urology residents became more demanding. On the other hand, in the face of modern training models, classical surgical training methods are becoming obsolete. Moreover, from an ethical point of view, training surgical skills in patients is becoming increasingly controversial. In line with these concerns, the European School of Urology (ESU), in collaboration with the EAU Section of Uro-Technology (ESUT) and the EAU Section of Urolithiasis (EULIS), has developed a series of hands-on-training programmes to standardise the teaching and accreditation of technical skills training. The European training in Basic Laparoscopic Urological Skills (E-BLUS) and the Endoscopic Stone Treatment step 1 (EST s1) include a series of validated exercises with the objective of providing and assessing basic laparoscopic and endourological skills.

One of the most important hallmarks of this course is the one-on-one training model. To maximise the learning experience, a trainee has a dedicated station with an expert to mentor him/her for the entire duration of each module. With a series of different high-fidelity models and a considerable amount of state-of-the-art urological equipment, trainees are provided with standardised hands-on trainings in laparoscopy; flexible and semi-rigid ureterorenoscopy; transurethral resection of the prostate (TURP); transurethral resection of bladder tumour (TURBT); flexible and rigid cystoscopy; bladder catheterization; suprapubic catheter placement; and scrotal examination. After a successful course organised in Belgium under the same framework, the second edition of the ESU Urology Boot Camp was held in Lisbon on November 22, 2019. This course was organised in collaboration with the Lisbon Faculty of Medicine Center for Postgraduate Training in Urology (CFU) and with the scientific support of the Portuguese College of Physicians’ Board of Urology and the Portuguese Association of Urologists (APU). The intensive course programme provided participants the opportunity to acquire and train several urological skills. The hands-on training took eight hours wherein each participant worked on a model under the guidance of a trainer. This was a unique opportunity for first-year urology residents to learn a series of different technical skills that are of paramount importance in daily clinical practice.

The Urology Simulation Boot Camp, developed in Leeds by Mr. Chandra Shekhar Biyani (GB) and Mr. Sunjay Jain (GB), is a revolutionary course that, over five days of intensive training, aims to provide basic technical and non-technical skills for urology registrars in the United Kingdom. From the ground-breaking evidence originating from this course, the ESU Urology Boot Camp project was developed to provide standardised technical skills training to urology residents throughout Europe, within the framework of a standardised ESU training curriculum. Learn by doing during laparoscopy exercises Boot camp in Lisbon Following the great success of the pilot course organized in Lisbon in 2018, the ESU Urology Boot Camp Committee developed a standardized course for first-year residents. The course comprises a full day of intensive hands-on training and is organised into four separate training modules: Laparoscopy, Upper Urinary Tract Endoscopy, Transurethral Resection and Lower Urinary Tract Endoscopy.

"The quality of the models and the equipment; the motivation and competence of the faculty; and the use of ESU’s validated training models warranted the clear success of the course."

Renowned faculty members together with the course participants

The quality of the models and the equipment; the motivation and competence of the faculty; and the use of ESU’s validated training models warranted the clear success of the course. Future perspectives The aim of the ESU Urology Boot Camp Committee, which comprises of Dr. Ben Van Cleynenbreugel (BE), Mr. Shekhar Biyani (GB), Mr. Sunjay Jain (GB)

and Dr. Tiago Oliveira (PT), is to implement a yearly ESU Urology Boot Camp course for first-year urology residents on a national level. The objective is to provide first-year urology residents a platform to acquire and train basic urological technical skills based on a standardised curriculum, prior to starting urological clinical activities. The focused training can help improve clinical proficiency and self-confidence.

Transurethral resection training

Testimonials from Boot Camp participants Dr. Miguel Miranda (PT) Santa Maria Hospital, Lisbon

Dr. Frederico Gaspar (PT) Egas Moniz Hospital, Lisbon

“The ESU Urology Boot Camp was an innovative way of simulating several practical skills in the field of urology. In a world where simulation is gaining a more important role in training medical students and junior doctors, to make use of available technology is critical in giving the highest quality care to our patients.

"In November 2019, I had the opportunity to participate in the ESU Urology Boot Camp. It was a very enriching experience on a professional and personal level when I was given the opportunity to meet other residents.

The boot camp consisted of four different workstations dedicated to different procedures in urology such as laparoscopic surgery or cystoscopy. Together with a team of experienced specialists, the advanced models and the one-on-one Since it was a full-day experience, all the residents tutor-and-learner ratio allowed us to further had plenty of time to train on each workstation. There was always a dedicated tutor who offered develop our technical skills in laparoscopy and endourology. tips and tricks on each workstation. That´s an experience I've never had, and that was, in my Having very realistic models and first-hand tips and opinion, the major advantage in this course. tricks from real-life experience at our disposal, we can significantly increase our technical In conclusion, this boot camp was a very important performance without the harm and side effects of course in my progress as a urology resident. It allowed intensive practical training in diverse patient testing. urological procedures. Moreover, since the urology I believe that workshops like these should become residency in Portugal comprises of one year centred standard practice in every teaching hospital. on General Surgery (usually during the first year), Residents will have the unique opportunity to this boot camp consists of the ideal opportunity for an intensive introduction to the specific arsenal of strengthen their skills and improve patient urology instruments.” management through a vast array of procedures.”

January/February 2020

European Urology Today

Report

1st SEA-UREP commences in Manila EUREP inspires new residents’ programme in Asia Dr. Samuel Vincent G. Yrastorza President, Philippine Urological Association (PUA) East Avenue Medical Center Quezon (PH) samuelyrastorza@ yahoo.com Back in 2017, Dr. Juvido Agatep Jr. and I were fortunate to take part in the European Urology Residents Education Programme (EUREP), which took place in Prague, thanks to Prof. Dr. Ali Serdar Gözen’s invitation.

Impressed with EUREP’s set up, we expressed our interest to send some of our Filipino residents to attend the next EUREP to Prof. Joan Palou, Chair of the European School of Urology (ESU). This request was immediately granted by Prof. Palou and the Board but only two slots were made available as EUREP is incredibly popular and in-demand. This started the quest to recreate this great programme in the Philippines, open it up to more Filipino and Association of Southeast Asian Nations (ASEAN) urology residents. A formal project proposal was then made and presented to Prof. Palou that called for an initial one-day programme modelled after EUREP, and to which the European School of Urology (ESU) Board subsequently approved.

On 27 November 2019, the first South East Asia Urology Residents Education Program (SEA-UREP) was successfully held at the F1 Hotel located in the bustling Bonifacio Global City in Manila. SEA-UREP was attended by 80 urology residents from Cambodia, Indonesia, Malaysia, Myanmar, the Philippines, Thailand, Singapore and Vietnam. The lecturers included EAU Secretary General Prof. Christopher Chapple, Prof. Gözen, Prof. Evangelos Liatsikos, Prof. Palou, and Prof. Manfred Wirth from the EAU side; and from the PUA side, Prof. Dennis Serrano and Dr. Michael Macalalag. The programme on basic laparoscopy skills was also complemented with the E-BLUS (European training in basic laparoscopic urological skills) examination and certification.

The number of participants have exceeded our expectations. The feedback from the participants was truly encouraging. They were grateful that this programme was brought within the reach of ASEAN urology residents. This motivates us to continue with our collaboration with the ESU and the EAU by offering the programme on a yearly basis. Rest assured, the coverage of the SEA-UREP lectures and long-term plans will expand, and involvement of more ASEAN lecturers will grow. Thank you to the ESU, the EAU and the Federation of ASEAN Urological Association (FAUA) for their strong support for the programme. I look forward to welcoming residents from within and beyond the Southeast Asian region to the second edition of SEA-UREP. See you all in Manila!

Report

PUA 2019 unveils the “Best of EAU” A pioneering urological endeavour in Southeast Asia By Dr. Samuel Vincent G. Yrastorza, FPUA Most Filipino urologists strive to attend the annual congress of the European Association of Urology (EAU) to meet the world-renowned faculty up close, listen to them, and learn from them. Despite best efforts, only 5 to 10 % of these Filipino urologists are able to do so because of the distance and costs. This rings true for the rest of Southeast Asia and likely, for most of Asia as a whole. If this continues, it would be increasingly difficult for urologists in the region to receive vital urology updates. And so the idea of bringing the EAU to the Philippines and Southeast Asia was actualized. The first “Best of EAU” in the Philippines finally became a reality. The programme was held from 27 to 30 November 2019 during the 62nd Annual Convention of the Philippine Urological Association (PUA 2019) at the new Grand Hyatt Hotel in Manila.

Led by EAU Secretary General Prof. Christopher Chapple, a total of nine speakers from the EAU delivered state-of-the-art lectures: Prof. Ali Serdar Gözen, Prof. Rainer Kuntz, Prof. Evangelos Liatsikos, Dr. Francisco Martins, ESU Chair Prof. Joan Palou, Prof. Jens Rassweiler, Prof. Kemal Sarica, Prof. Nikolaos Sofikitis, and Prof. Manfred Wirth. These experts, together with 50 regional speakers from China, Hong Kong, Indonesia, the Philippines, Singapore, and Vietnam, make up the programme’s faculty.

streamed real-time. Dr. Guido Giusti performed ECIRS (Endoscopic Combined Intrarenal Surgery) from Italy, and Dr. Geert De Naeyer demonstrated robot-assisted partial nephrectomy from Belgium, in addition to the live surgeries done at the local government hospital, East Avenue Medical Center. The “Best of EAU” programme was indeed a truly successful collaboration between PUA and the EAU. From 2020 onwards, PUA’s annual convention will dedicate half a day to the “Best of EAU” sessions and every three years, the three to four-day “Best of EAU” programme will take place.

The attendance was beyond our expectations. A total of 580 delegates from Brunei, Cambodia, China, Indonesia, Hong Kong, Malaysia, Myanmar, Thailand, Vietnam to as far as Bahrain, Switzerland and Ukraine I personally would like to thank the EAU, especially Prof. Chapple for his trust, confidence and support for participated. this pioneering endeavour which has brought the EAU The programme was extensive and highly informative closer to Southeast Asia. comprised of plenary sessions, masterclasses, I would also like to express my gratitude to Prof. workshops and live surgeries. The latter were

With esteemed EAU experts

Rassweiler, my mentor and adviser in the PUA-EAU collaboration. This close relation will continue to grow and strengthen. A special thanks goes to all the speakers who have dedicated their time, effort and expertise to make the programme possible. From mentors to partners and now, special friends whom the Philippines and the PUA hold dear.

