European Urology Today Vol. 33 No.1 - January/February 2021

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European Urology Today Official newsletter of the European Association of Urology


Vol. 33 No.1 - January/February 2021

News from the European Union

Access the “living textbook”

The new gold standard?

EUpdate on the EAU campaign on prostate cancer

Open-access book on urogenital infections and inflammations

The management of complex recto-urinary fistulas with gracilis muscle interposition

Mrs. S. Collen


Prof. K. Naber


Prof. J. Romero-Otero

Urology education takes flight online in challenging times ESU Online is the umbrella for EAU’s educational activities in times of remote learning By Loek Keizer For about a year now, the absence of physical meetings has not slowed down the EAU’s ambitions in offering continuing medical education and training the next generation of urologists. As an EAU member you will have noticed that in the absence of physical meetings, a lot of the EAU’s activities have moved online. This includes the European School of Urology’s many masterclasses, courses and training activities, which now fall under the banner of “ESU Online”. These online activities address the hottest topics, the current state-of-art care and all of the latest technology. Perhaps most importantly, the ESU Online curriculum is accredited as opportunities for continued medical education have diminished in the past year. Joint forces This redevelopment of the EAU’s educational content is the result of the joining of forces between the ESU, the EAU’s Guidelines Office and Section Office. Each provided input into the new educational programme from their own unique expertise. A strategic planning task force was established, including representatives from each office. Their input was analysed and structured to create a holistic educational programme. The topics were chosen to cover the rest of 2021, with activities scheduled between two to three months in advance. This allows ESU Online to act quickly to new developments, attract speakers and prioritise certain topics.

"A lot of the EAU’s activities have moved online. This includes the European School of Urology’s many masterclasses, courses and training activities" Topics are the most important distinction for the different curricula. Arranged by topic, a curriculum features a mix of different formats, such as live or pre-recorded lectures, e-courses, discussions, and so on. Together, these different modules offer participants a concentrated and structured way of learning, in a single topic-based overview of available activities. The first multipart curricula for 2021 have been kicked off: “Current challenges for optimal individualised management of LUTS/BPE patients” and “Personalised management of Prostate Cancer patients with history and risk of CVD events”. New formats One pillar of ESU Online is the UROwebinars series. The UROwebinars are an online-only effort that predates the pandemic conditions, but has certainly taken flight since public events have become impossible.

questionnaire, 1 CME is awarded to the participant. UROwebinars are recorded and also made available on the EAU’s YouTube channel, where they reach another audience of thousands. In 2016-2019, six or seven UROwebinars took place annually, attracting on average 300-500 registrations. In 2020, the number of webinars increased to 29, averaging over 1,000 registrations per webinar. This is on par with the EAU’s larger events and much larger than regular educational courses or masterclasses. Webinars also supplemented the EAU20 Virtual Congress in the summer, joining a virtual selection of the ESU Masterclasses that are normally held on location, in conjunction with the EAU’s Annual Congress.

"The EAU’s online educational portfolio will be stronger and more comprehensive than it was before 2020" Particularly popular topics over the past year are related to prostate cancer, urinary stones and other surgical topics. In 2021, UROwebinars are so far scheduled to cover MRI fusion, paediatric urology, incontinence, bladder cancer and much more. New formats developed under ESU Online include the UROmotion video series. This marks an emphasis on surgical education, when traditional “hands-on” has become more difficult. UROmotion consists of step-by-step surgical videos, and live moderation of surgical videos to show the entire procedure in real time. Another new development under the ESU Online banner is the Tech Forum. The latest technical developments in surgical instruments, robotics, imaging and more will be discussed and critically reviewed by a panel of leading experts for an unbiased analysis. Accreditation and future As an online alternative to the more conventional on-site training options, the ESU Online courses, webinars and other parts of the curriculum are accredited. In order to claim CME points, participants will need to register in advance and take part live. (In some cases, a webinar is turned into an on-demand, accredited E-course.) ESU Online uses the MyEAU account to track progress and manage accreditation for attendance. Please note that a MyEAU account is not exclusively for EAU members, non-members can easily create an account and take part in the ESU Online programme. Be sure to update your MyEAU profile with your field(s) of interest. This will help us reach you with relevant ESU Online and other (online) events.

While online education is at the moment driven by necessity, the introduction of online education The UROwebinars are regularly-occurring online predates the global pandemic and will continue even seminars that have already covered a wide variety of once in-person events become feasible again. We feel topics, presented by experts on the respective topics. the online events are popular and well-received, and These webinars are designed to last around an hour, we will continue to offer opportunities for convenient take place in the early evening and can be joined by additional learning in the coming years. The EAU’s registering in advance. Upon completion of a online educational portfolio will be stronger and more comprehensive than it was before 2020. Check for updates. ESU Online Events are free to attend, also for non-members! Create and/or Update your MyEAU Profile so we can let you know when another event is coming up! January/February 2021

Education Online is now ESU Online All online educational activities by the European School of Urology in collaboration with the EAU Sections and Guidelines panels are now joined in the ESU Online curriculum. Join us in one of the upcoming ESU Online events!

Upcoming ESU Online Events 16 February UROwebinar Genetics in stone disease 18 February UROwebinar Fistulae repair 23 February UROwebinar Future roles for liquid biopsies in clinical decision making in uro-oncology 25 February UROmotion Penile Cancer Reconstruction 8-9 April ESU-ESOU Virtual Masterclass on Muscle-Invasive Bladder Cancer 22-23 April ESU-ESUT Virtual Masterclass on Operative management of benign prostatic obstruction 6-7 May ESU-ESUT-ESUI Virtual Masterclass on Focal therapy for localised prostate cancer Go to for registration details.

Hosted on the ESU Education Platforms

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European Urology Today


Seeding grants: Call for applications EAU RF supports highly innovative and original research by junior investigators Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ 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. Last year, the EAU Research Foundation (EAU RF) announced the availability of ‘seeding grants’ for short-term studies. A final selection from the 30 submissions was made during the first months of 2020. Following personal interviews with candidates, one was funded with € 25,000. The EAU RF is pleased to announce another opportunity for seeding grants, with the aim of supporting highly innovative and original research by a junior investigator. The call for applications is currently open, with a deadline closing on Wednesday 31 March 2021. Applicants are invited to submit one-year research projects with a total budget of 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.

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) Assoc. Prof. F. Sanguedolce, Barcelona (ES) Prof. S. Tekgül, Ankara (TR) 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 Disclaimer No part of European Urology Today (EUT) may be reproduced without written permission from the Communication Office of the European Association of Urology (EAU). The comments of the reviewers are their own and not necessarily endorsed by the EAU or the Editorial Board. The EAU does not accept liability for the consequences of inaccurate statements or data. Despite of utmost care the EAU and their Communication Office cannot accept responsibility for errors or omissions.

“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.” Funding amounts to a maximum of € 50,000 in total for two projects. The applicant must be an academically active researcher/clinician, a member of the EAU, and be younger than 40 at the time of the submission deadline. The total project period is one year. Successful projects will start in June 2021 and will end in June 2022.

First step Each application will be independently scored by three reviewers. The applications will be allotted to the reviewers in order to avoid potential bias (i.e., projects will not be reviewed by their own division/ centre/institute affiliates). The evaluation criteria for the first step of the 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

“These projects should be designed to collect or strengthen preliminary data and to help the start of clinical trials or other clinical research projects.” Reviewers will discuss the scoring results of individual applications and will reach a consensus ranking list. Second step The top 2-3 applicants will be invited to a personal meeting with the review panel, consisting of a brief presentation of their proposal (ten minutes) and a question & answer session. Reviewers will rank the candidates based on the following criteria:

Prof. Anders Bjartell, EAU RF Chairman

prospects, issemination, and impact (a written project proposal should not exceed two pages). • Specification of the costs / budget using the following categories: laboratory costs, travel costs, personal hours, other expenses. All details on the submission can be found on the application form via

Necessary steps to be taken by the applicant for the seeding grant: 1) The above-listed documents must be completed according to the specifications above (i.e. project proposal of two pages max.) and sent to the EAU RF according to the details on the form no later than Wednesday 31 March 2021 at 23.59 Central European Summer Time by email ( All applicants will receive a message of receipt. If you miss this deadline, your application can unfortunately not be accepted for evaluation this time. 2) The top 2-3 applicants will be invited for a personal meeting with the review panel in April 2021.

• 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: • A completed application form (.docx) • Their CV and list of publications • A copy of their passport • A written project proposal specifying the background, aims and objectives, project description and a paragraph with future

Budget The maximum budget request is € 25,000. Funds can be spent on salaries (including that of 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 of the application form. Ethical Issues • Research involving human subjects and/or vertebrate animals must comply with the relevant European and national laws. • All funded research must be conducted within the research ethics guidelines of the National Health and Medical Research Council. • Institutional approval by the appropriate ethics committee(s) must be demonstrated prior to release of funds. • Certification that approval has been given should be forwarded with the application or as soon as available. The evaluation process Applications that are incomplete or do not comply with the requirements stated in this Call for Applications will not be accepted. Grants will be awarded on a competitive basis. All accepted applications will undergo a two-step selection process. The review panel will be composed of the members of the EAU Research Foundation Board and an external expert reviewer, if needed.

Send your application to become member of one of the ten YAU Groups now!

Submission deadlines: 1 March - 1 July - 1 November Please check our website for details regarding the eligibility criteria and application procedure: or contact the office via

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 – or check our website

EAU Research Foundation


European Urology Today

January/February 2021

Update from the EAU Guidelines Office The European Network of Excellence for Big Data in Prostate Cancer PIONEER The European Network of Excellence for Big Data in Prostate Cancer (https:// gains momentum as further Data Sharing Agreements signed with external data contributor Prof. Mauro Gacci prostate cancer research group lead at the Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, Florence, Italy. Prof. Gacci and his research team have agreed to share three important datasets with PIONEER: two from the Italian National Research Council (MIRROR and Pros-IT CNR), and one from Unit of Urological Robotic Surgery and Renal Transplantation Careggi University Hospital Florence (Florence [PDF]), all via the centralised data sharing model.

MIRROR is a multicentre Italian dataset on radical prostatectomy outcomes and research which contains data from 2,408 men who underwent radical prostatectomy for prostate cancer from October 2007 to December 2008. Pros-IT CNR is an Italian prostate cancer monitoring dataset that contains data on 1,787 men diagnosed with biopsy-verified treatment-naïve prostate cancer after September 2014. The Florence [PDF] dataset contains data from >1000 men who underwent radical prostatectomy for prostate cancer from 2017. Prof. Gacci the principal investigator of all three studies told us why he believes it is important for researchers across Europe to contribute their data to Big Data initiatives: “We choose to contribute data to PIONEER because many of us only know our own perspective on a given question or problem, and therefore know very little. It is only with the shared knowledge derived from

studies on Big Data that we will be able to access new opportunities for progress” Prof. Mauro Gacci’s research group consists of urologists and PhD students Dr. Riccardo Campi and Dr. Simone Morselli and urologist in training Dr. Isabella Greco. The work of the group would not be possible without the continued support of Units Chief Prof. Sergio Serni. As well as engaging new data contributors, PIONEER is currently mapping 3 already shared datasets to OMOP, the European Common Data Model, with an additional 4 due to start early 2021. Once complete this will bring the total number of datasets in the PIONEER Big Data prostate cancer platform to 15: allowing us to answer more of the research gaps in prostate cancer care. Are you interested in joining this exiting project and contributing data to PIONEER? Contact us at Urology education takes flight online in challenging times. . . . . . . . . . . . . . . . . . . . . . 1

Guidelines Office Systematic Reviews 2019 Our Guidelines Office Associates have been most productive in supporting the Panels in the production of systematic reviews. The list below shows the citations for some of the 2019 publications (January 15, 2021). # citations 2019 Guidelines Office Systematic reviews (date assessed 2021, January 15th) 80 Prognostic Value of Biochemical Recurrence Following Treatment with Curative Intent for Prostate Cancer: A Systematic Review. Van den Broeck T, et al. Eur Urol. 2019 Jun;75(6):967-987. 50 Oncological Outcomes of Laparoscopic Nephroureterectomy Versus Open Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: An European Association of Urology Guidelines Systematic Review. Peyronnet B, et al. Eur Urol Focus. 2019 Mar;5(2):205-223. 31 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. Veskimäe E, et al. Eur Urol Oncol. 2019 27 Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel. Silay MS, et al. Eur Urol. 2019 Mar;75(3):448-461. 22 Potential Benefit of Lymph Node Dissection During Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the European Association of Urology Guidelines Panel on Non-muscle-invasive Bladder Cancer. Dominguez-Escrig JL, et al. Eur Urol Focus. 2019 Mar;5(2):224-241. 21 Management of Sporadic Renal Angiomyolipomas: A Systematic Review of Available Evidence to Guide Recommendations from the European Association of Urology Renal Cell Carcinoma Guidelines Panel. Fernández-Pello S, et al. Eur Urol Oncol. 2020 Feb;3(1):57-72.

Updated Guidelines available in March

New additions EAU Urolithiasis panel

Prof. Dr. Giovanni Gambaro

Prof. Dr Bhaskar Somani

The GO would like to extend a warm welcome to two new additions to the EAU Urolithiasis panel, Prof. Dr Bhaskar Somani and Prof. Dr. Giovanni Gambaro. Prof. Dr. Somani is a consultant endourologist based at University Hospital Southampton in the UK and will serve as a full panel member. Prof. Dr. Giovanni Gambaro is the head of nephrology and dialysis at Università degli Studi di Verona and serve as the panel’s special consultant on nephrology. Both panel members will be extensively involved in forthcoming revisions to the Urolithiasis and Bladder Stones guidelines.

YAU and GO collaboration Over the past years Guidelines Associates have most successfully supported updating and development of the EAU Guidelines, as well as taking part in other projects such as PIONEER, IMAGINE and consensus meetings. In 2021, the Young Academic Office will be joining forces with the GO, starting with several systematic reviews, in collaboration with certain Guidelines Panels, addressing current gaps in the literature. The GO is very much looking forward to a successful collaboration which will no doubt expand to other areas of interest for both groups. Guidelines Office

January/February 2021

EAU RF: Seeding grants: Call for applications. . . . . . . . . . . . . . . . . . . . . . . . . . 2 Update from the EAU Guidelines Office. . . . . . 3 EAU21: Offering the best of science, with new elements. . . . . . . . . . . . . . . . . . . . . 5 News from the European Union. . . . . . . . . . . 6 Facilitating exchanges of knowledge . . . . . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 TransPot: Tackling incurable prostate cancer. . 8 ESUO: Conservative treatment options for women with SUI. . . . . . . . . . . . . . . . . . . . 9 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . 10-13 ESUP: Queries from a patient with intraductal prostate carcinoma. . . . . . . . . . . 14 SATURN Registry enrols 750th patient. . . . . . 15 ESU section: 1st virtual ESU-ESUI Masterclass on Prostate biopsy. . . . . . . . . . . . . . . . . . . . . . . 17 ESU-ESUT Masterclass in Lasers in urology: A recap. . . . . . . . . . . . . . . . . . . . . . 17 Access the “living textbook”. . . . . . . . . . . . . 18 ATU annual meeting features vital updates on infections. . . . . . . . . . . . . . . . . . 19 Virtual ESU course and Albanian-Kosovan congress. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Virtual ESU Course delivers BPH fundamentals in Baghdad . . . . . . . . . . . . . . 21 ESU course imparts tips and tricks in challenging surgeries. . . . . . . . . . . . . . . . . . 21 ESGURS: The new gold standard?. . . . . . . . . 22 EAU Patient Information’s Working Group 2021. . . . . . . . . . . . . . . . . . . . . . . . . . 23 ESFFU: Latest developments in non-neurogenic LUTS treatment. . . . . . . 24-25 Legends in Urology – Prof. Imre Romics. . . . 27 YUO: My experience with mandatory resident rotation. . . . . . . . . . . . . . . . . . . . . . YAU Urolithiasis & Endourology Working Group. . . . . . . . . . . . . . . . . . . . . . . Young Academic Urologists Update . . . . . . . ESPU goes virtual in 2020. . . . . . . . . . . . . . . New Chair for YAU Working Group on Paediatrics in Urology. . . . . . . . . . . . . . . . . .

28 28 28 29 29

New SuperPulsed Laser (Soltive) first Romanian experience . . . . . . . . . . . . . . 30 Obituary Prof. Giorgio Pizzocaro. . . . . . . . . . 30 EAUN section: Provision of advanced uro-oncological care. . 31 A varied new EAUN21 programme to look forward to. . . . . . . . . . . . . . . . . . . . . . . 32

European Urology Today


Cutting-edge Science at Europe’s largest Urology Congress

Join us in Milan!

EAU21 is now a 4 day event 4

European Urology Today

January/February 2021

EAU21: Offering the best of science, with new elements Among great global uncertainties, the EAU is on course for EAU21 By Juul Seesing From 9 to 12 July 2021, the 36th Annual EAU Congress (EAU21) will offer the very best of urological science with challenging lectures, fascinating HD video surgery sessions, practice-oriented courses, and more. In that respect, nothing has changed in comparison to previous editions – but EAU21 will feature exciting new elements as well. In this period of great uncertainty due to the Covid-19 pandemic, a mathematical certainty is that EAU21 will offer state-of-the-art urological science and education as delegates are used to, either in a virtual or ‘hybrid’ fashion, the latter being a face-to-face meeting with accredited livestreams.

“The active participation of patients is one of the most important new elements of EAU21.” Prof. Peter Albers (Düsseldorf, DE), chair of the Scientific Congress Office (SCO), gave us a first look at the scientific programme. “Our current issue is, of course, that we do not know what the situation will be in Milan in July. We have to have multiple plans to be able to adapt if necessary,” he points out. “We are currently preparing a hybrid meeting for EAU21, for instance with physical sessions that are livestreamed and available online on-demand the next day. The thematic and plenary sessions will be held as usual, with gripping topics such as ‘Reconstructive surgery: Did the robot take over?’ and a Nightmare session on early detection of prostate cancer. The poster sessions, however, will introduce a few changes.” Novelties “First of all, we added four new subtopics for the abstracts: ‘Affordable medicines and technologies’ for scientists who contribute to the improvement of urological patient care in low-income countries with their research on affordable treatments, ‘Guidelines’

for research that assesses urological Clinical Practice Guidelines, ‘Trials in progress’, and ‘Patients’. This patient subtopic allows for a discussion with patient advocates. The aim is to improve communications and promote collaboration between healthcare professionals and patient advocates. The active participation of patients is one of the most important new elements of EAU21. The EAU is one of the first large scientific societies to actively enrol patients in its annual meeting.” “The poster sessions themselves will merge the well-known Expert-Guided Poster Tours with the classical poster presentations. Our plan is to hold Poster Discussion Sessions in large rooms taking three to four posters together and discuss them on stage like we used to do in the Expert-Guided Poster Tours. We specifically aim to select excellent moderators, and in this way we hope to generate a new, more efficient way to deliver new scientific knowledge while practising social distancing.” Tracks “Another novelty is that we will structure EAU21 more closely around thematic ‘tracks’ such as prostate cancer, imaging, and functional urology. We already did this to some degree in previous years, but now we have explicitly defined special tracks in which we combine sessions, select the best abstracts; in short, in which we present cuttingedge knowledge of that subspeciality. This will allow for both the online and in-person visitor to structure their own personal meeting by means of a user-friendly selection of high-quality science that is most interesting to them.”

“The EAU is one of the first large scientific societies to actively enrol patients in its annual meeting.” This structure will also influence the souvenir session: the usual closing session of an Annual EAU Congress,

which offers delegates who were not able to attend every session they were interested in an overview of highlights from the sessions they might have missed. Prof. Albers: “For EAU21, the souvenir session will be named the ‘Best of EAU 2021 session’. We plan to have these tracks I mentioned structure the souvenir session, too. The SCO is going to select three best abstracts per track to be presented and discussed by an SCO member expert in this particular subspeciality.”

“We have to have multiple plans to be able to adapt if necessary.” Hybrid or virtual meeting Prof. Albers: “We hope for a mostly in-person meeting in order to bring together the European urology community as we have done in the past. However, we had a very positive experience with EAU20 Virtual last year, which became an instructive meeting. This showed us that a virtual meeting does not mean a reduction in quality compared to a physical meeting. We are now trying to merge the best of two worlds.” Register now for EAU21 and benefit from the discounted early fee! We are offering two different options for registration: a face-to-face/hybrid registration and a virtual-only registration. Please visit for more information.

Prof. Peter Albers, chair of the EAU Scientific Congress Office (SCO), presenting at EAU19 in Barcelona

Europe’s Beating Cancer Plan brings hope to PCa patients Prostate cancer among the cancers considered for possible extension of targeted cancer screening Mrs. Sarah Collen EAU Policy Coordinator Brussels (BE) We warmly welcomed the launch of Europe’s Beating Cancer Plan of the European Commission earlier this month, in particular the planned activities under early detection. The Commission aims to propose an update on the European Council’s Recommendation on cancer screening by 2022, including the potential addition of new cancers such as prostate cancer.

“This welcome announcement could unlock a new era of better outcomes for prostate cancer patients.” This gives the EU a unique opportunity to tackle the current unacceptable rise in mortality rates and ‘too late’ diagnoses of prostate cancer while avoiding the overdiagnosis and overtreatment challenges of the past. If Europe’s Beating Cancer Plan can harmonise an approach across the EU with regards to early detection of prostate cancer, we believe this will not only decrease mortality from prostate cancer but also support EU member states to sort out the current mess of opportunistic testing for prostate cancer, which has proven to be ineffective, with no mortality reduction and considerable risk of overdiagnosis. We at the EAU stand prepared to work with the Commission to provide scientific evidence and guidance on a clear and strategic approach to early detection of prostate cancer throughout Europe. January/February 2021

Linked to the EU Cancer research mission, which will develop novel approaches for screening and early detection and provide options to extend screening to new cancers, this welcome announcement could unlock a new era of better outcomes for prostate cancer patients.

“This gives the EU a unique opportunity to tackle the current unacceptable rise in ‘too late’ diagnoses of prostate cancer.”

especially those from black and ethnic minority backgrounds. Now is the time to change the outcomes for men across Europe. The recognition of prostate cancer in Europe’s Beating Cancer Plan as one of the cancers to be considered for the possible extension of targeted cancer screening is a first milestone in achieving this.


Recommendation s for the EU Can cer Plan to tackle Prosta te Cancer

The 2020 EAU White Paper on Prostate Cancer presents recommendations on what can be done by the EU at European level in the fight against prostate cancer. To read the White Paper visit

Innovation on prostate cancer EAU leads the academic consortium of the IMI’s Big Data for Better Outcomes programme on prostate cancer, which is three years into a five-year programme of creating a federated platform which can support necessary research. We are certain that this can contribute to several initiatives addressed in the plan: the European Knowledge Centre on Cancer, the European Initiative to Understand Cancer (, the European Cancer Imaging Initiative and the broader European health data space to support research and innovation on prostate cancer. We also believe that the creation of National Comprehensive Cancer Centres and inter-specialty training programmes (for oncology, surgery and radiotherapy) are promising steps towards a more effective and holistic diagnostic and treatment package for cancer patients across the EU. Why prioritise prostate cancer? Europe’s Beating Cancer Plan was published as Europe is facing a growing challenge from prostate cancer, the most diagnosed male cancer and the second leading cause of male cancer death. Every year, around 450,000 European men are diagnosed with prostate cancer, with over 2 million men across the EU now living with the disease. On top of this, the Covid-19 pandemic is hitting the same demographics as prostate cancer: older men,

Ursula von der Leyen, President of the European Commission, addresses the European Parliament at the announcement event of Europe’s Beating Cancer Plan on World Cancer Day, 4 February 2020 Source:

European Urology Today


News from the European Union Update on the EAU campaign on prostate cancer The European Health Data Space (EHDS) In other news, we have been following the plans for the establishment of EHDS, which is currently being designed. The idea is a federated data space that encourages safe and ethical sharing of data for both primary (individual healthcare) and secondary (research, etc.) purposes. There are clear links with the work of PIONEER, the big data platform to enhance prostate cancer diagnosis and treatment, and we have been exploring with the European Commission how we may collaborate in the future. There is work that needs to be done on data The long-awaited EU Cancer Plan was expected at governance and infrastructure, including a code of the end of 2020, but as the second wave of conduct on primary and secondary use of health data, coronavirus spread across the EU, the European which will be in line with the EU’s General Data Commission took the decision to delay the publication Protection Regulation (GDPR). We at the EAU are until early 2021. We now expect the plan to be interested to engage on these issues to learn how this launched on the eve of World Cancer Day. can support us in our research and clinical guidelines. Mrs. Sarah Collen EAU Policy Coordinator Brussels (BE)

While we await the publication, the EAU continues the advocacy work calling for more attention to prostate cancer in the EU Cancer Plan. We keep on circulating the White Paper on Prostate Cancer and the recording of the virtual European Prostate Cancer Awareness Day (EPAD20), which can be found at

“The resolutions of the European Cancer Summit included our recommendations to develop EUwide guidelines on early detection of prostate cancer.”

An article was also published in European Urology which highlights the algorithm for early detection for European policy makers.

Update from the European Medicines Agency (EMA) In December, the EMA held a meeting on big data for stakeholders, which was attended by Prof. Theo De Reijke (NL) and Mrs. Collen on behalf of the EAU. The meeting gave an update on the EMA plans to use big data for regulatory purposes, which includes a project which will be linked to EHDS. In addition to the importance of the role of health care practitioners in this process, the PIONEER project was referenced by a number of participants. On a similar subject, a group of EAU experts on registries have written a joint EAU response to the EMA Guideline on registry-based studies for regulatory purposes. The EMA also organised a public session on COVID-19 vaccines, which gave an interesting and thorough

Let’s Talk Prostate Cancer We are also involved in the Let’s Talk Prostate Cancer campaign, which is a collective effort sponsored by Astellas. The campaign is led by an Expert Group which includes Prof. Hein van Poppel (BE) from the EAU, along with other key prostate cancer stakeholder organisations, including Europa Uomo, the European Oncology Nursing Society (EONS), the European Cancer Patient Coalition (ECPC) and the European Association of Urology Nurses (EAUN). In December, the campaign launched a Prostate Cancer Digital Atlas providing an overview of prostate cancer outcomes across the different EU member states. This atlas can be accessed through www.

picture of the development and approval processes for the vaccines. The recording can be found here:

There will be a revision of the EU legislation on orphan and paediatric medicines and a renewed effort to find an agreement on the Health Technology Assessment (HTA) Regulation.

“The European Health Union is designed to ensure that the EU will be more prepared to tackle health crises like COVID-19 in the future.” Prof. Theo De Reijke (NL)

European Health Union In November, the European Commission also published two health-related policies. The first of these was the ‘European Health Union’, designed to ensure that the EU will be more prepared to tackle health crises like COVID-19 in the future. There will be increased investment in preparedness structures and mechanisms to support public health emergencies in the future, including a strengthened role for the European Centre for Disease Prevention and Control and the European Medicines Agency. It also includes plans for a new agency called the Health Emergency Response Authority (HERA) to rapidly deploy vaccines and the most advanced medical equipment, covering the whole value chain from conception to distribution and use, and to rapidly take measures in the event of a health emergency. EU Pharmaceutical Strategy The second policy launched in late November was the EU’s pharmaceutical strategy on availability and affordability of medicines. This is a broad package of measures ensuring access to affordable medicines for patients and addressing unmet medical needs (e.g. in the areas of antimicrobial resistance and rare diseases); supporting competitiveness, innovation and sustainability of the EU’s pharmaceutical industry; providing crisis preparedness and response mechanisms, and addressing medicine shortages.

