European Urology Today Vol. 31 No. 5 – October/December 2019 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology

Vol. 31 No.5 - October/December 2019

Full Report of Urology Week 2019

Two decades of Peyronie’s surgery

Endourological nurses in Alexandria

New survey suggests men’s knowledge of prostate very low

A look at the significant evolution of corrective surgery

EAUN participates in new minimally-invasive meeting

Prof. N. Sofikitis

H. Omana

EMUC19: Four days of the best in uro-oncology Multidisciplinary approach to urological cancers matures in 11th edition By Erika De Groot and Loek Keizer Specialists from genitourinary (GU) cancer-related disciplines convened in Vienna, Austria from 15 to 17 November for the 11th edition of the European Multidisciplinary Congress on Urological Cancers (EMUC19). EMUC19 was preceded by the 8th Meeting of the EAU Section of Urological Imaging (ESUI19) and other supplementary meetings held on the 14th. The annual EMUC congress is a collaboration of the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).

In his next lecture, Assoc. Prof. Maurer enumerated the preoperative requirements for PSMA radioguided surgery and introduced the multicentre study, ProSTone, which stands for “Early Prostate cancer recurrence with PSMA PET positive unilateral pelvic lesion(s): is one-sided salvage extended lymph node dissection enough?”. The study will open for the inclusion of patients in the coming few years.

Dr. Herrmann’s lecture centred on the comparison among 3 tracers 99mTc-PSMA, 68Ga-PSMA and 18 F-PSMA. He concluded that 18F-PSMA will be used Imaging updates at ESUI19 more in the future. Although both 68Ga-PSMA and ESUI19 commenced with the “The MRI corner” session 18F-PSMA are similar in terms of performance, 18 which was moderated by ESUI Chairman Prof. Georg F-PSMA is more advantageous in terms of Salomon (DE), Prof. Tillmann Loch (DE), and Prof. production scale and cost-effectiveness. Arnauld Villers (FR). Liquid biopsies: potential for BCa During the session, Dr. Massimo Valerio (CH) The EMUC Symposium on Genitourinary Pathology underscored performing an MRI first before initial and Molecular Diagnostics, also known as the ESUP biopsy as it provides an improved accuracy. Symposium, examined the current state of liquid biopsies in uro-oncology, and its future applications. According to Dr. Lars Budäus (DE), MRI-targeted The symposium was organised by the EAU Sections of prostate biopsy (MRI-TB) defines risk groups and Uro-Pathology (ESUP) and Urological Research (ESUR) outperforms conventional Transrectal ultrasound and the Uropathology Working Group of the European (TRUS). However, historic Active Surveillance (AS) series Society of Pathology. It also took place on November demonstrate excellent overall survival and cancer14th, before the start of the regular EMUC specific survival rates. He added that quantification of programme. During the ESUP Symposium Prof. Thomas Gevaert (BE) said that compared to other urological cancers, BCa has an advantage when considering the use of liquid biopsies: “We can look at both blood and urine for more information. By combining analysis of the liquids, and with a variety of techniques we can investigate different substances.” He added that majority of patients Discussants of the multidisciplinary case discussion on PCa with metastatic BCa have circulating tumour DNA therefore potential Gleason scores adds further diagnostic value. value to stratify patients for clinical trials, as well as, Concluding the session, Prof. Villers stated that potential value in diagnostic and follow-up although MRI is not perfect for local staging, it may flowcharts. “Cell-free DNA (cfDNA)/circulating tumour improve the prediction of the pathological stage when DNA (ctDNA) is a very sensitive tool to detect early combined with clinical data. Given its low sensitivity recurrence and minimal residual disease,” stated for focal (microscopic) extraprostatic extension (EPE), Prof. Gevaert. MRI is not recommended for local staging in low-risk patients. He underlined the use of prostate MRI for 40 years after PSA's discovery local staging in intermediate and high risks. EMUC19 launched on the 15th with a session on early PCa detection, tied to the 40th anniversary of the New developments on radioguided surgery, tracers, discovery of prostate-specific antigen (PSA). It was and rationale use of the prostate-specific membrane chaired by radiation oncologist Prof. Thomas Wiegel antigen positron emission tomography (PSMA PET) (DE), radiologist Prof. Raymond Oyen (BE), pathologist were also explored during the ESUI19 session “The Prof. Eva Compérat (FR), and urologist Prof. Chris PSMA PET Corner”, which was moderated by Prof. Bangma (NL). Presenters offered insights on the Manuel Ritter (DE) and Dr. Ken Herrmann (DE). continued use of PSA as a screening tool, the current state and potential application of imaging or According to Assoc. Prof. Tobias Maurer (DE), PSMA biomarker-based alternatives. PET is potentially the most valuable in early In her lecture, Prof. Monique Roobol (NL) proposed the approach of starting with baseline PSA, followed by risk stratification, imaging, further risk stratification, biopsy and finally, treatment (including AS if required). Prof. Hein Van Poppel (BE) discussed the recent decline in PSA screening and the associated increase in mortality in several Western European countries: October/December 2019

14-17 November 2019 Vienna, Austria

biochemical recurrence (BCR) after radical prostatectomy (RP) and in primary high-risk prostate cancer (PCa).

EMUC19 welcomed 1300 participants from 98 countries over the course of four days

“This could be prevented with early detection and appropriate treatment.” Prof. Van Poppel concluded that effective use of supplementary tools and technologies such as new biomarkers and MRI, can prevent overdiagnosis and overtreatment.

The faculty members of the HOT course were comprised of Course Chair Dr. Jochen Walz (FR), Prof. Jurgen Futterer (NL), Dr. Gianluca Giannarini (IT), Prof. Valeria Panebianco (IT) and Dr. Francesco Sanguedolce (ES).

The session included topics on the current state and potential of various early detection options including MRI, specifically the Prostate Imaging–Reporting and Data System (PI-RADS); certification for hypothetical prostate imaging centres; and the role of artificial intelligence (AI) in risk stratification.

Participants learned about the advantages, handling and limitations of MRI Ultrasound fusion biopsies during the ESU/ESUI Hands-on Training Course in MRI

ESU courses and HOTs Two Hands-on Training (HOT) courses organised by the European School of Urology (ESU) and the ESUI simultaneously commenced on EMUC19’s second day. The ESU/ESUI Hands-on Training Course in Prostate MRI reading for urologists was designed to teach familiarisation with the imaging workstation; the basic concepts/principles behind different MRI sequences such as T2-weighted imaging, Diffusion Weighted Imaging (DWI) and Dynamic Contrast Enhanced (DCE) imaging; and the viewing order of sequences when interpreting prostate MRI. The programme also included the PI-RADS and Likert scoring systems and the image quality criteria to meet.

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Fusion biopsy under the tutelage of Course Chair Dr. Lars Budäus (DE) with mentors Ass. Prof. Jan Philipp Radtke (DE), Dr. Karsten Gunzel (DE), Dr. Silvan Boxler (CH), Dr. Angelika Borkowetz (DE) and Dr. Andreas Maxeiner (DE). ESU courses “Oligometastases in genitourinary cancers” and “Immunotherapy for urological tumours” preceded the HOTs held the day before. The courses were chaired by Assoc. Prof. Maurer and Dr. Jeroen Van Moorselaar (NL), respectively. GU cancer reports Chaired by Dr. Walz and Prof. Oyen, the “Highlights in GU cancers” session delivered GU reports from the Advanced Prostate Cancer Consensus Conference (APCCC), ESUI19 meeting, EAU Research Foundation (EAU RF), and Prostate Cancer Research International Active Surveillance (PRIAS). Prof. Nicolas Mottet (FR) presented the outcome of the APCCC, a consensus meeting which consisted of a Demonstrations during the HOT course in MRI Fusion biopsy round of 123 questions answered by 57 panel members. Specific questions were based on 10 controversial areas regarding PCa. Prof. Pär Stattin (SE) discussed the SPCG4 trial and in Only 36 questions resulted to consensus such as the his lecture, he explored whether the risk of death 80% vote for PSMA PET CT/MRI (plus/minus pelvic from the trial were applicable to current patients MRI) as the recommended imaging modalities in undergoing RP. Unfortunately, the trial did not collect rising PSA levels after radical radiation therapy of the data on prostate volume, extent of cancer on biopsy, prostate. nor comorbidities. Comprehensive data on changes in detection, cancer characteristics and work-up have to Prof. Salomon presented highlights of the ESUI19 be considered to interpret data in old trials. meeting which included coverage on portable ultrasound scanners. He underlined that although The risk of PCa death in SPCG-4 is not applicable to devices are getting better, the clinical impact is still men undergoing RP in 2019. related to the abilities and experience of the doctor handling said devices. The harm of false positives Prof. Harriet Thoeny (CH) co-chaired a session on the Prof. Salomon also reiterated that although AI helps clinical impact of false positives in uro-oncology. The improve workflow and prevent missing significant lectures offered further awareness of possible false cancers, AI does not help avoidance of unnecessary positives which should be ruled out before any biopsies. conclusions can be drawn from imaging or pathology.

European Urology Today Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Dr. D. Karsza, Budapest (HU) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Dr. F. Sanguedolce, Barcelona (ES) Prof. S. Tekgül, Ankara (TR) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL) J. Seesing, Arnhem (NL) EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680 F +31 (0)26 389 0674 EUT@uroweb.org 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.

Prof. Anders Bjartell (SE) shared the future aims of the EAU RF such as expanding EAU RF’s portfolio of investigator-initiated oncology and non-oncology clinical trials through seeding grants and other set-ups.

Prof. Thoeny recommended checking the morphology and clinical data available such as PSA. She stated that if there is a discrepancy (e.g. low PSA but a lot of metastasis) and minimal doubt, perform a biopsy.

She emphasised that chemo and hormone therapy have a huge impact on the patient and should be avoided whenever possible. Prof. Thoeny added that the PI-RADS scale also has scope for false positives. “The difficult ones are PI-RADS 3, because you’re not sure how to proceed. Taking the PSA density into account can help you rule out false positives.” She advised, “If the whole story doesn’t fit, you should be more critical. In the case of PSMA-PET, you should have a biopsy for confirmation before undergoing the extremely impactful systematic treatments. In the case of a prostate MRI, if you take PSA density into account, follow-up should be enough.” Access EMUC19 abstracts, webinars and posters via the EMUC19 Resource Centre: www.resource-centre. uroweb.org/resource-centre/EMUC19. Feel free to explore the ESUI19 Resource Centre via www. resource-centre.uroweb.org/resource-centre/ESUI19.

Prof. Roobol presented an overview of the PRIAS meeting which concluded the session. PRIAS is a web-based international prospective registry study established to validate the AS approach for low-risk PCa and to develop an evidence-based algorithm. Prof. Roobol stated that the PRIAS website will be updated and the study will also address the growing interest in lifestyle and food issues: “Our study is flexible; we can culminate these kinds of pursuits next to our PRIAS protocol.” New trials The third day of EMUC19 launched with a two-hour session on new trials. The session was chaired by radiation oncologist Dr. Carl Salembier (BE), medical oncologist Prof. Aristotelis Bamias (GR), and Assoc. Prof. Maurer. The session delivered current updates and preliminary conclusions from the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) trial, ARAMIS trial, KEYNOTE 057 study, with lectures concerning first-line treatment options for metastatic renal cell carcinoma (mRCC) and the duration of androgen deprivation therapy (ADT) in high-risk PCa. Prof. Karim Fizazi (FR) covered updates on the ARAMIS trial and the potential for the use of darolutamide for non-metastatic castration-resistant prostate cancer (M0CRPC). According to Prof. Fizazi, primary endpoints were improved overall survival and time to pain progression. The structure of Darolutamide might explain its low blood-brain barrier penetration, leading to fewer side effects and better tolerability compared to enzalutamide (ENZA) and apalutamide (APA). Prof. Fizazi concluded that all three agents showed clear and meaningful improvement of metastasis-free survival, particularly Darolutamide. However, costs can be a deciding factor when choosing among the drugs.

Call for

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

Deadline: 21 January 2020 (23:59 CET) The award will be handed out at the 35th Annual EAU Congress in Amsterdam during the ESUI section meeting on Saturday, 21 March 2020.