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ESU course imparts PCa & BCa essentials in Uzbekistan Course addresses clinical challenges, offers region-tailored updates Dr. Bekhzod Ayubov Consulting Urologist Republic Specialized Center of Urology Tashkent, Uzbekistan

bekzod.ayubov@ gmail.com Since 2007, it had become our tradition to have esteemed experts from the European Association of Urology (EAU) share the latest urological news and innovations with colleagues from Uzbekistan through European School of Urology (ESU) courses every two years. Topics and themes of ESU courses are based on the urological needs of a country and/or region: From its current challenges in clinical practice, to treatment modalities and technologies that would benefit its patients the most. When we planned the ESU course “Prostate and bladder cancer; Insight into research and lecturing” which took place on 11 November of 2019 in Tashkent, we invited our honoured guest, ESU and Course Chair Prof. Joan Palou, to come to Uzbekistan earlier, to organise additional lectures together not only for urologists, but for students and young doctors of medical academies and institutions. Within the framework of the planned visit, he delivered 24

European Urology Today

wonderful lectures at the Tashkent Medical Academy (TMA) and at the TMA branch in Khorezm Medical Institute. This was organised in collaboration with the Scientific Society of Urology of Uzbekistan (NOUU). In the early morning of 06 November, Prof. Palou arrived in Tashkent and an hour later, presented his lecture "How to become good specialist” at the TMA. The students, undergraduates and young doctors posed their questions and received answers from Prof. Palou. More than 50 participants enjoyed his outstanding lecture and engaging teaching skills. Late in the evening on the same day, Prof. Palou was on flight to the Khorezm region to continue the education and share with his knowledge. On 7 November, we went to the Urgench branch of the medical academy after a quick sightseeing in the ancient city of Khiva. Prof. Palou shared his expert insights in his lectures based on the theme "The modern innovations in urology". The topic sparked great interest among the audience and encouraged a lot of questions from young specialists. More than 250 students, residents and young specialists of the Khorezm region participated. After the lectures, Director of the Urgench branch of the medical academy, Prof. Ruzibaev presented Prof. Palou with the recognition of Honorary Professor of the Urgench branch. On 8 November, Prof. Palou conducted a lecture at the Bukhara Medical Institution, which resulted to lively

Eager and enthusiastic faculty members and delegates

discussions and fruitful deliberations with young urologists of the region.

re-TUR in the treatment of bladder cancer; exploring multiparametric MRI as the standard in treating prostate cancer; biopsy of the prostate, and more.

On 11 November, the full-day ESU course for the urologists in Uzbekistan and in neighbouring countries commenced. Prof. Palou and Prof. Caroline Moore delivered six high-level lectures which comprised of interactive discussions of interesting patient cases.

More than 250 delegates-urologists from Tashkent, from various regions of Uzbekistan, and neighbouring countries such as Kazakhstan, Kyrgyzstan, and Tajikistan participated and enjoyed the ESU course.

The ESU course constituted of detailed and highlyinformative explanations of diagnostic and surgical procedures. The internationally-known speakers addressed numerous inquiries on varied topics of interest during the ESU course.

This event has proved once again the importance and necessity of having the ESU courses in Uzbekistan to improve the knowledge and skills of local urologists, who cannot travel to Europe and procure new scientific information.

Some of the topics covered included EAU Guideline recommendations on prostate and bladder cancer; tips and tricks in transurethral resection (TUR) and

On behalf of the NOUU, we express our appreciation to the EAU, the ESU, the renowned speakers at the ESU course and its organisers. January/February 2020

Report

Art in Flexible step 2 prepares for minimally-invasive field Mix of training and talent scouting fuels hunger to grow as an endourologist By Juul Seesing Designed for third-year residents to meet the contemporary needs in the treatment of urolithiasis, Art in Flexible is a mix of complementary hands-on training sessions and theoretical insights. Divided into three steps each being reached by fewer participants, the format prepares residents to perform the endoscopic stone treatment procedure with the increasing use of minimally invasive approaches. Art in Flexible step 2 took place at the KARL STORZ Visitor and Training Centre in Berlin from the 3rd to the 5th of December 2019. Through assessment by tutors with the aid of the Pi (Performance Improvement)-score algorithm, 16 participants were chosen out of the 48 residents who had enrolled in Art in Flexible step 1 which focused on the Endoscopic Stone Treatment step 1 (EST-s1) protocol. Step 2 centred on “complex skills; those manoeuvres that require more training before performing a full procedure for the first time,” according to Dr. Domenico Veneziano (IT), Art in Flexible’s overall coordinator. “Following our modular hands-on training structure, step 2 focused on the use of lasers and their configuration for fragmentation and dusting, plus the acquisition of stone basketing skills for urinary tract clearance.” Being the brainchild of a collaboration between the European School of Urology (ESU), the EAU Section of Urolithiasis (EULIS), and the EAU Section of UroTechnology (ESUT) with the support from KARL STORZ and Cook Medical, Art in Flexible is both an educational and talent-scouting programme – and this excites participants, Dr. Veneziano noticed. “The EST-s2 protocol allows participants to apply the skills acquired during the basic step to more advanced tools, getting much closer to the actual clinical setting. We are still improving and finalising the four tasks, but the residents already love it.”

Participants and faculty of Art in Flexible step 2

A passion for excellence Two residents, Dr. Stefan Tiganu (RO) and Dr. Wouter Goedertier (BE), gained a favourable impression about the second step of Art in Flexible. “It was a very well-organised training,“ Dr. Goedertier said. “A perfect mix of theoretical classes, interesting case discussions, and realistic hands-on training. We were able to perform several important steps in flexible ureteroscopy and stone management. There was also a tutor for every 2 to 3 residents. This made the course very interactive.” Dr. Tiganu added, “Our tutors explained to beginners how things worked and gave many tips and tricks to those who already knew how to carry out a procedure. It was an unbelievable experience.” The 4 most skilled and most enthusiastic residents were selected to proceed to the third and final step of the course, which is taking place in Caceres, Spain, in

February 2020. Prof. Bhaskar Somani (GB), chairman of step 2, elaborated on the selection process, “All the trainees were good and worked hard. Eventually, motivation and a passion for excellence were the most significant factors in the decision-making process. The selectees clearly showed a hunger to learn and to succeed as endourologist. For example, one of the trainees who had not done many ureteroscopic procedures prior to the course, developed the skills and not only performed a procedure, but also fragmented and dusted the stones as per the curriculum -- thus being picked up for step 3.” Take home message No matter whether a participant advanced to the next step or not, he or she travelled home having obtained valuable information. Dr. Tiganu provided us with an example, “High intrarenal pressure and temperature rise are two of the most important issues related to

the stone procedure that can occur and that we should be aware of. This is the top thing I have learned from step 2. My take home message was that most of the urological procedures can be taught without any risk for patients or at least while considerably lowering the risk for patients if a proper hands-on module is developed.” While the current edition of Art in Flexible is yet to come to an end, the new edition is already around the corner. The first step is scheduled to take place from 26 to 28 May 2020, again in Berlin. Keep an eye on www.artinflexible.uroweb.org to stay up to date about the application process. Please be aware that an application will only be accepted if you are an EAU member, if you deliver a letter from your department proving that you are a third-year resident, and if you have full availability for the whole programme.

First GUA-CCA meeting secures future editions Dynamic programme results in high turnout in Tbilisi Prof. Archil Chkhotua Congress President Secretary General, GUA National Center of Urology Tbilisi (GE) achkhotua@ gmail.com Active since 2010, the Caucasus and Central Asia (CCA) group is comprised of urological associations from Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan. The group has dedicated joint “EAU Beyond Europe” sessions at the annual EAU congresses where urological associations of the member countries have been giving presentations in English and moderate scientific sessions independently for almost a decade. While discussing plans for collaboration during the EAU19 Congress which took place in Barcelona, leaders of the eight urological associations came to a united decision that the CCA group should expand its activity and organise a regional congress similar to that of Baltic or Central European meetings.

Live simultaneous transmissions on Saturday

January/February 2020

GUA-CCA19

4-5 October 2019 Tbilisi, Georgia

With the support of the EAU, the Georgian Urological Association (GUA) initiated to host the first collaborative meeting of GUA and CCA in Tbilisi, the GUA-CCA19, in conjunction with GUA’s annual congress. The two-day meeting commenced on 4 October 2019. GUA-CCA19 was a multidisciplinary event with a comprehensive and interesting scientific programme, which consisted of the following sessions: Innovations in Urology, Expert Session, interactive case discussions, state-of-the-art presentations, and satellite symposia, to name a few. The half-day ESU course “The treatment of muscleinvasive and metastatic bladder cancer” marked the commencement of the meeting. Two distinguished speakers: EAU Adjunct Secretary General – Executive Member Science Prof. Arnulf Stenzl (DE) and Prof. Levent Türkeri (TR) discussed current management of invasive bladder cancer and principles of urinary derivation.

Promising urologists recognised for their research work

At GUA-CCA19, three poster sessions took place wherein 60 posters were featured. The top six posters were selected and recognised with coveted awards.

As a whole, the meeting was highly successful. For the first time in the region, the session of the 344 delegates from 20 countries attended the International Continence Society (ICS) “Contemporary event. The delegates represented the following management of BOO and male LUTS” took place. Mr. specialties such as urologists, medical oncologists, Rizwan Hamid (GB) and Prof. Sakineh Hajebrahimi radiation oncologists, radiologists, morphologists, (IR) spoke about role of urodynamics in bladder outlet nephrologists, transplant physicians, and more. obstruction (BOO) and management of post-surgical male stress urinary incontinence. At the end of the event, the CCA Board Members assessed the scientific level of the meeting and EAU Adjunct Secretary General, Prof. Hendrik Van defined plans for collaboration. Leaders of the eight Poppel (BE), gave the EAU Lecture on nephronsparing surgery (NSS) for renal cell carcinoma (RCC) which was entitled “Tips and tricks in NSS for RCC”. Most of day two was dedicated to live surgeries transmitted from two separate urological clinics. The delegates watched the surgeries on two parallel screens, asked the surgeons questions, and commented on the procedures. The four operations were successfully performed by Prof. Antonio Alcaraz (ES), Prof. Evangelos Liatsikos (GR), Assoc. Prof. David Nikoleishvili (GE), and Prof. Jens-Uwe Stolzenburg (DE). Crowd gathers at poster displays

national association unanimously agreed that the meeting’s success secured its future editions. To illustrate equal opportunity, the meeting’s future venues will take place in member countries on a rotational basis. In 2020, the meeting will take place in Nur-Sultan, Kazakhstan. The following year, the venue will be in Baku, Azerbaijan. And in 2022, the GUA-CCA meeting will be in Tashkent, Uzbekistan. We appreciate the support that the EAU has provided which contributed to the meeting’s success. We look forward to seeing you next year in Nur-Sultan!

A full house at GUA-CCA’s first edition

European Urology Today

EAU Research Foundation sessions at EAU20 EAU RF presents results in poster sessions and game changer session in Amsterdam Research is vital to the mission of the EAU. The EAU Research Foundation (EAU RF) is active in several large areas promoting advancement and translation of science into clinical practice. Since its foundation in 2007, the EAU RF has designed and carried out several projects. Some of the projects are still running and there are more in development. Results of EAU RF research conducted by groups from all parts of the world are published e.g. in European Urology, reviewed for the EAU Guidelines, presented at the association’s meetings and integrated into numerous ESU courses.

various questionnaires. Effects of treatments used in daily practice were analysed in various countries.