The ERICA Project: ERNs joining forces on research and innovation The European Rare Disease Research Coordination and Support Action (ERICA) Project received a positive evaluation for an Horizon 2020 grant to establish a structural framework in support of the research activities of the 24 ERNs. ERN eUROGEN is very happy to be part of this project as the ERN dedicated to patients with a rare urogenital disease or complex condition. ERICA will strengthen research and innovation capacity by the integration of ERN research activities, outreach to European research infrastructures to synergistically increase impact and innovation. This will result in efficient access and safe therapies for the benefit of patients suffering from rare diseases and complex conditions. The ERICA Project builds on the strength of the 24 ERNs by promoting inter-ERN research activities and by establishing firm collaborative ties with existing European and international infrastructures and consortia involved in rare disease research and innovation. The ERICA Consortium also includes EURORDIS, the EJP RD, Orphanet, Mapi Trust Research, and EATRIS, and is coordinated by Alberto Pereira (ENDO-ERN coordinator, Leiden University Medical Center, NL). For further information, please contact us via our website:

Research infrastructures


Rare Disease Consortia


All 24 ERNs

Sara MacLennan (GB)

European Cancer Summit Prof. Arnulf Stenzl (DE) represented the EAU at the European Cancer Organisation board meeting in November 2020. Together with Prof. Van Poppel, Dr. Sara MacLennan (GB) and Mrs. Sarah Collen (BE), he also attended the European Cancer Summit from 17 to 18 November 2020. This was a great opportunity to highlight our concerns on prostate cancer, too, and the resolutions of the summit included our recommendations to develop EU-wide guidelines on early detection of prostate cancer (see

Industry European Commission

ERNs Bodies Board of Member States Coordinators Group

Facilitating exchanges of knowledge ERN eUROGEN stimulates collaboration in the field of rare uro-recto-genital diseases By Ms. Jen Tidman (NL), eUROGEN Business Support Manager European Reference Networks (ERNs) are virtual networks involving healthcare providers across Europe. They aim to facilitate discussions on complex or rare diseases and complex conditions that require highly specialised treatment and a sufficient concentration of knowledge and resources. The first ERNs were launched in March 2017, involving more than 900 highly specialised healthcare units from over 300 hospitals in 26 EU countries. 24 ERNs are working on a range of thematic issues including bone disorders, childhood cancer and immunodeficiency. ERN eUROGEN, one of the 24 ERNs, deals with rare uro-recto-genital diseases and complex conditions. It 6

European Urology Today

actively collaborates with patient organisations in the field, EURORDIS, the EAU, ARM-Net, ESSIC, ESPU and EUPSA. Last year the network consisted of 29 full members from eleven countries, twelve associated national centres from four countries and four coordination hubs based in an additional four EU countries. However, the UK's withdrawal from the EU took effect on 1st January 2021 and UK healthcare providers have ceased to be part of the ERN eUROGEN network. This means that eUROGEN now comprises 23 full members, rather than the original 29. The strong collaboration is expected to continue with clinicians outside the EU as individual experts in areas such as research and education. Funded by the European Commission, the objective of the ERN Exchange Programme is to spread and share knowledge, stimulate collaboration between healthcare professionals, and to help fill gaps in

expertise by facilitating the arrival of professionals with high-level expertise in a considerable number of diseases at a large number of healthcare providers. In the coming two years ERN eUROGEN has 35 exchange packages to distribute across the network, each lasting an average of 5 working days. Three different rounds of exchange visits will take place between such professionals. The first round of visits was planned to start in March but will now be postponed until the summer or later, due to COVID-19 restrictions. Exchanges in ERN eUROGEN The exchanges in ERN eUROGEN will focus on spreading knowledge of supra-specialised urology surgery and will also support exchange visits from other members of the multidisciplinary team. In February, healthcare providers who are a member of ERN eUROGEN will be able to sign up to host an

exchange between healthcare providers using an online platform which has been developed for the ERNs. Trainees who want to apply for an exchange will also be able to use this online platform to submit their applications.

“If you would like to receive advice on a patient with a rare urorecto-genital disease or complex condition, please contact us.” For further information, please contact ERN eUROGEN via our website here: If you are a healthcare professional and would like to receive advice from our network on a patient with a rare uro-recto-genital disease or complex condition, please contact us via this website, too. January/February 2021

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


Case study No. 67 This 42-year-old man had a traumatic urethral catheter placement with a false passage after surgery for inguinal hernia. Two months later, he had acute urinary retention and it was not possible to pass a catheter beyond the fossa navicularis. A suprapubic catheter was placed. A voiding cystogram suggested bladder neck contracture (Fig. 1). A guidewire was inserted into the suprapubic catheter followed by dilatation which allowed antegrade flexible cystoscopy to be performed. The endoscope could only be passed to the level of the

Case study No. 68

Figure 2

penile base (Fig. 2) where there was a complete obstruction. Distal endoscopy showed complete obstruction at the level of fossa navicularis.

Figure 1

Case provided by Dr. Amin Bouker, Clinique Taoufik, Tunis, Tunisia. E-mail:

Discussion point 1. In this situation, can an MRI reliably assess the urethra and its lumen between the proximal and the distal penile strictures? 2. What treatment is advisable?

This 86-year-old man was referred with painless macroscopic haematuria. A CT scan, which had been performed without contrast media because of elevated serume creatinine, showed a ‘large tumorous lesion of the left lateral bladder wall’ (Figure 1, arrow sign). Cystoscopy showed that a mesh implanted for a laparoscopic left inguinal hernia repair several years previously had ingrown into the bladder and that around this foreign body papillary formations suggestive of a bladder malignancy were present. TUR-biopsy confirmed urothelial carcinoma grade 2 without evidence of muscle-invasion but there was no detrusor tissue in the biopsies.

Ventral meatotomy for the fossa stricture, then assess the penile urethra using a specific approach Comments by Dr. Pankaj Joshi Pune (IN)

Management: This depends on the length of the obliteration at the penoscrotal junction and the status of the urethra between the fossa and penoscrotal junction. My surgical algorithm would be ventral meatotomy for the fossa stricture, then assess the penile urethra using either:

This is a challenging case. Iatrogenic strictures are common and on the rise. Complete obliteration can occur in iatrogenic strictures. In young men, the bladder neck often does not open during RGU/ MCU. We usually give patients tamsulosin an evening prior and then perform MCU. MRI is very useful and provides an excellent soft tissue visualisation. I have published a protocol on MRI with water as a natural contrast.(1)

mucosa anastomosis on the dorsal wall plus the ventral Orandi flap. For the fossa stricture, we can insert a small graft dorsally and cover the ventral wall with a long Orandi flap -- or else perform a meatoplasty. Figure 1

References: Approach 1. If there is an obliterative stricture, we can lay open the urethra as Johansson’s until the urethra can be seen well at the penoscrotal junction. After 6 months, enter Stage 2 with dorsal inlay graft and closure.(2) Approach 2. If there is short obliteration at the penoscrotal junction, we can perform mucosa-to-

1. Joshi P, Desai D, Shah D, Joshi D, Kulkarni S. How to perform MRI for Pelvic Fracture Urethral Injuries and Rectourethral fistulas: A simplified protocol. Turk J Urol 2020; DOI: 10.5152/tud.2020.20472. 2. Pankaj Joshi, Guido Barbagli et al. A novel composite two stage urethroplasty for complex penile strictures: A multicenter experience. Indian Journal of Urology 2017 vol 33: Issue 2,155-158.

Discussion point • Which management and treatment is advisable?

Case provided by Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany. E-mail:

A two-stage surgery with a wide buccal graft (>25mm) – still a challenging issue without data Comments by Dr. Abdulghani Khogeer Grenoble (FR)

The examinations show a long, fully obliterated urethra from bulbar to penile urethra in a 42-yearold patient with urinary retention secondary to a single traumatic urinary catherization.

and Prof. Bernard Boillot Grenoble (FR)

1. The MRI will not provide information about the urethra without contrast inside the urethral lumen, which is not possible in this case. Furthermore, palpation is not inferior to imaging for spongiofibrosis evaluation.

Case study No. 67 continued In this patient, MRI was nearly normal due to the absence of contrast that could fill the lumen, but surgical exploration showed complete obstruction between the fossa and penoscrotal junction.

Figure 1

January/February 2021

Figure 2

This urethral segment was excised, leaving a thin layer of well vascularised dorsal spongiosum over the cavernous bodies (see Figure 1). Buccal mucosa graft (BMG) was harvested from both cheeks, then defatted and quilted into a nice bleeding graft bed (see Figure 2). Note that the junction between the two grafts is oblique to avoid stenosis when tubularised.

Figure 3

2. In the first line, we offer this patient a definite perineal urethrostomy with or without buccal graft according to local conditions, which is easy to do and to follow up. If the patient is asking for reconstruction, we cannot apply the BRACKA technique here, because we cannot justify salpingectomy to apply the graft on the corpus cavernosum.

Due to the COVID-19 pandemic, it took one year to schedule the second stage, which led to a proximal meatus graft contracture (see Figure 3). Intermediate revision was needed, and a small BMG was added at the penoscrotal junction (see Figure 4).

Figure 4

Figure 5

We can discuss here a two-stage surgery with a wide buccal graft (>25mm) located superficially on the all-long incised corpus spongiosum to preserve the spongiosal tissue and to prepare it for the second stage with incorporation of urethroplasty inside the corpus spongiosum. It is still a challenging issue without data in the literature.

Four months later, the urethra was tubularised (see Figure 5) and waterproofed with a double layer of penile dartos (see Figure 6).

Figure 6

European Urology Today


TransPot: Tackling incurable prostate cancer Innovative programme identifies a number of promising novel targets for future analysis Dr. Linda Rushworth TransPot Scientific Programme Manager Glasgow (GB)

linda.Rushworth@ The Translational Research Network for Prostate Cancer (TransPot) is a pan-European research training network focussed on obtaining an unmatched depth of molecular, mechanistic and informatics systemslevel disease understanding of incurable prostate cancer to help develop novel prognostic tools and treatment. TransPot, as a Horizon 2020 Marie Skłodowska-Curie Innovative Training Network (ITN), integrates leading European research scientists and laboratories with an interest in these research fields, and is composed of academic and industrial institutions from the United Kingdom, Finland, Germany, Greece and The Netherlands. Eleven Early Stage Researchers (ESRs) were recruited and offered a unique opportunity to perform high-impact research. This four-year project has received over €2,500,000 in EU funding. It began in January 2017 and is led by Prof. Hing Leung (UK), Professor of Urology and Surgical Oncology at the University of Glasgow.

“A priority for the consortium has been the development of complex systems to overcome the limitations of 2D cultures in high-content assays.” The project incorporates the latest multidisciplinary research technologies to understand aggressive disease, including castration-resistant prostate cancer (CRPC), and offers an innovative training programme to ESRs for both research and transferable skills to ensure that they can effectively operate in today's multidisciplinary programmes. The project benefits from a substantial secondment program designed to facilitate the progression of each research project through key interaction between beneficiaries in the consortium. Throughout the project, TransPot meetings have served as training opportunities for ESRs, as well as platforms for dissemination of results and collaboration. In addition to four bespoke courses which were tailored to the training requirements of the ESRs, a joint scientific exchange was held with another prostate cancer ITN consortium, TRAIN, allowing knowledge sharing of methodologies and infrastructure for translational research in prostate cancer. The TransPot Collaborative Symposium was held virtually in May 2020 and brought together external experts in the field. The project is now in its final year, and major progress has been achieved to date. The TransPot consortium is supported by a wide range of preclinical and clinical tools: in vitro models, including those which mimic castration resistance or resistance to anti-androgens; conditional GEM models where clinically relevant genes are under the control of prostate-specific promoters; and a range of patient derived xenografts. A priority for the consortium has been the development of complex systems to overcome the limitations of 2D cultures in highcontent assays. Our collaborative efforts have explored (1) cultures of human induced pluripotent stem cells (iPSCs), (2) primary prostate organoids from whole human prostates, (3) 3D co-cultures that include cancer-associated fibroblasts and other components of the tumour microenvironment, and (4) 3D cultures of patient derived xenografts and tissue explants. Multi-omics approaches within the consortium using these prostate cancer models have provided a comprehensive collection of data sets from both 2/3D culture and tissue samples.

The TransPot consortium and European Commission Project Officer Julien Giordani during the TransPot project review and third training course at the University of Glasgow

the expression of the LAT1 amino acid transporter. Consequently, SLFN5 knockout in CRPC cells alters amino acid metabolism, supporting the idea of targeting metabolism for the treatment of prostate cancer, and establishing SLFN5 as a potential target for CRPC treatment. Metabolomics analysis has been used to identify CRPC-associated alterations in urine using three independent sample cohorts. Collectively, these analyses have already provided some promising results and biostatistical analyses have highlighted various metabolite signal changes associated with aggressive forms of prostate cancer, which are currently under further evaluation and identification. Chromatin immunoprecipitation (ChIP) and transcript profiling has been utilised to characterise androgen receptor (AR) binding sites in the human genome. AR was found to drive the expression of a network of genes encoding metabolic enzymes linked to steroid hormone biosynthesis, lipid turnover and anabolic metabolism. Additionally, AR recruitment to DNA involves interactions with a number of other transcription factors implicated in disease progression. By overlaying the pathways regulated by AR and transcription factors, we can identify drug targets which, when combined with AR inhibitors, might enhance response. Work is ongoing to evaluate drugs to the targets in combination with enzalutamide in pre-clinical models, using proteomic and transcriptomic analysis. Pioneering RNA-sequencing studies have been carried out to identify novel prostate cancerassociated long non-coding RNAs (lncRNAs) as potential novel markers of aggressive disease, and to identify novel drug targets in CRPC. A list of coding genes that were highly correlated with our significant lncRNAs was obtained and functional analyses were performed. GO analysis identified several cell-cyclerelated terms highly enriched in the coding gene list, and KEGG analysis revealed that these genes were enriched in the p53, cell cycle and focal adhesion pathways; most of which are implicated in cancer biology.

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Through our network-wide multi-omics strategy, TransPot has identified a number of promising novel targets for future analysis. Studies involving the extensive range of pre-clinical and clinical models available, including more complex 3D systems, have increased our understanding of incurable prostate cancer, including CRPC, and we aim to be able to translate our findings to the clinic to improve treatment.

• Biomedical Research Foundation of the Academy of Athens (Greece) • Tampere University (Finland) • Genomescan B.V. (The Netherlands) • Almac Diagnostics Limited (United Kingdom) Find out more about TransPot here: Website: transpot.html Facebook: @TransPotITN Twitter: @TransPot_ITN YouTube: UC7FcnJCVIjKSOW8p1gGeofA

The TransPot consortium members are: • University of Glasgow (United Kingdom) (Coordinator) • University of Newcastle Upon Tyne (United Kingdom) • The Queen's University of Belfast (United Kingdom) • University of Turku (Finland) • Erasmus Medical Center (The Netherlands) • numares HEALTH (Germany)

Become an EAU member today!

“Studies involving the extensive range of pre-clinical and clinical models available have increased our understanding of incurable prostate cancer.”

A systems biology approach A systems biology framework for CRPC has been established, incorporating data from the transcriptome, proteome, ChIP-seq and metabolome data produced by the consortium. There is substantial overlap between candidate genes provided by multiple beneficiaries and arising from different experimental contexts, which served as an initial indicator of their relevance in prostate cancer and CRPC. More importantly, the results demonstrated concordance between genes that were found to be prognostic across different clinical Multi-omics data from culture and tissue samples cohorts. Work is also underway to identify consensus Analysis of hormone naïve and castration-resistant molecular subgroups in prostate cancer through a orthografts led to a putative list of genes implicated in meta-analysis of curated gene expression datasets the transition to castration resistance, and proteomics using novel software. This will include publicly data from the same orthografts identified schlafen 5 available gene expression microarray datasets and (SLFN5) as upregulated in castration resistance. SLFN5 commercial datasets. Additionally, integrating deletion dramatically impairs the growth of CRPC multiple transcriptomic datasets provides an insight tumours in vivo, and mechanistically, SLFN5 controls into gene regulatory circuits relevant to prostate 8

cancer, and master regulons have been identified that hold a great prognostic potential for cancer recurrence.

Apply online today and be part of the largest urological community.

January/February 2021

Conservative treatment options for women with SUI Cost effective first-line treatments with minimal side effects Dr. Athanasios Zachariou ESUO Board Member Dept. of Urology University of Ioannina Ioannina (GR) The impact of stress urinary incontinence (SUI) on individual patients, their families, and on the healthcare system as a whole, is devastating. There are many potential methods for treating SUI which might be used alone or as part of a management strategy. Urologists in primary care realise that the initial consideration of an incontinent patient is selecting a less invasive alternative for SUI treatment1. Conservative treatment options for women with stress urinary incontinence include lifestyle changes, pelvic floor muscle training (PFMT), vaginal cones, electrical stimulation, drugs, and a combination of these individual therapies. It would be beneficial for patients if outpatient and office urologists could evaluate the relative worth of the proposed treatments (personalised medicine) and achieve the most significant benefit from allocated resources.

“Conservative treatment options for women with SUI include a combination of individual therapies.” Do lifestyle interventions lead to an improvement in SUI symptoms? Being overweight or obese has been identified as an adjustable and reversible risk factor for SUI (LE 1b) in many epidemiological studies2. We assume that obesity contributes to SUI by increasing intraabdominal pressure resulting in chronic stress on the pelvic floor. For overweight women, participation in a supported weight loss programme may improve incontinence3 (LE 1b). Excessive fluid intake usually exacerbates incontinence symptoms. Therefore, patients restrict fluid intake themselves to avoid bothersome urine leakage. A baseline frequency-volume chart is essential to distinguish patients with increased fluid intake and advise them to limit fluid intake. The daily volume of fluid intake should be approximately 1,500 mL or 30 mL/kg body weight per 24 h. Other common sense advice in terms of smoking cessation and resolving constipation may be worthwhile but lacks high-level evidence of benefit (LE 4)3. What is the first-line conservative treatment for SUI? Pelvic Floor Muscle Training (PFMT) is the most commonly used physical therapy treatment for women with SUI and aims to strengthen the striated pelvic floor muscles (LE 1). This improves the urethral sphincter closure mechanism in three distinct ways: by increasing urethral pressure, through the support of the bladder neck, and by interacting with the transversus abdominis via coordinated contractions between the pelvic floor muscles and the transversus abdominis. The degree of patient training, supervision by a clinician, intensity of exercise protocols and follow-up varies, which is often related to local service provision and available expertise. PFMT included in first-line programmes? The findings of a Cochrane systematic review suggest that primary care urologists could include PFMT in first-line conservative management programmes for women with SUI. Based on the data available, PFMT can cure or improve symptoms of SUI, may reduce the number of leakage episodes and the quantity of leakage in the short pad tests in the clinic4. Women who perform pelvic floor exercises were more likely to have a better quality of life and were more likely to report an improvement EAU Section for Outpatient and Office Urology (ESUO)

January/February 2021

or cure. Although the long-term effectiveness and cost-effectiveness of PFMT need further research, lifestyle changes and PFMT with extra sessions followed by TVT is a financially sound strategy4. Three times a week There is no standard and typical description concerning the optimal programme for PFMT. Patients with more contact with their healthcare professional and trained in group sessions were more likely to report a cure and improvement. The direct PFMT (voluntary pelvic floor contractions) training was better than sham training. Training is necessary three times a week, as well as adherence to the training regimen. The effect of PFMT in women with SUI does not seem to decrease with age. Overall, according to a Cochrane database review, the use of direct, higher-intensity PFMT with weekly supervision was an optimal approach for SUI patients5. What are the alternative options? Sometimes women have problems in identifying and controlling pelvic floor muscles or exhibit poor compliance. In that case, the alternative proposals are the vaginal cones or the electrical stimulation of the pelvic floor. Women using a vaginal cone are instructed to retain graded weights (cones) for timed periods within the vagina. Vaginal cones represent an alternative conditioning exercise to improve pelvic floor muscle strength. Patients advance progressively and retain increasing weights for a longer time. A reasonable goal is to maintain the cone for 20 minutes while walking. This procedure facilitates faster pelvic floor muscles training and the apparent improvement seems to motivate women to proceed. The vaginal cones conservative option presents better results than no active treatment6. Electrical stimulation Electrical stimulation entails a programme of intermittent direct or indirect electrical stimulation of the pelvic floor muscles. The mechanism of action relies on the electrical impulse to induce hypertrophy of skeletal pelvic floor muscles via reflex contractions while activating the detrusor inhibitory reflex arc7. The optimal reported parameters include stimulation frequency of 50 Hz, alternating or biphasic current, intermittent stimulation, and ideal stimulation intensity to allow a painless response. It is an easy and rapid alternative conservative treatment, presenting objective cure rates of up to 65% and overall patient satisfaction of up to 83%7. Electrical stimulation may add benefit to PFMT in the short term (LE 2).

was the significant discontinuation rate due to adverse events (24%), with nausea being the most common reason (6.4%) (LE 1a). A Cochrane review of 10 trials, including 3,944 adults with predominantly SUI randomised to duloxetine or placebo and PFMT confirmed the findings above9. The paper demonstrated that duloxetine could decrease the frequency of incontinence episodes by up to 50% compared to placebo and improve quality of life and perception of improvement. Provided to selected patients The European Union approved duloxetine for SUI in 2004 and the proposed dose is 40 mg twice daily. Duloxetine should not be used as first-line treatment or routinely offered as second-line treatment. Furthermore, there are strong recommendations that duloxetine should be provided in selected patients with symptoms of SUI when surgery is not indicated. Primary care urologists should initiate or withdraw using dose titration because of the high risk of an adverse event. Intravaginal oestrogen supplementation may be a useful adjunct to other more specific treatments for post-menopausal women with vulval-vaginal atrophy to enhance urethral coaptation (strong recommendation). Who is seeking help? Although many women with SUI choose to manage the problem by avoiding triggering events such as strenuous exercise, and by using absorbent pads, about 15% will seek help11. These women usually present more severe and bothersome symptoms that have an impact on their day-to-day life.

“Duloxetine should not be used as first-line treatment or routinely offered as second-line treatment.” It is fundamental, when we evaluate the worth of SUI treatments, to assess the individual women’s expectation of outcome. PFMT, either with extra supervision or combined with biofeedback, was on average most effective, curing an estimated 40% at the end of active treatment. Compared with a basic level of PFMT as commonly used, intensive pelvic floor muscle training with extra supervision or with added biofeedback were more effective than the other treatments considered alone. Conclusion Conservative treatments for SUI are demonstrated to be beneficial, cost-effective and to have minimum

Is biofeedback an additional tool to improve results? Biofeedback (BF) is used to make the patient more aware of muscle function, to enhance patient effort and to support other therapies, particularly PFMT and electrical stimulation. Typical devices are a vaginal pressure gauge (perineometer) or display of pelvic floor electromyographic activity.

Does pharmacological treatment cure or improve SUI? Duloxetine, a selective serotonin and norepinephrine re-uptake inhibitor, promotes urine storage by relaxing the bladder and increasing sphincter resistance8. Duloxetine demonstrates a significant improvement in incontinence episode frequency (IEF) and overall quality of life (QoL) in women suffering from pure SUI or MUI (LE 1a). The main disadvantage

“About 15% of women with SUI seek help.” References 1. National Collaborating Centre for Women’s and Children’s Health, National Institute for Health and Clinical Excellence (NICE). Urinary incontinence: the management of urinary incontinence in women. London: NICE; 2006. NICE Clinical Guideline 40 (CG40). 2. Nygaard, I, Barber M, Burgio K, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA, 2008;300:1311. 3. Subak L, Wing R, West D, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med 2009;360(5):481–90 4. Imamura, M., Abrams P, Bain C, et al. Systematic review and economic modeling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence. Health Technol Assess, 2010;14:40. 5. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010;CD005654. 6. Herderschee R, Hay-Smith EC, Herbison GP, et al. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women: shortened version of a Cochrane systematic review. Neurourol Urodyn. 2013;32:325-29. 7. Herbison P, Dean N. Weighted vaginal cones for urinary incontinence. Cochrane Database Syst Rev 2002;(1):CD002114. 8. Chêne G, Mansoor A, Jacquetin B, et al. Female urinary incontinence and intravaginal electrical stimulation: an observational prospective study. Eur J Obstet Gynecol Reprod Biol. 2013;170:275-80. 9. Juneau A, Gomelsky A. Pharmaceutical Options for Stress Urinary Incontinence Current Bladder Dysfunction Reports 2019;14:357–64 10. Mariappan P, Ballantyne Z, N’Dow JMO, Alhasso AA. Serotoninand noradrenaline reuptake inhibitors (SNRI) for stress urinary in-continence in adults. Cochrane Database Syst Rev. 2005;3:CD004742. 11. Shaw C, Das Gupta R, Williams KS, et al. (2006) A survey of help-seeking and treatment provision in women with stress urinary incontinence. BJU Int 97(4):752–757.

SUI conservative treatment

“PFMT, the most commonly used therapy for women with SUI, aims to strengthen the striated pelvic floor muscles.” Biofeedback is not a treatment on its own, but an adjunct to training, measuring response while the patient is contracting. A Cochrane systematic review, which included 24 trials involving 1,584 women with urinary incontinence, evaluated the effectiveness of adding biofeedback to PFMT. Women who received biofeedback were significantly more likely to report that their urinary incontinence was cured or improved compared to those who received PFMT alone5. However, it was not clear whether this was the effect of the biofeedback device itself or the benefit from spending more time in the clinic with the doctor, nurse or physiotherapist.

side effects. Conservative management enables patients to be actively involved in the management of incontinence while temporarily or permanently avoiding invasive procedures. According to current guidelines, lifestyle modifications (such as weight reduction) and conservative treatments should be advocated to all women with SUI as first-line treatment.

lifestyle changes

women able

women unable

to identify and controll

to identify and controll

Pelvic Floor Muscles

Pelvic Floor Muscles



Electrical stimulation

Vaginal cones

2ND line treatment: Duloxetine Bothersome SUI

Urological consultation for surgical treatment

European Urology Today


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


MRI features predict survival after radical prostatectomy Pre-operative prediction of post-surgery outcomes is mainly based on the d’Amico classification which takes into account tumour grade, PSA and clinical stage. However, given the advent of MRI before biopsies and imaging-based targeting, MRI characteristics and tumour grade derived from MRI-visible lesion could be more accurate tools for improving prognosis evaluation, patient counselling and treatment decision-making, compared with the standard systematic biopsybased risk stratifications.

Main MRI features were significantly correlated with biochemical recurrence-free survival. In this study, the authors have assessed the performance of MRI-based parameters for predicting the risk of recurrence after radical prostatectomy. In this two-centre series, all patients had a pre-biopsy-positive MRI and underwent both targeted and systematic biopsies prior to radical prostatectomy. Characteristics of imaging (PIRADS score, maximal diameter, number of lesions, stage on MRI) and grade on targeted biopsies were tested as predictor for oncologic outcomes after surgery. The authors also evaluated a pure imaging-based classification in one centre, validated it in the second centre, and compared it with the standard d’Amico classification. Overall, 521 consecutive patients were included. Mean PSA and patient age were 10.2 and 65 years. According to the d’Amico classification, 20% of cases were classified as high risk. Positive lymph nodes were reported in 13% of patients, with 22% of positive margins. Main MRI features were significantly correlated with biochemical recurrencefree survival. The rate of recurrence was 1.4%, 5.6% and 10.7% in patients having a PIRADS score of 3, 4 and 5, respectively (p = 0.006). The maximum diameter of the MRI lesion was also associated with an increased recurrence risk (< 10 mm, versus 10-15 mm, versus > 15 mm). Presence of a suspicion of an extracapsular extension on MRI predicted poorer oncologic outcomes (p = 0.004). Lastly, the tumour grade on targeted biopsies was positively associated with the recurrence rates (p = 0.001). The only MRI-based parameters not correlated with biochemical recurrence was the number of MRI lesions. The authors incorporated these MRI parameters into a new classification taking into account the PIRADS score, tumour grade on targeted biopsy, and MRI stage. Low risk was defined by the absence of extracapsular extension and a ISUP grade 1-2 and a PIRADS score < 5. High-risk cases were defined by extracapsular extension on MRI or ISUP grade 4-5. Intermediate cases included patients having no extracapsular extension, a PIRADS score 5 and/or a ISUP grade 3. This imaging-based classification was significantly correlated with biochemical recurrence in centre-1 and in centre-2 cohorts. Its AUC was 0.714 in the development cohort and outperformed the d’Amico classification (0.710). The 2-year recurrence-free survival rates were 93.4%, 90.4% and 77.0% in the newly defined low, intermediate, and high-risk groups, respectively. Some limitations have to be highlighted. The median follow-up was short (12 months) given that the pre-biopsy systematic assessment by MRI is a relatively new recommendation from the EAU guidelines. The second limitation was the lack of strong oncologic endpoints, such as metastasisfree or cancer-specific survival. The follow-up of Key articles


this cohort will surely provide these outcomes in the future. An external validation in another cohort of patients from another centre involving other radiologists for MRI reading and other urologists for biopsy targeting would also be of great value to reinforce these findings, and to prove the possible generalisation of this classification.

Source: MRI Characteristics Accurately Predict Biochemical Recurrence after Radical Prostatectomy. Manceau C, Beauval JB, Lesourd M, Almeras C, Aziza R, Gautier JR, Loison G, Salin A, Tollon C, Soulié M, Malavaud B, Roumiguié M, Ploussard G.

Source: Extended Versus Limited Pelvic Lymph Node Dissection During Radical Prostatectomy for Intermediate- and High-risk Prostate Cancer: Early Oncological Outcomes from a Randomized Phase 3 Trial. Lestingi JFP, Guglielmetti GB, Trinh QD, et al. Eur Urol. 2020 Dec 5:S0302-2838(20)30941-6

Adjuvant ADT combined with radiotherapy is superior to neoadjuvant ADT

J Clin Med. 2020 Nov 26;9(12):E3841

Randomised trial radical prostatectomy: extended versus limited pelvic lymph node dissection The EAU Guidelines recommend performing an extended lymph node dissection (not only limited to the node tissue under the obturator vein) during radical prostatectomy when this additional procedure is required for oncologic purposes (mainly in intermediate and high-risk prostate cancer cases). However, this recommendation was not based on high-level of evidence studies. In the present study, the authors report the results from a randomised trial which included 300 patients from 2012 to 2016. Randomisation was done between limited versus extended pelvic lymph node dissection in patients with intermediate or high-risk prostate cancer (expected survival benefit: 15% at 5 years after surgery). The primary endpoint was the biochemical recurrence-free survival. Secondary endpoints were metastasis-free and cancer-specific survival. The extended template included the obturator, external iliac, internal iliac, common iliac, and presacral regions bilaterally. Both arms were similar in terms of preoperative features. Particularly, the risk of lymph node involvement calculated by the Briganti nomogram was comparable in both groups (11-12%). Median lymph node retrieved was 17 versus 3 in the “extended” versus “limited” arm. Extended lymph node dissection revealed 5 times more positive lymph nodes (17% versus 3.4%, p < 0.001). The internal iliac region was most frequently positive for node metastasis (65%).