Prof. Maria De Santis (DE) pointed out changes in the 2019 EAU Guidelines gave a strong recommendation for APA or ENZA for patients with M0CRPC. Based on the new results, she expected that the 2020 Guidelines will do the same for Darolutamide. 2

European Urology Today

October/December 2019

Changing expectations on patient consent Will the profession ever wake up and smell the coffee? Mr. Bertie Leigh Specialist Healthcare Litigation and Clinical Negligence Hempsons London (GB) mamsl@ hempsons.co.uk - Advice from EAU’s Legal Nightmares specialist to prevent problems with the defence of consent allegations Legal specialists know that almost all consent processes that are used by the medical profession are not fit for purpose. Unfortunately, this is a truth universally there to be acknowledged whichever country you look at. The problem derives from the changing, secular relationship between doctors and patients. In some countries you can still get away with a more old-fashioned paternalist approach. Here patients expect the sort of minimal explanation that prevailed 50 years ago in Western Europe. The trouble is that patients’ attitudes change much faster than doctors expect. This is risky as often these cases are brought to court years after the event. Let us look at the components of the problem. It is commonly accepted that a valid consent means that the patient has been advised on the advantages and disadvantages of the alternative courses of action that are available to them. However, this advice should also include treatment options that the clinician is unable to offer themselves for whatever reason. The second self-evident premise from a legal angle is that, if the advice is not written down effectively it did not happen. This is because no doctor can be expected to remember all the options that they have discussed with any patient months after the event, especially with the clarity that will be required when things have gone wrong. If they claim to be able to do so without bothering to make a note the court is unlikely to believe them.

you go along. They will be approached through the hospital website using a personal unique identifier, so that the clinical notes will contain a record of their learning process. Most of this can be organised when a patient is referred to the urologist so that the average competent patient can be expected to arrive at the first consultation having done a lot of their homework. Those who have not done so for whatever reason can be shown into a side room with a screen to re-join the clinic later. There will of course be many patients who will find this difficult. Some will find the IT a challenge and will need assistance from an IT technician if the clinic nurse cannot do it for them. Some patients are medically semi-literate and may need help in understanding the terms. For these patients the cartoons and videos that can be created to assist understanding will be invaluable. The elderly with cognitive impairment will need special help. Some of them will refuse to do their homework – a specific record should be made of the fact before they go in. Such an IT programme has some advantages over a clinician. In many large cities up to as much as 25% of the patients share no common language with the person who is counselling them. IT based programmes can be translated into every language that is likely to attend the clinic. The EAU patient information in many languages may also proof useful. Doctors should be doing this, not only in order to protect themselves in Court, but because it is good medicine. There is ample evidence that the empowered autonomous patient who is able to take control of their own destiny does better when they do decide to have surgery. And they do far better during the other 99% of the time when they are avoiding surgery by pursuing sensible healthy lifestyle choices. Very soon doctors will be sued because they have

failed to convey the sort of advice that their patients need in appropriately sophisticated terms. Already we are seeing that actions about consent to treatment are not so much about whether or not a risk was mentioned, but about whether it was mentioned at the right time and whether it was explained in the right way. No-one can absorb and handle complex information about risk when they are frightened and excited just before an operation: this is so obvious that it is professional misconduct to try! The word doctor means teacher and the quality of your teaching or advising will be as much on trial as the quality of your diagnosis, your ‘cutting and sewing’. You are all more or less in the advising business. Unfortunately none of the clinical notes that I am asked to defend suggest that this aspect of the clinical work has been given sufficient priority. Even very good caring doctors who are interested in explaining things to their patients do not make defensible records of the fact. They cannot, because the modern outpatient clinic is simply not set up for the purpose that it has to achieve. How to improve? Some urologists are real experts in creating multi-media films illustrating new procedures. Some of them are brilliant, but almost all of them are only explaining things to other urologists. Why not create your own film explaining e.g. the complex choices open to someone who has just been diagnosed with prostate cancer? The best video award winner will not only make a great contribution to good patient care, but will also receive an official award and be a true hero earning the thanks of their colleagues and patients. On Sunday 22 March 2020 I will again be participating in the Nightmare Session on Robotics during the Annual EAU Congress in Amsterdam. For 2021 I challenge urologists to submit more patient oriented educational materials, but also the organisation to acknowledge great achievements in this field.

EMUC19: Four days of the best in uro-oncology. . . . . . . . . . . . . . . . . . . . . . . . . 1 Changing expectations on patient consent. . . 3 FutUrology: Exploring the past, present and future. . . . . . . . . . . . . . . . . . . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . 8-11 ESFFU: Treatment of OAB in the elderly population. . . . . . . . . . . . . . . . . . . . . . . . . . 12 Men’s knowledge of the prostate startlingly low . . . . . . . . . . . . . . . . . . . . . . . 13 ESUT: Cadaver courses in Malta to increase laparoscopic skills. . . . . . . . . . . . . . 14 Book review. . . . . . . . . . . . . . . . . . . . . . . . . 14 ESUO: A discussion of what we consider to be office urology. . . . . . . . . . . . . . . . . . . . 15 EAU-RF: SATURN Registry recruitment ahead of schedule . . . . . . . . . . . . . . . . . . . . 16 EAU-RF: NIMBUS trial to end in 2020. . . . . . 16 Opportunity to join for hospitals in smaller EU countries. . . . . . . . . . . . . . . . . . . 17 ‘Let’s talk Prostate Cancer’ campaign launches. . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ESU section: New masterclass receives praise for 1st edition. . . . . . . . . . . . . . . . . . . . . . . . 18 Renal transplantation: "An inspiring activity”. . . . . . . . . . . . . . . . . . 19 SET-UP Programme recap of 2018 and 2019. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 ESU Course delivers PCa essentials in Hungary. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Cancer patient advocacy. . . . . . . . . . . . . . . . 22 Guidelines collaboration. . . . . . . . . . . . . . . . 22 EUSP scholarship: A catalyst to my PhD acquisition . . . . . . . . . . . . . . . . . . . . . . 23 YUO leadership course sharpens key competences . . . . . . . . . . . . . . . . . . . . . . . . 23

Thirdly, this obligation does not apply only when advising a patient to submit to invasive surgery. It applies equally strongly when the patient is advised against surgery or when nobody considered surgery and the patient was merely being reassured. Advice that imaging the prostate is unnecessary can be just as life threatening as advice to perform surgery. Yet for some reason doctors do not ask a patient to sign consent forms when they omit to do something.

Latest developments in penile cancer. . . . . . 24

Fourth, the consent form is at best an irrelevant distraction. It primarily records the fact that the patient consented. But in 45 years of practice I have never seen a case where that was disputed.

Of course it is self-evident that a doctor cannot make laborious manuscript records of every option that has been discussed with every patient, including those where no surgery or medical therapy was advised. It would bring the average outpatient clinic to a juddering halt after 10 patients had been seen. The way forward What the medical profession must do is to take advantage of the levelling of the playing field of knowledge that has taken place between doctors and patients. There is no reason why the patient should not be expected to do the overwhelming majority of the work themselves, including the creation of the record of the research that they have done. The doctor should be there to tell patients where they need to look and in some cases to create the learning materials that they need to use. Appropriate learning materials will be multi-media, videos, drawings, cartoons and media with 'talking heads' (in which doctors explain issues to patients). Fortunately, the EAU has underpinned its commitment to good patient information with a website totally dedicated to Patient Information (patients.uroweb. org), which includes educational videos, explanatory visuals, and translations to many languages. Ideally, these learning materials offered by the hospital should be IT based and create a record as October/December 2019

YUO section: Evidence-based medicine: Training is lacking . . . . . . . . . . . . . . . . . . . . 25 Personal monetary costs of urology residency. . . . . . . . . . . . . . . . . . . . . . . . . . . 25 EUREP19 section: Prof. Palou bids EUREP farewell. . . . . . . . . . Profs. Ahyai and Karsenty join the EUREP team. . . . . . . . . . . . . . . . . . . . . . . . . Prof. Somani takes on new role at EUREP19. . . . . . . . . . . . . . . . . . . . . . . . . . Zambia represents at EUREP19 via Urolink. . . . . . . . . . . . . . . . . . . . . . . . . . EUREP19 meets great expectations. . . . . . . . EUREP19 delivers excellent opportunity for residents. . . . . . . . . . . . . . . . . . . . . . . . .

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ESAU section: Peyronie’s disease . . . . . . . . . . . . . . . . . . . . 28 Lessons from 20 years Peyronie’s surgery. . . 28 State-of-the-art in penile prosthesis implants. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 ERUS19: New steps in live robotic surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 EULIS19 delivers vital stone updates in Milan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 ELUTS19: Recap and highlights. . . . . . . . . . . 31 PCa19: “Practical conclusions for daily work” . . . . . . . . . . . . . . . . . . . . . . . 32 EAUN section: First MMISU meeting: Sharing MIS nursing skills. . . . . . . . . . . . . . . . . . . . . . . . Educational framework to support urological nursing . . . . . . . . . . . . . . . . . . . . National urological nursing congresses in Serbia and Turkey. . . . . . . . . . . . . . . . . . . Nurses and PhDs - a new trend . . . . . . . . . . Non-muscle invasive bladder cancer surveillance . . . . . . . . . . . . . . . . . . . . . . . . .

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European Urology Today

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

Examining the near future of uro-technology Urologists pride themselves on using the latest technology to better treat their patients: from minimally invasive surgery to robotics, improved imaging and even the construction of artificial implants, technology drives innovation. At EAU20, Prof. Chris Bangma technology is of course represented by the EAU Section of Uro-Technology and its live surgery sessions, but more specialised sessions can also point at developments that are not yet ready for demonstration. Prof. Chris Bangma (Rotterdam, NL) is co-chairing Thematic Session 21 (Monday, 23 March, 10:30), New Technology in Urology. As chairman of the Erasmus University urology department and an experienced prostate cancer researcher, Prof. Bangma is well placed to offer a glimpse of the future of the field. In this interview he gives a preview of Thematic Session 21 and what urologists can expect from medical technology in the coming decades. Practical applications “Technology is all about practical applications for the health professional,” Bangma explains, “…and urology is a profession for ‘doers’. We remove, replace, remake, reconstruct organs, tissues, or cells in the urinary tract. In order to improve our results and renew our skills, we often borrow the innovations of others, and integrate their findings into our profession.”

Important dates Early Bird Fee deadline 16 January 2020

All these topics will be discussed in the first part of Thematic Session 21, with experts presenting the latest developments in single cell capturing, so-called 4D regenerative medicine and printing technologies for complex tissue models. New ‘organs’ Bangma also considers a post-surgical future for urological conditions: “Maybe surgery can be improved with additional technology, maybe it will even disappear in the long run. One might argue that recent innovations in robotic surgery are good enough to handle cancer in the abdomen, but molecular sciences have designed targets that may beat surgery with so-called magic bullets. Intra-operative imaging with novel probes might enhance precision surgery, and improve functional and oncologic outcome.” Live surgery during the ESUT-ERUS-EULIS Session at EAU19, Barcelona

“Perhaps we can also make entirely new kidneys, or bladders, or urethras, and urologists are the ones who are going to insert them into the body. We are inserting new ‘organs’ already: we place neuromodulators to alter and correct bladder function, corpora cavernosa, and urinary sphincters. It is likely that these inserts will be improved: smarter, smaller, and personalised to the demands of the patient. Will we be able to integrate with the neurosurgical expertise of others, and stimulate the brain on top of the spinal cord?” Topics to be discussed in Amsterdam include modulation of urological nerves, brain stimulation and the effect of EU directives on urology implants. Putting data to use Information technology is also transforming urologists’ knowledge of cancers. “The age of information has started with an explosion of genomic data,” says Bangma.

Late Fee deadline 13 February 2020 Opening Ceremony & Network Reception 20 March 2020 Congress days 20-24 March 2020 Exhibition days 21-23 March 2020

rview at

Check out the programme ove

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“Can we operate better if we can see what a radiologist sees in the diagnostic phase, during the operation? Can we replace diseased tissue with a tissue similar in quality to what mother nature makes at birth? How can we learn from the experiences of thousands of patients to help the one person in front of me? The ‘New Technology’ session at EAU20 highlights some of the challenging technological developments needed to improve current urological practice just now or in the immediate future.”

“Massive amounts, unstructured, and therefore often lacking sufficient meaning. To find patterns between genomic profiles, epigenetic changes, immunologic alterations and environmental factors, we need more than our brain to create meaningful algorithms: artificial intelligence. Automatic pattern recognition in radiologic images and histology is already feasible. In cancer diagnostics, this provides the technology to stratify patients in high or low-risk groups, and use this classification to select the patients for a more intensive work up by the pathologist making a diagnosis.” “Clinical applications are around the corner, and can be incorporated in clinical decision tools. In the future, urologists might have a ‘second digital me’, or ‘digital twin’: an avatar that collects all of your data over time and allows information from different sources to be combined. This digital twin’s data can be applied during surgical procedures. The EAU is involved in projects (like PIONEER) preparing for such networks.” Innovations in data use will be covered in the section “Patterns & Computers”, which has

European Urology Today

Joint ESOU-ERUS-ESUT session with ECCO during EAU19, Barcelona

talks on image recognition, decision support and the potential of the ‘digital me’. Clinical relevance Advances in technology should ultimately end up in urologists’ hands and be a benefit to their patients. The practical application (and implications) of new technology is a primary concern of the EAU, and this is reflected in each speaker’s presentation at Thematic Session 21. Reflecting on the aforementioned topics, Prof. Bangma points out: “These developments are not for everyone, at least not immediately. But thirty years ago flexible cystoscopy was too expensive for routine care, and nowadays people are considering the idea of scopes for one-time use only.”

“We realise that not all developments are going to make it into the clinic. We only want to be there in time if they do, and we want them to be in our hands.” Chris Bangma is professor and chairman of the department of Urology at Erasmus University Medical Hospital since 2001. Prof. Bangma has been on the EAU scientific committee for 8 years. He is PI of the worldwide networks PRIAS and Movember GAP3 for active surveillance in low risk prostate cancer, and contributes to various research activities for the development of markers in bladder and prostate cancer. He is initiator of the Anser Prostate Cancer Network in the Netherlands.

October/December 2019

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

Working towards a sustainable congress Thanks to its relatively small size for a European capital, and its iconic canal belt, Amsterdam is naturally suited to eco-friendly ways of getting around. The city has a dense public transport network and is easily traversed on foot or by bicycle. You can cover most of Amsterdam’s sights on foot, take a canal tour or rent a bike, if you feel like mixing with the locals! Reaching the RAI Amsterdam congress venue from your hotel is no exception. You can get your daily exercise when you walk or cycle to and from the venue; see the sights along the way and leave no carbon footprint behind. The RAI is also a stop on the brand-new North-South metro line (‘Europaplein’) that goes straight through the city’s historic centre. This particular line has no schedule: metros simply come and go every six minutes and you can get to the city centre before you even realise.

up at the Transportation Desk located in the Registration Area. This ticket has a 96-hour validity from the first moment it is used. The GVB travel card includes metro, bus and tram service within Amsterdam. No need to ever use a taxi! If you’re still planning your trip to Amsterdam, consider taking one of the many high-speed rail options. Amsterdam is connected to several German, Belgian and French cities by convenient high-speed services. Amsterdam even has a Eurostar terminal with a direct connection to London.