the bladder with or without CIS and who did not receive any previous BCG intravesical instillation therapy. Safety analyses (cut-off date 1 July 2019) by A poster on Evolution is presented on Saturday, 21 the Independent Data Monitoring Committee (IDMC) March 2020, 16.00 – 17.30 hrs. Location: Green area, showed reduced frequency schedule of BCG to be Room 4. inferior to standard frequency schedule for the Poster session 29: Voiding male LUTS: Medical primary endpoint according to the previously defined treatment and patient trajectories stop criterion. Recruitment was immediately stopped Poster nr. 392: Quality of life with pharmacological and all participating sites were instructed to inform treatment in patients with benign prostatic enlargement: patients and offer patients in the reduced frequency Results from the evolution European prospective treatment arm the possibility to switch to the standard multicenter multi-national registry study frequency. The follow-up period, which was initially 3 years, will be shortened until all patients have at least At the EAU annual congress in Amsterdam, preliminary/ NIMBUS 6 months of follow-up. At the time of stopping final results are presented on the following projects: The Randomised Phase III Clinical Trial NIMBUS has recruitment, a total of 359 patients were randomised. stopped recruitment due to the results of a safety analysis. The trial, which ran from 2013, studied SATURN Results of the safety analysis are presented in the reduced frequency BCG instillations in NMIBC, and The SATURN Registry evaluates the cure rate of Game Changer session on Monday 23 March 2020, involved nearly 360 patients in seven countries. surgical procedures for treatment of male stress 7.30 - 8.00 hrs., Orange Area, eURO Auditorium. urinary incontinence with medical devices. The study The NIMBUS study assessed whether a reduced has started in 23 sites from 8 countries (Belgium, For more information on EAU RF projects, please visit number of BCG instillations was not inferior to Czech Republic, Germany, the Netherlands, Norway, the EAU RF website www.uroweb.org/research/ standard number and dose intravesical BCG treatment projects/ Spain, the United Kingdom and Italy). New sites in in patients with high grade non-muscle invasive Finland, France, Germany, Norway, Spain, United bladder cancer (NMIBC). Primary endpoint was time Kingdom and Sweden will become active soon. The If you are interested in participating in one or more of to first recurrence. The target was to recruit 824 project recruits ahead of schedule with a total of 536 our projects, please contact EAU RF at patients with high grade Ta-T1 urothelial carcinoma of researchfoundation@uroweb.org. patients recorded in the e-CRF. An update of the SATURN registry will be presented on Saturday, 21 March 2020, 14.15 - 15.45 hrs. Location: Green area, Room 1 Poster session 20: The iatrogenic blues of male stress incontinence, are we out of the dark ages? Poster nr. 269: Prospective registry for patients undergoing surgery for male stress urinary incontinence in multiple European centres. an update of the registry ‘SATURN’ EVOLUTION EVOLUTION is a registry in which 2,175 patients from five European countries received pharmacological treatment for their LUTS, and were followed for 2 years. Patient Reported Outcomes were collected with

EU-ACME MCQ winners 2019 From January 1 to December 31, 2019, EU-ACME members answered multiple questions published in European Urology. Three participants who answered most questions correctly were awarded with free registration for the 35th Annual EAU Congress in Amsterdam to be held from 20 to 24 March this year. The 2019 winners are: 1. Mr. H.S. Fernando, United Kingdom (CME-124253) 2. Mr. D.K-C. Mak, United Kingdom (CME-122852) 3. Mr. F-J. Schattka Franz-Josef, United Kingdom (CME-110659) On behalf of the EU-ACME committee, chairman Prof. R. Nijman congratulated the winners for their successful participation in our online CME programme!

EAU Research Foundation • Anders Bjartell, Chairman • Wim Witjes, Scientific and Clinical Research Director • Raymond Schipper, Clinical Project Manager • Christien Caris, Clinical Project Manager • Joni Kats, Junior Clinical Project Manager • Joke Van Egmond, Clinical Data Manager • Hans Noordzij, Marvin System Assistant • Xandra Helmonds, Financial Officer

Your Electronic Credit Registry Report The Credit Registry Reports 2019 for EU-ACME members will be generated electronically and sent to all members by e-mail. Log in to MyCME – www.eu-acme.org, and make sure your personal data and e-mail address are correct, so that the EU-ACME office can send information on the Credit Registry Report 2019 to you on time and to the correct address!

EAU Patient Information 2020 Come join the EAU Patient Information Session with the focus on Putting the Patient First. The session brings into focus bladder-, kidney-, and prostate cancers together with patient’s experiences and needs, by welcoming a range of medical experts with diverse backgrounds. Date & Time : Sunday, 22 March from 14.00 until 17.00 Location : Green Area, Room 1 Moderators : H.P.A.M. Van Poppel (BE) / M.A. Behrendt (NL) R. Greene (NL) Life After Cancer Treatment 14.00

14.15

Remote follow-up programme

P. Cornford (UK)

EAU Guidelines Office

14.15

14.30

Educational sessions for remote surveillance

M. Thomas (UK)

Liverpool University Hospitals NHS Foundation Trust

14.30

14.45

We wish we knew then what we know now

J. Daly (DE)

East Galway & Midlands Cancer Support

14.45

15.00

Survivorship care: from the CanCon F. De Lorenzo (IT) recommendations to the Mission on Cancer

European Cancer Patient Coalition

15.00

15.15

Working with Cancer: Restoring Normality

European Men’s Health Forum

I. Banks (UK)

Prostate Cancer 15.15

15.30

Predictive individual risks of incontinence C. Tillier (NL) after prostatectomy in patient with localized prostate cancer and impact on choice of treatment

European Association of Nurses

15.30

15.45

EUProms Study

J. Dowling (IE) A. Deschamps (BE)

Europa Uomo

15.45

16.00

ADT Educational Programme

P. Bush Østergren (DK) Herlev Hospital, Denmark

Bladder Cancer 16.00

16.15

Medicine shortage and recalls in bladder cancer

K. Bagshaw (CA)

World Bladder Cancer Patient Coalition

16.15

16.30

EVOLVE Study

J. Bjorkqvist (UK) L. Makaroff (UK)

University of Aberdeen World Bladder Cancer Patient Coalition

Kidney Cancer 16.30

16.45

Kidney cancer follow-up

M. Staehler (DE) (tentative)

Ludwig-Maximilians-University of Munich

16.45

17.00

Meta-analysis of cancer patient engagement interventions in hard clinical outcomes

R. Giles (NL)

International Kidney Cancer Coalition

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

patients.uroweb.org 26

European Urology Today

January/February 2020

Young Urologists/Residents Corner Getting ready for the European robotic curriculum fellowship A preparatory visit to a high-volume centre St. James in Leeds (UK) Dr. Jose Vicente Sánchez González University and Polytechnic Hospital La Fe Valencia (ES) josevicente.sg@ gmail.com The European robotic curriculum programme is one of the fellowship programmes provided by the EAU Robotic Urology Section (ERUS), consisting of a 6-month period of both theoretical and practical training in robotic surgery that enables surgeons to perform a robot-assisted prostatectomy independently and effectively. In order to get prepared for this great challenge, I visited the urology service of St James´s Hospital in Leeds (UK), a great institution with an enormous experience in robotic surgery. It is a centre of reference for prostate cancer treatment with a high volume of robot-assisted radical prostatectomies. Guided tour This visit took place in October and November 2019. Yorkshire´s autumn received me with the traditional rain and cold weather, but I could deal with it due to the warm welcome that the members of the staff gave me. On my first day Dr. Sunjay Jain introduced me to the other doctors. Dr. Marcelino Yazbek, senior fellow in robotic urology, gave me a guided tour of the hospital facilities including the urology wards (reserved for acute or electively admitted patients), operation theatres, the Paul Sykes centre (location of the urology clinics) and the David

Beevers unit, where the day procedures and cystoscopies are performed. Daily routine In the course of the next weeks, I got immersed in the daily routine of the unit. I started in the early morning with the ward round, which is divided into seeing acute patients, who have been admitted because of an emergency, and elective patients, who underwent an elective surgical procedure and need further care to recover. The total number of patients varies between 12-20 elective and 30-40 acute patients. The ward round is performed by two teams, formed by a registrar or fellow and a consultant. This challenging work is only possible thanks to the excellent work of the nursing staff. I found the services of the highly qualified nurses, for example Mr. Benjamin Hunting, nurse of the J42 ward, remarkable. Apart from the fact that they know the case of each patient by heart and have a thorough knowledge of urology, these professionals are empowered and independent workers who make decisions, ask for tests and work side by side with the medical staff.

Author in the Leeds Clinical Simulation Centre (left) and attending the Yorkshire Urology Audit Group meeting (right)

Jose Sánchez González, with the staff in the operating theatre

Operating theatre After visiting the patients, it was time to attend the operation theatres. There are 3 theatres for major interventions in this hospital: 1 equipped with a robot and 2 for other types of procedures. During my stay I had the opportunity to assist in several interventions: 8 robot-assisted radical prostatectomies, 4 open cystectomies with ileal conduit (3 using the Bricker technique and 1 with Wallace reconstruction), 1 robot-assisted nephroureterectomy, 1 urethrectomy, 3 extra anatomical urine diversions, 1 implantation of artificial sphincter and several flexible cystoscopies. By attending in all those interventions, I had the opportunity to learn valuable ‘tricks’ and different ways of solving problems. This will prove to be very valuable in the future. Furthermore, being in a robotic theatre for the first time brought me the experience I was looking for. Dr. Cross, Dr. Prescott and Dr. Kotwal taught me in a brilliant way how the robotic ports should be placed in order to perform a correct prostatectomy and avoid a clash of the robotic arms.

Mr. Jerry Mudonhi, a highly qualified nurse, very patiently showed me the best way to assist the surgeon without interfering with the robot movements. Leeds Clinical Simulation Centre But my Leeds experience was not limited to the hospital. Thanks to the excellent help of Dr. Biyani I was able to spend some time in a robot simulator in the Leeds Clinical Simulation Centre, practising the most important uro-oncological procedures step by step. Furthermore, I had the chance to attend the Yorkshire Urology Audit Group, a regional meeting where the most recent clinical findings of the hospitals in the region were shared. In conclusion, my visit to the urology department of St James´s Hospital in Leeds exceeded my expectations! It was an unforgettable experience in so many ways and has prepared me to face my next great challenge: the EAU Fellowship.

E-BLUS exam now also held in Poland Local third edition of exam “a great facilitation for Polish residents” By Dr. Bartosz Brzoszczyk, Dept. of Urology Jan Biziel University Hospital, Bydgoszcz (PL) Co-authors: Dr. Marcin Jarzemski, Dr. Piotr Słupski, Dr. Sławomir Listopadzki, Dr. Piotr Jarzemski, Bydgoszcz, Poland Thanks to the cooperation with the European School of Urology (ESU), the Department of Urology of the Jan Biziel University Hospital in Bydgoszcz, and the European Medical Training Center (EMTS) in Bydgoszcz, Polish residents do not have to leave the country to acquire certification for their laparoscopic skills. Despite the extensive development of robotic techniques in urology, laparoscopic training still plays an important role in the education of young urologists. This is also expressed in the summary of previous editions of exams by Prof. Bhaskar Somani (GB), et al. published in the January 2019 issue of European Urology Focus.

Over the past six years, interest in taking part in the European training in basic laparoscopic urological skills (E-BLUS) exam has been steadily increasing, and the passing rate has increased from 35% to 70%. The E-BLUS is no longer associated only with the European Urology Residents Education Programme (EUREP) but now also with other international and national dedicated ESU events (EUREP, n = 385; other ESU events, n = 490). E-BLUS in Poland Every two years, the Department of Urology of the Jan Biziel University Hospital and the EMTS in St. Luke Hospital in Bydgoszcz, in cooperation with ESU and Section of Uro-Technology (ESUT), organise the E-BLUS exam, which was preceded by hands-ontraining (HOT) courses. Head of the Department of Urology of the Jan Biziel University Hospital and Chairman of the Section of Endourology in Poland, Dr. Piotr Jarzemski (PL), stated that the cooperation with the ESU is a great honour for his medical centre. He emphasised that this cooperation offers the opportunity to improve the quality of education of Polish residents. Participants of the 3rd edition of the E-BLUS exam in Poland Since 2000, the School of Laparoscopy in Bydgoszcz has provided a system-teaching programme which includes all aspects of modular training except for an official certification. Now the E-BLUS exam complements the modular training in laparoscopy in Poland. All editions of the exam in the country have been supervised and supported by the ESU team which is comprised of Prof. Ali Serdar Gözen (DE), Mr. Giles Hellawell (GB) and ESU Coordinator, Mr. Ton Brouwers (NL).

HOT course before the E-BLUS exam under the tutelage of Mr. Hellawell (pictured right)

January/February 2020

Altogether, 34 residents participated in the three editions of the E-BLUS exam in Poland. The incidence rate was 51% (36% in 2015, 50% in 2017 and 66% in 2019). As stated in the summary of Prof. Somani, the significant predictors of success were passing tasks 1 and 2 among Polish residents.