The potential benefit of an extended lymph node dissection in the highrisk population has to be confirmed in a dedicated trial.

Mr. Philip Cornford Section editor Liverpool (GB)

The exact timing of concomitant androgen deprivation therapy (ADT) in addition to radiotherapy remains debatable for localised or locally advanced prostate cancer management. However, the sequencing of systemic therapy combined with radiotherapy may be of importance to optimise outcomes. This has been demonstrated in randomised studies for other malignancies (head and neck, lung). In prostate cancer, randomised trials focused mainly on the use and the duration of ADT rather than the sequencing of this systemic therapy in addition to radiotherapy.

The delay in initiating radiotherapy is unnecessary, does not lead to a decrease in high-grade adverse effects, and can generate a higher risk of distant metastasis. In the present meta-analysis, the authors have identified two randomised trials evaluating the sequencing of ADT with radiotherapy (Ottawa 0101, RTOG 9413). The first trial randomly assigned patients to neoadjuvant or concurrent versus concurrent or adjuvant short-term (6 months) ADT. The second trial randomised patients to neoadjuvant or concurrent versus adjuvant short-term (4 months) ADT. For this meta-analysis assessing progression-free survival as primary endpoints, individual patient data were collected and analysed. A total of 1065 patients were included with a median follow-up of 15 years. All baseline characteristics were well balanced between the neoadjuvant (n=531) and the adjuvant groups (n=534). Median age was 70 years.


COVID 19 patients may develop de novo urinary symptoms Coronavirus disease 2019 (COVID 19) causes a wide range of symptoms, including several unexpected symptoms such as loss of taste, skin changes, and eye problems. The authors of the present paper recently observed patients with documented COVID 19 develop de novo severe genitourinary symptoms, most notably urinary frequency of ≥ 13 episodes/24 h and nocturia ≥ 4 episodes/night. They suggest calling these associated urinary symptoms COVID-19-associated cystitis (CAC). The authors collected urine samples from COVID-19 patients, including patients with CAC, and noted an elevation of proinflammatory cytokines also in the urine. It has previously been shown that patients with urinary incontinence and ulcerative interstitial cystitis/ bladder pain syndrome have elevated urinary inflammatory cytokines compared to normal controls. In addition, it is known that COVID-19 severity is associated with inflammation.

The authors collected urine samples from COVID-19 patients, including patients with CAC, and found elevation of proinflammatory cytokines also in the urine.

They therefore hypothesised that CAC, with presentation of de novo severe urinary symptoms, can occur in COVID-19 and is caused by increased inflammatory cytokines that are released into the urine and/or expressed in the bladder. The most Progression-free survival was significantly improved important implications of their hypothesis are: by 10.8 months in the adjuvant group compared with 1) Physician caring for COVID-19 patients should be the neoadjuvant group (95% CI: 2.7 to 18.8). The risk of aware of CAC; progression was increased by 25% in the neoadjuvant 2) De novo urinary symptoms should be included in group (15-year recurrence rates: 29% versus 36%). the symptom complex associated with COVID-19; Adjuvant ADT also significantly reduced the risk of 3) COVID-19 inflammation may result in bladder dysfunction. biochemical failure (p=0.002) and of distant metastasis (p=0.04). The HRs for the neoadjuvant group were 1.29 (p=0.10) and 1.11 (p=0.20) for cancer-specific and Source: COVID-19 inflammation results in urine overall mortality. Thus, all endpoints favoured cytokine elevation and causes COVID-19 adjuvant ADT. Statistical significance was not reached associated cystitis (CAC) Laura E. Lamba, for cancer-specific and overall survival. Nivedita Dharc, Ryan Timare, Melissa Willse,

Sorabh Dhard, Michael B. Chancellora.

No benefit from extended lymph node dissection was reported regarding all the survival outcomes: biochemical recurrence-free survival (p=0.6), metastasis-free and cancer-specific survival. A post-hoc sub-group analysis in the population of patients having a biopsy ISUP grade 3-5 demonstrated a survival advantage for extended template concerning the biochemical recurrence curves (p=0.024). This analysis was not pre-stratified at the time of the study statistical elaboration. Only one centre (five urologists) was involved in this trial limiting the generalisation of these findings. Moreover, the adjuvant strategy was not clearly defined in the study design and might have affected the comparative biochemical results. Indeed, the augmented node yield due to an extended template may have artificially increased the rate of positive lymph nodes (Will-Rogers phenomenon) and the need for adjuvant therapy in the “extended” arm. The potential benefit of an extended lymph node dissection in the high-risk population has to be confirmed in a dedicated trial. The impact of new imaging modalities as staging tool, including high-sensitivity PET/CT imaging and the use of MRI-targeted biopsy for improving the tumour grade and prognostic assessment, are interesting ways to explore in order to reduce the unnecessary need for an extended template and to reinforce its role, at least as a mean to improve post-operative staging, in very high-risk patients.

Given trial-level differences in terms of years of enrolment, ADT duration (4 versus 6 months, country), an adjustment for clinical trial was done. It did not change the findings and all outcomes remained unchanged. No difference in terms of grade 3-5 gastrointestinal or genitourinary toxicity was reported between neoadjuvant and adjuvant ADT. The short-term ADT regimens used in the two included trials mainly concern patients currently treated for unfavourable intermediate-risk prostate cancer. These findings could not be generalised to high-risk and/or locally advanced prostate cancer receiving long-term (2 years or more) ADT in addition to radiotherapy. Nevertheless, this meta-analysis demonstrates that adjuvant ADT combined with radiotherapy is superior to neoadjuvant ADT for treating primary prostate cancer. The present study highlights that the delay in initiating radiotherapy is unnecessary, does not lead to a decrease in highgrade adverse effects, and can generate a higher risk of long-term progression and distant metastasis.

Source: Prostate Radiotherapy With Adjuvant Androgen Deprivation Therapy (ADT) Improves Metastasis-Free Survival Compared to Neoadjuvant ADT: An Individual Patient MetaAnalysis. Spratt DE, Malone S, Roy S, et al. J Clin Oncol. 2020 Dec 4:JCO2002438. doi: 10.1200/ JCO.20.02438

Medical Hypotheses 145 (2020) 110375 Available online 5 November 20200306-9877/

Identification of pathogens, AMR-encoding genes and plasmids within one hour Bloodstream infections (BSI) and sepsis are major causes of morbidity and mortality worldwide. Blood culture-based diagnostics usually require 1–2 days for identification of a bacterial agent and an additional 2–3 days for phenotypic determination of the antibiotic susceptibility pattern. With the escalating burden of antimicrobial resistance (AMR), rapid diagnostics become increasingly important to secure adequate antibiotic therapy. Real-time whole genome sequencing represents a genotypic diagnostic approach with the ability to rapidly identify pathogens and AMR-encoding genes. In this study, investigators used nanopore sequencing of bacterial DNA extracted from positive blood cultures for the identification of pathogens, detection of plasmids and AMR-encoding genes. The authors argue that this is the first study to gather the above information from nanopore sequencing and conduct a comprehensive analysis for diagnostic purposes in real-time.


European Urology Today

January/February 2021

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

Identification of pathogens was possible after 10 minutes of sequencing. All predefined AMR-encoding genes and plasmids from monoculture experiments were detected within one hour, using raw nanopore sequencing data.

Identification of pathogens was possible after 10 minutes of sequencing and all predefined AMR-encoding genes and plasmids from monoculture experiments were detected within one hour using raw nanopore sequencing data. Furthermore, investigators could demonstrate the correct identification of plasmids and blaCTX-M subtypes using de novo assembled nanopore contigs. Results from this study hold great promise for future applications in clinical microbiology and for health care surveillance purposes. This is highly relevant for urologists dealing with acute severe infections such as urosepsis.

Source: Rapid identification of pathogens, antibiotic resistance genes and plasmids in blood cultures by nanopore sequencing. Arne M. Taxt, Ekaterina Avershina, Stephan A. Frye, Umaer Naseer & Raf Ahmad. Sci Rep 10, 7622 (2020). s41598-020-64616-x

Surgical trials: Difficult but worth it? Bladder cancer is a common malignancy and approximately a quarter of patients present with high-grade non-muscle invasive tumours. Those with concomitant carcinoma in situ, invasion of the lamina propria or prostatic urethral involvement are at increased risk of progression and constitute high-risk high-grade non-muscle invasive bladder cancer (HRNMIBC). Current treatment options - intravesical immunotherapy with BCG and radical cystectomy differ markedly. BCG leaves a risk of progression whilst radical cystectomy may be overtreatment. As with many surgical treatments, there is no direct comparative study available. This study attempts to assess if such a study is possible.

…this study may inform patients about the relative risks of each approach. BRAVO was a prospective multicentre randomised study including patients with new HRNMIBC suitable for both BCG with maintenance and radical cystectomy. Random assignment was stratified by age, sex, centre, stage, presence of carcinoma in situ, and prior low-risk bladder cancer. Successful maintenance BCG was defined as > 4 induction doses and at least 12 months of maintenance treatment using the SWOG protocol. Rigid cystoscopy with biopsy and bladder washings or urine cytology was mandated at the first check. Subsequently, cystoscopic approach was per local protocol. Radical cystectomy included at least regional lymph nodes up to the ureteric crossing of the common iliac vessels Qualitative work investigated how to maintain equipoise. The primary outcome was the number of patients screened, eligible, recruited and randomly assigned. Secondary outcomes included the acceptance rates of allocated treatments, 12-month BCG compliance and the feasibility of collecting health-related quality of life data.

assignment because of one or more of the following: BCG preference (77 [50.0%]), RC preference (39 [25.3%]), dislike of random assignment (27 [17.5%]), concerns about study participation (8 [5.2%]), or did not specify (3 [1.9%]). One participant did not proceed to random assignment (and chose BCG outside of the study). Consequently, 25 patients were randomly assigned to BCG and 25 to RC. Recruitment was halted after 18 months (as per statistical plan). In the BCG arm, 23/25 (92.0%) patients received BCG, four had non-muscle invasive bladder cancer (NMIBC) after induction, three had NMIBC at 4 months, and four received RC. At closure, two patients had metastatic BC. In the RC arm, 20 (80.0%) participants received cystectomy, including five (25.0%) with no tumour, 13 (65.0%) with HRNMIBC, and two (10.0%) with muscle invasion in their specimen. Therefore, of those recruited, seven did not accept their allocated treatments (compliance 86.0%); two of these also withdrew from further data collection and completion of questionnaires. A further participant withdrew from trial treatment 121 days after random assignment. At follow-up, all patients in the RC arm were free of disease. Adverse events were mostly mild and equally distributed (15/23 [65.2%] patients with BCG and 13/20 [65.0%] patients with RC). With respect to individual treatments, patients in the BCG arm had a higher regret score; “I regret the choice that was made” (mean = 22.1, SD = 15.6 vs. mean = 13.2, SD = 27.8), compared with the RC cohort. The quality of life (QOL) of both arms was broadly similar at 12 months. Recruitment was successful in one network, which accounted for 47/50 randomly assigned patients. Half of these were diagnosed at associated district hospitals, suggesting clinicians in this network were in equipoise. Other networks struggled to recruit, demonstrating the difficulty of maintaining equipoise across a multi-disciplinary team and between sites. Treatment acceptance was high (43/50, 86%) and comparable to other surgical versus nonsurgical trials (e.g. 78% in ProtecT). Fewer patients accepted RC than BCG, likely reflecting its irreversibility and greater physical impact. 10% of patients in this study had a potentially lethal disease at presentation and although outcomes were worse for men receiving BCG, this study was not powered to evaluate cancer outcomes. However, this study may inform patients about the relative risks of each approach.

Source: Radical Cystectomy against intravesical BCG for high-risk high-grade non-muscle invasive bladder cancer: Results from the randomised controlled BRAVO-feasibility study. Catto JWF, Gordon K, Collinson M et al. J Clin Oncol 2020 doi: 10.1200/JCO.20.01665

Gene therapy in bladder cancer BCG is the most effective intravesical therapy for patients with high-risk non-muscle-invasive bladder cancer. Although 80% of patients have an initial complete response to induction BCG, more than half of patients have recurrence and progression within the first year, and many will develop BCGunresponsive disease. Radical cystectomy is the most definitive cancer treatment in this setting, but many patients are unwilling or unable to undergo the procedure. The immune modulator pembrolizumab has been approved by the FDA in patients with BCG-unresponsive carcinoma in situ. In the KEYNOTE-057 trial, pembrolizumab lead to a complete response rate of 40% at 3 months with a durable response of 19% at 12 months. However, it is associated with systemic immune-related side-effects (colitis, pneumonitis and hypothyroidism), and the indication does not include patients with high-grade Ta or T1 tumours.

Intravesical recombinant interferon alfa-2b protein is well tolerated and has shown clinical effectiveness for patients with non-muscle-invasive bladder cancer after BCG. Unfortunately, responses were not durable, probably in part due to the short drug exposure time of 1–2 h. Intravesical interferon alfa gene delivery offers a novel opportunity for local management of non-muscle-invasive bladder cancer by greatly increasing the duration of exposure to interferon alfa-2b. Nadofaragene firadenovec (rAd-IFNα/Syn3) consists of rAd-IFNα, a non-replicating recombinant adenovirus vector-based gene therapy that delivers a copy of the human interferon alfa-2b gene to A total of 407 patients were screened and 215 patients urothelial cells. It also contains Syn3, a polyamide were found to be eligible. Investigators approached surfactant that enhances the viral transduction of the 185/215 eligible patients and 51 agreed to be randomly urothelium, producing local rather than systemic assigned (37.6%). Patients declined random interferon alfa-2b production. Key articles

January/February 2021

This phase 3 multicentre, single-arm, open-label, repeat dose clinical study was done across 33 sites in the USA. Patients with BCG-unresponsive high-risk non-muscle invasive bladder cancer and an ECOG status of 2 or less were recruited. Patients were excluded if they had upper urinary tract disease, urothelial carcinoma within the prostatic urethra, lymphovascular invasion, micropapillary disease, or hydronephrosis. At enrolment, all visible tumours or CIS were required to be resected and patients with T1 disease on transurethral resection of bladder tumour had an additional transurethral resection 14–60 days before study treatment. Eligible patients received a single intravesical 75 mL dose of nadofaragene firadenovec (3 × 10¹¹ viral particles per mL). All patients were evaluated for recurrence with urine cytology and cystoscopy (with biopsy if warranted) at efficacy assessment visits every 3 months. In the absence of high-grade recurrence, repeat dosing occurred at months 3, 6, and 9. At 12 months after initial treatment, patients had a biopsy of five sites (dome, trigone, right and left lateral wall, and posterior wall) in the bladder. Patients with no evidence of high-grade recurrence could continue receiving nadofaragene firadenovec once every 3 months at the discretion of their treating physician. The primary endpoint was complete response at any time in patients with carcinoma in situ (with or without a high-grade Ta or T1 tumour).

Intravesical nadofaragene firadenovec offers an additional therapeutic option in this difficultto-treat population. 198 patients were assessed for eligibility. 41 patients were excluded, and 157 were enrolled and received at least one dose of the study drug. Six patients did not meet the definition of BCG-unresponsive non-muscleinvasive bladder cancer and were therefore excluded from efficacy analyses. The remaining 151 patients were included in the per-protocol efficacy analyses. 55 (53.4%) of 103 patients with carcinoma in situ (with or without a high-grade Ta or T1 tumour) had a complete response within 3 months of the first dose and this response was maintained in 25 (45.5%) of 55 patients at 12 months. In the high-grade Ta or T1 cohort, 35 of 48 patients (72.9%; 95% CI 58.2 to 84.7) were high-grade recurrence-free at month 3, and 21 patients (43.8%; 29.5 to 58.8) were recurrence-free at month 12. Thus, 21 (60%) of 35 patients with high-grade Ta or T1 non-muscle-invasive bladder cancer who were high-grade recurrence-free at 3 months maintained that status at 12 months. Micturition urgency was the most common grade 3–4 study drug-related adverse event (two [1%] of 157 patients, both grade 3), and there were no treatment-related deaths. Intravesical nadofaragene firadenovec offers an additional therapeutic option in this difficult-to-treat population. Intravesical nadofaragene firadenovec is associated with an acceptable safety profile and promising efficacy outcomes to offer a realistic alternative to chemotherapy and systemic treatment options. It is also a first-of-its-kind efficacy for gene therapy, with a manageable safety profile and delivery schedule, resulting in a favourable benefit-risk profile.

Source: Intravesical nadofaragene firdenovec gene therapy for BCG-unresponsive nonmuscle-invasive bladder cancer: a single-arm, open-label, repeat-dose clinical trial. Boorjian SA, Alemazaffar M, Konety BR et al.

Prof. Oliver Reich Section editor Munich (DE)


We quantified patient comorbidities using the Deyo-Romano modification of the Charlson Comorbidity Index in the 2 years prior to the date of prostate cancer diagnosis for each patient. The primary treatment was defined using 4 mutually exclusive categories: 1) surgery; 2) radiotherapy; 3) androgen deprivation therapy; or 4) conservative management.

Interestingly, many other laboratory tests showed a more significant effect than PSA. They then collected all laboratory data for each patient in the 6 months prior to their diagnosis. They used only one test with results for at least 200 men and averaging tests if multiple results were available for a single variable giving a total of 3,345,083 values. Using the XWAS method (the application of a statistical method to examine thousands of candidate single-nucleotide polymorphisms that maybe associated with an outcome to other clinical problems), the false-discovery rate was calculated to test the association between multiple laboratory tests and survival. These results were validated using training, testing and validation cohorts. A total of 31 laboratory tests associated with survival. Not surprising, PSA (HR 1.07; 95% CL 1.06-1.08) and alkaline phosphatase (HR 1.22; 95% CL 1.20-1.24) were included as were tests of general health - such as serum albumin (HR 0.78; 95% CI 0.76-0.80) and creatinine (HR 1.05; 95% CI 1.03-1.07) - and markers of inflammation, such as leukocyte count (HR 1.23; 95% CI 1.98-1.26) and ESR (HR 1.33; 95% CI 1.09-1.61). Interestingly, many other laboratory tests showed a more significant effect than PSA. Identifying laboratory measures of overall health may aid in the challenging task of estimating life expectancy among men with prostate cancer, among whom overdiagnosis is common and in whom competing risks of mortality dominate prostate cancer–specific mortality risk. The question remains: can these laboratory tests identify men who can safely avoid radical treatment and its associated side effects?

Source: Laboratory-wide association study of survival with prostate cancer. Sohlberg EM, Thomas I-C, Yang J et al. Cancer 2020 doi: 10.1002/cncr.33341

Long-term safety, efficacy of mTOR-immunosuppression in CNI-free regimen

For men with prostate cancer, a sophisticated understanding of their overall health and estimated longevity would facilitate patient-centred treatment decisions. However, determining health and life expectancy from health records remains a challenge, despite a plethora of predictive models. This study used an approach adapted from the genome-wide association study to evaluate associations between routine collected laboratory tests and survival in veterans with prostate cancer.

Conversion to calcineurin-inhibitor (CNI)-free immunosuppression is thought to improve long-term renal allograft outcomes due to avoiding CNI toxicity. Furthermore mTOR-based immunosuppression offers advantages to the graft but is rarely used because of its side effects. The aim of this study was to preserve the advantages while avoiding the disadvantages of mTOR-based immunosuppression with a CNI-free regimen. In this prospective, randomised study (SMART trial), the early conversion to a CNI-free immunosuppression with SRL was in the short-term associated with an improved 1 and 3- year renal graft function as compared with a cyclosporin-based regimen. Mixed results were reported on the occurrence of de novo donor-specific antibodies (dnDSAs) under mTOR-immunosuppression. The authors present long-term results of the SMART trial with evaluation of dnDSA.

They identified a cohort of 133,878 veterans diagnosed with incident prostate cancer between 2000 and 2013 within the VHA electronic health record using the national Veterans Affairs Corporate Data Warehouse. Having excluded those with incomplete data they then stratified patient records into localised prostate cancer and locally advanced or metastatic prostate cancer risk groups (clinical classification T4, N > 0, or M > 0).

The original SMART trial included 140 patients randomised to either immunosuppression with cyclosporine A or sirolimus. Of these, 71 patients from 6 centres (n = 38 SRL and n = 33 CsA) of the original SMART trial (ITT n = 38 SRL and n = 33 CsA) were enrolled in this observational, non-interventional extension study to collect retrospectively and prospectively follow-up data for the interval since

Lancet Oncol 2020 doi: 10.1016/s1470-2045(20)30540-4.

Predicting prostate cancer survival


European Urology Today


Assoc. Prof. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ baseline. Primary objective was the development of dnDSA. Blood samples were collected on average 8.7 years after transplantation.

An early conversion to SRL did not result in an increased incidence of dnDSA nor increased long-term risk for the recipient Development of dnDSA was not different (SRL 5/38, 13.2% vs. CsA 9/33, 27.3%; p < 0.098). Glomerular filtration rate (GFR) remained improved under SRL with 64.37 ml/min/1.73m2 vs. 53.19 ml/min/1.73m2 (p < 0.045). Patient survival did not differ between groups at 10 years. There was a trend towards a reduced graft failure rate (11.6% SRL vs. 23.9% CsA, p = 0.064) and fewer de novo neoplasias under SRL (2.6% SRL vs. 15.2% CsA, p = 0.09).

Source: Impact of sympathetic renal denervation: a randomized study in patients after renal transplantation (ISAR-denerve). Schneider S, Promny D, Sinnecker D, Byrne RA, Müller A, et al.

Which congenital anomalies are more common on which side?

Nephrol Dial Transplant (2015) 30: 1928–1936

There are various patterns of sidedness in relation to the common urogenital malformations observed in paediatric urology. There seems to be different trends for sidedness in certain congenital abnormalities in humans. Internal asymmetry is common and generated through three main mechanisms: bending and rotation, regression or persistence and differential growth. Asymmetry in the left-right axis occurs both in unpaired organs such the heart, stomach, spleen and liver as well as in paired organs including the lungs and kidneys.

Febrile UTI in children: does the bladder need draining during treatment? Febrile urinary tract infections (fUTIs) account for 0.7% of outpatient department visits and 5–14% of emergency department visits by children annually. Up to 30% of infants and children experience recurrent infections during the first 6–12 months after initial UTI. A delay in treatment of fUTI may cause renal damage and often hospitalisation is required. Use of an indwelling catheter may be used to drain the bladder and facilitate treatment of infection. There are different trends and management guidelines of fUTIs in children in different specialties (paediatrics, paediatric urology and paediatric surgery) and different practices in North America (NA) and Europe (EU). Some of the differences arise from different forms of training and perspectives rather than evidence.

The authors survey 47 different paediatric urology training centres (seventeen (28.3%) participants from NA and 43 (71.7%) from EU). They analyse the practice An early conversion to SRL did not result in an increased incidence of dnDSA nor increased long-term patterns for the management of fUTI and mainly inquire about the drainage of bladders by the use of risk for the recipient. Transplant function remains improved with benefits for the graft survival. indwelling catheters.

Source: Early conversion to a CNI-free immunosuppression with SRL after renal transplantation – long-term follow-up of a multicentre trial. Andrassy J, Guba M, Habicht A, Fischereder M, et al. PLoS ONE 15(8): e0234396.

Twenty-seven (45%) participants reported that it is common practice at their centre to always (n = 4, 6.7%) or sometimes (n = 23, 38.3%) insert a catheter for drainage in fUTI, while in 33 (55%) centres bladder drainage is not a part of fUTI management. Paediatric urologists were more inclined to insert a drainage catheter compared to paediatric surgeons (66.7% versus 33.3%, p = 0.02).

Is renal sympathetic denervation safe in transplant Inserting a transurethral catheter … is implemented in 45% of cases recipients? across North America and Europe, Sympathetic overactivity is frequently observed despite the lack of consensus and following renal transplantation and post-transplant evidence… hypertension is a major factor in long-term graft

There is supportive evidence of a side tendency in some congenital urogenital conditions commonly seen in paediatric urology. The authors review the literature for eighteen urogenital conditions. For each condition, the five largest studies that noted laterality were included. The sidedness of each condition was then analysed for statistical significance.

Three conditions had a statistically significant higher proportion on the right side: palpable undescended testis (63%, p = 0.0002), inguinal hernia (59%, p = 0.0001) and hydrocele (60%, p = 0.003). Three conditions were significantly more common on the left side: impalpable undescended testis (59%, p = 0.0008), renal agenesis (54%, p = 0.02) and vesicoureteric junction obstruction (71%, p < 0.0001) while both pelviureteric junction obstruction (62%, p = 0.09) and absent vas deferens (61%, p = 0.11) were trending towards significance. Various urogenital malformations display a predilection for one side. Proximal malformations tend to be more frequently seen on the left side, whereas inguinoscrotal malformations are more frequently observed on the right.

In the inguinoscrotal region right-sided predilection Inserting a transurethral catheter for drainage in fUTIs was significant. This may be explained in some is thus a practice that is implemented in 45% of cases conditions by sequential differences in the descent of across North America and Europe, despite the lack of the right-side testis and subsequent delayed closure of the processus vaginalis. Impalpable testis is present consensus and evidence supporting it. The only systematic review of use of indwelling catheters in a more commonly on the left. When the current study is different group (neurogenic bladder patients) has not interpreted in combination with previously published revealed any more solid evidence. Continuous bladder reviews, there is a statistically significant left-sided predilection seen in renal agenesis, multi-cystic drainage has not significantly reduced UTI rate 18 patients with post-transplant hypertension were dysplastic kidneys, pelviureteric junction obstruction compared to other approaches. randomized 1:1 to receive RDN or medical treatment and vesicoureteric junction obstruction. A wide range alone. RDN was performed as catheter-based of theories have been presented regarding the The rationale of this practice is largely based on the radiofrequency denervation of the renal arteries possible aetiology of these conditions. However, side presumed pathophysiology of fUTIs, where ongoing which has emerged as a promising treatment for vesicoureteral reflux or bladder dysfunction plays a predilection remains poorly explained. resistant hypertension. The primary efficacy end point major role in the febrile event. Breaking that cycle with was change in office systolic blood pressure (SBP) and continuous drainage is the key. The lack of solid Despite the presence of an increasing body of mean 24-h ambulatory blood pressure monitoring evidence was the most common reason for not draining literature regarding aetiological factors for these (ABPM) at 6 months. Safety end points were changes the bladder with a urethral catheter, regardless of the conditions, our current understanding of the in renal function or renovascular complications. centre location and the specialty. The second reason not pathophysiology of these conditions fails to fully to insert a catheter was because it was too invasive, explain this pattern of observation. regardless of the centre location and the specialty.

After 6 months, patients in the RDN group had a significant reduction in office SBP of 23.3 ± 14.5 mmHg (p < 0.002 for change difference between the groups). In ABPM, nocturnal blood pressure was reduced in the RDN group by −10.38 ± 12.8 mmHg (p < 0.05), whereas no change was measured during the day. In the RDN group, significantly more patients converted from non-dippers to dippers (p < 0.036). There were no adverse safety events in either group. The authors suggest that RDN is feasible and safe in renal transplant recipients and has the potential to improve long-term graft survival. However, larger sham-controlled studies will be necessary to clarify the potential role of RDN in this population. Clinical trial registration. NCT01899456. Key articles


This is another common practice many still employ without any solid evidence, while obtaining the information should not be so difficult.

Source: Young Pediatric Urology Committee of the European Society for Paediatric Urology (Y.P.U.C.-E.S.P.U.). Correspondence: transurethral catheter drainage in febrile urinary tract infection-practice patterns among specialized centers in North America and Europe. Salama AK, Haid B, Strasser C, Smith C, Spinoit AF, Saad KN, Peycelon M. J Pediatr Urol. 2019 Dec;15(6):678-680.

The impact of catheter-based bladder drainage method on urinary tract infection risk in spinal cord injury and neurogenic bladder: A systematic review. Kinnear N, Barnett D, O'Callaghan M, Horsell K, Gani J, Hennessey D. Neurourol Urodyn. 2020 Feb;39(2):854-862.

There are some concerns with respect to whether an immediate SWL (iSWL) could expose patients to a higher risk of complications due to ongoing acute inflammation or even less effectiveness. A recent matched-pair study has been conducted comparing two groups of 104 patients attending the ED for renal colic due to obstructive ureteric stones. One (n = 52) was selected to undertake iSWL and another (n = 52) to have a JJ stent inserted prior to a deferred SWL (dSWL). The emergency interventions (iSWL and JJ stent) were undertaken within 48 hours after ED attendance. Potential infections were ruled out clinically (no fever) and by urine work out (no positive urinanalysis). Diagnosis of ureteric stone was based on CT or X-ray findings.

Another interesting finding was the significantly higher SFR reported in favour of the iSWL patients in the Three conditions had a statistically subgroup with ureteric stone 6-9 significant higher proportion on the mm in size. right side: palpable undescended Primary end point was the stone-free rate (SFR) at 6 testis (63%, p = 0.0002), inguinal weeks after the SWL (either immediate or delayed), hernia (59%, p = 0.0001) and although no definition of SFR was provided. Secondary end point included complication and hydrocele (60%, p = 0.003).

failure and cardiovascular morbidity. This process is perpetuated by preservation of sympathetic afferent activity from the native non-functional kidneys, in the absence of efferent feedback to the renal transplant, which would otherwise modulate neurohumoral activity. We investigated the feasibility and efficacy of renal sympathetic denervation (RDN) in renal transplant recipients.