The EAU is providing free four-day Transportation Passes to congress delegates. These can be picked

A modern congress When you collect your EAU20 bag (goodies included) at the Registration Area, note that these tote bags are reusable. They are made of 100% organic cotton and, for the first time, printed with amusing urology-themed slogans. There are five different bags, so keep an eye out for one that tickles you.

Discover the slogans, grab a tote bag at the congress

This year, we are using the NEW EAU Events app to communicate with our delegates, and to offer an up-to-date and convenient scientific programme. The app also allows for audience interaction (voting, asking questions to moderators) in select sessions. You can compile your own daily schedule with a few simple ticks. Using the app saves in printing thousands of traditional 600-page programme books. Go paperless and download the new app via Google Play (https://bit.ly/2OCCaeG) or the App Store (https://apple.co/2VunJKW).

Explore Amsterdam on foot, via tram/bus and bikes for passionate cyclists

How the little things count RAI Amsterdam uses recycle bins. The bins are divided into paper, plastic and organic waste. Like the rest of the country, Amsterdam separates its waste so it can be recycled and/or disposed properly. Amsterdam even uses plastic-fishing boat tours to help keep its canals clean. Did you know that tap water in the Netherlands is safe to drink? Bring a bottle and refill it as much as you want without the need for bottled waters and the associated waste.

Tap water in the Netherlands is safe to drink

Beware of fake EAU20 websites

Register for EAU20 by 16 January 2020 and benefit from discounts of up to 30% (see chart). Until 19 March, all registrations should be made through the online registration system. Please visit eau20.org for more information about the registration process.

Beware of individuals and companies that claim to offer you EAU20 registration and hotel accommodation in Amsterdam. In the past, we have received reports from delegates who, upon their arrival at their hotels, discovered they did not have a reservation at all. Other delegates paid registration fees significantly more expensive than the actual congress fees. Here are ways you can avoid overpayment and false confirmation:

EAU members Fees in EURO (€) Incl. 21% VAT All invoices include VAT

• •

Early fee 01 Oct 2019 – 16 Jan 2020

Late fee 17 Jan 2020 – 13 Feb 2020

Onsite fee 14 Feb 2020 – 24 Mar 2020

Active/ Affiliated

€905.00

€1,145.00

€1,300.00

Junior/ Medical Student/ PhD Student

€188.00

PhD Researcher * (Affiliated member)

€230.00

€286.00

€441.00

Proof of status is required. A proof of status is an official letter written in English by the head of the hospital department on official hospital letterhead Note: this fee is not applicable for those who are an active member doing a temporary PhD research

1. Register for EAU20 only via eau20.org. 2. Book your hotel room only through eau20.org. K.I.T. Group GmbH is appointed as the official housing agent for EAU20. Their team is ready to assist you in booking your accommodation at a reasonable price with guaranteed rooms. 3. Unsure if you are visiting a fake website? Always check the contact details. The congress is officially organised by Congress Consultants B.V. which is based in Arnhem, the Netherlands. The K.I.T. Group GmbH is based in Berlin, Germany. 4. Official EAU20 emails will only come from the following: @congressconsultants.com @kit-group.org @uroweb.org 5. Always be cautious when disclosing personal information to third parties.

FAKE

To further help you spot fraudulent websites, check out the screenshots of some of the fake websites:

FAKE

October/December 2019

European Urology Today

FutUrology: Exploring the past, present and future History Office meets in Maastricht for urology symposium and board meeting By Loek Keizer The EAU History Office held its annual autumn meeting in Maastricht, the Netherlands on 11-12 October. On October 10th, the History Office also participated in the FutUrology Symposium which was held in honour of the retirement of Prof. Philip Van Kerrebroeck at Maastricht University. A great variety of experts in urology gave their views on the past, present and future of certain procedures. The lectures that dealt with the past perspective of these urological topics were given by History Office experts. Historical perspective The symposium was divided in six sessions, each with three speakers on the past, present and future of said topic. Topics ranged from neuro-urology (Prof. Van Kerrebroeck’s specialty) to endourology and andrology to urological oncology.

EAU Secretary General Prof. Chris Chapple also spoke at the symposium, presenting on the future of uro-andrology

Mr. Jonathan Goddard spoke on the history of uro-gynaecology, presenting a variety of early medieval texts with reference to the treatment of female incontinence. A variety of options, including As the “past” speaker of the latter session, History stoppers, the artificial narrowing of the urethra or the Office board member Prof. Roman Sosnowski gave a injection of a variety of substances like paraffin were historical overview of prostate surgery. While a proposed throughout the ages, until the development common and life-saving procedure in the 21st century, of slings reached a maturity in the 20th century. until the 1980s, the surgical anatomy of the prostate was poorly understood. Additional history-themed talks came from former History Office chairman Prof. Dirk Schultheiss (a look It was the pioneering work of Patrick Walsh (and his at Leonardo Da Vinci’s work on male anatomy), Prof. collaboration with Pieter Donker of Leiden University) Jens Peter Nørgaard (paediatric urology), Dr. Sajjad that led to the first nerve-sparing prostatectomy in Rahnama’I (the discovery of the relationship between 1982. Up to that point, hormone therapy was the nervous system and urology) and Dr. Rob considered the primary treatment for prostate cancer. Schipper (the development of endourology). The next major development was the discovery and implementation of PSA. Combined with an The symposium was closed by a highly personal improvement in biopsy procedures, the survival rate lecture by Prof. Frans Debruyne, former EAU Secretary for prostate cancer significantly improved since the General and one of the department heads that Prof. early 1980s. Van Kerrebroeck worked under in his long medical career. Prof. Van Kerrebroeck then held his own farewell lecture in the historical setting of the Sint-Janskerk (Saint John’s Church), marking the end EAU History office of his academic career.

Prof. Van Kerrebroeck giving his farewell lecture to mark his retirement at the University of Maastricht

Looking to EAU20 But the visit to Maastricht also served as a board meeting for the History Office, allowing the office to discuss its planned activities in Amsterdam for EAU20, on-going research projects, new publications and management of the EAU’s collections of urological instruments.

In Amsterdam, Dr. Mattelaer will present Roma Intima, a co-production with classical historian Dr. Bert Gevaert that examines Ancient Roman attitudes to sex and other urology-related topics. The book will be available as a congress gift to EAU Members who are attending EAU20. The book will be introduced at the History Office at EAU20 (Saturday, 21 March) by both authors, with a launch and signing to follow at the EAU Exhibition afterwards. The rest of the Special Session will focus on urology topics related to the Netherlands, such as Dutch (proto-) urologists, the depiction of urological topics in Low Countries art, and the special relationship between Patrick Walsh and the Dutchman Pieter Donker. A special slot will be reserved for the 2020 winner of the Desnos Prize, an EAU Prize honouring contributions to the study of the history of urology.

A brief break in the History Office Board meeting means a chance to examine some instruments or discuss a few things one-on-one

Participants can also look forward to a dedicated History of Urology poster session, and of course the annual Historical Exhibition next to the EAU Booth. This year will feature unique objects related to urology in the Netherlands from the EAU’s and private collections.

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European Urology Focus proudly announces to be indexed in SCI and to receive an Impact factor in 2020! We would like to thank our Readers, Authors and Reviewers for helping to make EU Focus one of the most recognized journals in Urology.

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European Urology Today

Christian Gratzke, EiC On behalf of the Editorial Team

October/December 2019

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

Case study No. 63

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.

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

Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 62

The patient wanted treatment but was concerned about fertility. A sperm count was normal.

A 24-year-old Arabian man was referred with the diagnosis of Zinner syndrome for further treatment. Zinner syndrome is a rare congenital syndrome resulting from an abnormality of the Wolffian duct defined as the triad of unilateral renal agenesis , ipsilateral seminal vesicle cyst and ipsilateral obstruction of the ejaculatory duct. The patient complained of intermittent left lower abdominal pain which is compatible with the clinical picture of this syndrome. An MRI investigation (fig.1 a-c) led to the diagnosis. On all images, the left kidney was absent.

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

Figure 1 a-c

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

Complete abdominopelvic imaging preferably with MRI Comments by Prof. Guy Bogaert Leuven (BE)

Discussion points 1. Are further investigations needed? A complete abdominopelvic imaging, either by CT or by MRI should be performed to confirm the absence of the kidney and rule out an ectopic kidney. In addition, both imaging modalities are able to make 3-D simulation reconstructions of the seminal vesicles, as well as the prostate. If MRI is readily available, it should be preferred due to the superior ability to characterize the anatomic relationship of the seminal vesicle, the prostate and the bladder. 2. Are there other diagnoses that should be considered? Every urologist should have the reflex if he/ she would see a man in his 20-30s and find a seminal cyst, to look for a possible absent ipsilateral kidney, or an absent kidney to look for a seminal vesicle cyst, of course with the knowledge of the common embryology of the seminal vesicle and the ureteric bud from the mesonephric duct in the back of his/her mind.

Figure 1

In addition, a man in his 20-30s with non-specific symptoms, such as this patient with intermittent lower abdominal pain, urinary urgency, dysuria, ejaculation problems and or perineal discomfort, the urologist should have the reflex to perform a renal and pelvic ultrasound. Although there are other causes of pelvic cysts, prostate utriculus cysts, ejaculatory duct cysts, Müllerian remnants, bladder diverticula, ureterocoeles, if this is in association with an ipsilateral absent kidney, one should always think primarily of the Zinner syndrome, because it is a typical embryological anomaly.

3. What treatment would you advise? The management of a patient with the diagnosis of a Zinner syndrome should be mainly clinically oriented. In addition, it should be primarily minimal invasive especially of the symptoms are minimal and if the sperm count of the semen would be normal. Reconstruction is not possible. If the seminal cyst is large, there are no signs of infection and the cyst causes clinical complaints, it can be punctured, either transurethral or transperineal. To reduce the chance of recurrence, as in other cysts, instillation of a sclerotic agent or a doxycycline can also be performed. If this treatment fails, a more aggressive method, such as laparoscopic or robotic retrovesical resection of the seminal vesicle can be performed.

References 1. Pereira BJ, Sousa L, Azinhais P, Conceição P, Borges R, Leão R, et al. Zinner’s syndrome: An up-to-date review of the literature based on a clinical case. Andrologia 2009;41:322–30. doi:10.1111/j.1439-0272.2009.00939.x. 2. Florim S, Oliveira V, Rocha D. Zinner syndrome presenting with intermittent scrotal pain in a young man. Radiol Case Reports 2018;13:1224–7. doi:10.1016/j.radcr.2018.08.012.

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

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No need for further investigation Comments by Prof. Serdar Tekgül Ankara (TR)

I think there is no need for further investigation. The management should be symptoms oriented and should start from the most conservative. I would consider percuntanous or transurethral aspiration of the seminal vesicle cyst or transurethral aspiration combined with sclerosin substance instillation as the primary step Invasive treatment (seminal opening by transurethral resection of the ejaculatory duct or open, laparoscopic or robotic vesiculectomy) should follow in case the pain does not resolve. If the contralateral ejculatory system is properly preserved during the procedures fertility should be expected in the future.

October/December 2019

Case study No. 62 continued The diagnosis of Zinner’s syndrome had been based on the referring hospital and its assessment of the radiological features. As the patient was symptomatic we performed open surgery and resected the seminal right vesicle. In addition, we found a large intravesical cyst connected to an atrophic right ureter. The cyst was also resected and we interpreted this as a fairly large remnant ureterocele. Therefore, in hindsight we interpreted this not as a Zinner’s syndrome but as an atrophic right kidney with a remnant ureter and a persistent cystic ureterocele. However, this is somewhat hypothetical. The surgery was well tolerated and recovery uneventful.

Discussion point: • What treatment is advisable?

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European Urology Today

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

philip.cornford@ rlbuht.nhs.uk

Study explores the evidence base for national and regional policy interventions to combat resistance The effectiveness of existing policies to control antimicrobial resistance is not yet fully understood. A strengthened evidence base is needed to establish the effectivity of policy interventions across countries with different income levels and human health and animal sectors. The authors of this paper examine three policy domains—responsible use, surveillance, and infection prevention and control—and consider which will be the most effective at national and regional levels.

Global Health Security Officers call for a global surveillance system to secure accountability for control of antimicrobial resistance and improve between-country comparisons There are many complexities in the implementation of such policies across sectors and in varying political and regulatory environments. Therefore, the authors make recommendations for policy action, calling for comprehensive policy assessments, using standardised frameworks of cost-effectiveness and simplification. Such assessments are especially important in low-income and middle-income countries, and in the animal and environmental sectors. They also advocate a One Health approach that will enable the development of sensitive policies to accommodate the needs of each sector involved and addressing concerns of specific countries and regions. Several key messages from this study are relevant for urologists: • The effect of antimicrobial resistance policies seems to be variable. The absence of progress is partly due to an insufficient evidence base to inform policy makers • Stewardship programmes in secondary care can be effective in encouraging responsible use of antibiotics and should be scaled up. • Effective infection prevention and control interventions (IPCIs) can reduce the demand and need for antimicrobials, but evidence on appropriate IPCI strategies in low and middle income countries is inadequate. • Evidence of the most cost-effective systems for surveillance of antibiotic use and resistance remains weak worldwide. • A global surveillance system should be created to secure accountability regarding control of antimicrobial resistance and improve betweencountry comparisons.