Resident perspective The facilitation of passing the E-BLUS exam in Poland is great for Polish residents. In the past, one had to travel abroad to take part in both the HOT course and the E-BLUS exam. Now, a resident simply travels to Bydgoszcz, which is almost in the centre of Poland. From the perspective of a fourth-year resident, taking an exam in Poland was not only a logistical convenience but a psychological one as well, as passing the E-BLUS exam gave residents more confidence in becoming better surgeons. Of course, it required regular training on the box-trainer. However, thanks to the available E-BLUS kit models, it has become easier to prepare for the exam. We are very pleased and enthusiastic that the Polish residents have the same certification opportunities

just like their colleagues from other European countries. What’s next? Undoubtedly, the E-BLUS exam and the Endoscopic Stone Treatment step 1 (EST-s1) exam, which we had the pleasure of co-organising in Bydgoszcz, have provided excellent opportunities for further development; standardisation of the training process; and broadening of the professional network of dedicated tutors who are committed in sharing their knowledge and skills. The next promising initiative is to adopt the E-BLUS protocol at a residency level during the SimBase project in Italy, which is definitely something to look forward to. European Urology Today

Certified Residency Training Programme in Urology (RTPU) Austria Hanusch-Krankenhaus Vienna Krankenhaus der Barmherzigen Brüder Vienna Landeskrankenhaus Leoben Landeskrankenhaus Salzburg - Universitätsklinikum der PMU LKH Wiener Neustadt Medical University of Vienna SMZ Ost - Donauspital Vienna SMZ Süd - Kaiser-Franz-Josef-Spital Vienna Belgium AZ Maria Middelares Gent AZ Nikolaas Sint Niklaas AZ Sint-Lucas Gent OLV Ziekenhuis Aalst-Asse-Ninove U.L.B. Hôpital Erasme Brussels Universitair Ziekenhuis Gent Croatia KBC Sestre Milosrdnice Zagreb Czech Republic 1st Faculty of Medicine, Charles University and General University Hospital Prague 2nd Faculty of Medicine, Charles University and University Hospital Motol Prague Faculty Hospital Plzen, Charles University Estonia North Estonia Medical Centre Foundation Tallinn Tartu University Hospital Finland Oulu University Hospital Turku University Hospital University of Helsinki Germany Helios Marien Klinik Duisburg Justus Liebig University of Giessen Klinikum der Stadt Ludwigshafen am Rhein gGmbH Klinikum Garmisch-Partenkirchen Klinikum Ludwigsburg Klinikum Nürnberg Klinikum rechts der Isar der Technischen Universität München SLK-Kliniken Heilbronn GmbH St. Antonius-Hospital Gronau GmbH Städtisches Klinikum Braunschweig gGmbH UKH Universitätsklinikum Halle (Saale) Uniklinik RWTH Aachen Universitätsklinikum Carl Gustav Carus Dresden Universitätsklinikum Düsseldorf Universitätsklinikum Hamburg-Eppendorf Universitätsklinikum Jena University Hospital Schleswig-Holstein University Hospital Schleswig-Holstein, Campus Lübeck University of Leipzig

Greece Sismanoglio General Hospital Athens University General Hospital of Heraklion

Certified Sub-Specialty Centre Institute Specialty United Kingdom Leeds Teaching Hospitals NHS Trust

Stone Treatment

Hungary Semmelweis University Budapest Italy General Hospital of Bolzano Malta Mater Dei Hospital Malta Norway Sorlandet Sykehus HF Arendal Sorlandet Sykehus HF Kristiansand Sykehuset i Vestfold Tønsberg Poland Europejskie Centrum Zdrowia Otwock Gdansk Medical University Interdisciplinary Hospital Miedzylesie MCPE Warsaw Medical University of Warsaw

Certified EBU-EAU Host Centres Institute Sub-Specialty Belgium OLV Ziekenhuis Aalst-Asse-Ninove

Renal Cancer

OLV Ziekenhuis Aalst-Asse-Ninove

BPH

OLV Ziekenhuis Aalst-Asse-Ninove

Female Urology & Incontinence

OLV Ziekenhuis Aalst-Asse-Ninove

Prostate Cancer

OLV Ziekenhuis Aalst-Asse-Ninove

Urothelial Cancer

UZ Leuven

Female Urology & Incontinence

UZ Leuven

Neuro-urology

UZ Leuven

Prostate Cancer

UZ Leuven

Paediatric Urology

France Portugal Centro Hospitalar e Universitário de Coimbra Spain Clínica Universidad de Navarra Fundació Puigvert Barcelona Hospital Del Mar Barcelona Hospital Universitari Clínic de Barcelona Hospital Universitari de Bellvitge L'Hospitalet de Llobregat Hospital Universitari Vall d'Hebron Barcelona Hospital Universitario La Paz Madrid Switzerland HUG - Hôpitaux Universitaires Genève Inselspital Bern Kantonsspital St. Gallen Kantonsspital Winterthur UniversitätsSpital Zürich

University Hospital La Pitié-Salpêtrière Paris

Renal Cancer

University Hospital La Pitié-Salpêtrière Paris

Neuro-urology

University Hospital La Pitié-Salpêtrière Paris

Prostate Cancer

Germany Eberhard-Karls-University Tübingen

Urothelial Cancer

Ludwig Maximilians University Munich

Urothelial Cancer

Ludwig Maximilians University Munich

Prostate Cancer

Universitätsklinikum Carl Gustav Carus Dresden

Prostate Cancer

Universitätsklinikum Düsseldorf

Testicular Cancer

Universitätsklinikum Düsseldorf

Urothelial Cancer

Universitätsklinikum Düsseldorf

Prostate Cancer

Universitätsklinikum Düsseldorf

Renal Cancer

Universitätsklinikum Leipzig

Prostate Cancer

University of Bonn

Neuro-urology

Italy Turkey Ankara University, School of Medicine Bagcilar Hospital Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital Istanbul Ege University Medical School Izmir Hacettepe University School of Medicine Ankara Istanbul University, Faculty of Medicine Uludag Üniversitesi Tıp Fakültesi Bursa University of Cukurova United Kingdom Bristol Urological Institute

EBU Certification as a Mark of Quality

Ospedale Pediatrico Bambino Gesù Rome

Paediatric Urology

Lithuania National Cancer Institute Vilnius

Prostate Cancer

The Netherlands Canisius-Wilhelmina Ziekenhuis Nijmegen

Prostate Cancer

Máxima Medisch Centrum Veldhoven

Prostate Cancer

Radboud University Medical Centre Nijmegen

Prostate Cancer

Radboud University Medical Centre Nijmegen

Paediatric Urology

Radboud University Medical Centre Nijmegen

Female Urology & Incontinence

Radboud University Medical Centre Nijmegen

Neuro-urology

Spain Hospital Universitario Ramón y Cajal Madrid

Transplantation

Switzerland Ospedale Regionale Bellinzona e Valli

Prostate Cancer

Turkey Hacettepe University School of Medicine Ankara

Paediatric Urology

United Kingdom

European Urology Today

Leeds Teaching Hospitals NHS Trust

Renal Cancer

North Bristol NHS TRUST Female

Urology & Incontinence

North Bristol NHS TRUST

Stone Disease

Sheffield Teaching Hospitals NHS Foundation

Reconstructive Urology

January/February 2020

EBU Certification for Erasme Hospital in Brussel Numerous benefits of certification of standard of training quality Prof. Thierry Roumeguère Head of the Urology Department U.L.B. Hôpital Erasme Brussels (BE) thierry.roumeguere@ erasme.ulb.ac.be

Dr. Simone Albisinni U.L.B. Hôpital Erasme Urology Department Brussels (BE)

Today, the urology department has a 30-bed capacity, a day care unit and an outpatient clinic. Six full-time and five part-time senior urologists are covering all urological pathologies in their expertise. We have integrated activities with the Jules Bordet institute for uro-oncology, the Centre de Traumatologie et Rehabilitation (CTR) for the management of neurogenic bladder diseases and the ULB academic paediatric hospital, Hôpital Des Enfants Reine Fabiola (HUDERF). We collaborate with a wide network of Belgian hospitals in Brussels and in Wallonia. Training of residents We train 20 residents in urology, who rotate between a broad network of hospitals in Brussels and Wallonia. Every year, 4 to 5 residents serve as full-time residents in the Erasme Hospital. After completing medical school, a resident must successfully complete a training period of six years to become a board-certified urologist in Belgium.

albisinni.simone@ gmail.com

Residency includes two years of general surgery (including training in vascular, cardio-thoracic, digestive and emergency surgery) followed by four The European Board of Urology (EBU) recently certified years of urology. These four years are generally the department of urology of the Erasme Hospital, divided into 18 months of general urology in a academic hospital of the Université Libre de Bruxelles peripheral hospital of our network, including 6 (ULB, BE), reflecting the department’s high quality of months rotations in our dedicated paediatric urology service. training and medical services in the field of urology. Integrated activities The Erasme Hospital is a tertiary referral centre with over 1,000 beds. It takes care of patients from the Brussels urban area as well as a vast part of the French-speaking Wallonia region of Belgium. Our department of urology was founded by Willy Grégoir (known for the extravesical reimplantation technique) in the seventies; Claude Schulman (former Editor in Chief of European Urology) succeeded him. Currently, Prof. Thierry Roumeguère is Head of the Department since 2009. EBU Certified Centres

After these two initial years, residents pass 1-2 years in the Erasme Hospital and Jules Bordet institute, a clinic fully dedicated to oncology. During this time the residents are exposed to all aspects of urologic care. This includes an endoscopic clinic with two daily operating rooms, with access to flexible ureteroscopes, PCNL, laser surgery and modern minimally invasive BPH treatments. Robotic surgery Our oncology programme includes daily work in the operating theatre, mainly dedicated to major oncologic surgery. A DaVinci Xi system with a double console allows adequate exposure of residents to

robotic surgery. By the end of their training, senior residents have acquired experience with most robotic procedures. As part of our oncology programme, we invite residents to attend a weekly multidisciplinary meeting. They are invited to expose and discuss both simple and complex oncology patients, in collaboration with experts from the oncology, radiation oncology, pathology and nuclear medicine Prof. Roumeguere (left, sitting) with the staff of the Urological Department of the U.L.B. departments. Erasme Hospital Furthermore, during their rotation in Erasme At the end of their training, residents are strongly Hospital, residents can take part in a functional neuro-urology programme in the CTR. Here they learn encouraged to take the EBU exam, which is financially supported by our department, in order to obtain the to manage complex neuro-urologic diseases and management of spinal cord injuries. title of Fellow of the EBU (FEBU). An in-service self-assessment is organised on an annual basis; it is regarded as a powerful learning tool. Residents are also requested to present weekly journal clubs, analysing recent urologic literature. We strongly encourage other urological institutions Moreover, the senior staff organises a weekly grand rounds meeting, including the discussion of a clinical in Europe to apply for the EBU certification since case, in order to train residents in real-life clinical there are numerous benefits. First, the EBU certification allows other departments and management of urologic patients. urologists to identify a standard of training quality, Advantages EBU certification leading to a fruitful exchange of experiences and In addition to their clinical work, residents are asked multicentric research possibilities. The advantage for to conduct clinical studies and present the results at residents is that they are offered a structured, high-level education every year. Furthermore, a national and international meetings. In order to become a board-certified urologist, residents must certified department maintains a better position in have published at least one study as first author in a the hospital compared to other departments. Finally, recognised, peer-reviewed journal. Furthermore, the the EBU certification allows control over the campus of Erasme Hospital has an excellent department’s training ability, allowing an improvement of the fields lagging in the struggle to interdisciplinary medical research centre where urologists can perform basic research. realise the best patient care.