The authors suggest that RDN is feasible and safe in renal transplant recipients and has the potential to improve long-term graft survival.

benefits of undertaking a SWL within 48 hours after ED attendance may prevent patients from experiencing stent-related symptoms – which we know may occur > 80% of the cases - which reduce the time needed to return to a normal life significantly.

Source: Side predilection in congenital anomalies of the kidney, urinary and genital tracts. Kirkpatrick J, Upadhyay V, Mirjalili SA, Taghavi K.

re-intervention rates, involving any further active treatment. Subgroup analysis was conducted with respect to different ranges of stone size (≤ 5 mm, 6-9 mm, ≥ 9 mm) and stone location (proximal vs distal ureter). From the cohort of 104 patients selected for the matched-pair analysis, mean stone size was 7 mm, equally distributed in each group. The proportion of stones located in the proximal and distal ureter was also equally distributed (70 and 30%, respectively).

Interestingly, patients who had a JJ stent inserted first had to wait 23 days on average (SD 14.6 days) before undertaking the dSWL. Unfortunately, no data were available in terms of loss of quality of life as well as outcomes from patients treated with alternative options (URS or PCNL) after JJ stent insertion. The authors did not find any difference between iSWL and dSWL in terms of SFR (67 vs 49 %) and complication rates (33 vs 35%). On the other hand, a significant difference was found in terms of lower re-intervention rate for the iSWL (33 vs 54%, p = 0.05). Another interesting finding was the significantly higher SFR reported in favour of the iSWL patients in the subgroup with ureteric stone 6-9 mm in size. Finally, on multivariate analysis, factors associated with a SWL failure were BMI > 30 and stones ≥ 8 mm. Overall, the authors confirmed that iSWL remains a safe and effective treatment option for the acute treatment of obstructive ureteric stones, as long as facilities and logistics are promptly available.

Source: Safety and effectiveness of immediate Shock Wave Lithotripsy of obstructive urinary stone after presentation at emergency department. Julian Cornelius, Dominique Zumbühl, Luca Afferi, Livio Mordasini, Carlo Di Bona, Stefania Zamboni, Marco Moschini, Edoardo Pozzi, Andrea Salonia, Agostino Mattei, Hansjörg Danuser, Philipp Baumeister. Journal of Endourology, ahead of print http://doi. org/10.1089/end.2020.0384

J Pediatr Urol. 2020 Dec;16(6):751-759.

Is SWL preferable to other treatments for obstructive urinary stones? Shock Wave Lithotripsy (SWL) has lost some popularity after the introduction of mini ureteroscopes and nephroscopes. Nevertheless, it is still regarded as an effective treatment option. Based on the clinical presentation it may even be preferable: immediate SWL in patients attending the emergency department (ED) is proposed as a safe and effective option, especially if the alternative is the insertion of a JJ stent for renal decompression and pain relief, prior to a deferred active treatment. In fact, the potential

Is infection complication rate after URS higher than reported? The endoscopic approach for the treatment of urinary stones by means of ureteroscopy (URS) is considered the first-line option in most of the international guidelines. Nowadays it is also one of the most popular endourological techniques. It is especially indicated for small/middle sized urinary stones, thanks to the high stone-free rate and relatively low risk of complications. Nevertheless, post-operative infection is reported as one of the most common adverse events. It is regarded as a complication that could be prevented by means of a pre-operative work-out. In fact, an infection post-RIRS could lead to sepsis, which in turn is a potentially lethal


European Urology Today

January/February 2021

Dr. Guillaume Ploussard Section editor Toulouse (FR)

not necessarily translate into an improvement of patients’ health-related quality of life.

g.ploussard@ condition. As most of the data available in literature have been published by high-volume centres, it is estimated that the actual infection complication rate may be higher than reported.

In recent years, several patient-reported outcome measures (PROMS) have been introduced in urology, although in urinary stone disease the development of such tools proceeds at a slower pace. One of the few validated PROMs in this field is the disease-specific Wisconsin Stone Quality of Life questionnaire (WISQOL), which reports in what way the quality of life of stone patients is affected in relevant domains.

Recently, a retrospective study that looks at the rates of the infection-related hospitalisations following a URS was published. The reviewed data were extracted from a web-based registry called ROKS (Reducing Operative Complications from Kidney Stones), which is a collaborative initiative of a network of academic and community practices in the US state of Michigan (Michigan Urological Surgery Improvement Collaborative - MUSIC).

A group of researchers thus prospectively evaluated the health-related quality of life of 313 patients who underwent surgical interventions for renal stones within 1-24 months at the time of the enrolment. Clinical data were collected retrospectively; SFR was defined as ‘no residual fragment identified postoperatively’. Unfortunately, no information was provided with respect to the time point at follow up and the mean size of the renal stones.

From 1817, URS was conducted in 11 centres; 43 (2.4%) patients were re-hospitalised within 30 days after the URS, of whom 3 (0.2%) died from a septic complication. At multivariable analysis, the factors more strongly associated with hospitalisation secondary to urinary infection appear to be history of recurrent urinary infections (OR 3.74) and intraoperative complication during URS (OR 3.7).

...seeking for an SFR at all cost may impair patients’ journey in the treatment of renal stones...

...12 of the 43 hospitalised patients (28%) had an abnormal preoperative urine test and none of them received any antibiotic treatment prior to the surgery... It is worth noticing that 20.9% (n = 9) did not have a pre-operative urine work-out (either a urinalysis or a urine culture). Nevertheless, this proportion was mirrored by the group of patients that did not experience post-operative hospitalisation (n = 335, 20.5%), so that this factor seemed not to be associated with a higher risk for post-op hospitalisation. Even more interestingly, 12 of the 43 hospitalised patients (28%) had an abnormal pre-operative urine test and none of them received any antibiotic treatment prior to the surgery. It is not clear why this happened, which highlights the importance of regular internal data auditing for quality control. Important limitations of the study are the scarce granularity of the data as several important variables - such as stone composition, surgical time, preoperative stenting dwell-time - could not be computed as well as the inability to differentiate between a urinanalysis and a urine culture as pre-operative urine test. Considering the lower sensibility of the former, it remains unknown whether some post-operative infections were in reality caused by false-negative urinanalyses. Overall, the importance of this study is to identify not only those clinical factors associated with the infective complication post-URS, but also the potential actions in the patients’ journey which facilitate an infectious event and may have been overlooked.

This discrepancy is considered more and more considered by scholars. A switch to a patient-centred approach is generally initiated at all levels, including research.

The majority of the patients was rendered stone-free (n = 189; 60.4%) after the first intervention. On the other hand, 124 (39.6%) were found with residual fragments whose cumulative median size was 7 mm, with a very wide range of values (1-60 mm). Nevertheless, the authors did not find any significant difference between the two groups of patients for individual WISQOL domain scores. Among the patients who had residual fragments post-operatively, the authors identified a subgroup of patients (n = 28) who received a secondary treatment. Interestingly, in most of the cases (94.7%) the secondary procedure was unplanned (i.e. it was not clearly discussed on the consent form). Moreover, most of the patients were asymptomatic (73.3%), and scored significantly lower on the questionnaires than those in whom observation was the preferred option. Nonetheless, the study was limited by several biases, including: 1) a recall bias because of the wide range of time from the intervention; 2) a selection bias as it was unclear which criteria were applied to determine which patients should be offered a secondary treatment versus observation; 3) a lead-time bias as it is unknown how patients with residual fragments and short follow-up could have their QoL affected as a result of recurrence of the stone disease when follow-up was longer.


Urology. 2020 Dec 5:S0090-4295(20)31433-3. doi: 10.1016/j.urology.2020.09.058. Online ahead of print.

Does the stone-free rate always indicate better quality of life?

Emotional condition in patients with LUTS performing uroflowmetry

Nearly always, the stone-free rate (SFR) is indicated as the primary end point of studies on urinary stone interventions. The assumption is that the smaller the residual fragments are, the higher the effectiveness of the treatment in observation.

This study aimed to evaluate the prevalence of the general and uroflowmetry (UF)-related anxiety in patients performing UF, and to assess whether anxiety may affect patient's micturition at UF. This prospective study recruited candidates to UF. Recorded data were: demographics, lower urinary tract symptoms (LUTS) and anxiety questionnaires (IPSS, ICIQ-FLUTS, GAD-7, APAIS-M), UF parameters, linker-type scale for UF satisfaction/reproducibility and discomfort.

Key articles

January/February 2021

Anxiety affected women twice more than men, and patients with high anxiety had worse urinary symptoms. According to the ICIQ-FLUTS questionnaire, only the sub score F was significantly greater in women with a high level of general and UF-related anxiety (7.8 ± 6.1 vs 12 ± 4.9; p < 0.001). A low UF satisfaction/ reproducibility was reported by 27.5% of patients, in 21.7% of subjects with general anxiety, and 36.6% of patients with UF-related anxiety. High discomfort was recorded in 58.1% of patients. Anxiety affected women twice more than men, and patients with high anxiety had worse urinary symptoms. The authors conclude that several patients showed high general and UF-related anxiety at UF, had worse subjective feelings about the reproducibility of their habitual micturition patterns. In anxious patients, knowledge of UF did not avoid a lower reproducibility of micturition, nor a more considerable discomfort.

Source: The Role of Emotional Condition in Patients With Lower Urinary Tract Symptoms Performing Uroflowmetry. Rubilotta E, Balzarro M, Castellani D, Tiso L, Panunzio A, Pirola GM, Antonelli A, Giannantoni A, Gubbiotti M. Urology. 2020 Nov 17:S0090-4295(20)31367-4. doi: 10.1016/j.urology.2020.10.045. Online ahead of print.

Effectiveness of electromyographic biofeedback for female urinary incontinence This study aimed to assess the effectiveness of pelvic floor muscle training (PFMT) plus electromyographic biofeedback or PFMT alone for stress or mixed urinary incontinence in women. In 23 community and secondary care centres providing continence care, 600 women, newly presenting with stress or mixed urinary incontinence, were selected. 300 were randomised to PFMT plus electromyographic biofeedback and 300 to PFMT alone.

Participants in both groups were offered six appointments with a continence therapist over 16 weeks. Participants in the biofeedback PFMT group Overall, these data seemed to suggest that seeking for received supervised PFMT and a home PFMT an SFR at all cost may impair patients’ journey in the programme, incorporating electromyographic treatment of renal stones, especially when a clear and biofeedback. The PFMT group received supervised transparent discussion about pros and cons of each PFMT and a home PFMT programme. PFMT clinical decision is not appropriately undertaken. The programmes progressed during the period of the integration of PROMs in the primary outcomes of appointments. studies on renal stone interventions is warranted.

Source: Is Stone-free Status After Surgical Intervention for Kidney Stones Associated With Better Health-related Quality of Life? A Multicenter Study From the North American Source: Infection-related hospitalization following ureteroscopic stone treatment: results Stone Quality of Life Consortium. Streeper NM, from a surgical collaborative. Cole, A., Telang, J., Galida M, Boltz S, Li S, Nakada SY, Raffin EP, Brown DR, Pais VM, Chan JYH, Scotland KB, Kim, TK. et al. Chew BH, Penniston KL. BMC Urol 20, 176 (2020).

Nevertheless, the SFR is a practitioner-centred outcome, and not necessarily coincides with the patient’s perspective. Seeking for the best SFR may

The trial enrolled 167 patients (non-naïve 59.3%). One hundred twenty-five were men. General anxiety was found in 55.3% of patients (63.2% naïve), and UF-related anxiety in 41.3% (46.5% non-naïve). No significantly different rate of anxiety was found between naïve and non-naïve patients. A significant difference was found between IPSS total score in patients without anxiety (10.9 ± 6.4) and subjects with anxiety (16.9 ± 7.3; p < 0.001).

No evidence was found of any important difference in severity of urinary incontinence between PFMT plus electromyographic biofeedback and PFMT alone groups. The primary outcome was self-reported severity of urinary incontinence (International Consultation on Incontinence Questionnaire-urinary incontinence short form (ICIQ-UI SF)) at 24 months. Secondary outcomes were cure or improvement, other pelvic floor symptoms, condition-specific quality of life, women's perception of improvement, pelvic floor muscle function, uptake of other urinary incontinence treatment, PFMT self-efficacy, adherence, intervention costs and quality adjusted life years.

Prof. Serdar Tekgül Section Editor Ankara (TR)

serdartekgul@ The investigators conclude that at 24 months no evidence was found of any important difference in severity of urinary incontinence between PFMT plus electromyographic biofeedback and PFMT alone groups. Routine use of electromyographic biofeedback with PFMT should not be recommended. Trial registration: ISRCTN57756448.

Source: Effectiveness of pelvic floor muscle training with and without electromyographic biofeedback for urinary incontinence in women: multicentre randomised controlled trial. Hagen S, Elders A, Stratton S, Sergenson N, Bugge C, Dean S, Hay-Smith J, Kilonzo M, Dimitrova M, Abdel-Fattah M, Agur W, Booth J, Glazener C, Guerrero K, McDonald A, Norrie J, Williams LR, McClurg D. BMJ. 2020 Oct 14;371:m3719. doi: 10.1136/bmj.m3719.

Study on the effect of nasal testosterone gel on symptomatic hypogonadism This study aimed to evaluate the effect of short-acting 4.5% nasal testosterone gel (Natesto®) on serum testosterone, gonadotropins, total motile sperm count, health-related quality of life and sexual function. This was a single institution, open label, single arm trial. Men 18 to 55 years old diagnosed with symptomatic hypogonadism (total testosterone less than 300 ng/dl on 2 occasions) were included. Men with azoospermia, vasectomy or a total motile sperm count less than 5 million were excluded. Enrolled patients were treated with Natesto®, a short-acting nasal testosterone (125 μl per nostril, 11.0 mg testosterone per dose, TID) for 6 months.

Nasal testosterone gel appears to increase testosterone while maintaining semen parameters in a majority of men. In total, 60 men were enrolled in the study. Of these, 44 and 33 patients were evaluated for testosterone at 3 and 6 months, respectively. A total of 31 patients (90.9%) reached a normal testosterone level (greater than 300 ng/dl) at 6 months. Follicle stimulating hormone and luteinising hormone levels were maintained within the normal range in 81.8% and 72.7% of patients at 6 months, respectively. Total motile sperm count was maintained, with total motile sperm count greater than 5 million over the treatment period in 88.4% of men at 3 months and 93.9% at 6 months. There were statistically significant improvements on International Index of Erectile Function, sexual desire and overall satisfaction domains at 6 months. Nasal testosterone gel appears to increase testosterone while maintaining semen parameters in a majority of men. It has the potential to be a safe and effective treatment for men with functional hypogonadism who wish to preserve semen parameters. The authors close with the outlook, that long-term studies beyond 6 months are needed before we can safely prescribe nasal testosterone gel for men interested in fertility.

Source: Effect of nasal testosterone on Reproductive Hormones, Semen Parameters and Hypogonadal Symptoms: A Single Center, Open Mean ICIQ-UI SF scores at 24 months were 8.2 (SD 5.1, Label, Single Arm Trial. Ramasamy R, Masterson TA, Best JC, Bitran J, Ibrahim E, Molina M, Kaiser n=225) in the biofeedback PFMT group and 8.5 (SD UB, Miao F, Reis IM. 4.9, n = 235) in the PFMT group (mean difference -0.09, 95% confidence interval -0.92 to 0.75, p = 0.84). Biofeedback PFMT had similar costs (p = 0.64) and quality adjusted life years (p = 0.28) to PFMT.

J Urol. 2020 Sep;204(3):557-563. doi: 10.1097/ JU.0000000000001078.


European Urology Today


Queries from a patient with intraductal prostate carcinoma And how two separate uropathology societies deal with IDC-P Prof. Rodolfo Montironi ESUP Chairman Section of Pathological Anatomy School of Medicine Ancona (IT) r.montironi@

Co-authors: Dr. Alessia Cimadamore, ESUP Board Member; Prof. Marina Scarpelli, Section of Pathological Anatomy, School of Medicine, Ancona (IT); Prof. Liang Cheng, Dept. of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis (US); Prof. Antonio LopezBeltran, ESUP Honorary member, Dept. of Surgery, Cordoba University Medical School, Cordoba (ES) One of us was recently approached via email by a patient who was diagnosed with prostate cancer (PCa) and intraductal carcinoma of the prostate (IDC-P) based on his radical prostatectomy (RP) specimen. He is a medical doctor and came across some recent papers about IDC-P published by eminent uropathologists and/or by scientific societies. He sent the email because he needed clarification about pieces of information available on the internet. In particular, he put forward the following questions related to IDC-P: 1. What is IDC-P? 2. Why are two separate uropathology societies dealing with IDC-P? 3. What is the position of the International Society of Urological Pathology (ISUP)? 4. What is the position of the Genitourinary Pathology Society (GUPS)? 5. Comparison between ISUP and GUPS 6. Is there an attempt to “homogenise” ISUP and GUPS?

“It has been suggested choosing one or the other recommendation “to apply uniformly in practice with fellow departmental or institutional colleagues.” Please find below our attempt to give him some answers. 1. What is IDC-P? IDC-P is characterised by malignant prostatic epithelial cells growing along ducts and acini. Most cases of IDC-P derive from an adjacent high-grade invasive PCa (see Figure 1) via retrograde spreading of cancer cells within pre-existing ducts and acini. It is an aggressive type of PCa associated with a high risk of local recurrences as well as distant metastases. A small number of IDC-P cases arises from the intraductal proliferation of precancerous cells. Such isolated IDC-P lesions may function as a carcinoma in situ1. Molecular characterisation of these two types of IDC-P as well as a better understanding of the mechanisms underlying its development and progression could represent valuable biomarkers for differential diagnosis as well as for therapeutical targets1.

• approaches to reporting Gleason patterns 4 and 5 quantities, and minor or tertiary patterns; • reporting of invasive cribriform carcinoma; • individual vs. global grading of systematic and multiparametric magnetic resonance imaging–targeted biopsies; • IDC-P and PCa grading. Basically, IDC-P is considered an “extension of cancer cells into pre-existing prostatic ducts and acini, distending them, with preservation of basal cells.” IDC-P is typically seen adjacent to high-grade invasive PCa. Only rarely it is unaccompanied by invasion. The ISUP members noticed that at least 3 conflicting definitions of IDC have been given. It was proposed that IDC-P associated with invasive PCa should be incorporated into the Gleason Score (GS). Overall, 76% voted in favour of the proposal. Thus, without having to perform immunohistochemistry, cribriform IDC-P with invasive PCa is graded as a Gleason pattern 4, and solid pattern IDC-P or IDC-P with comedonecrosis is Gleason pattern 5. Assignment of a grade to IDC-P means that IDC-P can be included in Gleason pattern 4 or 5 quantification and tumour extent evaluation. Since IDC-P has a prognostic significance independent of the GS, 83% of the participants agreed with the fact that the presence and significance of IDC-P is commented on in the pathology report, despite incorporating IDC-P into the GS. There was 91% consensus that IDC-P without invasive PCa should not be graded. The final agreement was: “Incorporate the grade of IDC into the GS when invasive cancer is present.” Supporting the fact that IDC-P is included in the grading of cancer, the ISUP paper mentioned that “all historical and contemporary GS outcome data, including those used in multiple clinical phase 3 trials, are based on morphology without application of routine immunohistochemical basal cell staining”. This sets a precedent with regard to incorporating IDC-P into the GS3. 4. What is the position of the GUPS? The paper published by GUPS reports that “IDC-P is an intra-acinar and/or intraductal neoplastic epithelial proliferation that exhibits greater architectural and/or cytologic atypia than high-grade prostatic intraepithelial neoplasia”. A small subset of IDC-P, not associated with invasive PCa, represents a precursor lesion. IDC-P should be reported on both prostate biopsy and RP specimen. Only approximately one quarter (i.e. 23.2%) of GUPS participants in the survey would include IDC-P in the final GS, either both on needle biopsy and RP (16.6%), only on needle biopsy (3.8%), or only on RP (2.8%). The final agreement was: “Do not include IDC-P in determining the final Gleason score on biopsy and/or radical prostatectomy4.” Supporting the fact that IDC-P is not included in the grading of PCa, the GUPS paper mentions that “There are no studies showing that grading IDC-P as invasive carcinoma correlates with prognosis more accurately. For example, in a case of Gleason score 4 + 3 = 7 (Grade Group GG 3) with IDC-P showing comedonecrosis, if the IDC-P was included in the grade the tumour would be Gleason 4 + 5 = 9 (GG 5); no data support this marked increase in grade in this setting”4.

2. Why are two separate uropathology societies dealing with IDC-P? In 2018, a number of ISUP members left and formed the GUPS “because of irreconcilable differences in governing ideology and bylaws”2. In 2019, ISUP and GUPS held their own consensus conferences on PCa grading, with separately published manuscripts3,4.

5. Comparison between ISUP and GUPS The pros and cons for the ISUP and GUPS recommendations are reported in detail in an article on this topic5. In particular:

3. What is the position of the ISUP? A manuscript published by the ISUP members summarises the proceedings of their consensus conference held in Nice (FR)3 in September 2019. The issues brought to consensus included:

• The ISUP and the GUPS concur on the reporting of pure IDC-P, both recommending that pure isolated IDC-P should not be graded, and that immunohistochemistry should be performed in such cases when no associated invasive PCa component is seen2.

EAU Section of Uropathology (ESUP)


European Urology Today

• There is no fundamental disagreement between the ISUP and the GUPS regarding the clinical implication of IDC-P associated with invasive

Figure 1: Intraductal carcinoma of the prostate and high-grade prostate cancer in the adjacent parenchyma

PCa. Both societies agree that the presence of an IDC-P component in such a setting represents an adverse prognostic factor. • A major point of departure between the two uropathology societies is that ISUP recommends grading IDC-P, when associated with invasive PCa, whereas GUPS recommends not grading IDC-P in any setting2. 6. Is there an attempt to “homogenise” ISUP and GUPS? As mentioned above, overall many of the ISUP and the GUPS PCa grading manuscripts reached the same conclusions and recommendations7. Yet, each consensus was conducted somewhat differently, and, in a couple of key areas, each reached different conclusions and recommendations. It is anticipated that the two publications will have an impact on future recommendations and guidelines for reporting PCa by organisations such as the European Association of Urology, the European Society of Pathology, and the College of American Pathologists, “which will promote best practices for their respective constituents.”7

“There is a need for international consensus on this issue.” Concerning the issue of whether or not to grade IDC-P patterns into the overall grade assessed, it has been suggested choosing one or the other recommendation “to apply uniformly in practice with fellow departmental or institutional colleagues, in consultation with local urologist, oncologist, and radiation oncologist stakeholders.”7 Which of the two sets of recommendations is used is “referenced in report comments, documenting the approach taken, especially for the key divergent scenario where incorporating (or excluding) the pattern seen in extensive IDC-P admixed with invasive carcinoma into the grade assessment could change the definitive GG.” However, the current situation can be confusing for clinicians and patients as well.

Patient’s feeling The attempt to answer his questions helped the patient understand the clinical importance of the presence of IDC-P and the differences in the grading results based on the opposite view of the two uropathology societies. There is a need for international consensus on this issue7. He has expressed his hope that in the near future morphology, molecular assays and artificial intelligence will form an integrated approach to grade assessment beyond current practice. References 1. Zong Y, Montironi R, Massari F, Jiang Z, Lopez-Beltran A, Wheeler TM, Scarpelli M, Santoni M, Cimadamore A, Cheng L. Intraductal Carcinoma of the Prostate: Pathogenesis and Molecular Perspectives. Eur Urol Focus. 2020 Oct 29:S2405-4569(20)30291-1. doi: 10.1016/j. euf.2020.10.007. Epub ahead of print. 2. Epstein JI, Kryvenko ON. A Comparison of Genitourinary Society Pathology and International Society of Urological Pathology Prostate Cancer Guidelines. Eur Urol. 2020 Nov 11:S0302-2838(20)30853-8. doi: 10.1016/j. eururo.2020.10.033. Epub ahead of print. 3. van Leenders GJLH, van der Kwast TH, Grignon DJ et al. The 2019 International Society of Urological Pathology (ISUP) consensus conference on grading of prostatic carcinoma. Am. J. Surg. Pathol. 2020; 44; e87-e99. 4. Epstein JI, Amin MB, Fine SW et al. The 2019 Genitourinary Pathology Society (GUPS) White Paper on contemporary grading of prostate cancer. Arch. Pathol. Lab. Med. [published online ahead of print, 2020 Jun 26] 2020. 5. Varma M, Epstein JI. Head to head: should the intraductal component of invasive prostate cancer be graded? Histopathology. 2020 Jul 21. doi: 10.1111/his.14216. Epub ahead of print. 6. Epstein JI, Kryvenko ON. A Comparison of Genitourinary Society Pathology and International Society of Urological Pathology Prostate Cancer Guidelines. Eur Urol. 2020 Nov 11:S0302-2838(20)30853-8. doi: 10.1016/j. eururo.2020.10.033. Epub ahead of print. 7. Smith SC, Gandhi JS, Moch H, Aron M, Compérat E, Paner GP, McKenney JK, Amin MB. Similarities and Differences in the 2019 ISUP and GUPS Recommendations on Prostate Cancer Grading: A Guide for Practicing Pathologists. Adv Anat Pathol. 2021 Jan;28(1):1-7.

January/February 2021

SATURN Registry enrols 750th patient European Registry evaluates the cure rate of surgical procedures for treatment of Male SUI Nr.

(Sub) Investigator



Date EC Approval

First patient incl.

# Patients recorded in eCRF


F. Martens


Radboud UMC





E. Pascual/I. Salamanca


UH P. De Hierro Majadahonda





R. Zachoval/ L. Bartáková Prague

Thomayer Hospital





F. Van Der Aa


UHs Leuven





L. De Kort


UMC Utrecht





A. Haferkamp


UH Mainz





R. Hamid


Royal National Orthopaedic Hospital





M. Castro Diaz


HU De Canarias





J. Romero-Otero


HU 12 De Octubre





N. Thiruchelvam


CUH - Addenbrooke's Hospital





O.J. Nilsen


Oslo UH





K. Van Renterghem


Jessa Ziekenhuis





K. Everaert


Ghent University Hospital





I. Puche-Sanz


HU Virgen De Las Nieves





M. Tutolo


San Raffaele Hospital



E. Sacco






C. Ochoa V.


Fondazione Policlinico Universitario Agostino Gemelli IRCCS HU Germans Trias i Pujol





E. Lledó


HU Gregorio Marañón





G. Bozzini

Busto Arsizio

ASST Valle Olona



F. Queißert


Universitätsklinikum Münster





S. Van Bruwaene


AZ Groeninge





S. Arlandis


University Hospital La Fe





M. Fisch


UK Hamburg-Eppendorf





A. Sahai


Guy’s and Thomas’ Hospital





A. Fraile Poblador


Hospital Universitario Ramón Y Cajal






A. Romero Hoyuela


H. General Morales Meseguer




Van der Aa F., Heesakkers J., Martens F., et al. (2019). Prospective European registry for patients undergoing surgery for male stress urinary incontinence: An initial report of the registry ‘SATURN’. European Urology Supplements. 18. e1063. DOI: 10.1016/S15699056(19)30767-5 Van der Aa F., Heesakkers J., Martens F., et al. Prospective registry for patients undergoing surgery for male stress urinary incontinence in multiple European centres. an update of the registry ‘SATURN’. European Urology Open Science 2020;19(Suppl 2):e464. DOI: 10.1016/S26661683(20)32876-7 Heesakkers J., Van der Aa F., Martens F., et al. Prospective Registry for Patients Undergoing Surgery for Male Stress Urinary Incontinence in Multiple European Centres. A novel update of the European Registry ‘SATURN’. ICS2020. Abstract 134. watch?v=HiGivCpQ_YQ


J.M. Gómez De Vicente


Hospital La Paz





S. De Wachter


Universitair Ziekenhuis Antwerpen




Martin Pedersen


UNN Narvik



Introduction The aim of the SATURN registry is to prospectively recruit 1,000 male patients undergoing implant surgery to treat Stress Urinary Incontinence (SUI). The patients will be followed up for 10 years with regard to safety and efficacy. Cure rate is defined as no pad use or the use of 1 security pad. PROMS (e.g., quality of life; incontinence) and clinical data are collected from study visits at baseline, surgery, 6 weeks for activation in case of AUS or devices that need to be activated, 12 weeks post-surgery and yearly post-surgery up to year 10. Study update The study has started in 29 sites in Belgium, Czech Republic, Germany, Italy, the Netherlands, Norway, Spain and the United Kingdom. To date (10 January, 2021), 25 sites recorded in total 764 patients in the e-CRF. Updates of the SATURN registry were presented at EAU annual congresses (EAU19, EAU20) and the ICS 2020 annual meeting. Baseline data showed a 2:1 distribution of AUS compared to other devices. The major cause of SUI was prostatectomy which in most cases was performed by RALP. Prospective collection of predefined data from patients undergoing surgical SUI treatment in multiple European centres will enable evaluation of long term efficacy, safety and impact on QoL. Based on non-biased data patients can select the treatment option that fits them best, based on solid expectations about efficacy and complications that they might encounter. With the current inclusion rate planned recruitment numbers are achievable and the registry will yield clinically useful and long term results.