Source: Exploring the evidence base for national and regional policy interventions to combat resistance. Osman A Dar, Rumina Hasan, Jørgen Schlundt, et all. Lancet 2016; 387: 285–95. Series: Antimicrobials: access and sustainable effectiveness. Published Online November 18, 2015. http://dx.doi. org/10.1016/S0140-6736(15)00520-6

Condition-specific surveillance in HCAUTI as a strategy to improve empirical antibiotic treatment Health care-associated urinary tract infection (HAUTI) consists of unique conditions (cystitis, pyelonephritis and urosepsis). These conditions could have different pathogen diversity and antibiotic resistance impacting on the empirical antibiotic choices. The aim of this Key articles

study was to compare the estimated chances of coverage of empirical antibiotics between clinical conditions (cystitis, pyelonephritis and urosepsis) in urology departments from Europe. A mathematical model based on antibiotic susceptibility data from a point prevalence study was used. Data from HAUTI patients were obtained from multiple urology departments in Europe from 2006 to 2017. The primary outcome of the study was the Bayesian weighted incidence syndromic antibiogram (WISCA) and Bayesian factor. Bayesian WISCA is the estimated chance of an antibiotic to cover the causative pathogens when used for first-line empirical treatment. Bayesian factor is used to compare if HAUTI conditions did or did not impact on empirical antibiotic choices.

Findings can improve empirical antibiotic selection towards a personalised approach… Bayesian WISCA of antibiotics in European urology departments from 2006 to 2017 ranged between 0.07 (cystitis, 2006, amoxicillin) to 0.89 (pyelonephritis, 2009, imipenem). Bayesian WISCA estimates were lowest in urosepsis. Clinical infective conditions had an impact on the Bayesian WISCA estimates (Bayesian factor > 3 in 81% of studied antibiotics). The main limitation of the study is the lack of local data. Investigators concluded that their estimates illustrate that antibiotic choices can be different between HAUTI conditions. Findings can improve empirical antibiotic selection towards a personalised approach but should be validated in local surveillance studies.

Source: Condition-specific surveillance in health care-associated urinary tract infections as a strategy to improve empirical antibiotic treatment: an epidemiological modelling study. Zafer Tandogdu, Bela Koves, Tommaso Cai, et all. World J Urol. 2019 Sep 25. doi: 10.1007/ s00345-019-02963-9. [Epub ahead of print] https://doi. org/10.1007/s00345-019-02963-9

Which PET scan for BCR after prostatectomy? Treatment of patients with biochemical recurrence of prostate cancer is guided by disease location and extent. Whole-body PET-CT imaging can depict increased L-amino-acid-transporter-1 (LAT1) activity with 18F-fluciclovine or overexpressed cell-surface proteins such as prostate-specific membrane antigen (PSMA) with 68Ga-PSMA-11. Both 18F-fluciclovine and PSMA PET-CT localise biochemical recurrence with higher detection rates and sensitivity than conventional imaging (e.g. CT, bone scanning and MRI) and choline PET-CT. However, these imaging tests have not been compared prospectively and directly. This paper presents a head-to-head comparison localising biochemical recurrence after radical prostatectomy in patients with a PSA < 2.0 ng/ml). This was a prospective, single-centre, open-label, single-arm comparative study done at the University of California, Los Angeles (US). Patients with prostate cancer biochemical recurrence after radical prostatectomy and PSA levels ranging from 0.2 to 2.0 ng/mL without any prior salvage therapies (including salvage radiotherapy or salvage lymph node dissection) and with a Karnofsky performance status of at least 50 were eligible. Patients underwent 18 F-fluciclovine (reference test) and PSMA (index test) PET-CT scans within 15 days. Patients were enrolled. Detection rate of biochemical recurrence at patient level and by anatomical region were primary endpoints. A statistical power analysis demonstrated that a sample size of 50 patients was needed to show a 22% difference in detection rates in favour of PSMA (test for superiority). Each PET scan was interpreted by three independent masked readers who were not involved in study design or data acquisition. Readers assessed the presence of prostate cancer (positive vs. negative) for five regions: prostate bed (T), pelvic lymph nodes (N), extrapelvic nodes (M1a), bone (M1b) or another organ (M1c). In cases of disagreement regions were assessed and a majority view was accepted.

The primary outcome was the detection rate (proportion of patients with PET-positive findings) of 18 F-fluciclovine (reference test) and PSMA PET-CT (index test) for the identification of tumour locations, at the patient level and by anatomical region. The secondary outcomes were detection rates of 18 F-fluciclovine and PSMA PET-CT stratified by PSA value (0.2–0.5 ng/mL vs. 0.51–1.0 ng/mL vs. 1.01–2.0 ng/mL); and the inter-reader agreement of 18 F-fluciclovine and PSMA PET-CT studies.

PSMA PET-CT detects biochemical recurrence sites at low PSA concentrations more frequently and with higher reader agreement than 18 F-fluciclovine PET-CT 143 patients were screened for eligibility, of whom 50 patients were enrolled into the study. Median follow-up was 8 months (IQR 7–9). Detection rates were significantly lower with 18F-fluciclovine PET-CT (13 [26%; 95% CI 15–40] of 50) than with PSMA PET-CT (28 [56%; 41–70] of 50), with an odds ratio (OR) of 4.8 (95% CI 1.6–19.2; p = 0.0026) at the patient level; in the sub analysis of the pelvic nodes region (four [8%; 2–19] with 18F-fluciclovine vs. 15 [30%; 18–45] with PSMA PET-CT; OR 12.0 [1.8–513.0], p = 0.0034); and in the sub analysis of any extra pelvic lesions (none [0%; 0–6] vs. eight [16%; 7–29]; p = 0.0078). Focal therapy (metastasis surgery and metastasis stereotactic body radiation therapy) was applied to PET-positive lesions in 15 (30%) of 50 patients, 30 (60%) patients received androgen deprivation therapy, and nine (18%) were managed with active surveillance. PSMA PET-CT detects biochemical recurrence sites at low PSA concentrations more frequently and with higher reader agreement than 18F-fluciclovine PET-CT. However, it is not yet clear if higher detection rates translate into improved oncological outcomes or just more treatment.

Source: 18F-fluciclovine PET-CT and 68Ga-PSMA-11 PET-CT in patients with early biochemical recurrence after prostatectomy: a prospective, single-centre, single arm, comparative imaging trial. Calais J, Ceci F, Eiber M, et al. Lancet Oncology.

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

tebj@medisin.uio.no metastasis and prostate cancer death, informed by models from the Scandinavian Prostate Cancer Group 4 trial, were projected under biopsy surveillance schedules ranging from watchful waiting (WW) to annual biopsies. Outcomes included the risk of metastasis, the risk of death, remaining life years (LYs), and quality adjusted LYs. Compared with WW, AS biopsies reduced the risk of prostate cancer metastasis and prostate cancer death at 20 years by 1.4% to 3.3% and 1.0% to 2.4%, respectively; and 5-year biopsies reduced the risk of metastasis and prostate cancer death by 1.0% to 2.4% and 0.6% to 1.6%, respectively. There was little difference between annual and 5-year biopsy schedules in terms of LYs (range of differences, 0.04-0.16 LYs) and quality adjusted LYs (range of differences, −0.02 to 0.09 quality-adjusted LYs). Increasing biopsy frequency offered benefits versus WW in terms of the downstream risks of metastasis and death, but there were only modest differences in LYs and QALYs between surveillance schedules that varied the biopsy interval from every 1 to 5 years. Furthermore, compared with 3-year and 4-year biopsy schedules, the marginal declines in the risk of metastasis and death for more frequent schedules were small relative to the mean increase in biopsies. Therefore, until validated tools are available for accurate risk stratification, determining the exact frequency with which to biopsy each patient should depend on patient-specific risk factors and personal preferences.

Source: Prostate cancer mortality and metastasis under different biopsy frequencies in north American active surveillance cohorts. Lange J, Laviana AA, Penson DF, et al. Cancer. 2019; DOI: 10.1002/cncr32557.

2019; 20: 1286-94.

How often should biopsy be performed in active surveillance? Active surveillance (AS) offers men with low-risk prostate cancer the opportunity to avoid treatments that may be unnecessary, while still offering curative treatment to those reclassifying as higher risk during surveillance.

…until validated tools are available … the exact frequency with which to biopsy each patient should depend on patient-specific risk factors and personal preferences Despite widespread acceptance, uncertainties remain regarding preferred strategies and their effects on long-term outcomes. Differences in AS protocols across existing cohorts present an opportunity to compare short-term outcomes. However, there is an absence of long-term clinical outcomes in existing AS cohorts.

Cabazitaxel, further novel antiandrogen: What should we use next? Four different classes of medical treatments have prolonged survival among patients with metastatic castration-resistant prostate cancer (mCRPC). However, the therapeutic landscape has shifted. Treatment with these life-extending therapies is increasingly used during earlier stages of disease, meaning many men have already developed resistance to treatment by the time they develop CRPC. It is thought that cabazitaxel retains activity in patients whose disease progressed while they were receiving docetaxel or androgensignalling–targeted inhibitors. Therefore, the CARD trial investigated whether cabazitaxel would be superior to an androgen-signalling–targeted inhibitor in patients who had previously been treated with docetaxel and the alternative androgen-signalling– targeted agent (abiraterone or enzalutamide).

This study confirms poor outcomes with a second androgen-signallingtargeted inhibitor

This study reports the results from a microsimulation model of the comparative downstream effects of different AS schedules, harnessing recent work on the underlying upgrading risk across 4 North American AS cohorts.

255 patients who had previously received docetaxel and who had disease progression within 12 months while they were receiving an androgen-signalling– targeted inhibitor (abiraterone or enzalutamide) were randomised in a 1:1 ratio to receive cabazitaxel (at a dose of 25 mg per square meter of body surface area This study projected the comparative benefits of intravenously every 3 weeks, plus prednisone daily and different AS schedules in men diagnosed with prostate granulocyte colony-stimulating factor) or the other cancer who had Gleason score (GS) ≤ 6 disease and androgen-signalling–targeted inhibitor (either 1,000 low or very low risk disease. Time to GS upgrading was mg of abiraterone plus prednisone daily or 160 mg of simulated based on AS data from the University of enzalutamide daily). The primary end point was Toronto (CA), Johns Hopkins University (US), the imaging-based progression-free survival. Secondary University of California at San Francisco (US), and the end points of survival, response, and safety were Canary Pass Active Surveillance Cohort. Times to assessed.

EAU EU-ACME Office

European Urology Today

October/December 2019

Prof. Oliver Reich Section editor Munich (DE)

Source: Pre-transplant dialysis modality and long-term patient and kidney allograft outcome: A 15-year retrospective single centre cohort study. Balzer MS, Pankow S, Claus R, Dumann E, Ruben S, Haller H, Einecke G. Transpl Int. 2019 Nov

noncarriers. Only 36% had had a previous PSA test. Overall prostate cancer detection rate was 3.8% (incidence rate per 1000 person years: 15). The cancer incidence rates were 19 and 12 in BRCA2 carriers and noncarriers, respectively (p = 0.031).

Dr. Francesco Sanguedolce Section editor Barcelona (ES)

9. doi: 10.1111/tri.13552. [Epub ahead of print]

oliver.reich@ klinikum-muenchen.de

After a median follow-up of 9.2 months, imagingbased progression or death was reported in 95 of 129 patients (73.6%) in the cabazitaxel group, as compared with 101 of 126 patients (80.2%) in the group that received an androgen-signalling– targeted inhibitor (HR, 0.54; 95% CI, 0.40 to 0.73; p < 0.001). The median imaging-based progressionfree survival was 8.0 months with cabazitaxel and 3.7 months with the androgen-signalling–targeted inhibitor. The median overall survival was 13.6 months with cabazitaxel and 11.0 months with the androgen-signalling–targeted inhibitor (HR for death, 0.64; 95% CI, 0.46 to 0.89; p = 0.008). The median progression-free survival was 4.4 months with cabazitaxel and 2.7 months with an androgensignalling–targeted inhibitor (HR for progression or death, 0.52; 95% CI, 0.40 to 0.68; p = 0.004). Adverse events of grade 3 or higher occurred in 56.3% of patients receiving cabazitaxel and in 52.4% of those receiving an androgen signalling–targeted inhibitor. No new safety signals were observed. This study confirms poor outcomes with a second androgen-signalling-targeted inhibitor. Although it should be noted the study population had all progressed relatively quickly before randomisation. It also shows clearly that cabazitaxel continues to be effective in this group of patients and should be the treatment of choice if patients remain fit enough to consider third-line therapy.

Source: Cabazitaxel versus abiraterone or enzalutamide in metastatic prostate cancer. De Wit R, de Bono J, Sternberg CN, et al. NEJM. 2019; DOI: 10.1056/NEJMoa1911206.

Pre-transplant dialysis modality and long-term patient and kidney allograft outcome Among factors determining long-term kidney allograft outcome, pre-transplant renal replacement therapy (RRT) is the most easily modifiable. Previous studies analysing RRT modality impact on patient and graft survival yielded conflicting results and are scarce, lack sufficient size and follow-up. The authors retrospectively studied patient and allograft survival together with allograft function and its decline in 2,277 allograft recipients during 2000-2014. Pre-transplant RRT modality ≥ 60days as grouped into 'no RRT' (n = 136), 'haemodialysis (HD)' (n = 1847), 'peritoneal dialysis (PD)' (n = 159), and 'HD + PD' (n = 135) was evaluated.