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January/February 2020

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European Urology Today

eUROGEN and ESSIC work together against interstitial cystitis News from the 2019 meeting of the International Society for the Study of BPS/IC (ESSIC) Dr. Mariangela Mancini ERN eUROGEN Network Board Member Dept. of Urology University of Padova (IT) mariangela. mancini@unipd.it As a clinician and a member of the ERN eUROGEN Network Board, it is my pleasure to summarise my experience at the last ESSIC Meeting, which was held in Amsterdam, NL, 5-7 December, 2019. This year’s meeting objective, as emphasised by Dick Janssen, ESSIC Meeting Chair, was to focus on the multidisciplinary approach to diagnosing and treating BPS/IC with the aim of giving all attendees the tools and knowledge to be able to provide state-of-the-art treatment for patients. Personalised treatment strategies and patient participation were also extensively explored at the meeting. A novel feature this year was a presentation from ERN eUROGEN, which proposes collaboration with ESSIC to take a more strategic approach to the efforts to improve the diagnosis and treatment of IC for the benefit of patients across the European Union (EU). ERN eUROGEN is led by Prof. Wout Feitz, Consultant Paediatric Urological Surgeon, Radboudumc, the Netherlands and was established and approved, alongside 23 other ERNs covering different medical fields, by the European Commission (EC) in 2017 as a framework for facilitating multidisciplinary teamwork between medical experts across the EU.

Presentation of eUROGEN on December 5

Centres of particular expertise in different countries provide specialised input and share knowledge and advice. ERN eUROGEN began with 29 healthcare provider members from 11 member states and a recent call from the EC for new members means that as many as 31 new applicants could be joining by the end of 2020. This is a very welcome development. The expansion of the geographical coverage of the network will allow more patients to access the collective expert advice of the clinicians involved in the network. ERN eUROGEN discussions involve at least six experts from at least six countries to include most member states; expanding the number of members and states involved will give wider coverage which will be to the benefit of the patients. Members of the ERN are already collaborating to provide expert advice on the diagnosis and management of patients with rare and complex urogenital conditions.

eUROGEN then holds a multidisciplinary panel case consultation with the appropriate experts, and gives advice to the treating clinicians. All this can be done without the patient having to travel. ERN eUROGEN is also working on developing clinical guidelines and research projects on IC/BPS. One of these, with strong support from the patient organisations, is devoted to the establishment of a biobank of urine or tissue samples from IC patients, in order to support research projects and basic science work. A location to establish an international IC biobank is currently being investigated.

ERN eUROGEN is structured into three workstreams: Workstream 1 – rare congenital urogenital anomalies (led by Prof. Wout Feitz); Workstream 2 – complex functional urogenital conditions and pelvic floor disorders requiring highly specialised surgery (led by Prof. Margrit Fisch); and Workstream 3 – are urogenital tumours (led by Prof. Vijay Sangar). Each workstream is subdivided into disease areas, with IC/ BPS being one of these (Workstream 2.5 BPS/IC), and this was the main topic of the ERN eUROGEN presentation at the ESSIC meeting (Fig. 1).

The presentation highlighted the central role of patients in ERN eUROGEN activities, which is also strongly supported by the EC. Patient representatives both present the patient view and represent patients’ voices within ERN eUROGEN. They provide the patients’ point of view and experience, and communicate back to and connect with the patient community. They constantly review the effectiveness of the ERN and evaluate how the ERN acts on feedback received, promoting a patient-centred approach. Finally, they contribute to the definition of research priorities and the ethical standards of the ERN. In ERN eUROGEN, patient representatives regularly participate in and talk at meetings, providing their precious input. With the support of the president of the AICI, Loredana Nasta, IC/BPS was included in eUROGEN, supported by the coordinators of the three workstreams, and together with EURORDIS.

The presentation demonstrated how ERN eUROGEN is working to implement the Clinical Patient Management System (CPMS), the web-based clinical software application provided by the EC, where healthcare providers from across the EU can work together virtually across national borders to diagnose and recommend treatment for patients with IC/BPS within Europe. The system is fully secure and complies with all national and European data protection legislation. Using CPMS for discussions on a particularly complex patient by several experts in different countries represents a step-change in collaboration at European level between healthcare providers. Clinicians treating IC/BPS patients who cannot be easily managed or treated at a national level can contact ERN eUROGEN and ask for cases to be reviewed by the expert teams. The treating clinicians are issued with a guest login to CPMS so they can upload the relevant medical information. ERN

The ERN eUROGEN presentation at the ESSIC Meeting was delivered by myself, as the eUROGEN Disease Area Coordinator (DAC) for IC/BPS, and Serena Bartezzati, ERN eUROGEN ePAG (European Patients Advocacy Group) Representative and Board member of the Italian Association of Interstitial Cystitis (AICI).

Some important quotes from the lecture on the work of the ERN eUROGEN network are: “An important result of patient involvement in research is to balance the scientists’ hypothesis with what is possible, desirable and acceptable to individual patients.” “To fast-transfer the data from bench to bedside, with an interest on clinical application of rough data.” “One of the main advantages of Patients Driven Research (PDR) is its speed”. The first day of the meeting ended with a ceremony chaired in person by the legendary St. Nicholas (Sinterklaas in Dutch), an early Christian Bishop and

Sinterklaas joining the speakers at the end of the day

benefactor of children with the secret habit of gift-giving, who traditionally brings presents to children in Belgium and the Netherlands on the night of December 5! A special moment was dedicated to the memory of this historical religious leader (Fig. 2). May he bring the gift of better treatment opportunities to all IC/BPS patients in Europe! I am sure that everybody enjoyed the spirit and positive atmosphere of the cosmopolitan city of Amsterdam during the three-day congress. The ERN eUROGEN Network Board would like to express their gratitude to ESSIC for their support and for integrating the ERN eUROGEN presentation into this year’s programme. Joints efforts between institutions and groups involved in IC/BPS treatment is highly desirable. The final objective of these efforts is to build new bridges and wider perspectives for our patients’ benefit and assure them of the best clinical care, reaching to the edges of the EU, without borders and beyond single nations. We hope to strengthen and enrich these joint efforts in the near future!

Preparing for Horizon Europe The future of EU research and innovation and EAU priorities By Sarah Collen, EAU Policy Coordinator

The overall aim of this cluster is to demonstrate the EU’s support to the UN’s Sustainable Development Are you active in clinical research with international Goals calling for universal health coverage for all at all partners? Then you must have heard about Horizon ages by 2030 by: Europe, the new 7-year European Union scientific • developing innovative solutions to prevent, research programme by the European Commission. diagnose, monitor, treat and cure diseases; This programme will be the successor of the current • mitigating health risks, protecting populations and EU research and innovation programme- Horizon 2020. promoting good health; • making public health systems more cost-effective, With a proposed budget of 100 billion euro, Horizon equitable and sustainable; Europe aims to strengthen the EU's scientific and • and supporting and enabling patients' technological bases and the European Research Area, participation and self-management. to boost Europe's innovation capacity, competitiveness and jobs and to deliver on citizens' priorities and The Health cluster is divided into several areas of sustain socio-economic model and values. intervention that were defined on the basis of key challenges to public health in the EU: The ambitious initiative proposes to raise EU science • Health throughout the life course spending levels considerably over the years 2021-2027 • Environmental and social health determinants with a planned funding to address public health issues • Non-communicable and rare diseases of 7.7 billion euros. Of course, this offers possibilities • Infectious diseases, including poverty-related and for research and innovation in urology as well. For that neglected diseases reason the EAU hosted a workshop last November on • Tools, technologies and digital solutions for health Horizon Europe together with the Biomed Alliance, a and care, including personalised medicine conglomerate of 32 medical societies that facilitate and • Health care systems improve biomedical research . Gianpietro Van De Goor, who is one of the leaders on the team pulling together A new mission on cancer all the activities of the ‘health cluster’ of Horizon The new 'missions' are a key novelty of Horizon Europe, gave the opening presentation. Europe. Missions will consist of portfolios of research and innovation projects at all Technology Readiness Structure of the programme Levels, with a clear goal that matters for EU citizens. Horizon Europe will consist of three pillars; open The EU political process has defined cancer as the science; global challenges and industrial health mission, which will fall under the health cluster. competitiveness. The second pillar on global The Commission has appointed members to each challenges includes a health cluster, and is of mission board. Mission boards will advise the particular relevance for the EAU. European Commission how to define and implement 30

European Urology Today

each Mission area. The three priority areas identified in this cancer mission are prevention, treatments and survivorship. The new public private partnership (formerly the Innovative Medicines Initiative) The Commission has proposed that the Innovative Medicines Initiative (IMI) should expand its scope to become the Innovative Health Initiative (IHI), broadening the remit from pharmaceuticals to include diagnostics, medical devices, medical imaging and biotech. This would impact not only the research agenda, which is currently decided by the research directors of pharmaceutical companies, but also its composition, since the industry partners’ contribution to IMI is managed by EFPIA (European Federation of Pharmaceutical Industries and Associations). IMI also has an assortment of associated partners including charities, universities, research institutes and small companies.

EU citizens access their electronic health records and prescriptions when abroad in the EU, but will also aim to support the use of data for research purposes. PIONEER can really assist this initiative.

Taking EAU priorities forward with the European Commission As a follow up of the workshop, representatives from the EAU discussed the shared priorities for the themes emerging from Horizon Europe. We agreed that the research on cancer would be an important theme for our research alliances, with a particular focus on prostate cancer. Also, the work on sharing and inputting digital data for research purposes is a critical theme, and leads on from our work on eUROGEN and A network of researchers from the EAU is currently PIONEER. Both will be priorities of our shared work involved in a project funded by the IMI, using ‘big data’ together. The next step will be a meeting with the to better prostate cancer outcomes, called PIONEER. At relevant European Commissioners on these subjects, the earlier mentioned workshop on Horizon Europe, highlighting how the EAU can support them in their Magda Chlebus from EFPIA highlighted the importance aims. of medical societies joining in with these projects, as they ensure the link with translation of research to If you’re interested to play a role in one of these clinic, and to the patients their members care for every initiatives or in case you have a research project at day. The use of ‘big data’ is likely to remain a key national level contributing to urology, please contact priority in the IHI programme, especially as the new Sarah Collen, the new EAU policy coordinator at European Health Commissioner has been asked to EUoffice@uroweb.org. More information on Horizon deliver a European Health Data Space, which will help Europe can be expected in the course of this year. January/February 2020

‘Magic Bratislava’: Stimulating inter-academic collaboration Slovakian capital hosts 18th Annual Association of Academic European Urologists Meeting Research Exchange Friday morning November 29th started early with the traditional research exchange meeting under the chairmanship of Profs. Thalmann (Berne, CH) and Bangma (Rotterdam, NL). Here new academic scientific programmes were proposed and discussed. The aim of this meeting is to enhance and stimulate scientific inter-academic urological collaboration and exchange.