For more information, please visit the EAU RF website Collaborator Boston Scientific Corporation Study team • Principal Investigator: • Rizwan Hamid, Assistant Professor of Urology




Consultant Urological Surgeon, Department of Urology, University College London Hospitals, London, United Kingdom

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

Introducing the newest member of our family of journals: European Urology Open Science

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

We are pleased to announce the launch of European Urology Open Science, a member of the European Urology family of journals. The journal is dedicated to the publication of high quality, innovative research that will benefit patients with urological conditions and will serve the world-wide community of urologists in academia and practice. European Urology Open Science is a broad-scope, gold open access (OA) journal published on behalf of the European Association of Urology (EAU) and the European Board of Urology (EBU). All OA articles will be immediately and permanently accessible online-only for everyone to read, download, copy and distribute.

EAU Research Foundation

January/February 2021

European Urology Today


ESU-ESOU Masterclass on Muscle-Invasive Bladder Cancer Virtual 8-9 April 2021

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

ESU-ESUT Masterclass on Operative management of benign prostatic obstruction Virtual 22-23 April 2021

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

18-19 June 2021, Patras, Greece

ESU - Weill Cornell Masterclass in General urology

12-16 July 2021, Salzburg, Austria

ESU-ESUT Masterclass on Urolithiasis

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


European Urology Today

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

January/February 2021


1st virtual ESU-ESUI Masterclass on Prostate biopsy Updates on the benefits of prostate biopsy and MRI reading By Erika De Groot

The presentations continued with coverage on antibiotics and biopsy (Prof. Francesco Porpiglia); getting the most out of randomised biopsy (Prof. Salomon); and fusion biopsy basics (Prof. Budäus).

Under the tutelage of 10 highly-respected experts, participants from 21 countries within and beyond Europe received insights and updates of the benefits, potential and limitations of prostate biopsy and MRI The video sessions that followed showcased various reading at the ESU-ESUI Virtual Masterclass on Prostate techniques and technologies, such as demonstrations biopsy. on electromagnetic navigation, image-based navigation, to name a few. Organised through the collaborative efforts of the European School of Urology (EAU) and the EAU After the video sessions, more riveting discussions Section of Urological Imaging (ESUI), the masterclass took place during the Q&A session, which preceded took place from 26 to 27 November 2020. the final presentations of the day. The last lectures This report contains an overview of topics covered, covered considerations for starting a fusion biopsy as well as, impressions of the participants such as service (Dr. Kastner); prostate biopsy specimen Dr. Francesco Claps and Dr. François Triffaux. (Prof. Porpiglia); and risk stratification based on targeted biopsies (Dr. Walz). A packed programme Day one of the masterclass commenced with a Masterclass impressions and experience welcome message from Course Director, Dr. Jochen When asked what impact will joining the masterclass Walz, which was followed by presentations of have on their clinical practice, Dr. Claps and Prof. Georg Salomon and Prof. Pieter De Visschere on Dr. Triffaux shared their points of view. “Having the the fundamentals of ultrasound and MRI, respectively. possibility to read an mpMRI while being guided by experts step by step is a unique opportunity. What I’ve Then Prof. Jurgen Fütterer demonstrated how to read learned can help my clinical practice in enhancing my MRI using the MIM software during his presentation, technique and accuracy,” stated Dr. Claps. which preceded the Breakout session: MRI reading course with MIM software. During this session, the participants were divided into five groups, each guided and supervised by one to two masterclass faculty members. The first day concluded with expert feedback on patient cases. Day two kickstarted with lectures on the indications for prostate biopsy (Prof. Lars Budäus); biomarkers and MRI in prostate cancer diagnosis (Asst. Prof. Antti Rannikko and Dr. Veeru Kasivisvanathan, respectively); and transperineal or transrectal approaches (Dr. Christof Kastner). These were followed by lively deliberations during the Q&A session.

Dr. Triffaux said, “This masterclass taught me the fundamentals in prostate MRI reading, the latest research results supporting MRI use, and targeting biopsy as part of my PCa strategy. These will help me discuss and inform other urologists whom I work with, so we can collectively decide which approaches are optimal.” Both enjoyed the mpMRI reading activity and discussions, and found the virtual format of the masterclass a viable option given the COVID-19 situation. Dr. Triffaux shared, “The virtual masterclass was an incredible opportunity for me. It was back in summer when I learned about the call for applications but I wasn’t sure if I was able to go. Eventually, I missed the chance to apply. When we had the second lockdown, I was curious about happened to the masterclass. I checked the website and discovered the masterclass will be an online event. I immediately contacted ESU project coordinator, Ms. Sophie Mills, and she informed me that the roster was already full. A few days later, she offered me a spot due to a cancellation! I felt so happy and very lucky!” When asked about their reasons for applying, Dr. Claps said, “I was really pleased with my

All smiles: masterclass faculty members and attendees

experience at previous ESU events I’ve joined, such as Art in Flexible. Moreover, prostate biopsy represents one of my field of research and training so it was a great opportunity to participate in this masterclass. I'm going to apply to the ESU-ESOU Virtual Masterclass on Non-muscle-invasive bladder cancer as bladder cancer represents another important part of my research and clinical activity.” “I applied for this masterclass because I had an offer to stay as a senior urologist in the coming year to develop the andrology pursuits of my department and to further the activity of (targeted) prostate biopsy. I, of course, became very excited in becoming a masterclass participant and in my future role! I already applied to the masterclass NMIBC and hoping to join the ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie’s disease as well,” stated Dr. Triffaux. To (re)watch some of presentations from this masterclass, please visit UROsource at For more information on ESU masterclasses, feel free to explore

MRI-reading using the MIM software during the Breakout Sessions


ESU-ESUT Masterclass in Lasers in urology: A recap Virtual edition centres on clinical applications and new systems By Erika De Groot The virtual ESU-ESUT Masterclass in Lasers in urology drew in urologists and residents from 25 countries as far as Nepal. Through the collaborative efforts of the European School of Urology (ESU) and the EAU Section of Uro-Technology (ESUT), the masterclass took place from 19 to 20 November 2020 and 17 well-respected experts delivered a complete spectrum of clinical laser applications in urology; insights in the use of contemporary laser systems; and the best practices in the field. This report encapsulates the topics covered, activities that took place, and feedback from the participants as a whole, as well as, the masterclass experience of participants Dr. Lorenzo Angelini and Dr. Spyridon Nellas. Scientific programme Led by Course Director Dr. Alberto Breda, the initial day of the masterclass commenced with highlyinformative presentations on laser basic concepts (Prof. Andreas Johannes Gross), holmium laser (Prof. Olivier Traxer), 532-nm Laser (Dr. Giovanni Ferrari), thulium (TCC) and super thulium lasers (Dr. Esteban Emiliani).

upper tract?” by Dr. Guido Giusti which preceded two video sessions centred on upper tract urothelial carcinoma (UTUC), and benign prostatic hyperplasia (BPH). The UTUC video session showcased procedures such as percutaneous nephrostomy (PCN) laser ablation of UTUC; URS and laser incision of ileo-intestinal stricture; en-bloc laser resection of bladder TCC/super thulium, to name a few. This session was followed by the BPH video session which featured procedures such as holmium laser enucleation of the prostate (HoLEP) three-lobe technique; total en bloc enucleation of the prostate; Thulium fiber laser enucleation of the prostate (ThuFLEP), and more. Testimonials and impressions Feedback from masterclass participants commended the high scientific level of the lectures; the coverage from all aspects of laser application to modern endourology; and the speakers who were they deemed knowledgeable, well-prepared and adhered to the schedule.

When asked which concepts from the masterclass were most impactful, Dr. Angelini said, “In the treatment of urolithiasis, I will try to use more laser mini-PCNL techniques instead of the traditional PCN. I will also try to implement en-bloc resections of bladder tumours using holmium laser or Collins loop. The masterclass also increased my interest in the new thulium laser devices.” To Dr. Nellas, many of his questions were answered during the masterclass and thought that a complementary hands-on training will bring additional benefits. Dr. Angelini agreed as he, too, would like to have a hands-on training experience to go with the masterclass. When asked about their reasons for applying to the masterclass, Dr. Nellas stated, “I applied because of the increasing use of lasers in endourology and my supervisors highly recommended it. I was pleased to know that I could directly ask the faculty my questions during the masterclass. I also enjoyed the very interesting presentations. Overall, the

masterclass completely satisfied my expectations. In terms of other masterclasses that I’m interested in, the ESU-ESUT-ESUI Virtual Masterclass on Focal therapy for localised prostate cancer and and the virtual ESU-ESUI Masterclass on Prostate biopsy are my priorities.” Dr. Angelini said, “In my clinical practice, I use lasers on a regular basis. Furthermore, I am convinced that they will be used increasingly in the future. In my opinion, the masterclass was an excellent opportunity to keep up-to-date with this topic. I especially enjoyed watching the surgeries with listening commentary from the experts. I would certainly like to participate in other ESU masterclasses, particularly the ESU-Weill Cornell Masterclass in General urology which I think is very interesting.” To (re)watch some of presentations from this masterclass, please visit UROsource at For more information on ESU masterclasses, feel free to explore

These lectures were followed by in-depth videos centred on stones. These videos demonstrated pre-surgery set-ups; retrograde intrarenal surgery (RIRS) + super thulium laser; mini percutaneous nephrolithotomy (PCNL) with stone dusting; mini PCNL with Moses technology; RIRS + LithoVue and more. Day one concluded with a Prof. Gross’s lecture on the various techniques for different prostates with regard to lasers for benign prostatic obstruction (BPO). The second day kickstarted with the state-of-the-art lecture “Which is the best laser for TCC/ bladder/ January/February 2021

A demonstration during Dr. Giusti’s video presentation on RIRS + Holmium

Prof. Traxer elaborates fundamentals during holmium laser presentation

European Urology Today


Access the “living textbook” Open-access book on urogenital infections and inflammations Through the collaborative efforts of the EAU Section of Infections in Urology (ESIU), ZB MED – Leibniz Information Center for Life Sciences, and the German Medical Science (GMS), the “living textbook” (LTB) entitled “Urogenital Infections and Inflammations” came to fruition. The newly-published LTB is a free open-access book which is continually updated with contemporary developments, systematic literature review per topic, recommendations based on levels of evidence for contemporary clinical practice, and research suggestions. The LTB is an updated continuation of “Urogenital Infections”, the textbook on urinary tract infections published by The International Consultation on Urological Diseases (ICUD) in 2010. The principal aim of the ICUD was to promote improvement in the management of urological diseases worldwide by producing evidence-based recommendations. The main inspiration for the

The objectives are the following: 1. To update present knowledge and modern management of the thematic disease, as well as, assess the cost-effectiveness of various diagnostic and therapeutic options Prof. Naber, father of the LTB 2. To prepare recommendations for a number of on urogenital infection and selected topics, based on the most compelling inflammation information available 3. To prepare consensus or a widely accepted strategy concerning diagnosis and treatment according to evidence-based medicine whenever establishment of the LTB is to continue the work of the ICUD in the field of infection and inflammation in possible urology. These conditions have a core position in most 4. To propose standardised response criteria and define standards for clinical research in the medical fields, and prevention of infectious future complications is a key task in all surgical procedures 5. To propose measurement instruments for whether diagnostic or therapeutic (see Figure 1). intensity and impact for various urological The LTB will continue to pursue ICUD’s objectives in a diseases e.g. the International Prostate Symptom more timely manner. Hence, the easy-to-update Score (IPSS) online format. LTB contents This “living textbook” is comprised of 26 sections that cover infections and inflammations of the kidney, urinary tract, and genital tracts taking into account pathogenesis, diagnostics, treatment, prophylaxis and future aspects. Each section is overseen by two co-chairs who are responsible for peer review of each chapter. A chapter includes a background of a topic background and highlights critical evidence relating to the subject. Sections consist of topics such as: • Antibiotic usage and stewardship • Classification of urinary tract infections • Urinary tract infections with extraurogenital risk factors • Nosocomial and health-care associated urinary tract infections • Chronic prostatis/chronic pelvic pain syndrome • Current and future antibiotics for urogenital tract infections, and many more.

To develop the contents, recruiting authors and editors was one of the main challenges in establishing the LTB. In this respect, the LTB is a testament to Assoc. Prof. Kurt Naber`s lifelong efforts to improve guidelines and clinical practice. The LTB would not have been possible without his dedication, working capacity, organisational skills and unique global network. The editorial board is comprised of the highlyregarded experts Prof. Truls E. Bjerklund Johansen, Prof. Yong-Hyun Cho, Prof. John Krieger, Prof. Tetsuro Matsumoto, Prof. Kurt G. Naber, Prof. Daniel Shoskes and Prof. Florian Wagenlehner who consider the book a useful instrument for physicians of varying specialties. They consider the LTB as a source of evidence and recommendations provided with less stringent methodology than those of the EAU Guidelines. The LTB offers emphasis on principles and a broader scope for clinical situations where urologists cannot find practical recommendations in the Guidelines. For more information on the LTB “Urogenital Infections and Inflammations”, explore the chapters now via publishing/books/overview/52.

Figure 1: The core position of infections in urology. Drawing by Magnus Grabe


European Urology Today

January/February 2021


ATU annual meeting features vital updates on infections Online congress showcases ESU course & more EAU collaborations By Asst. Prof. Marouene Chakroun (TN) Despite the impact of COVID-19 on global events, the Tunisian Urological Association (ATU) kept its promise to organise its yearly congress albeit online. Focused on the main theme “Infections in urology”, the 20th National Urological Congress of the ATU took place from 10 to 12 December 2020. In the past few years, the strong relationship between the European Association of Urology (EAU) and the ATU continued to grow. The EAU was invited once more to participate at ATU’s congress. ESU course overview The course “Dealing with the challenge of infection in urology” by the European School of Urology (ESU) took place on the first day. Dr. Ahmed Said Zribi (TN) and I were in charge of coordinating this session. ESU faculty members, Profs. José Medina Polo (ES) and Tommaso Cai (IT), gave presentations on infections in urology. Over 300 participants from various countries such as Algeria, Morocco, Mauritania, Libya, Ivory Coast, Senegal, and Burkina Faso, attended the course. Prof. Cai first introduced the ESU’s vision and mission centred on offering unique opportunities in urological education to urologists in training and young certified urologists. Then Prof. Medina Polo provided detailed EAU guidelines recommendations on urological

Prof. Medina Polo shares EAU Guidelines recommendations

On-site view: During the clinical case deliberations

infections. This was followed by side-by-side lectures of Prof. Cai on the classification of urinary tract infection (UTI) and surgical field contamination categories as a basis for treatment and prophylaxis, low grade and recurrent UTI.

When asked about the interaction between presenters and the local organises, Prof. Cai said, “The interaction was perfect. I think we had a very good collaboration. They presented three interesting cases covering a lot of fields of interest.”

Day one proceeded with Prof. Medina Polo’s presentation on male genital infections such as epididymitis and urethritis; then Prof. Cai’s lecture on hospital-acquired UTI and antibiotic resistance. The two final lectures of the and perioperative prophylaxis with a special focus on prostate biopsy.

Dr. Zribi stated, “The course provided by experts have made a very good impression. Although it was virtual, we have been pleasantly surprised by the highly interactive environment and friendly atmosphere created by Prof. Cai and Prof. Medina Polo during the clinical case discussions. When we ran out of time, both presenters stayed with us for more than 30 minutes to answer to the questions. We were grateful about that.”

Prof. Cai presents “Hospital-acquired UTI and antibiotic resistance”

The course ended with interactive case discussions followed by a quiz wherein the winner was awarded with a He added, “The scientific content of the lectures was very attractive to the specialists in infectious diseases prize. and general physicians among the attendees. We are Course impressions receiving good feedback from urologists who viewed the course on replay on the platform.” According to Prof. Medina Polo, although the course was virtual, the proposed topics More ATU coverage On the second day of the ATU congress, Prof. Franck were good and organisation Bruyere (FR), member of the panel EAU Working through the virtual platform Group on Urological Infections, offered his expert was problem-free.

insights on the management of positive preoperative urine culture, urinary stents and probes infections, and the management of positive urinary culture in patient with intermittent self-catheterization. Dr Ahmed Saadi (TN) shared his experience about the place of urine culture and rectal swab before prostate biopsy. The congress’s third and final day addressed fundamental issues as the rule of good antibiotic prescriptions. These were presented by members from the Tunisian Society of Infectious Diseases. They also tackled the issue of the management of recurrent cystitis, and genital infections in hypofertile men such as the presentation of Prof. Abderrazek Bouzouita (TN). The collaboration with the EAU and the ESU at the congress had a significant impact on the scientific content of the sessions. The interactivity with the speakers and level of discussions were key to the success of the event. More collaboration with the EAU is expected in future which will further create learning opportunities from the experts and share mutual experiences in the field of urology.


Virtual ESU course and Albanian-Kosovan congress Meeting delivers vital urology updates onsite and online In light of the COVID-19 situation, a hybrid event was organised and commenced on 4 December 2020: the virtual course of the European School of Urology (ESU) took place in conjunction with the national congress of the Albanian Association of Urologic Surgeons and Kosovo Urologists Association. Approximately 30 urologists were onsite and 80 urologists, doctors and nurses from Albania and Kosovo attended online. ESU course coverage The ESU course themed “Upper tract laparoscopic surgery” was organised with the support of the associations’ respected members, Dr. Oltion Alibali, Dr. Xhevdet Cuni and Dr. Gezim Galiqi. Dr. Jose Maria Gaya Sopena spearheaded the course and with fellow ESU course faculty member, Assoc. Prof. Roman Sosnowski, who both offered expert insights in five highly-informative lectures. The ESU course commenced with Dr. Gaya Sopena’s presentation on what unique possibilities for urological education the ESU offers. He also presented the lectures on the techniques and management of complications with regard to trans- and retroperitoneal access, as well as, laparoscopic pyeloplasty and adrenalectomy. Prof. Sosnowski shared his expertise during his presentations “Laparoscopic nephrectomy and nephro-ureterectomy: Technique and management of complications” and “EAU Guidelines recommendations: What are the indications for laparoscopy?”. In the latter presentation, Prof. Sosnowski stated that according to the EAU Guidelines, surgical management in patients with kidney tumours should be recommended in every possible case, because it is January/February 2021

possible to obtain an effective treatment. With regard to small kidney tumours (<T1), partial nephrectomy is recommended whenever technically feasible. He added that the ESMO Guidelines for the management of local disease of partial nephrectomy (PN) is recommended as the preferred option in organ-confined tumours measuring up to 7 cm (elective indication). PN can be carried out via open, laparoscopic or robot-assisted laparoscopic approaches. Laparoscopic RN is recommended if PN is not technically feasible. In patients with compromised renal function, solitary kidney or bilateral tumours, PN is also the standard of care, with no tumour size limitation (imperative indication). In terms of T2 tumours (> 7 cm) laparoscopic RN is the preferred option. Prof. Sosnowski stated, “Likewise, the NCCN Guidelines constitute radical nephrectomy should not be employed when nephron sparing surgery can be achieved. When compared with radical nephrectomy, partial nephrectomy can achieve preserved renal function, decreased overall mortality, and reduced frequency of cardiovascular events. Studies show that the oncologic outcome for laparoscopic versus open nephron-sparing surgery appears to be similar.” He added that according to the EAU Guidelines, tumour resection is potentially curative only if all tumour deposits are excised. This includes patients with the primary tumour in place and single- or oligometastatic resectable disease. For most patients with metastatic disease, cytoreductive nephrectomy (CN) is palliative and systemic treatments are necessary. The recommended surgical technique was not clearly specified.

Adhering to the social distancing rules at the congress

Congress’ other scientific updates During the congress, topics such as prostate cancer and alternatives for the treatment of oligometastatic disease were covered where the most optimal treatment, surgery and radiotherapy were examined and discussed.

To know more about ESU activities such as upcoming courses, UROwebinars, e-courses, masterclasses and more, please visit

The congress also tackled topics such as advanced renal carcinoma and its treatment; update on the treatment of urethral stricture; and the treatment of congenital urological pathologies. The ESU course was interspersed with lively Q&A sessions and case discussions between the faculty and the attendees.

Prof. Gaya Sopena explains trocar placement

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January/February 2021


Virtual ESU Course delivers BPH fundamentals in Baghdad New technologies, enucleation, tips & tricks By Prof. Nibbras Al-Hamdani, President of the Iraqi Urology Association Through an initiative and policy established by Urology Beyond Europe, the European Association of Urology (EAU) has formed numerous collaborations with urology societies within and beyond Europe. One of these notable collaborations is with the Iraqi Urology Association (IUA). For more than 10 years now and through the European School of Urology (ESU), renowned experts share their valuable insights and experience during ESU Courses which take place during IUA’s national congresses. This year, the ESU Course was redesigned to fit the extraordinary COVID-19 situation. ESU Course on BPH Despite travel restrictions and postponement/ cancellation of many scientific congresses, the IUA and ESU remained enthusiastic and driven to continue with the course programme. The typically on-site ESU Course was adapted as a virtual event instead and took place on 20 November 2020. The virtual ESU course “Recent advancements in treatment of BPH” was comprised of presentations by Prof. Dr. Sascha Ahyai (DE) and Dr. Panagiotis Kallidonis (GR), and attended by more than 85 Iraqi urologists. Prof. Ahyai kickstarted the course with an overview of ESU’s aims and objectives, followed by an informative lecture on anatomical enucleation as part of benign prostatic hyperplasia (BPH) treatment. Lively deliberations between the ESU and local faculty members took place during an interactive case discussion, which was preceded by an

Prof. Ahyai explores new technologies for BPH management

informative presentation of Prof. Kallidonis on the tips and tricks in laser enucleation. Prof. Ahyai proceeded with the enumeration and discussions on the new technologies in BPH management. His lecture was followed by a presentation by Prof. Kallidonis on the tips and tricks for minimally-invasive surgical enucleation of the prostate demonstrating both laparoscopic and robotic procedures. All ESU Course presentations were succeeded by a question-and-answer activities to further expound on the topics discussed.

Prof. Kallidonis shares his insights on trocar placement

programme of BPH education which I think is a hot topic since there so many new technologies emerging and trials being conducted. The course was an excellent way to enhance the friendship between the ESU and Iraqi urologists.”

From a personal standpoint, the ESU Course was organised and delivered well. To experience it as a virtual event for the first time taught us the benefits of organising future events with either a virtual or hybrid format.

According to Prof. Andrea Minervini (IT), the new technologies featured were interesting especially from a scientific point of view.

“The course was a fantastic programme of BPH education which I think is a hot topic since there so many new technologies emerging and trials being conducted…”

Prof. Jens Rassweiler (DE) added, “I think the ESU Course was very helpful. It introduced the benefits of bipolar enucleation such as cost-effectiveness.”

The ESU course concluded with another interactive case discussion between the ESU Course and local faculty members.

Prof. Jeroen Van Moorselaar (NL) said, “The ESU Course programme and the virtual format was very good. We can still use this even after the COVID-19 period ends.”

Impressions from the Board Members of the ESU Board were asked what their impressions were of the ESU Course. Prof. Prokar Dasgupta (GB) stated, “The course was a fantastic

Prof. Hein Van Poppel (BE) concluded, “It was a good course. Congratulations to the staff and faculty for adapting the course so quickly and efficiently.”

We would like to express our sincerest appreciation to EAU Secretary General Prof. Chris Chapple (GB), ESU Chair Prof. Joan Palou (ES), Mrs. Jacobijn Sedelaar-Maaskant (NL) and Mrs. Kristel Klein Hesselink (NL) for their immense effort and support which made the ESU Course a success.


ESU course imparts tips and tricks in challenging surgeries Virtual event offers new techniques, complex cases and updates By Erika De Groot Held during I Congreso Nacional Virtual de Urología of the Spanish Urological Association (AEU) on 23 November 2020, the virtual course of the European School of Urology (ESU) entitled “Tips and tricks in challenging surgeries” offered expert insights and relevant updates to 423 urologists. ESU Chair Prof. Joan Palou (ES) spearheaded the course and was joined by fellow esteemed faculty members Dr. Alberto Breda (ES), Prof. Thomas Knoll (DE), and Dr. Mario Alvarez-Maestro (ES) of the AEU. Comprised of four presentations and a Q&A session, the ESU virtual course kickstarted with the presentation of Prof. Palou which was entitled “European School of Urology: A unique possibility for urological education”. He was followed by Dr. Breda, who shared his expertise during his lecture “Robotic transplant surgery is present and future”. Prof. Palou stated, “Dr. Breda is one of the leaders of the robotic programme in Europe. He demonstrated robotic renal transplant during the course. In addition, the creation of collaborative groups is a must in the development of medicine. Dr. Breda has created one such group focused on robotic kidney transplant. They are very active in developing and pursuing further developments.” The third presentation was by Prof. Knoll who gave the lecture “Percutaneous Nephrolithotomy (PCNL): Not always easy”. He encapsulated the key points of his presentation: “Percutaneous nephrolithotomy is a standard procedure for renal stone removal. While many interventions are straightforward, some may challenge the urologist. It is important to standardize the procedure and to develop a strategy for the best approach, especially in complex situations.” January/February 2021

According to Prof. Palou, Prof. Knoll demonstrated his skilfulness in complex stone percutaneous approach. “He presented complex cases in the management of kidney stone disease which are not always easy cases to treat. Complex stones cases or patients with previous surgeries incite urologists to use all of their expertise to come up with treatment solutions.”

“The course was an excellent combination of thought-provoking and contemporary topics presented by knowledgeable speakers” The final presentation was by Prof. Palou entitled “Ureterointestinal stenosis: Endourology or what?” wherein he underscored the importance of expertise in management and minimising complications. According to Prof. Palou, the development of a ureterointestinal stenosis is a significant problem in the follow-up of patients who have undergone radical cystectomy because of bladder cancer. “It is one of the most important factors in the impairment of renal

function after a radical surgery. Endourology can temporarily solve the problem but recurrence can happen, unless it is a short stricture on the right side and occurs later than one year after the surgery.” He added that reconstructive surgery may be difficult to perform due to the complications (intraoperatively and postoperatively) with open surgery, but it has been published that laparoscopic procedures have shown good results. “In the previous years, we have been doing minimally-invasive robotic surgical reconstruction with excellent results and very few complications. Potentially it can become the technique of choice because of its feasibility and safety,” said Prof. Palou. The virtual course concluded with lively deliberations during the Q&A wherein Dr. Alvarez-Maestro discussed the applications of different techniques, implementation of working groups and the robotic solution of challenging situations with the speakers. “The Q&A consisted of high-level discussions packed with valuable insights and additional updates,” recalled Dr. Alvarez-Maestro.

Deliberations among the experts that made up the ESU and AEU faculty

Impressions According to Dr. Alvarez-Maestro, the interaction between the presenters and the participants was good. He added that at the end of the course, the participants gave positive comments with regard to the level and scientific content of the lectures. Dr. Breda shared, “The virtual course was organised and well-attended, and the discussions were overall good.” Prof. Knoll agreed. Dr. Breda, added, “However we would like to have the participants to ask even more questions. So to future participants of ESU courses, we highly encourage you to keep asking questions.” “The course was an excellent combination of thought-provoking and contemporary topics presented by knowledgeable speakers,” concluded Prof. Palou. For more information on educational activities such as upcoming ESU virtual courses, UROwebinars, e-courses, masterclasses and more, please visit

Dr. Breda shows 3D model during presentation on the present and future of robotic transplant surgery

European Urology Today


The new gold standard? The management of complex recto-urinary fistulas with gracilis muscle interposition Prof. Javier RomeroOtero Head Urological Department HM Hospitals Madrid (ES) jromero@

Dr. José Medina-Polo Urologist HU 12 Octubre Madrid (ES) The gracilis muscle with both ends free and fixed by the pedicle only

josemedinapolo@ The Reconstructive Surgery-Andrology Unit of Hospital Universitario 12 Octubre (UCRA12) and HM Hospitales (UCRA_ROC) is composed of four dedicated urologists, Javier Romero-Otero, José Medina-Polo, Borja García-Gómez, and Manuel Alonso-Isa, and a multidisciplinary team. We are one of the two referral centres in Spain that is recognised by the Spanish Health Minister for penile prosthesis, male urinary incontinence surgery, urethral strictures, Peyronie's surgery, recto-urinary fistulas, neophallus, bladder exstrophy, and other complex reconstructive surgeries. Recto-urinary fistulas are a rare complication in patients with Crohn's disease or diverticular disease after radical prostatectomy, colorectal surgery, or cryosurgery. For after radical prostatectomy, the estimated incidence is lower than 2%. A rectourethral fistula is the most common type, with its highest incidence percentage identified in the combined treatment of surgery and pelvic radiotherapy for prostate cancer. Radiotherapy or a lesion in the rectal wall during radical prostatectomy are the leading causes. If a fistula occurs during the surgery, primary closure is needed. However, in some cases the urinary-rectal fistula is diagnosed in the postoperative period. Surgical repair The management of recto-urinary fistulas represent a challenging task. A surgical repair is required in most of the cases. Several surgical procedures are possible, including the resection of the fistula tract and direct closure of the fistula with the perineal approach, mucosal flaps, the instillation of fibrin glue, endorectal advancement flap, or York-Mason operation. An alternative would be a fistula closure with the abdominal approach. The less aggressive procedures report good outcomes in not-complex fistulas. However, complex fistulas in patients who had previous surgeries or prior radiotherapy may require an interposition of tissues in order to achieve fistula closure and reduce the incidence of recurrence. Among the tissues used for transposition in the recto-urethral fistula are the gracilis muscle, rectus abdominis, omentum, dartos, gluteus maximus, and latissimus dorsi.