Urinary biomarkers for predicting allogenic graft function The aim of this study was to analyse the value of urine α- and π-GST in monitoring and predicting kidney graft function following transplantation. In addition, urine samples from corresponding organ donors were also analysed and compared with graft function after organ donation from brain-dead and living donors.

…authors suggest that in deceased donor kidney transplantation, evaluation of urinary α- and π-GST seems to predict .. impaired graft function Urine samples from brain-dead (n = 30) and living related (n = 50) donors and their corresponding recipients were analysed before and after kidney transplantation. Urine α- and π-GST values were measured. Kidney recipients were grouped into patients with acute graft rejection (AGR), calcineurin inhibitor toxicity (CNI), and delayed graft function (DGF) and compared to those with unimpaired graft function. Urinary π-GST revealed significant differences in deceased kidney donor recipients with episodes of AGR or DGF at day one after transplantation (p = 0.0023 and p = 0.036, respectively). High π-GST values at postoperative day 1 (cut-off: > 21.4 ng/mg urine creatinine (uCrea) or > 18.3 ng/mg uCrea for AGR or DGF, respectively) distinguished between rejection and no rejection (sensitivity, 100%; specificity, 66.6%) as well as between DGF and normal-functioning grafts (sensitivity, 100%; specificity, 62.6%). In living donor recipients, urine levels of α- and π-GST were about 10 times lower than in deceased donor recipients. In deceased donors with impaired graft function in corresponding recipients, urinary α- and π-GST were elevated. α-GST values > 33.97 ng/mg uCrea were indicative of AGR with a sensitivity and specificity of 77.7% and 100%, respectively. The authors suggest that in deceased donor kidney transplantation, evaluation of urinary α- and π-GST seems to predict different events that are associated with impaired graft function. This small study suggests a potential in these urinary biomarkers that should be further investigated.

Source: Urinary biomarkers α-GST and π-GST for evaluation and monitoring in living and deceased donor kidney grafts. Katou S, Globke B, Morgul MH, Vogel T, Struecker B, Otto NM, Reutzel-Selke A, Marksteiner M, Brockmann JG, Pascher A, Schmitz V. J Clin Med. 2019 Nov 7;8(11). pii: E1899. doi: 10.3390/jcm8111899.

Pre-transplant peritoneal dialysis is superior to pre-transplant hemodialysis regarding transplant outcomes A Kaplan-Meier analysis demonstrated superior 5-/10-/15-yr patient (93.0/81.8/73.1% vs. 86.2/71.6/49.8%), death-censored graft (90.8/85.4/71.5% vs. 84.4/75.2/63.2%), and 1-yr rejection-free graft survival (73.8 vs. 63.8%) in PD vs. HD patients. Adjusted Cox regression revealed 34.5% [1.5-56.5%] lower hazards of death, whereas death-censored graft loss was similar (HR=0.707 [0.469-1.064]) and rejection was less frequent (HR = 0.700 [0.508-0.965]). Allografts showed higher 1-/3-/5-yr estimated glomerular filtration rate (eGFR) in ‘PD’ vs. ‘HD’ groups. Living donation benefit for allograft function was most pronounced in the groups 'no RRT' and 'PD'. Functional allograft decline (eGFR slope) was lowest for 'PD'. This study shows that allograft recipients on pretransplant PD vs. HD demonstrated superior all-cause patient and rejection-free graft survival, along with better allograft function (eGFR). Key articles

October/December 2019

Prostate cancer screening in BRCA2 mutation carriers BRCA2 gene mutations are linked to a higher risk of prostate cancer with a relative risk ranging from 2 to 8-fold. Associations with this status and the aggressiveness of detected disease have also been reported. BRCA2 mutations at diagnosis may be considered as an independent predictor of poorer outcomes. The role of BRCA1 mutations remains unclear with a lower estimated relative risk of prostate cancer detection.

Despite several study limitations …, this study demonstrates that BRCA2 carriers (but not BRCA1 carriers) have a higher incidence of prostate cancer, with more aggressive characteristics….

fsangue@ hotmail.com

androgen-signalling-targeted inhibitor. The use of docetaxel or abiraterone in the context of metastatic hormone-sensitive disease was allowed. The primary endpoint was imaging-based progression-free survival No significant difference was reported regarding the which was defined as the time between randomisation BRCA1 status (14 and 11, p = 0.3). The positive predictive until objective tumour progression, progression of value of PSA > 3 ng/ml was superior in BRCA2 carriers bone lesions, or death. (31% versus 18% in BRCA2 noncarriers, p = 0.025). The biopsy compliance rate was higher in BRCA2 carriers A total of 255 patients was randomly assigned in a 1:1 compared with noncarriers (73% versus 60%). Median ratio. Median age was 70 years. The median duration age at biopsy was 60 and 64 years in BRCA2 carriers of treatment was longer in patients receiving and noncarriers, respectively. No differences were cabazitaxel compared with those receiving androgenreported when stratifying according to the BRCA1 signalling-targeted inhibitor (22 versus 12.5 weeks). status. Progression as defined by the primary endpoint occurred in 73.6% of patients receiving cabazitaxel Overall, 48 and 15 cancers were detected in BRCA2 versus 80.2% in the androgen-signalling-targeted carriers and noncarriers with more intermediate/high inhibitor cohort. Median survival increased from 3.7 to risk proportion in BRCA2 carriers (p = 0.011). No deaths 8.0 months in the cabazitaxel group with a treatment were reported. effect consistent across all prespecified subgroups. Median overall survival was 13.6 months in the This international prospective screening study shows cabazitaxel cohort compared with 11.0 months in the that a PSA-based screening may be more efficient in a androgen-signalling-targeted inhibitor cohort (HR restrictive population of males at high risk for prostate 0.68, p = 0.008). PSA response (decline > 50%) was cancer. In the subgroup of BRCA2 carriers, both PSA reported in 35.7% of patients receiving cabazitaxel and prostate biopsy exhibited higher positive predictive compared with 13.5% only in the androgen-signallingvalues for prostate cancer detection (using a threshold targeted inhibitor cohort (p < 0.001). of 3 ng/ml). These values were also superior to those reported in the Göteborg cohort (PSA screening in the Tumour response occurred in 37% of cabazitaxel cases, general population). versus 12% in the androgen-signalling-targeted inhibitor cohort (p = 0.004). The use of abiraterone or Despite several study limitations (biopsy compliance enzalutamide in the androgen-signalling-targeted rate affected by the mutational status, contamination inhibitor cohort did not modify the superiority of bias with previous PSA tests, short follow-up), this cabazitaxel for all endpoints. The incidence of serious study demonstrates that BRCA2 carriers (but not BRCA1 adverse effects was similar in both groups (38.8%). carriers) have a higher incidence of prostate cancer, However, the discontinuation linked to treatment was with more aggressive characteristics, at a younger age, more frequent with cabazitaxel (19.8% versus 8.9%) and represent the target population for a systematic although adverse events leading to death were less PSA screening. frequent in the cabazitaxel cohort (5.6% versus 11.3%). This difference may be related to more disease Source: Interim Results from the IMPACT Study: progression cases in the androgen-signalling-targeted Evidence for Prostate-Specific Antigen Screening inhibitor cohort. in BRCA2 Mutation carriers. Page EC et al. Eur Urol 2019 This trial shows the superiority of cabazitaxel over abiraterone/enzalutamide as third-line therapy in metastatic castration-resistant prostate cancer. At progression after docetaxel and androgen-signallingThird-line therapy in mCRPC: targeted inhibitor use, cabazitaxel should be offered in Cabazitaxel versus hormone patients fit for chemotherapy because of its benefits, which were proven based on strong oncologic therapy endpoints (imaging-based progression free survival, overall survival). This confirms the poor outcomes Several life-prolonging therapies are now available for obtained by a second androgen-signalling-targeted metastatic castration-resistant prostate cancer patients. inhibitor, which are mainly due to common These treatments are much more active when used mechanisms of resistance. Cabazitaxel results in a early, and no strong evidence supports the superiority reduced risk of death from any cause of 36% compared of one treatment sequence over another. The choice is with that obtained by an alternative androgenbetween chemotherapy (docetaxel, cabazitaxel) and signalling-targeted inhibitor. new generation hormone therapy (abiraterone, enzalutamide). Patients mainly receive docetaxel and Source: Cabazitaxel versus Abiraterone or enzalutamide/abiraterone as the first and second Enzalutamide in Metastatic Prostate Cancer. therapy lines. Until recently, in case of progression De Wit et al. NEJM 2019 after these two treatments, no high level of evidence study helped the physician to choose between Short-term androgen cabazitaxel or second androgen-signalling-targeted deprivation therapy combined inhibitor. In the CARD trial, the investigators have assessed the superiority of cabazitaxel over abiraterone/ enzalutamide as third-line therapy in patients who had previously been treated with docetaxel and the alternative second androgen-signalling-targeted inhibitor. Overall, 62 sites were involved in this multicentre, randomised, open-label, clinical trial across 13 European countries.

This trial shows the superiority

Thus, BRCA1/2 carriers may represent the ideal population for a PSA-based prostate cancer screening of cabazitaxel over abiraterone/ programme, given the current controversy of such enzalutamide as third-line therapy programmes in a more general population. The IMPACT study recruited men aged 40-69 years with in metastatic castration-resistant germline BRCA1/2 mutations and male controls testing prostate cancer negative for a familial BRCA1/2 mutation. Men underwent annual PSA testing for 3 years (four rounds) and a prostate biopsy in case of PSA > 3 ng/ml. A total All patients suffered from metastatic castrationresistant prostate cancer which had already been of 3,027 males were included: 919 BRCA1 carriers, 902 treated by 12-month chemotherapy (docetaxel) and BRCA2 carriers, 709 BRCA1 noncarriers, and 497

with radiotherapy as salvage treatment after radical prostatectomy for prostate cancer The use of short-term androgen deprivation therapy (ADT) concomitant to salvage radiotherapy after radical prostatectomy has been investigated in two randomised trials. The RTOG 9601 showed a better overall survival at 13 years when adding 2 years of bicalutamide to salvage radiotherapy (patients with true relapse and patients with detectable PSA after surgery). The GETUG-AFU 16 showed a 5-year progression-free survival improvement when using 6-month ADT but no improvement regarding overall survival. At the time of this first publication, metastatic progression could not be captured adequately. The present publication reports the updated results after a 10-year follow-up in a cohort of 743 men

EAU EU-ACME Office

European Urology Today

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com randomly assigned (1:1 ratio) between salvage radiotherapy and salvage radiotherapy with goserelin. The pelvis was irradiated (46 Gy) in men who did not undergo pelvic lymph node dissection. The primary endpoint was the progression-free survival defined by the time from randomisation to biological or clinical progression. Biological progression was defined by a PSA increase > 0.5 ng/ml above the nadir. Metastasisfree survival was assessed as a secondary endpoint. Any metastatic event outside the prostatic bed was considered as a metastatic relapse, including nodal relapse. Median dose to the prostate bed was 66 Gy for a 7-week regimen. Only 16% of patients received nodal pelvis irradiation. Median time to nadir was 9.4 months in the radiotherapy group compared with 3.0 months in the combined group. The progression-free survival rate at 5 years was higher in the radiotherapy plus goserelin group (80%) compared with that reported in the radiotherapy group (62%, p < 0.001). The 10-year rates were similarly different: 64% versus 49%, respectively (p < 0.001).

Concomitant androgen-deprivation therapy improves metastasis-free survival after salvage radiotherapy for post-radical prostatectomy PSA recurrence The 10-year metastasis-free survival rates were 75% and 69% in patients assigned to radiotherapy and to radiotherapy plus goserelin, respectively. The log-rank p value was 0.031 with a HR of 0.73.

prostate cancer (GETUG-AFU 16): a 112-month follow-up of a phase 3, randomised trial. Carrie et al. Lancet Oncol 2019

independent predictors for detrusor underactivity. The prediction model for detrusor underactivity consisting of these five factors showed satisfactory performance with a C statistic of 0.724.

Overactive bladder symptoms post rigid and flexible cystoscopy

The authors developed a prediction model for detrusor underactivity in male patients with nonneurogenic lower urinary tract symptoms. The model was based on five predictive factors, namely older age, smaller prostate volume, two symptoms (less urgency and weak stream) and lower maximum flow rate. The model helps estimate the probability of detrusor underactivity in clinical practice without an invasive pressure-flow study.

The aim of this paper is to evaluate overactive bladder (OAB) symptoms in patients undergoing diagnostic cystoscopy. Overall changes in the entire study population were assessed, as well as broken down into Source: A Prediction Model for Detrusor various subgroups.

Underactivity Based on Symptoms and Noninvasive Test Parameters in Men with Lower A prospective multi-centre study among 450 Urinary Tract Symptoms: An Analysis from a consecutive adults undergoing diagnostic cystoscopy Large Group of Patients Undergoing Pressure was conducted. OAB symptoms were evaluated with the validated eight-item OAB screening awareness tool Flow Studies. Namitome R, Takei M, Takahashi R, Kikutake C, Yokomizo A, Yamaguchi O, Eto M. (OAB-V8) immediately before and on days 1, 4, and 7 after cystoscopy. Patients were distinguished between being OAB negative and OAB-positive (< 8 and ≥ 8 sum-score, respectively). Average sum-scores and subdomains were evaluated.