Prof. Frans Debruyne Honorary Communication Officer Association of Academic European Urologists Arnhem (NL) f.debruyne@ uroweb.org The AAEU experienced another very successful annual meeting, this time in Bratislava. The Association of Academic European Urologists (AAEU) is an exclusive gathering of old and young European Academic Urological leaders. They provide a forum for in-depth discussion of recent clinical and scientific progress in Urology. The two-day annual meeting is therefore a showcase for intense exchange of urological science and moreover an excellent opportunity for urological academic collaboration and networking. Membership of the AAEU is by invitation only. Currently the AAEU has 72 active members, 35 emeritus members and 10 international members. A large number of members from the different membership categories were present at the Bratislava annual meeting which excelled again through its very high scientific quality and very friendly and amiable atmosphere under the efficient and generous leadership of Prof. Jan Breza (Bratislava, SK), the 2019 AAEU president. The 18th annual AAEU meeting took place in the Bratislava River Park Hotel, a very convenient venue for such a high-standard reunion, on 29 and 30 November, 2019. It started as usual with a welcome reception and buffet dinner on the Thursday evening when participants gradually arrived for some excellent food and a glass of delicious Slovakian wine. Old friends were greeted and new guests and members introduced and welcomed.

After a ceremonial opening by AAEU President Prof. Jan Breza and AAEU Secretary General Prof. Ian Eardley (Leeds, GB) the ‘proper’ AAEU meeting started with the Michael Marberger Lecture. Prof. Marberger, a founding father of the AAEU was present to admire the excellent presentation from Prof. Thalmann (Berne, CH) who gave a sublime and impressive overview of several decades of scientific and clinical research at the Berne University department of urology. The morning was further devoted to two sessions on new developments in prostate cancer. The format of each session consists of an introductory state-of-theart lecture selected by the AAEU programme committee, followed by five seven-minute strict presentations each completed with an eight-minute and sometimes very lively and critical interactive discussion. After lunch, two more sessions followed: one on functional urology and one on the kidney and surrounding organs.

Local host and 2019 AAEU President Prof. Jan Breza

AAEU participants pose on the north bank of the Danube

On Friday evening a very ceremonial gala dinner took place. Before the dinner a demonstration was given of Slovakian music and dance which delighted everybody present. During the dinner the Michael Marberger Lecture Award was presented to Prof. Thalmann, followed by the presentation of the Laurent Boccon-Gibod Award (named another founding father of the AAEU) to Prof. Hartwig Huland (Hamburg, DE). The ceremonial part of the dinner was concluded by the nomination of Prof. Laurent Boccon-Gibod (Paris, FR) as AAEU Honorary member. The ceremonial and gastronomic dinner took place in a beautifully decorated historical building of the Slovakian National Council.

guests also had the obligation to present. Moreover all members and guests contributed to the usually intense discussion. The rest of the Saturday was devoted to the business meeting, followed by an interesting guided tour in the old town of Bratislava which was already beautifully decorated for Christmas. The day was enjoyably concluded by a wonderful dinner with music and songs in the majestic UFO restaurant 50 meters above the historical illuminated old city of Bratislava. It was again a scientifically and socially unforgettable AAEU meeting. It’s a privilege to belong to this association. Later this year (3-6 December, 2020) we will meet in Malmö (SE) under the presidency of Professor Per-Anders Abrahamsson.

Eulogies Saturday November 30th started with two morning sessions: one on bladder diseases and the second again on the prostate. The sessions were concluded by two eulogies for deceased members, the first one presented by Prof. Janetschek (Salzburg, AT) in memory of Prof. Gerhard Jakse (Aubel, BE) the second one given by Prof. Schulman (Brussels, BE) in memory of Prof. Van Cangh (Court-Saint-Étienne, BE). Finally local author and speaker Mr. Martin Sloboda (Bratislava, SK) gave an enthusiastic and colourful special lecture on the magic of Slovakia. During the two days most presentations were given by active members and some by emeritus members. All invited AAEU Secretary General Prof. Ian Eardley

ELUTS20 European Lower Urinary Tract Symptoms meeting 29 -31 October 2020 Lisbon, Portugal By

www.eluts20.org

In collaboration with

January/February 2020

European Urology Today

BCa-RCC20: The best of both worlds Combined update for non-prostate urological cancers coming to Frankfurt this summer BCa-RCC20 is a combined uro-oncology update that builds on past years’ BCa and RCC meetings. BCa will follow RCC over the course of three days, offering delegates a chance to participate in either or both meetings. The meetings take place in Frankfurt (DE) on 26-28 June 2020 and are a collaboration between the EAU, its Oncological Urology Section (ESOU) and the European School of Urology (ESU). Combined, BCa-RCC20 is a major three-day meeting that complements other scientific meetings that are focused on prostate cancer only. It will not only take into account the most recent scientific outcomes but also examine guideline-compliant practices through in-depth case discussions in small break-out sessions with experts. The strong educational and interactive character of the meeting sets it apart from other, larger meetings. We spoke to Prof. Morgan Rouprêt (Paris, FR) and Prof. Axel Bex (London, GB), members of the BCa-RCC20 Steering Committee about combining the EAU’s non-prostate cancer uro-oncology meetings and some highlights for participants. Register now for the early fee! Deadline: 26 March 2020 Either or both Prof. Rouprêt explained the organisation’s shift to a combined 2020 Update after separate meetings in previous years: “It was an important decision to combine these two meetings to have a big oncology event that is not dedicated to prostate cancer. We felt that there are enough novelties, drugs in the pipeline, trials, new discoveries for bladder and renal cell cancer to have a sufficient amount of material and data to share with our colleagues in a single meeting.” Rouprêt feels that a further advantage of combining means that BCa-RCC20 can serve as a “sister

congress” to PCa20, the EAU’s Prostate Cancer Update which will take place later in the year. Prof. Bex points out that the decision “was also driven by the fact that many urologists who do oncology are either solely treating prostate cancer, or are treating bladder and renal cancer together with other ‘smaller’ urological tumours.” Rather than intertwining the scientific programmes with alternating cases or overlapping parallel sessions, the BCa and RCC scientific programmes follow each other over the course of the three days. Rouprêt: “We view BCa-RCC20 as one whole congress with two distinct parts. The two programmes are not running in parallel to avoid the frustration of not being able to attend both sessions.” The two topics are strongly complementary, and in practice, urologists may be involved in both in their daily practice. “Colleagues have an ‘academic’ topic when they communicate outside their institution, but in daily practice, as onco-urologists we are all involved in the management of both diseases. Thus, it is a unique opportunity to have a broad overview of all new insights in bladder and kidney cancers in a unique event in two parts.” Participants are encouraged to attend both meetings, requiring only one extra day of attendance and heavily discounted registration compared to paying for both meetings separately. Accommodation at the congress venue in Frankfurt is included in the registration fee for EAU Members. Special rates are also available for nurses and residents. Scientific programme highlights In terms of changes to the scientific programme of each meeting now that they are combined, Prof. Rouprêt emphasizes that each part has its own scientific committee. Uniquely, BCa-RCC20 has an overarching Steering Committee, of which Profs.

For the preliminary Scientific Programme visit www.bca-rcc20.org “The effect is that we came up with a unique steering committee that coordinates two distinct scientific committees. It is a unique structure for meeting organisation, much more efficient and focusing on the most important scientific aspects. From the feedback we had from former editions, we kept the popular break-out sessions to increase the interactivity between participants but we reduced as much as we could the length of plenary sessions to short and straight-to-the-point lectures to spare endless discussions about moot points.” On Friday and early Saturday, the Renal Cell Cancer programme will be taking place. Prof. Bex is looking forward to talks on the management of the small

EAU Update on Bladder Cancer and Renal Cell Cancer EAU Update on Bladder Cancer and Renal Cell Cancer

26-28 June 2020 Frankfurt, Germany

renal masses, as well as advanced RCC where most of the new developments are occurring. “I believe we have an excellent speaker panel,” Bex says. “The advanced RCC session features presentations on the surgical and perioperative challenges of the large renal tumours (vena cava and lymph node involvement) and the perioperative care of geriatric renal tumour patients.” On Saturday afternoon, the programme changes to bladder cancer, where there are several new developments worthy of attention. Prof. Rouprêt: “Personally, I am excited about the area of immunotherapy in localised and locally advanced disease. There is a huge opportunity for urologists to start using these drugs in their daily practice.” “Delegates can expect some excellent presentations on the topic, including an overview of the indications for immune checkpoint inhibitors in advanced urothelial carcinoma, the role of imaging and risk stratification.”

EAU onco-urology series

www.bca-rcc20.org

Accommodation included in registration fee for EAU Members!

www.esui20.org

www.erus20.org

ERUS-DRUS20

Palou and Stenzl are members in addition to Bex and Rouprêt.

Robotic Live Surgery

17th Meeting of the EAU Robotic Urology Section in conjunction with the 12th meeting of the German Society of Robotic Urology

ESUI20 9th Meeting of the EAU Section of Urological Imaging 12 November 2020, Athens, Greece In conjunction with the 12th European Multidisciplinary Congress on Urological Cancers

5-7 November 2020, Dusseldorf, Germany

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

European Urology Today

January/February 2020

ESUT20: 54 Cases on three screens over two days Almost 750 technology-minded participants welcomed to Leipzig By Loek Keizer Two days of non-stop surgery: that’s what the delegates came to Leipzig for and that’s exactly what they got. ESUT Chairman Prof. Liatsikos sees his section’s meetings as a chance to give delegates live surgery in an unadulterated form: “We’ve settled on a structure for our meetings: no talks, only surgery. We decided a few years ago that we would no longer have hands-on training at the ESUT meetings because people always want to see surgery. I feel that we offer a lot of other options for those who want hands-on training or other technical education.”

A chance to get hands-on with the latest tech

The 7th Meeting of the EAU Section of Uro-Technology boasted almost 750 uro-technology experts in the Kongresshalle am Zoo on 23 and 24 January. Attendance figures were undoubtedly boosted by members of the German Working Groups of Endourology, Laparoscopy and Robotic Assisted Surgery, as ESUT20 was organised in conjunction with these DGU bodies. Prof. Liatsikos: “This year we offered 26 live cases as transmitted from Leipzig University Hospital, 21 pre-recorded cases, and, remarkably: seven live transmissions from across the world. These came from China, Canada, Russia and the Netherlands. These cases were transmitted through the internet and we were very pleased with the streaming quality. This is clearly something to consider for future meetings.”

for the transmissions, with smaller rooms for meetings and exhibitions. All this together is key to success.”

ESUT20

23-24 January 2020 Leipzig, Germany

"Many leading surgeons are of course famous because of their excellent technique but it’s also a technique that has become or should become standardised." In terms of restructuring: this was the result of the ESUT20 scientific programme that calls for nearcontinuous live surgery in the hosting department to be displayed on two screens, and the third screen reserved for long-distance streaming and prerecorded cases. Prof. Stolzenburg: “Normally we have three ORs assigned to urology, now we needed five. The gynaecologists were kind enough to lend us their capacity for the two days. We were able to offer three ORs for endourology, and two Thanks to tight scheduling and long-distance broadcasting, delegates could at points see three simultaneous live procedures for laparoscopy and robotic surgery. So not only my own department was involved, but we had the support of the entire hospital. Many people told me “Kidney surgery is completely different from prostate how pleased they were with the meeting and naturally “There is also the opportunity to interact with the surgeon. Moderators can ask a surgeon to explain surgery. Every procedure is unique. You can have a that makes me proud.” certain choices or to demonstrate a specific approach. small tumour in the middle of the kidney which is They also pass on audience questions. In pre-recorded more difficult than a large one on the side. This is “Live is live” ESUT20 was a unique meeting in that it focused almost cases, the surgery simply proceeds with no interaction extremely individual. But even so you need entirely on live surgery. The meeting was held in one or chance to pause the procedure for an interaction. standardised techniques. I’m a fighter for room, with three screens and headsets that allowed Also, the surgeon will come to the venue after the standardisation, both in steps and in techniques.” participants to follow the moderated procedure of their procedure, giving an opportunity for further choice. What can surgeons learn from watching other discussion. In fact, many people use these events to “The EAU and its sections ESUT, EULIS and ERUS surgeons in this setting, as opposed to attending network, to meet top surgeons and invite them to their have important roles to play in standardising these master classes or hands-on training? centres for training purposes.” procedures. Many leading surgeons are of course famous because of their excellent technique but it’s Prof. Stolzenburg: “I’ve been doing live surgery for Prof. Stolzenburg himself was one of the surgeons on also a technique that has become or should about fifteen years and I’m a big supporter of its the first day of ESUT20, performing a robotic partial become standardised. I want the audience of a live educational value. Even an experienced surgeon can nephrectomy. When asked what he had hoped to surgery meeting to see surgeons follow the learn from other surgeons. In the end, the quality of teach the audience with this procedure, he explained standardised steps, and I hope that the audience surgery improves, and so does the patient outcome. that kidney surgery is particularly suited for picks this up and takes it with them to their own The EAU has set high standards for live surgery, demonstrative purposes. centres.” including a patient advocate, pre-surgery meetings and all sorts of safety measures. Over the years we have not seen a higher than average complication rate for patients treated in a live surgery setting.”