“During the postoperative procedure, it is essential to adequately control the donor site in the thigh to minimise the incidence of wound infection or delayed healing.” The abdominal approach has the advantage of placing healthy, well-vascularised tissue in the affected area. On the other hand, the abdominal approach potentially has significant perioperative adverse sequelae. Gracilis interposition allows for a well-vascularised tissue using the perineal approach. Simple technique The repair of perineal fistulas with gracilis muscle interposition was first described by Garlock et al. in EAU Section of Genito-Urinary Reconstructive Surgeons (ESGURS)


European Urology Today

1928. In 1952, Igelman-Sundberg described it as a technique for patients with vesicovaginal fistulas. The interposition of gracilis muscle is one of the procedures that provides satisfactory outcomes with limited functional limitation in the donor area as the gracilis muscle only has a vestigial function. Transposition of a gracilis muscle flap may be used for the surgical management of rectovaginal, rectourethral, pouchvaginal, and pouch-urethral fistula.

“Complex fistulas in patients with previous surgeries or prior radiotherapy may require an interposition of tissues.” The gracilis muscle is situated in the thigh's medial part from the ischiopubic branch to its tibial insertion forming the goosefoot. It is the most medial and superficial muscle of the inner thigh, fulfilling adduction functions, internal rotation, and flexion of the hip. It has a very proximal pedicle consisting of the circumflex medial femoral artery, which allows adequate transposition to the perineal area. There is also a distal vascular pedicle from the deep femoral artery, which can be divided and ligated to achieve the flap's correct rotation. Other minor pedicles can be dissected. The main advantages of a flap in the gracilis muscle are that it provides low morbidity at the donor site and enough tissue from the donor site to correct interposition and limited functional loss. Moreover, when the procedure is carried out by an experienced surgeon, the gracilis muscle's dissection is a simple technique. A complex urinary-rectal fistula When a complex urinary-rectal fistula is diagnosed, a faecal and urinary diversion is recommended. At the beginning of the procedure, ureteral catheterisation may be performed as the fistula's orifice may be close to the ureteral meatus. The surgical procedure with the transposition of the gracilis muscle consists of the perineal approach with a dissection above the transversus perineum muscle and below the bulbocavernosus muscle. The dissection is carried out until the identification of the fistula. The fistula's edges are resected to leave soft, viable tissue for the closure of the fistula. The rectal wall and the urethra are closed with absorbable stitches. The suture must be done using healthy tissues. The gracilis muscle is dissected from the non-dominant leg and transposes to the perineum to preserve the proximal pedicle through a subcutaneous tunnel. For a gracilis muscle requiring an incision at the medial thigh, perform the incision immediately posterior to the saphenous vein from four to eight fingerbreadths distal to the anterior superior iliac spine. The gracilis muscle is then interposed between the rectal and urethral closure of the fistula and fixed with an absorbable suture. The surgery is associated with a complication rate from 0% to 49%. The most common complication is a perineal wound infection or delayed healing. Although the donor site morbidity at the gracilismuscle-harvesting site is low, during the postoperative procedure it is essential to adequately control the donor site in the thigh to minimise the incidence of wound infection or delayed healing. It is necessary to advise patients that in the postoperative period urinary incontinence and faecal incontinence is reported in 14% and 4,2% of the patients respectively.

The gracilis muscle interposed between the recto and bladder

The surgery must be carried out by a multidisciplinary team which include a urologist, colorectal surgeons, and urological reconstructive surgeons with the specific skills required for perineal surgery. Repair of

the urinary-rectal fistula with transposition of the gracilis muscle is challenging as many patients have received prior radiotherapy and have had previous failed attempt to repair the fistula.

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January/February 2021

EAU Patient Information’s Working Group 2021 New members and new horizons Mr. Eamonn T. Rogers EAU Patient Information Chairman Galway (IE)

Dr. van Balken has a special interest in healthilliterate patients and improving the way we get information from and give information to especially those patients. He started several projects as well as scientific research regarding this subject. Dr. Burhan Coskun (Bursa, TR) is a urologist specialising in female urology, functional urology, neuro-urology, and renal transplantation.

Dr. Markus Eckstein (Erlangen, DE) is a The importance of individuals taking responsibility pathologist specialising in uropathology for their own healthcare is fundamental to modern with a research focus on locally advanced healthcare reform. Empowering patients to bladder cancer and tumour immunology at the participate in the management of their disease University Hospital Erlangen, FAU Erlangen-Nürnberg, facilitates early diagnosis and management, in Germany. promotes prevention and wellbeing, and familiarises patients with healthcare services in the community as Mrs. Louisa Fleure (London, GB) is an well as hospitals, in turn supporting and socialising Advanced Nurse Practitioner specialising in innovative healthcare initiatives. Patient oncological urology. empowerment depends on the availability of accurate, innovative, updated information based on Dr. Markos Karavitakis (Athens, GR) is a best medical evidence. urological surgeon specialising in laparoscopic surgery and is actively The EAU Patient Information (EAU PI) Working Group involved in several panels and committees of the (WG) plays a vital role for EAU PI as they bring to the European Association of Urology and of the Hellenic table their experience and expertise in helping to Urological Association. develop and disseminate accurate and evidencebased medical information for patients with a Dr. Kristian Krpina (Zagreb, HR) is a urological disease. urologist specialising in urological oncology. The contributions of our WG result in multi-language, patient-friendly content for the EAU PI website, Dr. Serena Maruccia (Milan, IT) is a consisting of animated videos and a range of topics, urologist specialising in laser surgery including leaflets which are free to download. The (holmium and thulium), andrology, and group is involved in various aspects of content, surgery relating to infertility and sterility, functional including creating, localising, updating, and translating urology, general urology, uro-oncology, and materials which are in accordance with the evidencereconstructive surgery. based EAU Guidelines. Just as important, however, is the dissemination of our content to all classes, Dr. Maruccia serves additionally as a university requiring creativity, cultural sensitivity, and innovation professor at the Master in Urological Rehabilitation from the WG. We rely on our WG members to develop - University of Milano-Bicocca - University new ideas, to liaise with their national societies, and to Professor of Andrology at the Postgraduate Course connect with local patient support groups to actively in Sexual Counseling - Department of Psychology promote EAU PI in their country and make sure that - University of Milano-Bicocca - hands-on tutor in they have access to EAU PI as a reliable resource. Prostatic Laser Enucleation Courses and coordinator of the facility team for the Italian Society of Urology Despite the challenges that come with the COVID-19 – Communication division. pandemic, we are more than ever committed to fulfilling our ambition to further expand and Dr. Laura Mateu Arrom (Barcelona, ES) professionalise our activities for the benefit of patients. is a urologist specialising in female & In the year to come, EAU Guidelines topics which are functional urology, incontinence, not yet covered will be developed, such as urological infections in urology, male LUTS, neuro-urology infections, urological trauma, and paediatric urology. and pelvic pain. Furthermore, the quality of lay language will be improved, the animated video library will be expanded, Prof. Pierre Mongiat-Artus (Paris, FR) is a vital urological information will be disseminated Professor of Urology specialising in among European citizens, and investigations into the oncology, competent in geriatrics, genetics development of patient care pathways as well as other and ethics. products that will enhance the experience of visitors to the EAU PI website will continue. Prof. Mongiat-Artus has specific interests in communication, patient-centred care, and health Due to having served two terms, a number of WG literacy. members have left the group in October 2020. Needless to say, we are most grateful for the Dr. Sergio Pereira (Lisbon, PT) is a urologist commitment and support we have received from each specialising in laparoscopy and urolithiasis. of them. We will build on their legacy as we move Dr. Pereira serves as the coordinator of the forward and into the future. We want to thank: urolithiasis unit at the Centro Hospitalar Universitário Lisboa Norte. • Dr. Mark Behrendt (Amsterdam, NL) • Dr. Francesco Esperto (Rome, IT) Dr. Selçuk Sarikaya (Ankara, TR) is a • Dr. Sarah Ottenhof (Amsterdam, NL) urologist specialising in andrological • Dr. Giulio Patruno (Rome, IT) urology and sexual medicine: specifically • Dr. Ricardo Pereira E Silva (Lisbon, PT) erectile dysfunction, premature ejaculation, and male • Dr. Yiloren Tanidir (Istanbul, TR) infertility. • Dr. Juan Luis Vasquez (Roskilde, DK) Dr. Sarikaya is currently working at the Gülhane Subsequently, EAU PI has recently welcomed to the Research and Training Hospital in Ankara and is also WG six new members who will serve a four-year term involved in the Biochemistry PhD programme at the effective since 1 January 2021. University of Health Sciences in this city. He has completed an observership in andrology at the We are delighted to present to you our current WG, University College London Hospitals, St. Peter’s consisting of 15 members from across Europe who Department of Andrology. collectively create a broad foundation of knowledge for EAU PI. Dr. Bente Thoft-Jensen (Aarhus, DK) is a clinical nurse and senior researcher Dr. Nabil Atassi (Sindelfingen, DE) is a specialising in oncological urology. urologist specialising in urolithiasis, endourology, laser surgery, male LUTS, and Dr. Sara Tolouee (Copenhagen, DK) is a robotic urology. third-year resident specialising in urology. Dr. Michael R. van Balken (Arnhem, NL) is a urologist specialising in female & Dr. Barbora Zemlickova (Prague, CZ) is a functional urology, genitourinary urology resident specialising in reconstruction, history in urology, incontinence, endourology, urolithiasis, bladder cancer neuro-urology, and male LUTS. and andrology. January/February 2021

Prof. Hein Van Poppel and Mr. Eamonn Rogers

We are very excited about the opportunity to work with this excellent group of experts and look forward to their combined talents and insights enriching the patient experience. Questions or interested? If you would like to learn more about EAU Patient Information and its activities or if you have any

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European Urology Today


Latest developments in non-neurogenic LUTS treatment What is important in the field in 2021? Dr. Pedro AbreuMendes Faculty of Medicine University of Porto (PT)

with the other groups. The recommendation of a regular vigilance of blood pressure after mirabegron prescription and the contra-indication of its use in patients with severe, uncontrolled hypertension remain active.


A large population-based survey which included > 20,000 Canadian new users of mirabegron and > 40,000 new users of anticholinergic medications (oxybutynin, tolterodine, solifenacin, darifenacin, fesoterodine, trospium) concluded that the risk of dementia was lower in the mirabegron cohort2.

Prof. Francisco Cruz Faculty of Medicine University of Porto (PT)

Vibegron In contrast to mirabegron A, the second β3adrenergic receptor agonist, vibegron, does not inhibit CYP2D6, a cytochrome P450 enzyme9. How this characteristic can contribute to decreasing drug interaction between vibegron and other drugs in real life is still unclear. Despite the recent approval by the FDA, no references to vibegron can be found yet in worldwide clinical guidelines. Nevertheless, the pivotal phase III trials have been carried out. A 12-week study conducted in Japan by Yoshida et al. Pharmacotherapy and electrical nerve stimulation for exposed 1,232 OAB patients to vibegron 50 or 100 mg the treatment of non-neurogenic lower urinary tract OD, placebo, or the antimuscarinic imidafenacin9. A symptoms (LUTS) witnessed considerable advances in reduction in the number of micturitions per 24h, of recent years. At the beginning of 2020, we performed urgency episodes and incontinence episodes/day, an Embase/Pubmed search of the English literature to was found. Interestingly, more than 40% of the identify randomised clinical trials, prospective and subjects exposed to Vibegron referred to the retrospective cohort series involving antimuscarinics, normalisation of nocturia10. beta-3 adrenoreceptor (β3-AR) agonists (mirabegron, vibegron), alpha-blockers, botulinum toxin A, sacral Vibegron was also investigated in the EMPOWUR trial neuromodulation, percutaneous tibial nerve that enrolled 1,518 OAB patients randomised to stimulation (PTNS) and overactive bladder (OAB) in vibegron 75 mg, placebo, or extended-release non-neurogenic patients. tolterodine, 4 mg11. Vibegron brought a statistically significant reduction in UUI episodes (in patients with Oral OAB pharmacotherapy ≥ 1 episode/day) and in voids/day over placebo. Current EAU guidelines list a strong recommendation Adverse events were few. for the use of the β3-AR agonist mirabegron for the treatment of idiopathic OAB/LUTS. This “Despite the recent approval by the recommendation is likely to be reinforced in face of the most recent studies. FDA, no references to vibegron can The 12-week randomised placebo-controlled PILLAR study aims at clarifying the efficacy and safety of mirabegron in an elderly population. This study was conducted with 900 incontinent subjects of ≥ 65 years. Mirabegron was started at a dose of 25 mg with a possible escalation to 50 mg after week 4. The drug caused significant improvements in incontinence and voiding episodes. For the first time, cognition was estimated by the Montreal Cognitive Assessment score. After 12 weeks, no changes were detected in the patients exposed to mirabegron1. The Believe study evaluated mirabegron 50 mg in a 12-month observational study with 862 patients, half of whom were above 65 years3,4. Quality of life improved significantly and the percentage of dry patients increased by about 10% at the end of the study. A decrease in pad use was noticed. Improvements were similar across all ages and persistence on treatment exceeded 50% of patients. Hypertension was observed in 1.3% of the total population and in 3.2% of the elderly. The Miracle study randomised 464 OAB Korean males to mirabegron 50 mg or placebo5. Storage symptoms improved significantly and a numeric reduction in the number of voids was found with mirabegron. Changes in Qmax and PVR were clinically irrelevant after mirabegron. Comparison mirabegron and antimuscarinics Well-powered head-to-head comparisons between mirabegron and antimuscarinics were not reported. A systematic review showed that mirabegron 50 mg and most antimuscarinics have equivalent effects in controlling incontinence and urinary frequency. Combination of solifenacin 5 mg plus mirabegron 25/50 mg and solifenacin 10 mg monotherapy may be a more efficacious option6. Confirmation of mirabegron safety was provided by the analysis of a large data set of 5,244 patients exposed to mirabegron, 2,999 to antimuscarinics, and 3,018 to placebo7. Adverse events were less common in those exposed to mirabegron (17.0%) than to antimuscarinics (21.4%). Specifically in the population ≥ 75 years, the remarkably lower rates of dry mouth and constipation were striking8. De novo hypertension was similar across the 3 groups, except in patients ≥ 75 years, who showed a 1% higher score compared EAU Section of Female and Functional Urology


European Urology Today

be found yet in worldwide clinical guidelines.” Dmochowski et al. evaluated patients treated with vibegron in a 52-week study12. From a total of 169 participants starting on vibegron 50mg, about 1/3 requested escalation to 100 mg. Daily micturitions, urgency, and UUI episodes were all significantly improved from week 4 until week 52. The number of patients who abandoned the study was very low and no serious adverse events were reported. Male LUTS A Korean nationwide population-based study13, involving 60,000 patients receiving different alpha-blockers (tamsulosin, doxazosin, alfuzosin, terazosin) during a median time of 1 year did not report any increase in the incidence of mild to moderate dementia. This large survey possibly relieved the concerns raised by the Duan et al. study which had reported a higher incidence of mild to moderate dementia after a median period of 20 months exposure to tamsulosin14, despite the lack of evidence that the alpha-blocker crosses the bloodbrain barrier in significant amounts. Oral combination pharmacotherapy is superior The availability of several classes of drugs that can improve LUTS and incontinence through different mechanisms offers the possibility of the drug combination to treat refractory cases to initial monotherapy. Mirabegron 50 mg plus solifenacin 5 mg were compared against each drug in monotherapy for 12 months in almost 1,500 OAB, predominantly women, wet patients (Synergy II)15. The improvement in frequency, urgency, and UUI favoured the combination arm and no safety issues were detected. In the Milai II, a 52-week study, patients refractory to mirabegron monotherapy received an add-on antimuscarinic (solifenacin, propiverine, imidafenacin or tolterodine)16. The combination increased efficacy and no safety issues were recognised during the duration. Comparison of vibegron alone or in combination with tolterodine 4 mg ER showed that the combination was superior to monotherapy in improving daily micturition frequency and in reducing incontinence episodes in OAB wet patients17.

Although it is effective and safe, the combination of alpha-blockers with antimuscarinics in patients with persistent storage LUTS (OAB), either in the add-on or in a fixed combination, is still feared by many physicians due to the potential risk of voiding dysfunction in elderly men18. The Match and the Plus trials19,20 investigated the safety and efficacy of adding on mirabegron 50 mg to tamsulosin. Significant improvements in storage LUTS were observed in both studies while Qmax and post voiding residual (PVR) did not show relevant variations. The CONTACT study investigated the efficacy and safety of tadalafil monotherapy 5mg/day versus the combination of tadalafil plus mirabegron (5 mg/50 mg/day) in 176 men with LUTS refractory to PDI5 monotherapy21. OAB symptoms were significantly improved in the combination arm and no adverse events were reported. Intravesical Onabotulinum Toxin A Two studies investigated OnabotA only in OAB males. Faure Walker used doses of 100-300 U of OnabotA in 65 men (mean age 57.1 ± 13 years), with a total of 133 treatments22. The numeric size of improvement in men was inferior to that found in women for the same baseline characteristics. Urinary tract infection (UTI) was reported after 29.0% of treatments and de novo clean intermittent catheterisation (CIC) was necessary after 42.6% of the treatments. Mateu et al.23 reviewed 146 men injected with 100 U. A positive response to the treatment was reported by 62.3% and the incidence of urinary retention, despite the higher age of the cohort, was only 13%. The ROSETTA study, a comparison between Onabotulinum toxin A (OnabotA, 200U) and sacral neuromodulation (SNM) in OAB drug-refractory patients released the 2-year data24. As the OnabotA dose is double the approved dose for OAB treatment, the results should be inevitably interpreted with some caution. Nevertheless, the reduction of urgency incontinence was similar in the two arms, in contrast to what had been reported at earlier time points. The rate of UTI in the OnabotA and SNM groups were respectively 24% and 10%. A total of 6% of the patients required CIC after the second injection of the toxin while the revision or removal of the SNM device was 3 and 9% at 2 years. Percutaneous Tibial Nerve Stimulation Percutaneous Tibial Nerve Stimulation (PTNS) in refractory OAB may have poor success if patients have severe nocturia, high-pressure detrusor overactivity, or have failed after OnabotA or SNM25. Two pilot studies were carried out to test implantable subcutaneous devices to deliver PTNS. A 6-month study with 36 patients evaluated the efficacy of a battery-less, wirelessly powered implantable BlueWind RENOVA™ (Rainbow Medical, Israel)26. With stimulation schemes of six times/week during 30 minutes for 3 months or three times/week for 6 months, clinical improvement was obtained in 71% of the patients who concluded the trial. Furthermore, 27% of incontinent subjects become "dry." MacDiarmid et al. enrolled 46 patients to assess a nickel-size PTNS device27. Episodes of urge urinary incontinence (UUI) were reduced after 3 months of treatment and more than 20% of patients were dry at 3 and 6 months. Adverse events were mild in both studies. References 1. Wagg A, Staskin D, Engel E, Herschorn S, Kristy RM, Schermer CR. Efficacy, safety, and tolerability of mirabegron in patients aged ≥65 yr with overactive bladder wet: a phase IV, double-blind, randomized, placebo-controlled study (PILLAR). Eur Urol [Internet]. 2019;1–10. Available from: eururo.2019.10.002 2. Welk B, McArthur E. Increased risk of dementia among patients with overactive bladder treated with an anticholinergic medication compared to a beta-3 agonist: a population-based cohort study. BJU Int [Internet]. 2020 Mar 19;0–1. Available from: http://doi. 3. Foley S, Choudhury N, Huang M, Stari A, Nazir J, Freeman R. Quality of life in patients aged 65 years and older with overactive bladder treated with mirabegron across eight European countries: Secondary analysis of BELIEVE. Int J Urol [Internet]. 2019 Sep 14;26(9):890–6. Available from: abs/10.1111/iju.14050 4. Freeman R, Foley S, Rosa Arias J, Vicente E, Grill R, Kachlirova Z, et al. Mirabegron improves quality-of-

life, treatment satisfaction, and persistence in patients with overactive bladder: a multi-center, noninterventional, real-world, 12-month study. Curr Med Res Opin [Internet]. 2018 May 4;34(5):785–93. Available from: n=viewrecord&from=export&id=L620365951%0Ahttp:// 5. Shin DG, Kim HW, Yoon SJ, Song SH, Kim YH, Lee YG, et al. Mirabegron as a treatment for overactive bladder symptoms in men (MIRACLE study): Efficacy and safety results from a multicenter, randomized, double-blind, placebo-controlled, parallel comparison phase IV study. Neurourol Urodyn [Internet]. 2019 Jan;38(1):295–304. Available from: 6. Kelleher C, Hakimi Z, Zur R, Siddiqui E, Maman K, Aballéa S, et al. Efficacy and Tolerability of Mirabegron Compared with Antimuscarinic Monotherapy or Combination Therapies for Overactive Bladder: A Systematic Review and Network Meta-analysis. Eur Urol [Internet]. 2018 Sep;74(3):324–33. Available from: S030228381830201X 7. Chapple CR, Cruz F, Cardozo L, Staskin D, Herschorn S, Choudhury N, et al. Safety and Efficacy of Mirabegron: Analysis of a Large Integrated Clinical Trial Database of Patients with Overactive Bladder Receiving Mirabegron, Antimuscarinics, or Placebo. Eur Urol [Internet]. 2020 Jan;77(1):119–28. Available from: https://doi. org/10.1016/j.eururo.2019.09.024 8. Wagg A, Cardozo L, Nitti VW, Castro-Diaz D, Auerbach S, Blauwet MB, et al. The efficacy and tolerability of the β3-adrenoceptor agonist mirabegron for the treatment of symptoms of overactive bladder in older patients. Age Ageing [Internet]. 2014 Sep;43(5):666–75. Available from: doi/10.1093/ageing/afu017 9. Yoshida M, Takeda M, Gotoh M, Nagai S, Kurose T. Vibegron, a Novel Potent and Selective β 3 -Adrenoreceptor Agonist, for the Treatment of Patients with Overactive Bladder: A Randomized, Double-blind, Placebo-controlled Phase 3 Study. Eur Urol [Internet]. 2018 May;73(5):783–90. Available from: http://dx.doi. org/10.1016/j.eururo.2017.12.022 10. Yoshida M, Takeda M, Gotoh M, Yokoyama O, Kakizaki H, Takahashi S, et al. Efficacy of novel β 3 adrenoreceptor agonist vibegron on nocturia in patients with overactive bladder: A post-hoc analysis of a randomized, double-blind, placebo-controlled phase 3 study. Int J Urol [Internet]. 2019 Mar 17;26(3):369–75. Available from: abs/10.1111/iju.13877 11. David Staskin, Boston, MA; Jeffrey Frankel, Burien WSV, Milford, CT; Jihao Zhou, Rachael Jankowich, Paul N. Mudd, Irvine C. International Phase 3, Double-blind, placebo-and active (Tolterodine)-controlled study to evaluate the safety and efficacy of vibegron in patients with symptoms of overactive bladder: EMPOWUR. J Urol Suppl. 2019;201(4S):e992. 12. Dmochowski R, Mitcheson D, Frenkl T, Bennett N, Mudd Jr PN. Durable Efficacy and Safety of Long-Term Once-Daily Vibegron, a Novel Oral B-3 Adrenergic Receptor Agonist: a 52-Week Phase 2 Study in Patients With Overactive Bladder Syndrome. J Urol [Internet]. 2018;199(4S):e970–1. Available from: https://doi. org/10.1016/j.juro.2018.02.2331 13. Tae BS, Jeon BJ, Choi H, Cheon J, Park JY, Bae JH. α-Blocker and Risk of Dementia in Patients with Benign Prostate Hyperplasia: A Nationwide PopulationBased Study Using the National Health Insurance Service Database. J Urol. 2019;202(August):362–8. 14. Duan Y, Grady JJ, Albertsen PC, Helen Wu Z. Tamsulosin, and the risk of dementia in older men with benign prostatic hyperplasia. Pharmacoepidemiol Drug Saf. 2018 Mar 1;27(3):340–8. 15. Gratzke C, van Maanen R, Chapple C, Abrams P, Herschorn S, Robinson D, et al. Long-term Safety and Efficacy of Mirabegron and Solifenacin in Combination Compared with Monotherapy in Patients with Overactive Bladder: A Randomised, Multicentre Phase 3 Study (SYNERGY II). Eur Urol [Internet]. 2018 Oct;74(4):501–9. Available from: https://doi. org/10.1016/j.eururo.2018.05.005 16. Yamaguchi O, Kakizaki H, Homma Y, Igawa Y, Takeda M, Nishizawa O, et al. Long-term safety and efficacy of antimuscarinic add-on therapy in patients with overactive bladder who had a suboptimal response to mirabegron monotherapy: A multicenter, randomized study in Japan (MILAI II study). Int J Urol. 2019;26(3):342-52. 17. Mitcheson HD, Samanta S, Muldowney K, Pinto CA, Rocha B de A, Green S, et al. Vibegron (RVT-901/ MK-4618/KRP-114V) Administered Once Daily as Monotherapy or Concomitantly with Tolterodine in

January/February 2021

Patients with an Overactive Bladder: A Multicenter, Phase IIb, Randomized, Double-blind, Controlled Trial. Eur Urol [Internet]. 2019 Feb;75(2):274–82. Available from: 18. Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, et al. EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), including Benign Prostatic Obstruction (BPO). Eur Urol [Internet]. 2020 Jun; Available from retrieve/pii/S0302283814013943 19. Kakizaki H, Lee K-S, Yamamoto O, Jong JJ, Katou D, Sumarsono B, et al. Mirabegron Add-on Therapy to Tamsulosin for the Treatment of Overactive Bladder in Men with Lower Urinary Tract Symptoms: A Randomized, Placebo-controlled Study (MATCH). Eur Urol Focus [Internet]. 2019 Nov;1–9. Available from: 20. Kaplan SA, Herschorn S, McVary KT, Staskin D, Chapple C, Foley S, et al. Efficacy and Safety of Mirabegron versus Placebo Add-On Therapy in Men with Overactive Bladder Symptoms Receiving Tamsulosin for Underlying Benign Prostatic Hyperplasia: A Randomized, Phase 4 Study (PLUS). J Urol [Internet]. 2020 Jan 2;201(Supplement 4). Available from: http:// JU.0000557495.41260.09 21. Yamanishi T, Kaga K, Sakata K, Yokoyama T, Kageyama S, Fuse M, et al. A randomized controlled study of the efficacy of tadalafil monotherapy versus combination of tadalafil and mirabegron for the treatment of persistent overactive bladder symptoms in men presenting with lower urinary tract symptoms (CONTACT Study). Neurourol Urodyn. 2020;(September 2019). 22. Faure Walker NA, Syed O, Malde S, Taylor C, Sahai A. Onabotulinum toxin A Injections in Men With Refractory Idiopathic Detrusor Overactivity. Urology [Internet]. 2019 Jan;123:242–6. Available from: https:// 23. Mateu Arrom L, Mayordomo Ferrer O, Sabiote Rubio L, Gutierrez Ruiz C, Martínez Barea V, Palou Redorta J, et al. Treatment Response and Complications after Intradetrusor OnabotulinumtoxinA Injection in Male Patients with Idiopathic Overactive Bladder Syndrome. J Urol [Internet]. 2020 Feb;203(2):392–7. Available from: JU.0000000000000525 24. Harvie HS, Amundsen CL, Neuwahl SJ, Honeycutt AA, Lukacz ES, Sung VW, et al. Cost-Effectiveness of Sacral Neuromodulation versus OnabotulinumtoxinA for Refractory Urgency Urinary Incontinence: Results of the ROSETTA Randomized Trial. J Urol [Internet]. 2020 May 18;203(5):969–77. Available from: http://www.jurology. com/doi/10.1097/JU.0000000000000656 25. Rostaminia G, Chang C, Pincus JB, Sand PK, Goldberg RP. Predictors of successful percutaneous tibial nerve stimulation (PTNS) in the treatment of overactive bladder syndrome. Int Urogynecol J [Internet]. 2019 Oct 29;30(10):1735–45. Available from: http://link.springer. com/10.1007/s00192-018-3834-9 26. Heesakkers JPFA, Digesu GA, van Breda J, Van Kerrebroeck P, Elneil S. A novel leadless, miniature implantable Tibial Nerve Neuromodulation System for the management of overactive bladder complaints. Neurourol Urodyn [Internet]. 2018 Mar;37(3):1060–7. Available from: 27. MacDiarmid S, Staskin DR, Lucente V, Kaaki B, English S, Gilling P, et al. Feasibility of a Fully Implanted, Nickel Sized and Shaped Tibial Nerve Stimulator for the Treatment of Overactive Bladder Syndrome with Urgency Urinary Incontinence. J Urol [Internet]. 2019 May;201(5):967–72. Available from: http://www.