OAB symptoms are common in patients undergoing cystoscopy Before cystoscopy, 44.7% of patients were screened OAB-positive and 55.3% OAB negative. Development of de-novo OAB was noticed in 16.8% of the patients with a negative screening, which declined to 8.1% on day 7 (p < 0.001). In patients who were OAB positive before cystoscopy, a decline of OAB positivity was noted during follow-up (p < 0.001). No statistically significant differences were noted when the patient group was broken down into gender (p = 0.92), age (p = 0.82) and type of cystoscope (rigid vs. flexible, p = 0.38). Average sum scores declined from 8.68 before cystoscopy to 6.9 during follow-up. Flexible cystoscopy was superior over rigid in four subdomains: uncomfortable urge to urinate (p = 0.04), sudden urge to urinate with little or no warning (p = 0.02), uncontrollable urge to urinate (p = 0.03), and urine loss associated with a strong desire to void (p = 0.009).

Post-hoc analyses were performed: low versus high-risk groups for progression-free survival, Gleason score, margins, PSA doubling time, seminal vesicle involvement for metastasis-free survival.

The authors conclude that OAB symptoms are common in patients undergoing cystoscopy. Cystoscopy itself can cause de-novo OAB-symptoms. Controversially, a decline of OAB symptoms was noted after cystoscopy when patients were screened OAB positive before Progression-free survival was improved by concomitant cystoscopy. Flexible scopes were superior in some goserelin in both low and high-risk groups. subdomains. Nevertheless, no difference in metastasis-free survival was reported between these two risk sub-groups. Source: Overactive bladder symptoms in patients undergoing rigid and flexible cystoscopy. Post-hoc analysis of metastasis-free survival showed no difference between treatment groups. Mortality rate Saratlija Novakovic Z, Puljak L, Sapunar D, Remzi was 12% in the radiotherapy plus goserelin group M, Fajkovic H, Resch I, Abufaraj M, Riedl C, versus 14% in the radiotherapy group. No difference Engelhardt P, Hübner W, Breinl E, Duvnjak M, was reported between both groups with regards to the Seklehner S. World J Urol. 2019 Nov 6. doi: 10.1007/ 10-year overall survival (85% versus 86%, p = 0.73). s00345-019-02993-3. [Epub ahead of print] The final analysis of this phase 3 trial confirms the benefit from adding short-term ADT to salvage radiotherapy in the context of PSA recurrence after radical prostatectomy. Advantages were seen in terms of progression-free survival and metastasis-free survival. However, the benefit was moderate regarding metastatic events, and all post-hoc analyses were negative. This could be explained by an insufficient follow-up with a low occurrence of events. Other limitations were the absence of centralised review for the baseline scans and the lack of systematic bone and CT scans during follow-up. Imaging was required at the time of recurrence but not regularly assessed thereafter. Metastatic events may have been underestimated. Unfortunately, given these results and contrary to the findings of the RTOG 9601 trial, we cannot stratify patients according to their PSA, Gleason score, or margin statuses, in order to identify those who could benefit most from this concomitant salvage strategy. A not negligible proportion of low-risk patients with favourable pathology could be overtreated by the addition of short-term ADT. Nevertheless, these GETUG-AFU 16 results confirm the efficacy of ADT plus radiotherapy in patients with more aggressive relapse, as evidenced in the RTOG trial. Finally, a longer follow-up approaching 15 or 20 years may be required to observe trends in overall survival outcomes between both groups.

Prediction model for detrusor underactivity in male LUTS The aim of this paper was to identify the symptoms and noninvasive test parameters associated with detrusor underactivity and to develop a prediction model for detrusor underactivity. The authors analysed the clinical data of male patients with lower urinary tract symptoms who underwent pressure flow studies.

The model helps estimate the probability of detrusor underactivity in clinical practice without an invasive pressure-flow study The investigators included 909 men who met the study criteria and whose data included an international prostate symptom score, free uroflowmetry, postvoiding residual urine volume, and prostate volume. Using these data, they examined the significant symptoms and noninvasive test parameters associated with detrusor underactivity and developed a prediction model.

454 (50%) of the 909 patients were classified as having detrusor underactivity. In a logistic regression Source: Short-term androgen deprivation therapy analysis, older age, smaller prostate volume, lower combined with radiotherapy as salvage urgency symptom score, higher weak stream symptom treatment after radical prostatectomy for score, and lower maximum flow rate were selected as Key articles

J Urol. 2019 Oct 24:101097JU0000000000000616. doi: 10.1097/JU.0000000000000616. [Epub ahead of print]

Association of concussion symptoms with testosterone levels and erectile dysfunction Small studies suggest that head trauma in men may be associated with low testosterone levels and sexual dysfunction through mechanisms that likely include hypopituitarism secondary to ischemic injury and pituitary axonal tract damage. Athletes in contact sports may be at risk for pituitary insufficiencies or erectile dysfunction (ED) because of the high number of head traumas experienced during their careers. Whether multiple symptomatic concussive events are associated with later indicators of low testosterone levels and ED is unknown. The authors aimed at exploring the associations between concussion symptom history and participantreported indicators of low testosterone levels and ED. This cross sectional study of former professional US-style football players was conducted from 2015 to 2017. Surveys on past football exposures, demographic factors, and current health conditions were sent via electronic and postal mail to participants within and outside of the United States. 3,506 (25.6%) of the 13,720 male former players eligible to enroll who were contacted, responded.

Source: Association of concussion symptoms with testosterone levels and erectile dysfunction in former professional US-style football players. Grashow R, Weisskopf MG, Miller KK, Nathan DM, Zafonte R, Speizer FE, Courtney TK, Baggish A, Taylor HA, Pascual-Leone A, Nadler LM, Roberts AL. JAMA Neurol. 2019 Aug 26. doi: 10.1001/ jamaneurol.2019.2664. [Epub ahead of print]

Definition of severity of stone disease in children using an objective scoring system Objective definition of the severity of stone disease in the kidney is essential to compare the outcome of PCNL treatment using different techniques in different patient groups. There are several scoring systems to define the clinical status of stone disease in the kidney to predict the outcome of PCNL in terms of stone-free status and complications. The management protocols and most innovative changes in paediatric stone disease have widely followed the adult stone disease literature, because there are few high-volume centres. Few patients are scattered around many centres and there has been limited interest. In the era of minimally invasive surgical treatment where interventions have been available for children, there is no predictive tool developed for this age group. Previously, doctors tried to adapt adult systems. However, because children are not merely ‘small human beings’, size always matters in children. Patient size, instrument size and stone size should be taken into consideration when PCNL is being planned in a child. A 2 cm stone in a 2-year old baby (with a 65 mm longitudinal renal length) corresponds to a 4 cm stone in an adult and a 20F working sheath (measuring 32 mm2) corresponds to a 40F (measuring 135 mm2) borehole in the renal parenchyma. Therefore, adult predictive tools are not fit for kids.

…the definition of the complexity of paediatric stone disease requires a different perspective including the size of the stone relative to the size of the kidney

A 1 cm stone in a small kidney of a 2-year”-old baby corresponds to more than twice as much stone burden Concussion symptom score was calculated by summing in an adult kidney. Therefore, the definition of the up the frequency with which participants reported 10 complexity of paediatric stone disease requires a symptoms, such as loss of consciousness, different perspective including the size of the stone disorientation, nausea, memory problems, and relative to the size of the kidney. dizziness, at the time of the football-related head injury. Self-reported recommendations or prescriptions The authors of this manuscript evaluated the factors affecting the stone-free and complication for low testosterone or ED medication served as indicators for testosterone insufficiency and ED. rates of PCNL in 434 paediatric renal units. They found the number of stones and the stone-kidneysize index (longitudinal length of stone/ Models adjusted for demographic longitudinal kidney size) as predictive factors in multivariate analysis. They developed a score characteristics, football exposures, size score) by using these two and current health factors showed a (stone-kidney parameters (the points were assigned in such a significant monotonically increasing way that high points meant unfavourable outcomes (2 points for multiple stones, 1 for a association of concussion symptom single stone, 2 for the SKI > 0.3 and 1 for the SKI < score with the odds of reporting the 0.3)]. The sum of these points resulted into three groups (2, 3 and 4) that successfully discriminate low testosterone indicator the stone-free and complication rates. In 3,409 former players (mean [SD] age, 52.5 [14.1] years), the prevalence of indicators of low testosterone levels and ED was 18.3% and 22.7%, respectively. The odds of reporting low testosterone levels or ED indicators were elevated for previously established risk factors (e.g. diabetes, sleep apnea, and mood disorders). Models adjusted for demographic characteristics, football exposures, and current health factors showed a significant monotonically increasing association of concussion symptom score with the odds of reporting the low testosterone indicator (highest vs. lowest quartile, odds ratio 2.39; 95% CI, 1.79-3.19; p < .001). The ED indicator showed a similar association. Concussion symptoms at the time of injury of former football players were associated with current participant-reported low testosterone levels and ED indicators. These findings suggest that men with a history of head injury may benefit from discussions with their health care clinicians regarding testosterone deficiency and sexual dysfunction.

This study brings new insight into paediatric stone disease using a simple scoring system which considers the kidney size. The system has been shown to be a reliable tool in predicting the outcome and complications. Furthermore, the study takes stone and kidney sizes into consideration which are important for the paediatric age group. Also, the authors claim that the presented SKS score is simple to apply since the other scoring systems are complex for daily practice and require multiple parameters (The S.T.O.N.E system requires five variables based on tomography findings, the CROES system requires six variables and the GSS four variables). Of course, external validation studies on larger groups are required to make a stronger conclusion.

Source: A new simple scoring system for prediction of success and complication rates in pediatric percutaneous nephrolithotomy: stone-kidney size score. Çitamak B, Dogan HS,

EAU EU-ACME Office

European Urology Today

October/December 2019

Prof. Oliver Hakenberg Section Editor Rostock (DE)

Is it always necessary to detect a kidney stone with CT scan?

Oliver.Hakenberg@ med.uni-rostock.de

The non-contrast enhanced CT scan (NCCT) is the gold standard for the diagnosis of renal and ureteric stones in the setting of patients attending the emergency department for suspected renal colic. It is also very useful for treatment planning.

Ceylan T, Hazir B, Bilen CY, Sahin A, Tekgül S. J Pediatr Urol. 2019 Feb;15(1):67.e1-67.e6. doi: 10.1016/j. jpurol.2018.09.019. Epub 2018 Oct 10. PubMed PMID: 30392887.

Urothelial cell carcinoma in children Urothelial cell carcinoma (UCC) of the bladder is exceedingly rare in paediatric patients. There is little data available about its natural history and management. Risk factors for UCC in paediatric patients may include early tobacco exposure, contact with environmental toxins, cancer predisposing syndromes (e.g. Costello syndrome), congenital abnormal bladder and parasitic infections. Common symptoms at presentation include haematuria, dysuria, urinary urgency, and frequency; or an incidental laesion may be identified during unrelated imaging. One hundred two articles describing 243 patients with an average age of 12.5 from 26 countries have been reviewed in this paper. Of those patients 32.6% were female, 15.3% had medical comorbidities, and 13.2% had known risk factors for bladder cancer. Initial management was transurethral resection in 95.5% of patients, whereas 6.2% required secondary intervention. Tumour stage was TaN0M0 in 86.4% and low grade in 93.4%. Recurrence and death occurred in 8.6% and 3.7%, respectively. Mean time to recurrence or death was 8.6 months (standard deviation [SD] 7.6) for 10.7%. Mean disease-free follow-up without recurrence or death was 56.9 months (SD 54.2) for 89.3%.

Despite more benign presentation and natural history, paediatric urothelial cell carcinoma patients also require a systematic follow-up for the first 3 years… Unlike in adults, the majority (86.8%) of paediatric patients identified in the review had no known risk factors for UCC. They mostly present as superficial bladder tumours with low grade. Isolated, painless, gross haematuria was the most common presenting symptom among paediatric patients diagnosed with UCC (approximately 75%). Transurethral resection of the bladder tumour is the mainstay of treatment for paediatric UCC and has been performed for initial management in more than 95% of reported cases. The modality of surveillance differed across studies, with most methods consisting of a combination of renal/bladder ultrasound, cytology and cystoscopy at 3-6 month intervals. Despite more benign presentation and natural history, paediatric urothelial cell carcinoma patients also require a systematic follow-up for the first 3 years and less aggressive surveillance afterwards. Disease recurrence or death occurred in 10.7% and within 9 months for most of the patients and within 32 months for all patients. This may suggest that low-grade and stage UCC of the bladder in paediatric patients can be systematically monitored with renal/ bladder ultrasound and cystoscopy for at least 3 years. Less aggressive surveillance may prevent unwarranted procedures and anaesthesia events after this time period.

Source: Urothelial cell carcinoma of the bladder in pediatric patients: a systematic review and data analysis of the world literature. Rezaee ME, Dunaway CM, Baker ML, Penna FJ, Chavez DR. J Pediatr Urol. 2019 Aug;15(4):309-314. doi:10.1016/j.jpurol.2019.06.013. Epub 2019 Jun 22. Review. PubMed PMID: 31326327.

Key articles

October/December 2019

Typically, this is a patient with haematuria and/or a persistent positive cytology of unknown origin, regardless negative standard cystoscopy and urography CT scan.