ESUT20 Chairman Prof. Jens-Uwe Stolzenburg looked back on a busy but rewarding two days as Leipzig, the Kongresshalle and his department hosted the meeting. Prof. Stolzenburg praised the cooperation between the ESUT organisers and his department at the University of Leipzig. Preparing the department “The meeting went fantastically,” Stolzenburg began. “First of all it was a very good cooperation between ESUT and our hospital. We know ESUT and Prof. Liatsikos very well, so with close communication it was very easy and straightforward to create a programme that our department could realise. We restructured our hospital’s units for this event. We were also pleased that the various companies and surgeons were happy to oblige, because we wanted to offer a variety of equipment for demonstrations at ESUT20.” “Secondly: we’re experienced in Leipzig. In 2018 we hosted the Challenges in Laparoscopy & Robotics meeting in the same venue. It is most suited to events like this, which require a large and dark single room

Prof. Jens-Uwe Stolzenburg welcomes the delegates to Leipzig

“Finally, I feel there is also a clear difference between live surgery and pre-recorded cases. Sure, pre-record (“semi-live”) recordings are a valuable part of the meeting. They allow a case to be condensed, and you can see a greater variety of procedures and approaches. But live is live. You see things you don’t see in semi-live. You can observe a surgeon dealing with unexpected developments as they crop up.”

12-15 November 2020, Athens, Greece

Implementing multidisciplinary strategies in genito-urinary cancers 12th European Multidisciplinary Congress on Urological Cancers In conjunction with the • 9th Meeting on the EAU Section on Urological Imaging (ESUI) • European School of Urology (ESU) • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) • Young Academic Urologists Meeting (YAU)

www.emuc20.org One advantage of live surgery is that moderators can pass on the audience' questions to the surgeons

January/February 2020

European Urology Today

Healthy hormones: Support for men on hormone therapy Five years after the first seminar – where are we now? prostate cancer. Using staff input and patient focus groups, we identified activities which would bring men and their loved ones together. The project is called the Advanced Prostate Cancer Club (APCC). To date we have provided 5 healthy hormone events, 4 daytrips to destinations in and around London, including Kew Gardens and Leeds castle, 2 art class courses, singing workshops and 2 very successful Christmas Lunch socials (the most recent of which louisa.Fleure@ involved 55 members enjoying lunch in a riverside gstt.nhs.uk pub in Greenwich). We have a regular walking group. We have also provided Look Good Feel Better In 2015 we published a paper in the International sessions, where men have participated in a Journal of Urological Nursing on a new service for men pampering workshop and were advised on skin care. on hormone therapy which we called ‘Staying healthy We have also run 3 ‘grave talks’ which are sessions on hormones’. This was an innovative way to provide run with the chaplaincy, palliative care and a local support and education for men on ADT regarding side undertaker, exploring issues around death and dying effect management and metabolic effects. in a safe space. Plans include an exercise club and memory book project. However, there have been (and We organised a seminar for men using hormone still are) some challenges. therapy away from the clinical area. The aims of the seminar were to understand treatment and its side "...an innovative way to provide effects, offer advice regarding side effect support and education for men management, suggest simple lifestyle changes to mitigate long-term metabolic effects and empower on ADT regarding side effect men to engage in primary care and play an active role management and metabolic effects" in their monitoring and care (improve self-efficacy). Louisa Fleure Lead urologyoncology CNS Guys and St Thomas NHS Trust London (UK)

Five years later, the seminars are still an important part of the care pathway for our patients. To date > 400 men and > 100 loved ones have attended the daylong event. I have presented in Europe, America, Australia and New Zealand. I am impressed and humbled by the way my fellow nurses have embraced the ideas and brought similar ideas to their own patient groups. Developments There have also been some exciting developments. We received a legacy donation from one of our patients for a project to support men with advanced European Association of Urology Nurses

Money The biggest challenge is funding. In order to run the Healthy Hormone days, we need to hire a room and provide refreshments. We have used a variety of means to pay for this over the years. For example, with the support of pharma or with charitable grants. And currently with the large legacy fund mentioned previously. However, this isn’t sustainable funding, thus one of our biggest challenges is making this service future-proof. To this end we have asked the group to propose ideas about fundraising. We set up a charitable website page in order to facilitate this. Members are planning a concert and a golf day, and even before these events, donations from members have already exceeded £2600. The page can be found at https://uk.virginmoneygiving.com/APCC

HYPERLINKS

Time Another challenge is the time commitment to make these projects successful. We have used some of the legacy funding to pay for a support worker who serves as contact person and organiser for events. This has been transformational, and she has become an essential and valued member of the team. Access for men Whilst the interest in seminars has been very positive, we are aware that not all men can or want to attend. We are looking into the reasons why and have started a focus group for black men to see whether the club could provide specific services to encourage more participation from this community. The feedback was that these men would prefer activity-based groups such as practical exercise classes. We are starting these soon. Measuring the impact Whilst feedback measured by questionnaires and by comments collected after events has been extremely positive, we are also working with colleagues to see whether attending seminars results in behavioural change in terms of diet and exercise. We are also collecting data on how attending the APCC affects measures such as anxiety, mood, and ability to socialise. Most of the feedback consists of emails, cards and letters from the men themselves. Peer support is a major unmet need for this patient group (Patterson 2017). This initiative meets that need, as is shown in the following feedback: “Many thanks for a most enjoyable social event at such a beautiful location. People were so relaxed and happy. You had everything organised perfectly. It made it so easy for us to mingle and meet new people” “There is such an empathetic connection amongst us which makes it so easy to talk about our experiences. I am amazed how positive our men and their partners are”

“Made my day seeing all my lovely friends.....receiving a warm welcome. Many thanks. Each walk opens discussions in the beautiful autumnal colours” “… it was good to even laugh with you after what has been a very difficult time following weeks of uncertainty and unreality. The thought of attending these events with others who are experiencing similar situations certainly makes the road ahead seem much more positive” “Meeting the other people in the group and talking to them and sharing the experiences of their prostate cancer journey was an eye opener. It made us realise that everybody has a different story to tell and that we are not on our own” “I was blown away by the kindness of the people attending and felt at home straight away” “Such a blessing to be with such an amazing group of understanding people” And from one 85-year old man after our “Look Good Feel Better” session: “Eyes, hair, mouth, make up The people they need to adore me So Christian Dior me from my head to my toes I need to be dazzling, I want to be rainbow high So Lauren Bacall me! Anything goes To make me fantastic, I have to be rainbow high” References Patterson et al. Unmet Supportive Care Needs of Men with Locally Advanced and Metastatic Prostate Cancer on Hormonal Treatment: A Mixed Methods Study. Cancer nursing 40(6). 2017 Fleure, L. ‘Healthy on Hormones’: improving the experience of men with advanced prostate cancer. International Journal of Urological Nursing, 9: 44–49. doi:10.1111/ ijun.12046. 2015

Urological Nursing

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January/February 2020

Nurses and Doctor of Philosophy (PhD) education - part 2 Diversity between universities a “strength which has to be underpinned by quality and sound practice" Corinne Tillier Nurse Practitioner Uro-oncology Antoni Van Leeuwenhoek Hospital Dept. of Urology Amsterdam (NL) c.tillier@eaun.org In the previous edition of EUT we explained why nurses are motivated to pursue PhD education. We will now discuss the striking variations of the requirements for doctoral education between European countries and even between universities in one country. All universities aim at offering high quality research and knowledge. Due to many differences in regulations and standards between universities, it seems legitimate to wonder whether the title of PhD has the same value between national universities in a country and across Europe. European University Association The European University Association (EUA) has formulated 10 recommendations for doctoral education in Europe (“Salzburg principles and recommendations”: https://eua.eu/downloads/publications/salzburg%20 ii%20recommendations%202010.pdf ). The EUA is aware of the diversity between universities and European countries but considers it a “strength which has to be underpinned by quality and sound practice”. The EUA refers to the primordial role of supervision and assessments in one of its recommendations. The grade of the main supervisor is not necessarily a professor, as is the case in e.g. the Netherlands. In Denmark, the supervisor must be “employed in the health sector and on the level of at least an associate professor” (Aarhus University). In the UK, the nurse European Association of Urology Nurses

can be supervised by a subject specialist and a methods specialist.

the necessity and advantages of doctoral nurses. It offers hope to French nurses.

Differences across Europe There are many differences across Europe with regard to PhD training and the rules for supervisor and doctoral dissertation. The EUA council for doctoral education has tried to highlight the differences across Europe by sending a survey (Eurodoc survey 2018) to European doctoral candidates. The results of the survey have not yet been completely analysed. From the raw data it is clear that there is a wide diversity across Europe concerning e.g. the duration of the doctoral training, which institutions are entitled to award doctoral degrees, the status and benefits of doctoral candidates, and transferable skills and qualifications required for doctoral supervision.

Something to aim for The title nurses acquire once they obtain their PhD is the same across Europe: Doctor (Dr.). However, a nurse from the UK explains the difficulties of using the title Doctor as a nurse nicely: “This is a title that is not without controversy and varying practice. Some people use the title, others do not. I personally use it in practice and when I present. I believe it should be used, as it gives nurses something to aim for. In practice I find that some medical doctors do not like it, they probably feel threatened”. This issue is likely not to be specific to the UK. But since doctoral nurses are not less educated than a physician who has achieved a PhD, they deserve respect and acceptation from their medical colleagues.

The nurse, as all other PhD students, has to face all these differences, however, a PhD nurse candidate also has to overcome obstacles. In some countries, such as Denmark, the Netherlands and the UK, obstacles have already been removed but in some European countries this is not the case yet. Situation in France The situation in France can be called exemplary: research by nurses and PhD are receiving great interest since 2009, the year the training of nurses was legally considered as a graduate study. However, the difficulties for French nurses to start and, maybe, finish a PhD training are comparable to climbing the Mont Blanc mountain! First the nurse has to develop a project plan and submit it to the hospital. Then, very often the nurse needs to find her own financial funds to allow the conduction of the PhD (an almost impossible mission). And of course the nurse must be affiliated to a university (this does not differ from other European countries). Many French nurses who are motivated to follow a PhD feel “forced” to move to Switzerland, Belgium or Canada because until recently a PhD was not available for them in France. Since 2018, some French university hospitals are becoming aware of

"...there is a wide diversity across Europe concerning e.g. the duration of the doctoral training, which institutions are entitled to award doctoral degrees, the status and benefits of doctoral candidates, and transferable skills and qualifications required for doctoral supervision."