Drug Class



Type of study


Main conclusions

Mirabegron vs. placebo

Efficacy and safety of mira in OAB wet pts > 65y

Wagg et al. (2019)

Phase 4 randomised, placebo-controlled study (PILLAR)

N= 888 patients 226 - mira25 mg 219 - mira 50 mg 442 - placebo

Mirabegron shows efficacy, safety, and to be tolerable over 12-wk in patients aged > 65 yr

Mirabegron vs. placebo

Risk of cognitive side effects of mirabegron (MoCA Score)

Griebling et al. (2020)

Phase 4 randomised, placebo-cont. study (PILLAR) *

N=888 445 pts under Mira 442 pts under placebo

12-wk treatment with mira did not contribute to drug-related cognitive side effects in pts aged ≥ 65 years


Evaluate the efficacy of mirabegron in male OAB pts

Shin et al. (2019)

Multicentre phase 4, randomised, double-blind, placebo-cont. (MIRACLE)

N =464 males 310 pts under Mira 50mg 154 pts under placebo

Mira improves OAB symptoms and is safe in male OAB patients


Evaluate the efficacy and safety of vibegron in OAB pts

Yoshida et al. (2018)

Randomised phase 3 study, placebo-cont., one comparator, multicentre, double-blind

N = 1,232 372 - Vibe50 mg 372 - Vibe100 mg 117 - Imi 358 - placebo

Vibegron, both doses, improved number of micturition, daily episodes of urgency incontinence and nocturia


Evaluate the efficacy and safety of vibegron in OAB patients

Staskin et al. (2020)

International phase III, randomised, double-blind, placebo and activecontrolled 12-wk trial (EMPOWER)

N = 1,518 526 - Vibe75mg 417 - Tol 4mg 520 - placebo

Vibegron decreased micturition and UUI episodes and was safer than tolterodine. Hypertension in mira and PLB arms identical


Evaluate long-term (52wk) efficacy and safety of vibegron in OAB pts

Dmochovski et al. (2019)

Randomised, double-blind, dose-ranging, placebo and active-controlled study

N = 660 223 - Vibe50mg 246 - Vibe100mg 240 - Tol 4mg 134 - placebo

Vibegron 50 mg and 100 mg once daily are well-tolerated and provide durable efficacy in long-term administration

Anticholinergic add-on to mirabegron

Long-term (52wk) efficacy and safety of combination therapy in OAB-wet pts

Yamaguchi et al. (2018)

Randomised, open-label, multicentre phase 4 study (MILAI II)

N = 649 167 - Mira + Soli 161 - Mira + Pro 167 - Mira + Imi 167 - Mira + Tol

Antimuscarinic add-on therapy to mira is well tolerated and effective in improving symptoms refractory to monotherapy

Vibegron monotherapy and vibegron plus tolterodine

Efficacy and safety of vibe Mitcheson et al. monotherapy compared (2018) w/ combination Vibe+Tol, in OAB pts

International, phase 2b, randomised, double-blind, placebo and activecontrolled study

N = 408 112 - Vibe100mg 122 - Tol 110 - Vibe100mg + Tol 67 - placebo

Once-daily vibegron showed its efficacy and safety in OAB, in the short-term. Proof of concept: Vibe+Tol is superior to Vibe monotherapy

Mirabegron add-on to tamsulosin

Efficacy and safety of combination therapy in OAB in men with LUTS

Kakizaki et al. (2019)

Randomised, double-blind, placebo-controlled, phase 4 study (MATCH)

N = 568 285 - Tam 0.2mg + placebo 283 - Tam 0.2mg + Mira 50mg

Mira improved refractory OAB in patients under Tam monotherapy. Combination was safe

Mirabegron add-on to tamsulosin

Efficacy and safety of combination therapy in OAB in men with LUTS

Kaplan et al. (2020)

Randomised, double-blind, placebo-controlled, phase 4 study (PLUS)

N = 676 339 - Tam 0.4mg + placebo 337 - Tam 0.4mg + Mira 25/50mg

Mira decreased micturition frequency and other refractory OAB in patients under Tam monotherapy. Combination was safe

Tadalafil plus mirabegron

Efficacy and safety of combination therapy in OAB pts

Yamanashi et al. (2019)

Prospective, multicentre, randomised, parallel-group, open-label study (CONTACT)

N = 176 87 - Tada 89 - Tada + Mira

Tadalafil + mirabegron is superior to tadalafil monotherapy in improving OAB symptoms

SNM vs. Onanbotulinum toxinA

Efficacy and safety of SNM or BontA in refractory OAB pts

Amundsen et al. (2018)

Multicentre, open-label, randomised, extension trial (ROSETTA)

N = 386 194 - SNM 192 - BontA 200U

No differences in the reduction of UUI cases were observed between the two arms at 2 year follow-up

SNM vs. Onanbotulinum toxinA

Cost- effectiveness of SNM or BontA in OAB

Harvie et al. (2020)

ROSETTA extension trial

N = 386 194 - SNM 192 - BontA 200U

SNM seems to be less costeffective relative to BontA at 5 years

Onabotulinum toxinA Effectiveness and safety of BotA in men with iDO

Faure et al. (2019)

Prospective single-centre study

N = 65

BontA in men with refractory OAB showed to be effective. High CIC rate.

Onabotulinum toxinA Efficacy and tolerability of BontA in male with OAB

Arrom et al. (2020)

Retrospective cohort study

N = 146

Most pts showed a positive response. High discontinuation rate. High BOOI = with worse outcomes

Table 1: Summary of selected RCTs in the systematic review. (*Cognition Function was not one primary endpoint of the study) OAB: overactive bladder; Mira: mirabegron; Wk: weeks; Soli: solifenacin; Pro: Propiverine; Imi: imifenacin; Tol: tolterodine; Tam: tamsulosin; Tada: tadalafil; SNM: sacral neuromodulation; BotA: Onabotulinum toxinA; UUI: urgency urinary incontinence TTNS: transcutaneous tibial nerve stimulation; PTNS: percutaneous tibial nerve stimulation; iDO: idiopathic detrusor overactivity.

EAU Education Online presents: Urological Infections

EAU Guidelines E-Courses

Urinary Incontinence

Primary Urethral Carcinoma

Prostate Cancer

Non-muscle-invasive Bladder Cancer

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Renal Cell Cancer


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

Muscle-invasive and Metastatic Bladder Cancer

Chronic Pelvic Pain

Renal Transplantation

Help urologists collect CME credits and register your activity today!


Men’s Health

Paediatric Urology

(Inter)National Urological Associations and the CME providers (organisers of CME activities) are invited and encouraged to send in requests to register nationally accredited CME activities or requests for European accreditation.

All Guidelines e-courses are reviewed and updated annually according to the most recent EAU Guidelines. EAU Education Online Platform is fully accredited January/February 2021 European Urology Today


EUREP21 19th European Urology Residents Education Programme 3-8 September 2021, Prague, Czech Republic A unique and exclusive training opportunity General information

Registration 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 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, 2 September Departure date: Wednesday, 8 September after the modules end at 12.30.

Important dates Online registration opened on 4 January 2021. The selection process will be made after registration closes on 1 May 2021. 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 2021. After this time a cancellation fee of €500 will be charged. 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. 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 4. First-come, first-served basis 5. English skills 6. Geographic spread. The nationality stated during the online registration process is leading 7. It is only allowed to attend the EUREP course once 8. There are limited places available for non-European residents

Important information for applicants!

For further detailed information regarding the registration rules for the 19th EUREP course we strongly recommend that you visit

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.

Registration non-European residents If you are a non-European resident that is interested in taking part in the 19th EUREP course please go to for the rules and regulations regarding participation.

Hands-on Training Courses Sharpening Your Skills: TUR, URS, and Laparoscopy 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. 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. 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 26

European Urology Today

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. 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. Participants can only participate in one session optimal learning is warranted. For more information on the different training modules, please visit The hands-on-training workshops are sponsored by an unrestricted educational grant from:

T +31 (0)26 389 0680

Preliminary programme 2021 Module 1 Urological cancer 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 Muscle invasive bladder cancer Surgical and non-surgical treatment options Neoadjuvant and adjuvant chemotherapy

F. Liedberg (SE), Chair

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

A. Merseburger (DE)

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

Module 2 Prostate cancer and male voiding LUTS 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

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 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 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

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

K. Sievert (DE)

Module 5 Paediatric urology, trauma and infection Paediatric urology Essentials of obstructive uropathy Congenital malformations of the external genitalia Infections Urinary tract infections

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

“If you meet the criteria, we would encourage you to register for this opportunity," - Prof. Palou, Course Director January/February 2021

Legends in Urology Prof. Imre Romics acknowledged for leading role in Hungarian urology In 2020, the Department of Urology of Semmelweis University in Budapest, Hungary, celebrated its 100th anniversary. One of the oldest independent Departments of Urology in Europe, its history is filled with great accomplishments under legendary leaders such as Professors Illyes, Babics and Balogh. However, the modern era of Hungarian urology was ushered in by Imre Romics, who was Chair of the Department from 1997-2012. In addition to being an excellent clinician and prolific researcher, Dr. Romics’ goal has been to elevate Hungarian urology to the standards of the EAU and to forge strong international relationships with the urology departments of neighbouring countries and the EAU. He served as a board member of the European School of Urology, the Association of Academic European Urologists and the EAU Historical Committee. He was founding Editor of the journal UROONKOLOGIA. Dr. Romics is the author of numerous books and publications on a wide variety of topics, but perhaps his greatest contribution has been the integration of Hungarian urology into the international urological community. He has been a great friend and mentor to many young urologists who today represent the finest of the profession. As recognition of his achievements, the Canadian Journal of Urology, International selected Dr. Romics as a “Legend-in-Urology”. The following article, which was published in this journal, describes in Dr. Romics’ own words those accomplishments which he is most proud of. Imre Romics recently retired from the practice of urology. We would like to recognise his many accomplishments and wish him the very best. On behalf of all his friends at the EAU Prof. Gabriel P. Haas Illinois, USA

Imre Romics, MD, PhD, DSc Professor (1997-) and Chairman (1997-2012) Urological Department, Semmelweis University Budapest, Romania

In the Hungarian language, the word legend is close in meaning to the word tale, that is, something that probably never happened. Upon receiving the invitation to contribute to this series, I felt that this was just a fairy tale, since I do not really belong with the urologists I have read about here. They are the "giants" of urology-a few that I can count as my friends-but I am only in their shadows. On the other hand, I am the first urologist from Central and Eastern Europe to be invited to share my story. M. Marberger mentioned being raised in Austria, on the border between "good" and "bad". I was born on the „bad" side, in Hungary, a communist country under Soviet influence. My ancestors, however, are Croatian. Croatia was part of Hungary from the end of the 11th century until 1920. In my home town, the surname Romics can be found in church records from 1710. At the beginning of the 18th century, the Roman Catholic Croats of Dalmatia moved north towards Budapest. My parents still spoke an ancient Croatian language. My father was a carpenter with a workshop on the ground floor of our home and two employees. In 1950, he was labeled a "bourgeois" and everything was taken away from him and consolidated into a kolkhoz, where he continued to work with the same hammer and saw-which no longer belonged to him. I entered Semmelweis University in Budapest in 1965, and received my MD in 1971. Besides studying, in my spare time I had to work on our peach farm to contribute to our family's income. Possibilities for travel were limited. Hungary was closed to the West and a special permit was needed to travel to Yugoslavia, although Hungarians could travel to the German Democratic Republic and Poland. On my first trip to Romania in 1968, I learned for the first time that 2 million Hungarians were living in Romania (Hungary's population is 10 million) and that Transylvania has been part of Romania since 1920. This came as a real shock! There had been no mention of this in school. After finishing university, I worked at the Department of Pathophysiology, at Semmelweis University. I realized I was more interested in working with patients, in healing. I came to the Urological Department of the university in 1974. Established in 1920, it was the first university clinic where urology was taught independent of surgery, and it was also the second oldest university clinic in Europe (after the one established in Paris in 1919). The first director was Professor Géza Illyés. According to the Department's guest book, from 1922 until the outbreak of World War II, 106 (!) American urologists and surgeons (including Charles Mayo) and 100 guests from other parts of the world visited the department. There must have been a reason for so many visits (see J Urol 2007;178(2):409413). Professor Illyés headed the department until 1941. Another great and distinguished professor was Antal January/February 2021

Babies (1945-1974). Following the war, visitors came almost exclusively from the Soviet Union and Eastern block countries. I was doing the everyday work of a young physician, but I missed the scientific part. My boss, F. Balogh, had a special interest in oncology, so my first research studies were related to zinc in the prostate. We studied urinary hydroxyproline as a marker of metastasis. Together with my immunologist friend, J. Horvath, who now lives in the United States, we investigated how the outcome of cancer patients is influenced by their immune status. We analyzed cellular and humoral immune parameters. We also treated bladder-cancer patients with an immune stimulant (levamisol) and were able to extend the interval between two recurrences. We didn't know anything back then about BCG or interferon-this was all happening in the 70s. I wrote my PhD dissertation on this topic in 1985. I spent 3 months in Bonn in 1984, the first time that I was in Germany. I had not received permission to exchange currency, so I had to travel without a single German mark. I attended my first international congress, the World Congress of Endourology, with some money I had stashed away. After delivering three oral presentations, I went to Bonn, the West-German capital, where Professor Vahlensick gave me money and a room. I was involved in everything: surgery, congresses, building relationships, learning German, writing articles, and I even saved money for my family by eating bread-and-butter sandwiches. On July 1, 1985, Professor D. Bach, the deputy chief in Bonn, was to become the chief urologist of a new hospital in Bocholt, Germany, close to the Dutch border, and he invited me to go there with him. I was due to start working on January 1, 1986, but my license was delayed, so I only started 6 months later. I had lots of patients to operate on, including children, and I was frequently on duty- a total of 110 times in 1987! I was 40 years old with a physician wife. She was with our 6-year0old daughter Kata and our son, Miklós, who was born in November 1987. Although I was often on duty, the money came in handy, because my wife and I planned to return to Budapest in 1998 and wanted to save money for a car and a bigger home than our 52 m2 apartment there. In Bocholt, in addition to all the routine work, I was always game to try something new. lt was here that I first saw an ultrasound machine; I gathered so many interesting materials about it that in 1989, I wrote a book entitled "Urological ultrasound," which was published in German and Hungarian. PSA determinations were introduced in 1987, and in 1988, I presented a poster on PSA at the EAU in London. Later that year I presented the first lecture on PSA in Hungary and published the first Hungarian article about PSA. Returning to Hungary in 1988, I did the first 100 PSA determinations, and that year I organized an international conference on the topic of prostate cancer

and PSA. Naturally, later on, PSA determinations became general practice in Hungary too. In Bocholt, Germany, I had been involved in a wide range of research. This included benign prostatic hyperplasia (BPH) studies, including-analyses of the trace element contents of prostatic exprimates; metabolic disorder (urinary citrate, magnesium, etc.) studies of the many patients with urinary stones; isotope scanning studies of patients with testicular torsion; and studies of the accuracy of CT in determining lymph node metastasis, compared with pathological data. I authored or co-authored approximately 30 published papers from those 2 years of research. Not only did I gain technical knowledge and skills, and obtain scientific results, but from my boss, Professor D. Bach, I also learned how to manage a department-which became very important later on.

endoscopic procedures and extracorporeal shock-wave lithotripsy were also frequently performed. Annually, 40 thousand (!) physician-patient encounters occurred at the clinic. I was a visiting professor in Vienna, Austria, and other cities in neighboring countries, and our department also hosted a visiting professor from the EAU each year. J. Fitzpatrick was the first, Anup Patel (UK) was the most recent one, and in between there were M. Marberger, F. Debruyne, Studer, Abrahamsson, Chapple, and others. Within the framework of the AUAEAU exchange program, J. Gillenwater and three young colleagues visited our department. In 2011, we were honored by the visit of Dr. Datta Wagle, the President of the AUA.

Ten years ago I established the first and only Hungarian urooncology (chemotherapy) center, which My wife and I had never thought of staying in Germany. is still functioning in the department. All examinations In those days, this could only be done illegally, and we related to cancer patients are carried out, from would not have been able to return to Hungary to visit screening to chemotherapy. our parents, family, and friends. While the possibilities Since we lack an adequate laboratory, most of our of acquiring more knowledge and seeing more of the scientific activities have been performed with world were appealing, we were not drawn by the chance to earn more money, if it would mean breaking Hungarian, German, and Austrian collaborators. In the past 15 years, in the Department of Urology, two DSc our ties with our family and friends. theses and ten PhD theses were defended and we After we returned to Budapest, I continued working in wrote 494 papers, 20 books, and textbooks. the Urological Department, in Semmelweis University. I and my colleagues used flow cytometry to determine In addition to being a member of the ESU, for many the DNA from the radical prostatectomy specimens years I was also member of the EAU Academic I had brought with me from Germany, and we Fellowship Committee, and I have been member of the compared our findings with clinical parameters and EAU Historical Committee for over 10 years. Along with patient outcomes. We determined various tumor Marberger, I played a small role in organizing the markers (Ki67, bcl2, etc.). We studied the effect of LHRH EAU-CEM (European Association of Urology-Central analogue on apoptosis by means of re-biopsies taken European Meeting) and the first and fifth Budapest at various intervals. I was interested in everything that meetings. In 2011 we organized the 5th World Congress was related to urooncology. I was among the first in of History of Urology. Hungary to carry out local BCG therapy, and I was the first to use interferon treatment for patients with I am or have been an Advisory Board member of CJU, kidney and bladder cancer. We studied numerous BJUI, and Int Urol Nephrol, and numerous Hungarian markers (TPA, E-cadherin, microsatellite analysis, periodicals and journals in neighboring countries. This urovision, claudin, etc.). I was also engaged in studies is my 10th year as editor of the Hungarian journal of thrombosis prophylaxis, incontinence following "Uroonkol6gia," which has occasionally been published radical prostatectomy, and HIFU therapy. As a result of in English. this work, in 1995, I defended my DSc thesis on urooncology at the Hungarian Academy of Sciences. I am an honorary member of the EAU, the Society of Urology of Germany, the Czech Republic, Poland, In 1992 I became associate professor at the Urology Slovakia, and Romania, as well as the Croatian Medical Department of Semmelweis University, but I wanted to Association. I am an honorary professor at the Medical become independent. In 1995 I became department University in Tirgu Mures, Romania, which also offers head of a 45-bed ward at a Budapest hospital. This Hungarian courses. In Hungary I was president of the gave me new strength and allowed me to perform College of Urology between 2000 and 2004; I had/have high volume surgical operations, start a journal club, several duties at the Hungarian Academy of Sciences; publish several articles, organize two congresses (one and I am currently president of the Hungarian of them German-Hungarian), and, with international Urooncology Society. Upon my recommendations co-authors, write a book about BPH. During this time G. Haas, M. Marberger, Ch. Chapple, H. Rübben, I also organized the first Hungarian prostate cancer and J. Schubert were appointed honorary professors at screening of 1000 patients. Semmelweis University. In 1997 the university chair was vacated and I was appointed head of the clinic, which I chaired until July 1, 2012, when I turned 65 years old. I was the 6th chairman of the department. The 15 years that I headed the department were the best years of my professional life.

I have special connections with Hungarian patients living in neighboring countries. Since the end of the 70s, countless patients have visited me from Transylvania (the Western part of Romania where the Hungarians live). I have also had numerous patients visiting from Slovakia, Ukraine; and Serbia. We are regular lecturers at medical congresses held in As a university clinic, our primary role was and still is Hungarian in Romania and we frequently teach to teach. University students from all over the world medical students there in Hungarian. We also have are taught in Hungarian, German, and English. We also close ties with Hungarian urologists around the world, give postgraduate training. The department received including G. Haas in America, T. Denes in Brazil, Ervin the nomination "EBU-Certified European Training (Zvi) Lob (Leib) in Israel, and Erik Schick in Canada. Centre." We had young urologists coming to us from countries ranging from Uzbekistan to Greece. For two Traditions are important to me. We founded a small terms, I was a faculty member and board member of museum at the clinic, we regularly visit the graves of the EAU ESU (European School of Urology). our previous professors, and we celebrate Christmas together at the clinic. There was a significant increase in the number of radical cystectomies and radical prostatectomies. It Among my honors, I wish only to mention the Officer's made me feel good whenever I removed a large renal Cross of the Order of Merit of the Hungarian Republic. cell carcinoma with or without cava involvement, and I derive satisfaction from my students' accomplishments every time I performed a radical prostatectomy or a and my recovered patients. On my 65th birthday radical cystectomy. At the beginning we performed Marberger said: "You have put this clinic on the map of Mainz II type sigma pouch operations; later most European Urology," which was a nice compliment. operations were ileum conduits. Few patients met the criteria for orthotopic bladder replacement. I am joyful because my son Miklós is a resident at the clinic. With his mother, Eva, who is a neonatology Over the years, we replaced the operating room assistant professor and our daughter, Kata, who holds equipment, and in the clinic's five operating theatres an MBA in economics, the family is complete. With we performed an average of 2500 open and what little spare time I have, I enjoy my hobbies, which laparoscopic surgeries annually.. In our polyclinic, a are history (the last 150 years), fine arts, painting, and large number of incontinent patients underwent all kinds of music. surgery using the new sling techniques. We also had a growing andrology program owing to microsurgical interventions. Patients with urethral and penile Republished with permission of © The Canadian Journal disorders were commonly seen. Lower and upper of Urology™; 20(2); April 2013 European Urology Today


Young Urologists/Residents Corner My experience with mandatory resident rotation Two months of paediatric urology at a national referral centre During the past two months I had the opportunity to Dr. Cristina do my paediatric urology rotation at La Paz Children's Ballesteros Hospital in Madrid (ES). This hospital, specialised in Resident of Urology paediatric care, is associated with my current training Hospital La Paz centre. A two-month mandatory rotation is part of our Madrid (ES) fourth year of residency. La Paz Children’s Hospital is widely known in Spain for the medical and surgical management of complex paediatric surgical cases and paediatric transplant. It was founded in 1965 and cristinabr02@ since then it has become a national and international reference centre. Currently, it has more than 226 beds, 6 operating rooms and 39 intensive care beds for paediatric patients and neonates. specialised nursing team that carries out urodynamic studies and runs a daily, dedicated clinic for office The paediatric urology department is composed of five procedures. sub-specialised paediatric urologists, plus the continuing rotatory paediatric surgical residents and National Reference Centre urology residents from all over the country. This The department receives more than 1,000 new department has also been accredited for fellowship referrals per year and gives attention to more than training by the European Society for Paediatric Urology 3,500 patients from all over the country, who are (ESPU) since 2010. studied and followed up annually. With more than 500 surgeries per year, surgical treatment is offered It offers comprehensive management of paediatric for a wide range of complex pathologies. The Ministry patients, part of which is provided by a highly of Health has given the National Reference Centre

(CSUR) certification to this department due to its long-standing commitment and experience in kidney transplantation, Exstrophy-Epispadias Complex treatment (bladder exstrophy, epispadias and cloacal exstrophy), neuropathic bladder and uro-oncology. Worth mentioning is the recent creation of a practice dedicated to adolescent and urogenital reconstructive surgery in conjunction with the adult urology department, including a dedicated monthly outpatient clinic and operating room.

“I witnessed all kinds of everyday consultations and complex pathologies.” The best year for rotation I had the great opportunity in my fourth year as urology resident to rotate in this centre. In my opinion, the fourth year is the best year for this rotation. From the first day I was part of the team, I could engage in their daily activities and attended more than 50 surgeries. During my stay, I had the opportunity to assist in three kidney transplants, one

of them from a living donor, and two Mitrofanoff-type urinary diversions. The team members produced a wide range of publications, ongoing studies and activities in the ESPU and offered me the possibility of joining and learning as much as I could. The department is very well organised in sub-units. During these months, I witnessed all kinds of everyday consultations and complex pathologies and acquired great knowledge of children's urological pathology. Paramount importance This rotation is of paramount importance for an adult urology resident, because childhood pathologies and congenital malformations vary in presentation. An understanding of these conditions is crucial to be able to offer these patients treatment options when they become adults. I highly recommend that a complete urology residency programme includes at least two months of rotation in paediatric urology. It is necessary to work in tertiary centres with a large volume of patients such as, in this case, a reference centre for several children's urological pathologies.

YAU Urolithiasis & Endourology Working Group Analysis of surgical YouTube videos to prevent patient anxiety among ongoing projects Dr. Amelia Pietropaolo Member, Urolithiasis & Endourology Working Group Southampton (GB) ameliapietr@ The YAU Urolithiasis & Endourology Working Group is an international group of promising academic urologists who are member of the European Association of Urology. The group consists of members below the age of 40, with university affiliations and actively involved in research. The group aims to evaluate and work in the exciting new areas of minimally invasive techniques and procedures in endourology. Urolithiasis working party’s aim The main aim of the group is to carry out research in the fields of endourology and urolithiasis. The results will be used to increase knowledge and raise awareness about stone disease within the urological community. We also aim at improving surgical outcomes for patients and concentrate on stone prevention. Metabolic screening and prevention are currently gaining renewed interest in view of sedentary lifestyles and metabolic syndrome. Our group also focusses on education and training, since many of its members are hands-on trainers and faculty members

in courses and masterclasses. Collaborations between the group and other sections of the EAU have been ongoing for the last few years, with particularly fruitful relationship with ESUT, EULIS and EUREP, subgroups of EAU. Members • Amelia Pietropaolo (UK) - Chairwoman • Panagiotis Kallidonis (GR) - Former Chair, senior member • Thomas Tailly (BE) • Esteban Emiliani (ES) • Nicola Macchione (IT) • Emre Sener (TR) • Vincent De Coninck (BE) • Etienne Keller (CH) • Senol Tonyali (TR) • Michele Talso (IT) Ongoing projects • Multicentric study on urosepsis post-ureteroscopy. We have set up a multicentric study on urosepsis episodes following ureteroscopy in several European centres. Data collected represent a snapshot of post-operative sepsis rates worldwide. The study concentrates on those patients requiring ITU admission due to post-operative urosepsis after ureteroscopy and laser stone lithotripsy. The main aim of the study is to identify common risk factors for postoperative urosepsis and identify predictive factors. • YouTube videos for patient information. The COVID pandemic has brought about substantial changes in our way of surgical counselling, which

often happens virtually. Videos are effective tools to instruct patients and illustrate the surgical techniques they will undergo. The aim of this study is to analyse the quality of surgical videos on YouTube in order to prevent unnecessary patient anxiety and misunderstanding. Lower pole stones - what is the most effective treatment? Systematic review. From among the stones in the urinary system, the lower pole stones are most difficult to treat due to their location. Multiple surgical procedures are often necessary to remove them. The aim of this systematic review is to investigate the best approach to treat lower pole stones, in term of better stone free rate and requirements for multiple procedures. Stone volume study (prospective, multicentric). The amount of stones to treat is still the most important variable to take into consideration when choosing the optimum treatment modality. Currently, all available guidelines use a linear measurement to help making this decision. Our idea is to adopt other stone variable measurements, such as stone burden instead of linear measurements, to help in clinical practice. Survey on what urologist would do if they had a stone. As doctors, we always try to be impartial when it comes to counselling our patients about surgery. This survey aims to investigate which procedure urologists would choose in case they develop kidney stones themselves and if their decision reflects the guidelines. Prospective database on ureteroscopy complications.

The aim of this study is to examine whether several pre-operative or peri-operative factors increase the risk of infectious complications (fever, urinary tract infection, sepsis) in patients who underwent endourological procedures (URS, PCNL). • Follow-up on impacted stones after treatment. Impacted stones can cause damage to the urothelial mucosa and result in stricture formation. This study collects data on follow-up imaging after impacted stone treatment and identifies the best way to predict stricture formation. • European survey on nephrostomy VS stent insertion. This is a European survey to compare urologists and radiologists practice when it comes to treating obstructed kidneys. The questionnaire compares the daily practice of urologists and radiologists and investigates their decision making when confronted with different clinical scenarios. The purpose is to determine whether the indication of nephrostomy or ureteric stent depends on clinical case, time of day and clinician involved. Plans for the future • This year, we have been proposed new projects to the EAU guidelines office. This allows the group to conduct systematic reviews and meta-analysis on urolithiasis and fill some of the gaps in the evidence and guidelines. • Our team is very eager, and we are working very effectively and efficiently as a group. This year we received a total of 5 new applicants. This reflects the never-ending interest in endourology and urolithiasis.

Young Academic Urologists Update Dr. Juan Gómez Rivas Chair, Young Academic Urologists Madrid (ES)


YAU Newsletter YAU starts the new year with a new initiative, the YAU newsletter by email. With this, we aim to keep all young urologists updated on what is happening within the YAU on a regular basis. 28

European Urology Today

Turnover / New positions YAU has renewed positions, from the chairman and groups chairpersons to YAU representatives in sections and offices. Nowadays our organization has a mixture of new blood and motivated people, together with experienced and talented members. We thank Selçuk Silay, Geert De Naeyer, Panagiotis Kallidonis, Guillaume Ploussard and Evanguelos Xylinas for their input through the years in YAU. Juan Gómez Rivas: Umberto Capitanio: Giorgio Gandaglia: Bernhard Haid: Luis Kluth: Alessandro Larcher: Tom Marcelissen: Marco Moschini:

Chairman YAU Renal Cell Carcinoma Prostate Cancer Paediatric Urology Reconstructive Urology Robotics Functional Urology Urothelial Cancer

Amelia Pietropaolo: Giorgio Russo: Domenico Veneziano: Michiel Sedelaar:

Endourology & Urolithiasis Men's Health Urotechnology Chairman YUO

Record in applications YAU is turning into a global phenomenon. We have received >50 applications in 2020 including those from America and Asia. This is a reflection of the interest of young people to start an academic career within the EAU through YAU. Growing YAU Collaborations Despite the COVID-19 pandemic, YAU is growing its presence at conferences, meetings and other EAU activities. Adding to previous relations, YAU has started a collaboration with EAU Research Foundation.