Photodynamic diagnosis (PDD) and narrow-binding imaging (NBI) have been the most recommended imaging techniques to enhance detection of non/ poorly visible lesions in white light (WL): while the former involves the instillation of the bladder with hexaminolevulinate - a precursor in the formation of However, it implies a significant exposure of radiations the photoactive intermediate protoporphyrin IX for patients, especially considering that low-dose (PpIX) that is reported to accumulate preferentially radiation protocols for CT scans are poorly applied. in neoplastic cells as compared to normal Facilities at the urgency sites may vary considerably urothelium - which eventually reacts with blue light, from place to place and burden of costs and time the latter uses a special wavelength light that should always be taken in consideration. An alternative enhances vascular contrast. However, the two to CT scans is the ultrasound scan, which is an modalities cannot be used in parallel and the operator-dependant tool, which can be performed at imaging systems allow for a switch to another mode the urgency site (point of care ultrasound - POCUS) or during a cystoscopy intervention. by a radiologist (radiology performed ultrasound – RPUS) if available at the urgency site. In case the Some German authors have recently worked on a former only provides information about the presence of prototype that will be able to combine WL, PDD and a hydronephrosis, the latter may provide more precise NBI with two other less known light modes information regarding the actual stone size, site and (autofluorescence and protoporphyrin IX number. Fluorescence) derived from the PDD technology. All the imaging modalities can be seen in parallel and Abdomen X-ray may be complementary to US scan, merged into one final vision during the procedure, in especially in the case of radiopaque stones. order to increase the detection rate of malignant lesions. To shed some more light on the actual need of NCCT for suspicious renal colic, a systematic review of literature was performed, preliminarily to a consensus Six different imaging modalities were meeting attended by three representatives of the American College of Emergency Physicians, American visualised in parallel and in realCollege of Radiology and of the American Urological time to increase the detection rate of Associations.

malignant lesions

... the emergency care pathway including CT scan as initial imaging tool for suspicious renal colic may generally be deemed not necessary

The results of a preliminary study have been published as a video article in which the technical aspects of the multiparametric cystoscopy (mpC) were discussed. 31 suspicious lesions were scanned with 27 resulting in Ta Low Grade in 22, CIS in 2, High Grade in 2 and muscle-invasive in 1 case. The 6 mpC The results of the systematic review highlighted that: sequences of the 27 lesions were mixed and reviewed 1) RPUS is superior to POCUS, although the sensitivity by two urologist readers independently, blinded to may vary significantly, also in this case; the authors the histology results, and for each of the suspicious found that RPUS could be more advantageous in lesion a score of likelihood for bladder cancer was the setting of young patients with lower BMI; assigned. 2) As expected, the need for a subsequent CT scan was less likely after a RPUS compared to POCUS The modality visualisation merging the 5 sequences (27% vs. 41%); resulted to be the only one consistently raising 3) More interestingly, the rate of misdiagnosis (e.g. suspicion on the malignancy of the lesions, while the appendicitis) requiring return to the emergency WL and autofluorescence imaging modalities had a department was not different by comparing the higher chance to miss a lesion, especially in the case three imaging modalities, suggesting that of flat lesions. performing US only for suspicious renal colic is safe in the acute setting management; There are some limitations in the study. Apart from 4) Overall, the risk of ‘alternative findings’ accounted the low number of cases, the recorded images only for < 5% even by CT, with no difference in high-risk dealt with proven lesions. Therefore, we do not yet diagnosis based on initial imaging modality. know how the different imaging modalities work in case of benign suspicious lesions. Moreover, no data Overall, the emergency care pathway including CT scan of inter-reader variability were provided, so that we as initial imaging tool for suspicious renal colic may do not know how subjective the interpretation of the generally be deemed not necessary. However, images is. Nevertheless, multiparametric cystoscopy according to the consensus meeting applying a Delphi is a promising new imaging modality that may help process/methodology to 29 different clinical scenarios, the recognition of tumour lesions even in the most the authors identified agreement in the following challenging circumstances. setting: CT scan can be safely omitted in young or middle-age patients with suggestive symptoms, Source: Multiparametric Cystoscopy for Detection especially in case of past medical history of urolithiasis. of Bladder Cancer Using Real-time Multispectral On the other hand, CT scan should be indicated as a Imaging. Kriegmair MC, Rother J, Grychtol B, triage test in older patients for the higher chances of Theuring M, Ritter M, Günes C, Michel MS, high-risk diagnosis/alternative findings. Deliolanis NC, Bolenz C. Eur Urol. 2019 Sep 26. pii: S0302-2838(19)30674-8. doi: 10.1016/j. Finally, RPUS is to be preferred in case of pregnant eururo.2019.08.024. [Epub ahead of print] women or paediatric patients, although this practice is already accepted everywhere.

Source: Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. Moore CL, Carpenter CR, Heilbrun ML, Klauer K, Krambeck AC, Moreno C, Remer EM, Scales C, Shaw MM, Sternberg KM. J Urol. 2019 Sep;202(3):475-483. doi: 10.1097/JU.0000000000000342. Epub 2019 Aug 8.

Does multiparametric cystoscopy become the new standard - the multiparametric saga continues A patient with a suspicion of bladder cancer poorly visible on the standard cystoscopy may become a nightmare for both the patient and the urologist.

Salvage robotic-assisted radical prostatectomy vs. focal therapy: outcomes may vary Focal therapy (FT) is an emerging treatment option for patients with localised prostate cancer. In highvolume/highly skilled centres it may be offered as an alternative to radical treatments, especially in patients particularly motivated to have less chance to compromise their functional outcomes. Failure of FT may be managed with either re-treatment – including focal or whole gland re-ablation - or a salvage radical approach, such as external beam radiotherapy (EBRT) or radical prostatectomy. While the first option is considered by some practitioners as part of the same focal treatment management, the

Prof. Serdar Tekgül Section Editor Ankara (TR)

serdartekgul@ gmail.com

latter is commonly preferred especially in the setting of high-risk patients. Nevertheless, there are unclear definitions of clinical/pathological features that should prompt one option (re-treatment) or the other (salvage radical). Biochemical recurrence (BCR) after EBRT can also be managed with different approaches, which include focal/whole gland ablation versus radical prostatectomy, depending on the willingness of the patients to be exposed to less toxicity at the cost of a poorer oncological control.

Salvage RARP provides better functional outcomes in case of salvage treatment after focal therapy failure, with no difference of BCR at 5-years In both cases, i.e. after primary failure of FT or EBRT, radical prostatectomy is the less common option, accounting for as low as 3% of the published cohorts, because of the higher risk of complication and technical challenges. Salvage robotic-assisted radical prostatectomy (sRARP) has been proposed as the best approach to minimise the risk of toxicity. A recent publication reported the outcomes from a single-surgeon cohort of 126 patients (out of an overall of > 11,500 RARP) undergoing sRARP after EBRT (n = 94, 74.6%) and FT (n = 32, 25.4%), with cryotherapy being the most common ablation source (n = 20, 62.5%). No differences in terms of operative complication rates – both intra and post-operative - were reported, and no patient experienced a rectal fistula. Salvage RARP provides better functional outcomes in case of salvage treatment after focal therapy failure, with no difference of BCR at 5-years. On the other hand, oncological and functional outcomes differed substantially between the two groups. With respect to the former, positive surgical margins were more common in the sRARP after FT (43.8 vs. 17%, p = 0.004), as well as a higher proportion of extracapsular extension (71 vs. 50%, p = 0.042). The authors explained these poorer results of the sRARP post-FT by a selection bias, consisting of the likelihood of patients to undergo sRARP because of more aggressive features. On the other hand, similar objections may be applied to the sRARP post-RT patients, as those with less aggressive features may have been selected for salvage ablation treatment. Nevertheless, BCR at 5 years is similar in both groups (59 vs. 56%, p = 0.76). With respect to the functional outcomes, sRARP after FT showed better results, especially for ‘de novo’ severe incontinence which was significantly more common in the sRARP post-RT (47.9 vs. 9.4%, p = 0.001). Interestingly, a higher proportion of this latter group of patients experienced post-operative leakage and longer catheterisation; these factors could have contributed to the poorer result. Even though a nerve-sparing approach was performed more frequently in post-RT patients, the recovery of potency was observed in a higher proportion of patients receiving sRARP post FT, although the rates did not differ significantly. Overall, sRARP is a safe and feasible salvage treatment option in experienced hands, providing different outcome profiles according to the type of primary treatment.

Source: Comparison of outcomes of salvage robot-assisted laparoscopic prostatectomy for post-primary radiation vs focal therapy. Onol FF, Bhat S, Moschovas M, Rogers T, Ganapathi H, Roof S, Rocco B, Patel V. BJU Int. 2019 Aug 20. doi: 10.1111/bju.14900. [Epub ahead of print]

EAU EU-ACME Office

European Urology Today

Treatment of OAB in the elderly population The frequently forgotten 'geriatric giant': An ongoing challenge Prof. Frank Van Der Aa Dept. of Urology UZ Leuven Leuven (BE)

frank.vanderaa@ uz.kuleuven.ac.be Doctors will be confronted with frequency, urgency and urinary incontinence more and more. The prevalence of overactive bladder disease increases with age. In an ageing population, as it is the case almost globally, the above-mentioned problems will therefore become increasingly important. Especially urinary incontinence has a major impact on the quality of life of elderly people. Apart from its social and psychological impact, urinary incontinence in elderly is also related to falls, as a substantial number of falls happen when people go to the toilet. Nevertheless, up to half of the elderly are not adequately diagnosed, probably due to embarrassment, lack of knowledge about the condition and its treatment and due to the belief that incontinence is an inevitable part of ageing. Urinary incontinence is often called the ‘frequently forgotten geriatric giant’1. Elderly patients should however have the same treatment options as younger patients. An understudied problem Elderly people are insufficiently represented in clinical trials for several reasons. Only few trials explicitly recruit older patients. Exclusion criteria such as comorbidities and complications are often present, excluding elderly again. Physicians do not easily recruit patients for trials and, last but not least, there are patient-related barriers in elderly, such as logistical issues2.

darifenacin versus placebo sponsored by Novartis3. The mean age of the patients was 72 and 35% of patients was older than 75. Three quarters of the patients were women. This trial did not show a significant difference in the primary outcome: median reduction in urgency urinary incontinence episodes per week from baseline at week 12, mainly due to a very large placebo effect. In the responder analysis some significant effects were found. A higher number of patients achieved 3 and 7 consecutive dry days in the darifenacin group, and a greater proportion of patients achieved normalisation of micturition frequency. Side effects included mainly dry mouth and constipation. In the Sofia trial, 794 patients were included in a double blind randomised study of fesoterodine versus placebo sponsored by Pfizer4. The mean age of patients was 73 and 33% of patients was older than 75. At 12 weeks, a significant improvement from baseline in urgency episodes per day was found in the treatment group. Again, an important placebo effect was found. The most important side effect was dry mouth.

“Elderly people are insufficiently represented in clinical trials” A third trial of antimuscarinics treatment for the elderly was the vulnerable elderly trial, which included 562 patients with urgency incontinence. It compared fesoterodine versus placebo in a randomised double-blind controlled study sponsored by Pfizer5. The mean age of the included patients was 75 and half of the patient was older than 75. 82% of patients were women. At 12 weeks, a significant improvement from baseline urgency episodes per day was found in the treatment group, next to an important placebo effect. Dry mouth and constipation were noted as the most important side effects.

Clinical importance Conservative measures Although both studies (Sofia trial and vulnerable Prior to starting medical treatment, conservative and elderly trial) show a significant improvement in behavioural measures should be implemented. primary endpoint, the clinical importance of the small difference can be questioned when comparing Caffeine intake reduction, bladder training and timed or prompted voiding can have a positive impact on the means/medians. In the responder analysis, the patient’s OAB complaints and on his/her quality of life. treatment group showed significantly better dry rates and two-point improvement rates in the PPBC scale. The evidence In both trials, half of the patients opted for dose To date, 3 randomised controlled trials have explicitly escalation within the trial protocol. studied the use of anticholinergics in the elderly. Chapple et al. reported on 399 patients in a Both studies did include older patients. In the randomised double-blind controlled trial of vulnerable elderly trial, a large group had indeed multiple comorbidities. In both trials, all patients had a Mini-Mental State (MMS) of at least 20. No impact EAU Section of Female and Functional Urology of anticholinergic treatment on MMS was observed. It

is unclear whether the MMS is an adequate tool to investigate the cognitive effects of medical treatment. Probably, a more detailed analysis of cognitive functioning is necessary to appreciate the effect of antimuscarinics on the cognition of elderly. By using the Cognitive Drug Research (CDR) computerised assessment system (which includes multiple tasks addressing different aspects of cognitive functioning) in the SENIOR study, Wagg et al. already addressed this issue during short-term medical treatment with antimuscarinics.