Hanny Cobussen-Boekhorst (Nijmegen, NL) receives her well-deserved doctorate degree

recommendations and, maybe in future, guidelines, it seems that uniformity in doctoral education is still far away. We can also point out that PhD education requires a lot of perseverance and we can only hope that doctoral nurses will soon be recognised for it in many European countries.

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

No financial advantage There is one thing similar all over Europe with regard to doctoral nurses: they do not have any financial advantages (higher salary) because of their title. Most of the PhD subjects are about educational sciences, philosophy, ethics, sociology, management, clinical research (about work situations). In conclusion, there are still many diversities across Europe and even among national universities in PhD education. Despite the efforts of the EUA to make

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

"Spot-on" evidence-based nursing care New research and developments Dear EAUN members,

Selected from PubMed November-December 2019

The growing evidence in urology nursing care is amazing!

Bladder Cancer

With this column, the EAUN SIG Groups want to put the spotlight on recent publications in their field of interest. This month’s articles have been carefully chosen because of the scientific value from PubMed and represent different methods and approaches in research and development in urological nursing care. We hope this new initiative will have your attention and continuously provide information on "spot-on" urological nursing care. If you would like to inform us and your colleagues about new initiatives or exiting developments in one of the special interest fields you can contact us using the email addresses below. Best regards

Bente Thoft Jensen, Chair, EAUN Special Interest Group - Bladder Cancer b.thoft@eaun.org

Lawrence Drudge-Coates, Chair, EAUN Special Interest Group - Prostate Cancer l.drudge-coates@eaun.org

Anna Mohammed, Chair, EAUN Special Interest Group - Endourology a.mohammed@eaun.org

January/February 2020

• Consensus in Bladder Cancer Research Priorities Between Patients and Healthcare Professionals Using a Four-stage Modified Delphi Method. Bessa A, Maclennan S, Enting D, et al. Eur Urol. 2019 Aug;76(2):258-259. doi: 10.1016/j.eururo.2019.01.031. Epub 2019 Jan 31. Pubmed PMID: 30712969. • https://www.ncbi.nlm.nih.gov/pubmed/30712969 • Intravesical device-assisted therapies for non-muscleinvasive bladder cancer. Tan WS, Kelly JD. Nat Rev Urol. 2018 Nov;15(11):667-685. doi:10.1038/s41585-018-0092-z. Review. Pubmed PMID: 30254383. • https://www.ncbi.nlm.nih.gov/pubmed/30254383 • Health-related quality of life after BCG or MMC induction for non-muscle invasive bladder cancer. Siracusano S, Silvestri T, Bassi S, et al. • Can J Urol. 2018 Oct;25(5):9480-9485. Pubmed PMID: 30281005. • https://www.ncbi.nlm.nih.gov/pubmed/30281005 • Radical cystectomy (bladder removal) against intravesical BCG immunotherapy for high-risk non-muscle invasive bladder cancer (BRAVO): a protocol for a randomised controlled feasibility study. Oughton JB, Poad H, Twiddy M, et al; BRAVO study group. BMJ Open. 2017 Aug 11;7(8):e017913. doi: 10.1136/bmjopen-2017-017913. PubMed PMID: 28801444; PubMed Central PMCID: PMC5724134. • https://www.ncbi.nlm.nih.gov/pubmed/28801444

Prostate Cancer • Pain, fatigue and depression symptom cluster in survivors of prostate cancer. Baden M, Lu L, Drummond FJ, Gavin A, Sharp L. Support Care Cancer. 2020 Jan 24. doi: 10.1007/s00520-019-05268-0. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/31980895 • Cardiovascular Morbidity in a Randomized Trial Comparing GnRH Agonist and GnRH Antagonist among Patients with Advanced Prostate Cancer and Preexisting Cardiovascular Disease. Margel D, Peer A, Ber Y,

Shavit-Grievink L, Tabachnik T, Sela S et al. J Urol. 2019 Dec;202(6):1199-1208. doi: 10.1097/ JU.0000000000000384. Epub 2019 Jun 12. https://www.ncbi.nlm.nih.gov/pubmed/31188734 • "TREXIT 2020": why the time to abandon transrectal prostate biopsy starts now. Grummet J, Gorin MA, Popert R3, O'Brien T, Lamb AD, Hadaschik B, Radtke JP et al. Prostate Cancer Prostatic Dis. 2020 Jan 13. doi: 10.1038/ s41391-020-0204-8. [Epub ahead of print]. https://www.ncbi.nlm.nih.gov/ pubmed/?term=trexit+2020

Endourology • Current European Trends in Endoscopic Imaging and Transurethral Resection of Bladder Tumors, Frank Waldbillig, Simon Hein, Britta Grüne, Rodrigo Suarez-Ibarrola, Evangelos Liatsikos, Georg Salomon, Alexander Reiterer, Christian Gratzke, Arkadiusz Miernik, Maximilian C Kriegmair, Manuel Ritter. J Endouro. 2019 Nov 19. DOI: 10.1089/end.2019.0651. PMID: 31617417. https://www.ncbi.nlm.nih.gov/pubmed/31617417 • Does the Use of a Robot Decrease the Complication Rate Adherent to Radical Cystectomy? A Systematic Review and Meta-Analysis of Studies Comparing Open With

Robotic Counterparts. Lazaros Tzelves, Andreas Skolarikos, Panagiotis Mourmouris, Lazaros Lazarou, Nikolaos Kostakopoulos, Dimitrios K Manatakis, Ali Riza Kural. J Endourol, 33 (12), 971-984. Dec 2019. DOI: 10.1089/end.2019.0226. PMID: 31161777 https://www.ncbi.nlm.nih.gov/pubmed/31161777 • Robot Assisted Surgery of the Vena Cava: Perioperative Outcomes, Technique, and Lessons Learned at The Mayo Clinic. Kyle M Rose, Anojan K Navaratnam, Haidar M Abdul-Muhsin, Kassem S Faraj, Sarah A Eversman, Adyr A Moss 2, William G Eversman 3, William M Stone 4, Samuel R Money 4, Victor J Davila 4, Erik P Castle 1. J Endourol , 33 (12), 1009-1016. Dec 2019. DOI: 10.1089/ end.2019.0429. PMID: 31588787. https://www.ncbi.nlm.nih.gov/pubmed/31588787 • Postoperative Complications After Robotic Partial Nephrectomy. Jessica Connor, Sai K Doppalapudi, Ethan Wajswol, Radhika Ragam, Benjamin Press, Thaiphi Luu, Helaine Koster, Tenzin-Lama Tamang, Mutahar Ahmed, Gregory Lovallo, Ravi Munver, Michael D Stifelman. J Endourol, 34 (1), 42-47. Jan 2020. DOI: 10.1089/ end.2019.0434. PMID: 31588795. https://www.liebertpub.com/doi/abs/10.1089/ end.2019.0434

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Fellowship Programme

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ERUS-DRUS20 ERUS-EAUN Robotic Urology

Robotic nursing & live surgery

European Association of Urology Nurses

Nursing Meeting 5-7 November 2020, Dusseldorf, Germany An application will be made for accreditation by the Dutch National Society of Operating Room Assistants

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

The English and the German full-day nurses’ programmes will be organised on separate days

For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

European Association of Urology Nurses

EAUN20 spotlights the best of urology nursing Sessions to tailor treatments, foster rapport & raise efficiency How do you deal with uncommon, complex patient cases? Do you think that nurses and doctors view patient care the same way? Is it possible that treatment can be both quality and cost-effective? Top experts with the latest research in urology nursing will offer you crucial insights to these questions. Read on to know more about activities at the upcoming 21st International EAUN Meeting (EAUN20) which will take place in Amsterdam, the Netherlands from 21 to 23 March 2020. Are your patients misinformed? One of the many notable activities at EAUN20 is the workshop “Patient education: Organised structured or invisible - How to promote compliance” which will take place on Friday, 20 March from 14:30 to 17:15 hrs. Urology nurse Ms. Eva Wallace of the EAUN Special Interest Group Continence will chair the must-attend workshop. “Ask yourself, are your patients misinformed? Do they understand the consequences of noncompliance? The workshop aims to foster a culture of learning, focusing on identifying key enablers and barriers to patient education. It is fundamental to empower your patients. Help them by giving them the necessary tools to self-manage their own urological issues and be experts in their own care,” stated Ms. Wallace.

Between two perspectives “The interaction between nurses and physicians is of paramount importance in offering efficient and safe treatment to patients. By optimising the division of tasks, the patient is better informed and treated. However, it's time for a paradigm-shift!” said Dr. Stefan Haensel (NL) who will present the doctors’ perspective in the two-part lecture during the Plenary Session 1 “Collaboration between nurses and doctors”. The session will take place on Saturday, 21 March 2020 from 09:00 to 10:00 hrs.

Join the conversation at #EAUN20

wide review, which sought to tackle variations in the way services were delivered. The report called for the development of specialist urology nursing to help in delivering the messages of the session,” stated Dr. Alcorn.

For the complete Scientific Programme visit www.eaun20.org He added, “The session is designed to help HCPs improve patient care and outcomes; streamline processes in the workplace; develop the skills of specialist nurses. In addition, the session will also explore the exceptional current and future activities that the EAUN has and will establish urology nursing.” Know more on what to expect at EAUN20. Visit www.eaun20.org for more information.

21st International EAUN Meeting

Dr. Haensel stated that according to a survey, the two most important factors in patient satisfaction is how well the staff works together and a pleasant environment in the clinic.

Join us in Amsterdam!

21-23 March 2020, Amsterdam

Nursing solutions in difficult cases On Saturday, 21 March 2020 from 11:30 to 12:30 hrs., the Specialty Session 1 “Nursing solutions in difficult cases” will commence and overseen by EAUN Chair Elect Mrs. Paula Allchorne (GB).

Centred on incontinence, catheter-associated urinary tract infections (CAUTIs), and erectile dysfunction, the workshop will help nurses adopt effective teaching strategies for their patients' learning needs. Interested participants can register online or by sending an email to registrations@congressconsultants.com.

An expert jury has evaluated the submitted cases for the session. The jury is comprised of the following renowned and respected healthcare professionals

European Urology Today

Getting it right the first time Lead Nurse for Uro-Oncology and Andrology, and EAUN Board Member Dr. Jason Alcorn (GB) will chair the State-of-the-art lecture 2 “Improving quality of care: Getting it right the first time (GIRFT)” which will kick-start on Sunday, 22 March 2020 from 11:00 to 11:30 hrs.

“The session is a must for those interested in boosting efficiency and cost-effectiveness in their daily practice. He added, “As an example, optimal patient care doesn’t Esteemed consultant urologist for over 20 years, Mr. always mean a speedy diagnosis. The first priority is to Simon Harrison (GB) will share valuable insights during this session. Mr. Harrison has led an Englandhelp a patient cope with fear and uncertainty. This can be achieved by providing reliable information and treatment strategy tailored to fit the patient.”

Generally, the EAUN Guidelines focuses on patient cases that are often encountered. The Specialty Session at the upcoming EAUN Congress will address and discuss atypical and/or difficult cases faced in daily nursing practice. The session will also offer delegates the opportunity to exchange knowledge; from discovered solutions to pressing, unanswered questions.

(HCPs): urology nurse Ms. Helen Forristal (IE), head nurse Mrs. Françoise Picard (FR), urology nurse Mr. Ronny Pieters (BE), urology nurse Ms. Eva Wallace, and professor in Surgery and Urology Prof. Steen Walter (DK).

in conjunction with

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January/February 2020

European Urology Today Vol. 32 No.1 - January/February 2020

Articles inside

Vol. 32 No.1 - January/February 2020