YAU representation in EAU: ESAU: Giorgio Russo ESFFU: Tom Marcelissen ESGURS: Bernhard Haid ESOU: Evanguelos Xylinas ESUI: Veeru Kasivisvanathan ESUT: Emiliani Esteban & Domenico Veneziano EULIS: Amelia Pietropaolo EAU Working Group on Paediatrics in Urology: Bernhard Haid Research Foundation: Giovanni Cacciamani EMUC Scientific Committee: Junan Gómez Rivas YUO Board: Giorgio Russo & Marco Moschini Record in publications As all years, the publications on behalf of YAU are increasing. The following graphic shows the PUBMED search related to “Young academic urologists”. Congratulations to all members for their efforts. January/February 2021

Young Urologists/Residents Corner ESPU goes virtual in 2020 Summary report from the EAU Paediatric Urology Working Group Dr. Bernhard Haid YAU Paediatric Urology Group EAU Paediatric Urology Working Group Linz (AT) bernhard.haid@

Prof. Anne-Françoise Spinoit YAU Paediatric Urology Group EAU Paediatric Urology Working Group Ghent (BE) afspinoit@

Prof. Mesrur Selçuk Silay EAU Paediatric Urology Working Group Istanbul (TR) selcuksilay@ Recently, the EAU Paediatric Urology Working Group was established in order to curate paediatric urologic activities inside the EAU. It is chaired by Prof. Mesrur Selçuk Silay and comprises a total of 10 members, representing the European Society for Paediatric Urology (ESPU) as the main paediatric urological community in Europe, as well as the EAU

guidelines panel, EAU abstract reviewers, the EAU Scientific Congress Office and the Young Academic Urologists (YAU). Online meeting Faced with the pandemic and its associated restrictions, the ESPU had to replace its annual meeting – originally planned in April 2020 in Lisbon (PT) – with a virtual, online meeting. With over 400 participants at any time and more than 2500 log-ons this was a unique gathering of paediatric urologists. The programme spanned a wide range of content, including not only clinically relevant topics but also highlighting educational and scientific issues. On the first session of the day, Prof. Serdar Tekgül (Istanbul, TR) moderated a panel discussion of paediatric stone cases featuring world class nephrolithiasis specialists dwelling on specific problems in paediatric stone management. Among many other aspects and details in treatment strategies, the role of retrograde intrarenal surgery with regard to the relatively low invasiveness of mini-PCNL was discussed in depth. Furthermore, the influence of stone localisation and composition on the effectiveness of ESWL – in many instances still the first line treatment for paediatric stone disease – was critically argued. With Prof. Naima Smeulders (London, UK) stating that “There is no such thing as clinically insignificant fragments (CIRF) in children”, the panel underlined the importance of complete stone clearance in children. Practical overview After the thesis award session – the ESPU thesis 2019 award was granted to Dr. Marie Andersson (city, country?) for her work on long-term follow-up after hypospadias surgery and the ESPU thesis 2018 award to Dr. Zeai Said (city, country?) – the ESPU research committee provided a practical overview of basic statistical knowledge. This is not only relevant to writing but also to critical reviewing and reading of scientific literature.

In an insight into his outstanding work, Prof. Guillaume Canaud (city, country?) demonstrated several yet unpublished data on the treatment of overgrowth syndromes from the COSY (Cure overgrowth SYndromes) project. His impressive results, for instance in treating children affected by PIK3CA-related overgrowth syndromes (CLOVES syndrome), gave much hope for the future prospects of these patients.

probable benefits regarding the motor neuron function and the need for ventriculoperitoneal shunting, the potential urological benefits as well as the interpretation of the published data remain disputable.

In an expert panel on paediatric urological robotic assisted surgery, Prof. Ramnath Subramaniam (Leeds, UK) and Prof. Mohat Gundeti (Chicago, US) presented comprehensive lectures about robotic assisted pyeloplasty as well as hemi-nephroureterectomy. Furthermore, they elaborated on potential Then, tips and tricks were revealed by experienced paediatric urology experts. They showed, for example, indications, pitfalls and challenges involved in implementation of the minimally invasive platform in how to establish an antegrade catheterisable enema in a minimally invasive way and how to achieve glans the armamentarium of paediatric urologists. closure without extensive glans wing mobilisation. Varicocele management in paediatrics After a breath-taking session entitled ‘My worst “With over 400 participants and complication’ the meeting was closed by two lectures covering the topic of varicocele more than 2500 log-ons this was management in children and adolescents. Prof. a unique gathering of paediatric Radim Kocvara (Prague, CZ) shared information from his decades of experience and research, not urologists.” only on the correct indication but also on technical aspects in varicocele repair in young patients. Dr. Online educational resource David Keene (Manchester, UK) reported about the Prof. Berk Burgu (Ankara, TR), chair of the ESPU controversial yet fascinating topic of fertility and educational committee, presented the ongoing paediatric varicoceles. He concluded that testicular project of an online educational resource in size, which shows high fluctuation during normal paediatric urology – the DEPPU (Digital Educational adolescent development, is not a good parameter Platform for Paediatric Urology) – that will be to diagnose possible varicocele-related subfertility. realised in the course of 2021. It is a collaboration of Rather, sperm concentration (in patients apt and the ESPU with several international societies. It is not old enough for sperm sampling) - and not total only intended for paediatric urologists but also for mobile count - as well as DNA fragmentation urotherapists, paediatricians, other clinicians and might be useful indicators for a future fertility risk. patients as well as their families, in order to gather knowledge and experience in different aspects and After a vivid discussion, Prof. Ram Subramaniam points of view. (Leeds, UK), the ESPU Secretary who moderated the entire live event, shared his closing remarks In an extensive session, the role of prenatal surgery in after nearly 10 hours of paediatric urology digest. spina bifida patients and its clinical outcomes were Recordings of the lectures can be reviewed online at and are highly discussed by Prof. Dominic Thompson (London, UK) and Prof. Antonio Macedo (Rio de Janeiro, BR). Their recommended for all urologists interested in paediatric urology. lectures highlighted the fact that while there are

New Chair for YAU Working Group on Paediatrics in Urology Work on a wide variety of paediatrics projects continues online Dr. Bernhard Haid Chair, YAU Working Group on Paediatrics in Urology Ordensklinikum Linz Linz (AT) bernhard.haid@

Collaborations The YAU Working Group on Paediatrics in Urology is one of the ‘younger’ YAU Groups and was established in 2014. Over the last four years, the group was led by Prof. Selçuk Silay (Istanbul, TR), who became YAU Chairman in 2016 and received the Crystal Matula Award in 2018. A number of projects could be realised, resulting in highly cited papers such as the Global Pyeloplasty Study (58 citations since 2016). Also, important collaborations with the European Society of Urogenital Reconstructive Surgeons (ESGURS) and the European Society of Paediatric Urology (ESPU) have been established.

The Young Academic Urologists (YAU) is a unique platform for academically active urologists younger than 40 years. Apart from providing them with opportunities to conduct studies together and in collaboration with the Guidelines Office, the Sections Offices as well as the ESU it serves as an invaluable hub for making contacts – and friends.

"As all members are in their relatively early stages of academic careers this network helps each member to grow and improve."

“Because there are no other opportunities to meet, these evenings, filled with lively discussion, prove especially precious...”

Thank you In May 2020, I had the great honour to take over the lead of the group, currently comprised of 6 full members: Lisette ‘t Hoen (Rotterdam, NL), Beatriz Banuelos Marco (Berlin, DE), Fardod O’Kelly (Dublin, IE), Anna Radford (Womersley, UK), Simone Sforza (Florence, IT), Anne-Françoise Spinoit (Ghent, BE) and 1 associate member – Manuela Hiess (Vienna, AT).

As all members are in their relatively early stages of academic careers this network helps each member to grow and improve. With its 10 groups, reflecting many important subspecialities, there is ample opportunity to discuss relevant scientific questions with the perspective of a different, new angle. The (formerly – hopefully soon again) twice yearly face to face meetings feature excellent talks on relevant topics evolving around science, leadership and career development.

Selçuk Silay – currently the chairman of the newly established EAU Paediatric Urology Working Party – still joins our (currently online) meetings and actively takes part in the discussion. Nevertheless, I would like to take this opportunity to thank him for his outstanding work as a leader, his friendship, his commitment and his unmatched enthusiasm!

January/February 2021

aspects of paediatric urology. A special edition of the International Journal of Impotence Research (IJIR) will shortly be published, featuring a set of 10 papers on paediatric sexual medicine from a paediatric point of view. This is a project all group members collaborated on by curating and editing, including several articles that emerged from discussions inside the group. Furthermore, we are working on a paper dealing with the current practice in paediatric stone management, a multicentric study on robot-assisted ureteral reimplantation and a study on the role of birth weight and gestational age in the management of hypospadias.

New applications welcome Currently, as a result of the COVID-19 situation, we hold monthly Skype meetings to discuss the current projects. Because there are no other opportunities to meet, these evenings, filled with lively discussion, prove especially precious to meet up with friends and advance together. As some of the group members, including myself, are shortly before their 40th birthday, the group is open for new applications from motivated colleagues. We very much look forward to welcoming new members!

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

you encountered an even worse case yourself? If so…

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

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

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

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

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

Please send the details of your personal Nightmare Case and photos to: Dr. David Karzsa,

Special IJIR edition The current projects of our group cover various European Urology Today


New SuperPulsed Laser (Soltive) - first Romanian experience Use of new laser type in stone management practice successful Prof. Petrisor Geavlete Saint John Emergency Clinical Hospital Dept. of Urology Bucharest (RO)

Co-authors: Dr. Razvan Multescu and Dr. Bogdan Geavlete, Bucharest (RO) According to the main urological guidelines (EAU and AUA), Holmium:YAG laser (operating at 2120 nm wavelength) is the “standard” laser applied in reno-ureteral stones’ lithotripsy. The new devices (high power holmium and Moses pulse 120H) demonstrate the best outcomes so far1,2. Another new laser type, the Thulium fibre laser (TFL) operates at a wavelength of 1940 nm using a silica fibre which includes Thulium ions3. The Thulium YAG laser is a solid-state laser, similar to the Holmium. Alternative lithotripsy modality During the last year, the SuperPulsed Thulium Fibre Laser (TFL) has been evaluated as an alternative lithotripsy modality4,5. This new laser has a completely new design and characteristics. The energy pulse in water is reduced from 37% to 1.7% over the same distance, the frequency between 5 and 2.200 Hz versus 30 Hz (physically limited for holmium), thinner fibres (16 times less crosssectional area delivering a 16 times more intense laser beam), reduced weight (36 kg versus 245–300 kg), 10 times less energy consumed as well as the standard power outlet versus the three-phase power supply. Consequently, promising impressive new frontiers in the efficacy and, maybe, indications for flexible ureteroscopy may be realised in urinary stones’ endoscopic treatment6,7.

Use in stone management practice In November, we started using this new laser type (SuperPulsed Laser - Soltive) in our stone management practice. We treated different kinds of calculi: calcium oxalate monohydrate, calcium oxalate dehydrates, uric acid and magnesium ammonium phosphate. The maximum stone diameter on CT scan was 11-39 mm while the mean stone density was 1021 ± 314 Hounsfield units. We used single-use ureteroscopes during all the procedures (PU3022A, Pusen, Zhuhai (CN)). The laser platform made an impression on us because of its ergonomic and environmental advantages, as well as the portable system feature. The available technical choices offered us a special module configuration with a wide range of possible settings, particularly represented by very low energies and high frequencies as well as thinner core-diameter laser fibre (CDF).

Smaller fibres offer better deflection We used the 150 µm and 200 µm fibres. It is clear to us that smaller fibres allow the ureteroscopes to have better deflection, thus allowing us to navigate easier throughout the pyelocaliceal system. In the “fine dusting” mode, we observed that the size of stone fragments was smaller and many of them evacuated spontaneously due to their floating ability. The SuperPulsed TFL (Soltive) proved able to deliver energy in a smaller area of the calculi and thus obtain smaller fragments resembling dust (approx. 1 mm), different from the holmium lithotripsy. Therefore, we can underline that the SuperPulsed TFL proved to constitute an effective and safe tool during flexible ureteroscopy regardless of stone density. We described practically no retropulsion, while obtaining stone dust seemed to be significantly easier and faster. We have to emphasise that, in the light of an experience of more than 5,000 holmium laser ureteroscopic procedures, the thinner laser fibres create the conditions for a substantial improvement concerning the irrigation flow, endoscopic view and deflection abilities provided by the ureteroscopes.

Professor Petrisor Geavlete using the new SuperPulsed Laser (Soltive) and single-use ureteroscope (PU3022A, Pusen, Zhuhain (CN)) in Sanador hospital in Bucharest

Holmium:YAG laser. World J Urol. 2020 Aug;38(8):1883In conclusion, we are convinced that thanks to this 1894. doi: 10.1007/s00345-019-02654-5. Epub 2019 Feb 6. new laser type, the size of the ureteroscopes will significantly reduce in the future, while the indications 4. Netsch C, Gross AJ, Herrmann TRW, Becker B. Current use of thulium lasers in endourology and future for flexible ureteroscopy will likely change our perspectives. Arch Esp Urol. 2020 Oct;73(8):682-688. protocols regarding renal stones retrograde PMID: 33025913 treatment.


Ureteroscopy detail: prof. Geavlete using the new SuperPulsed Laser (Soltive) and single-use ureteroscope (PU3022A, Pusen, Zhuhai, China) in Sanador hospital in Bucharest

1. Keller EX, de Coninck V, Audouin M, Doizi S, Bazin D, Daudon M et al. Fragments and dust after Holmium laser lithotripsy with or without « Moses technology »: how are they different? J Biophotonics, 2019, 12(4):e201800227 2. Hardy LA, Vinnichenko V, Fried NM. High power holmium:YAG versus thulium fiber laser treatment of kidney stones in dusting mode: ablation rate and fragment size studies. Lasers Surg Med, 2019, 51(6):522– 530. https :// 3. Traxer O, Keller EX. Thulium fiber laser: the new player for kidney stone treatment? A comparison with

5. Keller EX, Traxer O. SuperPulsed Thulium fiber laser: The ultimate laser for lithotripsy? Arch Esp Urol. 2020 Oct;73(8):767-776. PMID: 33025921 6. Kronenberg P, Traxer O. The laser of the future: reality and expectations about the new thulium fiber laser-a systematic review. Transl Androl Urol. 2019 Sep;8 (Suppl 4):S398-S417. doi: 10.21037/tau.2019.08.01. PMID: 31656746 7. Panthier F, Ventimiglia E, Berthe L, Chaussain C, Daudon M, Doizi S, Traxer O. How much energy do we need to ablate 1 mm3 of stone during Ho:YAG laser lithotripsy? An in vitro study. World J Urol. 2020 Jan 27. doi: 10.1007/ s00345-020-03091-5. [Epub ahead of print]

Giorgio Pizzocaro 1939-2020 “Italian pioneer in testicular and penile cancers”

With great sadness I heard that Giorgio Pizzocaro died on 26 November, 2020. He had been suffering from a long and grave illness for a considerable time, which resulted in an ever-increasing reduction of his physical and mental health. Prof. Pizzocaro started as an internal student at the Istituto Nazionale Tumori of Milan (IT) in 1960, where he remained until his retirement from the public health system at the age of 67 in 2006. His initial scientific interest was in breast cancer. Later, this was expanded to thoracic surgery. As surgery fellow, head and neck and abdominal surgery were his areas of interest. In 1969, he even won a stage period in the field of chest


European Urology Today

diseases at the London Brompton Hospital Institute (UK). Furthermore, he was a pioneer in the study and treatment of testicular and penile cancers in Italy. He deepened the knowledge in the field by introducing skills based on method and rigor of analysis. The Istituto Nazionale Tumori in Milan, where he worked in the second half of the 90s, was a world of medicine which was not yet permeated by these scientific concepts. He was responsible for the introduction and standardisation in Italy of retroperitoneal lymphadenectomy. As innovative surgeon, he implemented the first effective chemotherapy (with cisplatin) for testicular tumours. Furthermore, the

implementation of lymph node surgery and innovative schemes for the chemotherapy treatment of penile tumours can be attributed to him. Only a few years ago, Giorgio Pizzocaro recalled the time he made his first acquaintance with testicular tumours. He had studied the reports relating to testicular tumours recorded among soldiers of the American Army during and immediately after World War II. He was anxious to find new treatment options to help these, often young, patients. For many years, Dr. Pizzocaro was an authority in the field of oncological urology, even beyond our national borders. He earned his esteemed reputation based on his high level of competence, evident

scientific rigor and his strong character. There is no doubt in my mind that thanks to him, Italy enjoys widespread recognition for its competence in the pathologies most dear to Dr. Pizzocaro. However, we should also thank him for the dissemination of methodological principles that are currently used in the fields of urology and oncological urology. One of these days Giorgio Pizzocaro would have turned 81. Unfortunately, he died shortly before. Those who have known him, know what his legacy is. It will not be forgotten. I extend my sincere condolences and deep sympathy for Dr. Pizzocaro’s family. Dr. Nicolai Nicola

January/February 2021

Provision of advanced uro-oncological care Part I – EAUN committed to supporting urology nurses in expertise development Franziska Geese, MScN Research Associate EAUN Board Member Elect Berne (CH) For several years, it is a trend in many countries to implement Advanced Nursing Practice (ANP) services. ANP is an ‘umbrella’ term for an extended nursing practice. These ANP services are intended to achieve an improvement in holistic patient care.

Diagnostic thinking skills The basis of patient care is diagnostic thinking skills, which are part of the extended scope of practice. Furthermore, the APN advises health care providers, plans, implements and evaluates specific care programmes. This professional is the first point of contact for people with cancer and their relatives, e.g. in the follow-up of cancer survivors. Furthermore, the APN has the authority to diagnose, prescribe medication and treatment, refer people with cancer to specialists or admit them to hospital or other healthcare facilities4. EAUN is committed The European Association of Urology Nurses (EAUN) is also committed to supporting urology nurses in the practice of their competences and the development of their expertise on different skill and grade level. Thus, competences are to be developed through various training courses (e.g. Webinars, ESUN courses) based on an educational framework concept. This educational framework concept is currently in the development phase5. Furthermore, in the future, EAUN training courses might be creditable in the academic ECTS system. Further updates will be provided on the EAUN website ( nurses/education-2/other-resources/).

Advanced Practice Nurse The services are provided by Advanced Practice Nurses (APN) - usually by a Nurse Practitioner in the substitution model or a Clinical Nurse Specialist in the delegation model1. The prerequisite for both roles is a Bachelor’s degree in Nursing, the subsequent completion of a Master's degree and specialisation in a field with a focus on a specific patient group2. However, the tasks and competences of the APN often vary, depending on the setting (outpatient or inpatient care), the patient population and national Different settings and patient groups regulations3. Urological ANP care services are found internationally in different settings and are specialised for different European Oncology Nursing Society patient groups. They range from inpatient to Based on the educational framework of the European outpatient and from primary to secondary (hospital) Oncology Nursing Society4, the scope of practice of the care. In terms of uro-oncological patient groups, APN in oncology care includes parts of research, mostly people with prostate, bladder, kidney, penile education, clinical practice and management. The and testicular cancer are involved. In the case of APN has a high degree of professional autonomy and people with prostate cancer, the prevention of the runs an independent clinical practice. In addition, the disease through genetic counselling is of particular APN has independent case responsibility and the interest6. In addition, APNs support, for instance, ability to assess health/disease and make informed informed decision-making on prostate-specific decisions. antigen (PSA) testing as part of the diagnostic process. They are also involved in assisting patients in coping with symptoms and therapeutic side effects (e.g. erectile dysfunction, incontinence, bone health)

during the cancer survivorship phase. APNs are also trained to improve living conditions at home during the end-of-life phase and include relatives through the approach of Advance Care Planning. Key people It becomes clear that the care provided by an APN extends from the prevention of an oncological disease to the end of life phase. Various studies show that APNs can, among other things, improve healthrelated quality of life7 and patients symptom management8. In turn, the coordinative tasks of an APN can improve, e.g. interprofessional collaboration9, reduce waiting time for diagnostic/ treatment and the length of hospital stay10. In summary, APNs contribute to improve patient uro-oncological care in today's world. Understanding APNs tasks and competencies will help implement this role in the interprofessional team and let patients, as well as health care professionals, benefit from their interventions. APNs broad expertise and problem analysis skills make them key people in identifying health care service gaps as well as in nursing practice development.

challenges and responses. International Journal of Urological Nursing, 2020. 14(1): p. 5-12. 6. Connors, L.M., Genomics to personalize care of prostate cancer. J Am Assoc Nurse Pract, 2020. 32(2): p. 106-108. 7. Bryant-Lukosius, D., et al., Evaluating health-related quality of life and priority health problems in patients with prostate cancer: a strategy for defining the role of the advanced practice nurse. Can Oncol Nurs J, 2010. 20(1): p. 5-14. 8. Spoelstra, S.L., et al., A trial examining an advanced practice nurse intervention to promote medication adherence and symptom management in adult cancer patients prescribed oral anti-cancer agents: study protocol. J Adv Nurs, 2016. 72(2): p. 409-20. 9. McCorkle, R., et al., An Advanced Practice Nurse Coordinated Multidisciplinary Intervention for Patients with Late-Stage Cancer: A Cluster Randomized Trial. J Palliat Med, 2015. 18(11): p. 962-9. 10. Drudge-Coates, L., Khati, V., Ballesteros, R., MartynHemphill, C., Brown, Ch., Green, J., Challacombe, B., Muir, G., A nurse practitioner model for the assessment of suspected prostate cancer referrals is safe, cost and time efficient. ecancer, 2019. 13: p. 994.

References 1. ICN-AANP. Definition and Regulation of Advanced Nursing Practice. 2019 [26.08.2019]; Available from: 2. Hamric, A.R., Spross, J.A., Hanson, C.M., Competencies of Adcanced Practice Nursing., In Advanced Practice Nursing. An Integrative Approach. A.R. Hamric, Spross, J.A., Hanson, C.M., Editor. 2009, Saunders Elsevier: St. Louis. 3. CRNNS, Nurse Practitioner-Sensitive Outcomes. 2016 Summary Report. 2016, College of Registered Nurses of Nova Scotia. 4. EONS, European Oncology Nusing Society Cancer Nursing Education Framework. 2018, European Oncology Nursing Society. 5. Marley, J., et al., Developing an Educational Framework for Urological Nursing: Using a World Café approach to gain an emerging international understanding of issues,

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

Susanne Vahr (DK) Paula Allchorne (UK) Jason Alcorn (UK) Jerome Marley (GB) Tiago Santos (PT) Corinne Tillier (NL) Jeannette Verkerk (NL) Giulia Villa (IT) Franziska Geese (CH) Ingrid Klinge Iversen (NO)

European Association of Urology Nurses

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

Fellowship Programme

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

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 31 August 2021 • Only EAUN members can apply • Host hospitals in Belgium, Denmark, France, the Netherlands, Sweden, Switzerland and the United Kingdom • A great way of widening your horizon For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674

January/February 2021

European Association of Urology Nurses

European Urology Today


A varied new EAUN21 programme to look forward to EAUN21 adapts to new realities in the COVID-19 era We are delighted to be able to organise the 22nd International EAUN Meeting (EAUN21) as a live event in Milan despite the COVID-19 pandemic. The meeting will be taking place in July instead of in March, and it will be a two-day congress on 10 and 11 July 2021 instead of the usual three days.

Educational Framework for Urological Nursing (Curriculum).

Despite the limitations caused by the pandemic, we have organised a programme with a wide variety of sessions; some are new, others were part of EAUN20, which was cancelled. Have a glimpse at the programme in this article!

Abstract submission now open! Deadline: 1 March 2021 Difficult Case Submission now open! Deadline: 1 March 2021 Research Plan Submission now open! Deadline: 1 March 2021 The Special Interest Groups (SIGs) will present respective sessions on continence care, endourology (i.e. coverage on stone disease, benign prostatic hyperplasia, and technologies such as robotics), and

skeletal issues in metastatic prostate cancer. EAUN21 will also feature palliative and end-of-life care in urology and the effects of COVID-19 on urology care.

Save the date! Deadline: 10-11 July 2020 Profound impact Another session will increase the attendees’ know-how on the predictive factors and the management of enuresis and nocturia. Enuresis is prevalent among children and nocturia among middle-aged and older adults; both conditions have a profound impact on the patients’ quality of life.

The role of ANP The Plenary Session “Educational Framework for Urological Nursing (EFUN) (Curriculum) and the role of the ANP” will centre on the development of the Advanced Nurse Practitioner (ANP) role, which has advanced in a variety of ways across Europe. Experiences with the ANP role and the link to the current Guidelines will be shared with the audience, as well as the progress in the development of an

New research and developments

The growing evidence in urology nursing care is amazing! 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 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

Stefano Terzoni, Chair, EAUN Special Interest Group - Continence

Selected from PubMed Bladder Cancer • Jensen BT, Lauridsen SV, Jensen JB. Optimal Delivery of Follow-Up Care After Radical Cystectomy for Bladder


European Urology Today

Join other nursing specialists and affiliated medical professionals for a critical assessment of clinical

practices and key research developments at Europe’s biggest urological nursing event. EAUN21 presents the latest in science and education in various formats to suit the needs of all participants (such as continence nurses, stoma care nurses, oncology nurses, operating room nurses, etc.). Please visit to view the entire provisional scientific programme and to find all other relevant information, such as the information on registration and abstract submission.


Join us in Milan!

10-11 July 2021, Milan

“Having a profound impact” can also be said of the nurses whose dedication is a source of inspiration, and whose contribution helps boost the quality of nursing care. They will share their expertise in the session “Nursing solutions in difficult cases.”

"Spot-on" evidence-based nursing care

Dear EAUN members,

ESU course This year’s ESU course will involve Peyronie’s disease, one of the lesser-known urological conditions affecting men. The surgical treatment, which is the only effective treatment advised in the EAU Guidelines, will be discussed. Unfortunately, we can’t organise any workshops and hands-on training this year.

Cancer. Res Rep Urol. 2020 Oct 14;12:471-486. doi: 10.2147/RRU.S270240. eCollection 2020. PMID: 33117747 Free PMC article. Review. • McAlpine K, Lavallée LT, Stacey D, Moodley P, Cagiannos I, Morash C, Black PC, Kulkarni GS, Shayegan B, Kassouf W, Siemens R, So A, Leveridge MJ, Boorjian SA, Daneshmand S, Smith AB, Power N, Izawa J, Drachenberg DE, Fairey A, Rendon RA, Breau RH. Development and Acceptability Testing of a Patient Decision Aid for Urinary Diversion with Radical Cystectomy. J Urol. 2019 Nov;202(5):10011007. doi: 10.1097/JU.0000000000000341. Epub 2019 Oct 9. PMID: 3109972.

22nd International EAUN Meeting Abstract and Video Submission, Difficult Case Submission, Research Project Plan Submission Deadline: 1 March 2021

in conjunction with

HYPERLINKS The International Journal of

Urological Nursing

- the official Journal of the BAUN International Journal of

Urological Nursing the journal of the baun

ISSN 1749-7701

Volume 10 • Issue 2 • July 2016

Continence • Nolan R. NRH - Procedure for the Routine Change of a Suprapubic Catheter. Video. Oct 2020 healthcare-professional-disciplines-nrh/ • Aloush SM, Al Qadire M, Assmairan K, et al. Risk factors for hospital-acquired non-catheter-associated urinary tract infection. J Am Assoc Nurse Pract. 2019;31(12):747751. doi:10.1097/JXX.0000000000000175. • Smith DRM, Pouwels KB, Hopkins S, Naylor NR, Smieszek T, Robotham JV. Epidemiology and health-economic burden of urinary-catheter-associated infection in English NHS hospitals: a probabilistic modelling study. J Hosp Infect. 2019;103(1):44-54. doi:10.1016/j.jhin.2019.04.010. • Mundle W, Howell-Belle C, Jeffs L. Preventing Catheter-Associated Urinary Tract Infection: A Multipronged Collaborative Approach. J Nurs Care Qual. 2020;35(1):83-87. doi:10.1097/NCQ.0000000000000418. • Skelton-Dudley F, Doan J, Suda K, Holmes SA, Evans C, Trautner B. Spinal Cord Injury Creates Unique Challenges in Diagnosis and Management of Catheter-Associated Urinary Tract Infection. Top Spinal Cord Inj Rehabil. 2019;25(4):331-339. doi:10.1310/sci2504-331.

Editor Rachel Busuttil Leaver Associate Editor Jerome Marley

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

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

Subscription Offer to EAUN members

35% discount

Call for papers Visit:



New topics The opening session will be about the doctor-nurse cooperation in daily practice from both points of view, now an even more important subject than before, followed by a session on castration-resistant prostate cancer. As all International EAUN Meetings that came before, EAUN21 will present a diversity of sessions about prostate, bladder, and kidney cancer. Examples include sessions about gay men with prostate cancer and their special position and an interesting kidney session on the basics of the kidney function and dysfunction.

Mrs. Jeannette Verkerk Chair of the EAUN Scientific Congress Office

For the complete Scientific Programme visit

January/February 2021

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