Conclusion Overactive bladder in the elderly population should be more actively detected and treated. Prior to starting medical treatment, a ‘head to toe’ evaluation and a PVR measure should be performed. Lifestyle measures should be advised and reversible causes of OAB should be treated (“reverse what is reversible”). When medical treatment is started, start with low dose treatment and pay attention to side effects. References

In summary, anticholinergic treatment in elderly people shows that the treatment arm has a higher effect than placebo, at the cost of slightly higher complication rates. All trials have a high placebo response. Although there are currently no indications for severe cognitive impact of antimuscarinics on elderly, caution is required since in-depth testing of cognitive function in the long run has not yet been performed6. Anticholinergic burden Many elderly people take medication with antimuscarinic side effects, such as dry mouth, constipation, blurred vision and cognitive impairment and decline. Adding antimuscarinics for OAB to the treatment increases these side effects. In patients with a high anticholinergic burden the effectivity of add-on anticholinergics is not clear7. Therefore, prescribing anticholinergics to an elderly patient should be preceded by a quick ‘head to toe’ evaluation of that patient. The physician should perform a general assessment and should also exclude reversible causes of OAB, such as drug intake (diuretics, antipsychotics,…), constipation and vaginal atrophy in women. Furthermore, the anticholinergic burden should be estimated (www.agingbraincare.org )8. Post-void residual volume (PVR) Elderly people have a high prevalence of bladder emptying disorders. A high PVR is often not detectable on clinical examination. Therefore, ultrasound assessment of PVR is an important prequisite to start antimuscarinic treatment in elderly9. Other medication In a post-hoc analysis of older people based on several RCTs of mirabegron versus tolterodin versus placebo, a small but significant change in UUI episodes per week was found in the mirabegron group. The mean age of the included patients was 59 and 11% was older than 75. 70% were women. The most frequently reported side effects were arterial hypertension and urinary tract infections10.

1. Aharony L, De Cock J, Nuotio MS, et al. Consensus document on the management of urinary incontinence in older people. Eur Geriatr Med. 2017;8(3):210-215. doi:10.1016/j.eurger.2017.04.002 2. Kistler KD, Xu Y, Zou KH, Ntanios F, Chapman DS, Luo X. Systematic literature review of clinical trials evaluating pharmacotherapy for overactive bladder in elderly patients: An assessment of trial quality. Neurourol Urodyn. 2017;(January):1-13. doi:10.1002/nau.23309 3. Chapple C, DuBeau C, Ebinger U, Rekeda L, Viegas A. Darifenacin treatment of patients (greater-than or equal to) 65 years with overactive bladder: Results of a randomized, controlled, 12-week trial. Curr Med Res Opin. 2007;23(September):2347-2358. doi:10.1185/03007X226294 4. Wagg A, Khullar V, Marschall-Kehrel D, et al. Flexibledose fesoterodine in elderly adults with overactive bladder: Results of the randomized, double-blind, placebo-controlled study of fesoterodine in an aging population trial. J Am Geriatr Soc. 2013;61(2):185-193. doi:10.1111/jgs.12088 5. Dubeau CE, Kraus SR, Griebling TL, et al. Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: A double-blind, placebo controlled trial. J Urol. 2014;191(2):395-404. doi:10.1016/j.juro.2013.08.027 6. Wagg A, Dale M, Tretter R, Stow B, Compion G. Randomised, multicentre, placebo-controlled, double-blind crossover study investigating the effect of solifenacin and oxybutynin in elderly people with mild cognitive impairment: the SENIOR study. Eur Urol. 2013;64(1):74-81. doi:10.1016/j.eururo.2013.01.002 7. Macdiarmid SA. Concomitant Medications and Possible Side Effects of Antimuscarinic Agents. Rev Urol. 2008;10(2):92-98. 8. Ouslander JG. Geriatric urinary incontinence – Reflections on a EUGMS consensus update. Eur Geriatr Med. 2017;8(3):197-199. doi:10.1016/j.eurger.2017.03.011 9. Wagg A, Gibson W, Ostaszkiewicz J, et al. Urinary Incontinence in Frail Elderly Persons: Report From the 5th International Consultation on Incontinence Adrian. Neurourol Urodyn. 2015;34:398-406. doi:10.1002/nau 10. Wagg A, Cardozo L, Nitti VW, et al. The efficacy and tolerability of the ??3-adrenoceptor agonist mirabegron for the treatment of symptoms of overactive bladder in older patients. Age Ageing. 2014;43(5):666-675. doi:10.1093/ageing/afu017

How well do you know the EAU Guidelines? Do you consider yourself an EAU Guidelines expert? Show off your skills at the EAU Guidelines Cup set to take place during the YUORday at the upcoming EAU Annual Congress in Amsterdam. You could be named champion! What is the EAU Guidelines Cup? The EAU Guidelines Cup is a competition which will determine which EAU junior members know the EAU Guidelines the best. The Cup will consist of three rounds. The first and second rounds will be online and consist of multiple-choice questions. The top three participants from the second round will compete during the live finale during YUORDay20 on 21 March 2020. How to participate Here’s how you can join the Guidelines Cup in 3 easy steps: 1. Look out for your invitation to join the Cup. In the week of 13 January 2020 you will receive an email from the EAU with a personalised link. 2. Click on the link to enter the online quiz. 3. Answer the questions the best and fastest you can. You will receive immediate feedback on how many answers you got correct.

European Urology Today

If you are one of the top scorers of the first round, you will receive an invitation to participate in the second round. Let the games begin!

The second prize winner of the EAU Guidelines Cup will have the privilege to choose from a selection of comprehensive masterclasses organised by the European School of Urology. The masterclasses include the following:

The finale The three best participants of the second online round • ESU-ESUT Masterclass on Operative management will receive a free registration for EAU20 and will be of Benign Prostatic Obstruction invited to compete for the title of the Guidelines Cup champion on stage during YUORday. The contestant • ESU-ESUT Masterclass on Lasers in Urology with the most right answers and the quickest • ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer responses will be crowned as winner. • ESU-Weill Cornell Masterclass in General urology • ESU-ESUT Masterclass on Urolithiasis The audience can anonymously compete as well via voting pads. Bring your friends and supporters along, where they can both cheer for you and test their knowledge at the same time. From time to time, multiple choice questions will be posted on the EAU's Instagram. Follow @uroweb and use these questions to help train for the competition. Prizes to win The prize for the third place is the four-volume set of Campbell-Walsh Urology (11th edition). This series features 22 new chapters with an increased focus on robotic surgery and image-guided diagnostics. Easy online access to 130 video clips is also included.

The champion of the EAU Guidelines Cup will receive an Apple Watch, sponsored by Boston Scientific. The audience member with the highest score will receive free travel and accommodation during the URO Berlin Skills Teaching and Training (UROBESTT), a programme of the European School of Urology designed to expand the capabilities of young, promising urologists. You could be this year’s EAU Guidelines Cup champion. Are you up for the challenge?

Join the Guidelines Cup Young urologist, how well do you know the EAU Guidelines? Finale: YUORday at EAU20 Amsterdam, 21 March 2020

Win an Apple Watch!

October/December 2019

Men's knowledge of the prostate startlingly low Survey assesses knowledge of the prostate in 3,010 men over 50 years old in Europe How much does the average man know about Benign Prostatic Enlargement (BPE)? Why do you actually need the prostate and what is its function? The theme of Urology Week, which was held from Monday 23 September to Friday 27 September 2019, was based on these two questions. Survey To kick off Urology Week, the EAU (in collaboration with Boston Scientific) conducted an international survey to test men’s knowledge of the prostate. The results of the survey were startling. The survey, which assessed knowledge of the prostate in 3,010 men over 50 years old in the United Kingdom, Germany, and France, found that just one in four men (26%) are able to correctly identify the

prostate’s main function. Many respondents assumed that enlarged prostate and its symptoms are a normal aspect of the ageing process. Commenting on these findings, urologist Professor Hein Van Poppel, Adjunct Secretary General of the EAU, explains, “The results are worrying, especially as the survey targeted men in the age group that are most likely to suffer from prostate-related conditions, such as prostate cancer and an enlarged prostate. The incidence of these conditions and their impact on medical practice is only going to become greater due to the ageing population, so we must ensure that men are well informed to enable quick consultation and treatment if required.” The complete findings Attendees of the Symposium on Interdisciplinary treatment of Urological Diseases, hosted by the Urological Section of the were made available via press releases in eight Serbian Medical Association languages on www.urologyweek.org.

Here is a complete list of all events that were organised for Urology Week 2019:

Campaign posters To help raise awareness for BPE and what can be done to treat the disorder, the EAU created a series of campaign posters with various messages about the prostate. In addition to them being in English, they were also produced in nine other European languages: German, Dutch, Spanish, French, Italian, Bulgarian, Maltese, Polish, and Turkish.

Activities High levels of enthusiasm and creativity were demonstrated in the number and variety of events which were designed and hosted for Urology Week. Symposiums, open clinics, marathons, free health screenings, festivals, expositions and press conferences were among the 17 various activities which were hosted in Cyprus, Czech Republic, Greece, the Netherlands, Poland, Serbia, Switzerland, Turkey and Ukraine.

Name event Modern Technologies in Urology 2019 Symposium “Interdisciplinary treatment of Urological Diseases” Bridge-to-Bridge run for Urology Week Exposition: Les cancers urologiques chez l’homme Sanprobi UroRun 2019 Rajd rowerowy III UroRajd Football competition for children Prevention is the first step towards health Campaign for prostate diseases prevention: radio & television Urology Week PSA exams Urology Week 2019 in Kołobrzeg Prostate cancer A-Z Cyprus Urological Association scientific meeting Festiwal KultURO Screening Day Prostate Cancer and Benign Prostatic Obstruction presentation (URO)logical steps to health UroBike '19

Date 13-14 September 2019 13-15 September 2019

City Country Lviv-Truskavets Ukraine Bor Lake Serbia

15 September 2019 20 September 2019 17 March 2020 21 September 2019 21 September 2019 22 September 2019 23-27 September 2019 23-27 September 2019

Arnhem Lausanne

The Netherlands Switzerland

Szczecin Bolestraszyce Ceglana Belgrade Athens

Poland Poland Poland Serbia Greece

23-27 September 2019 23-27 September 2019 23-27 September 2019

Athens Kolobrzeg

Greece Poland Cyprus

23-28 September 2019 24 September 2019 25 September 2019

Krakow Szczecin Istanbul

Poland Poland Turkey

28 September 2019 28 September 2019

Prague Warsaw

Czech Republic Poland

The public got a chance to try laparoscopic equipment in Prague

Performance on stage at the UROlogical steps to health in Prague

Czech Republic Vojtech Novák, MD This is the second year that the Czech Urological Society has organized (URO)logical steps to health. This year’s theme "Urology - a modern discipline for all generations" aimed to highlight that urological problems not only affect adults and seniors, but also our youngest patients.

presentation of the field of urology, but also a rich social programme with performances by well-known Czech artists. More than 2,000 visitors attended the event.

(URO)logical steps was a unique educational event, both in the wide range of presented and discussed topics across urology, but also in the involvement of residents and young urologists from all over the country. The event also introduced new technologies that our specialisation offers. We saw great interest in robotic surgery, where participants had the chance to not only view interesting videos and try to work with a robotic console, but also compare the advantages of a robotic system over classical laparoscopy. The event was supported by the Czech Urological Society, as well as the Ministry of Health of the Czech Republic and the City of Prague. It offered visitors not only a high-quality professional programme and a

Join us!

October/December 2019

For public awareness of urological conditions

Serbia Prof. Dr. Dragoslav Basic The Urological Section of Serbian Medical Association also supported Urology Week 2019. An International Symposium on "Interdisciplinary treatment of Urological Diseases", was held 13 to 15 September in Bor Lake, Serbia. Dr. Basic translated the campaign posters into the Serbian language to help promote the event. Over 150 registered participants from Serbia, Romania and North Macedonia attended the symposium. Participants expended their knowledge on urosepsis challenges and rationale use of antibiotics, from the urological, anaesthesiological and pharmacological points of view, with interesting interactive discussions. Special attention was paid to male health and BPH in daily practice. Want to join us for Urology Week in 2020? Visit the official website www.urologyweek.org and get inspired.

21-25 SEPTEMBER

2020

European Urology Today

Cadaver courses in Malta to increase laparoscopic skills ESUT collaborates with IAMS in laparoscopic training Dr. Giovannalberto Pini IRCCS Ospedale San Raffaele Dept. of Urology Milan (IT) pini.giovannalberto@ hsr.it

Prof. Rosario Leonardi Clinica Musumeci Gecas Dept. of Urology Catania (IT)

leonardi.r@tiscali.it The International Academy of Minimally-Invasive Surgical training (IAMS) has organised the 6th edition of the ‘Urological advanced course (UAC) on laparoscopic cadaver lab’, in collaboration with the EAU Section of Uro-Technology (ESUT), last October. Over the past 2 years, 6 courses were organised and more than 60 European trainees were invited to come visit the anatomy department of the University of Malta. The department is leading in the advanced preparation of bodies following Thiel’s soft-fix embalming method1, a perfect way to preserve corpses and offer well-preserved organs and tissues with natural colour, consistency, flexibility, plasticity and transparency. Thiel method Prof. Rosario Leonardi (IT), urologist and president of the foundation, says that the ‘Thiel method’ is a fundamental requirement to perform laparoscopy on cadavers. The method consists of an intravascular injection formula, and submersion in a stainless steel tank for a fixed period, in a special solution that lacks toxics or irritating gases due to minimum formaldehyde concentrations. The 10 urologists who participated in the two-day course showed great enthusiasm and said that the cadaveric model was very realistic and forms a necessary step before starting surgery in the operative field. Dr. Giovannalberto Pini (Milan, IT), associate member of the ESUT scientific group, and Prof. Leonardi held a 6-hour interactive lecture on embalming techniques, preparation of the corpses, pelvic and retroperitoneal anatomy and patient positioning. This was followed by step-by-step modular videos on pelvic and kidney surgery. The hands-on session began early on the EAU Section of Uro-Technology (ESUT)

second day. The course, supported by the expert faculty, allowed simultaneous practising on three cadavers for a total of 24 hours. Two 4h-modules were focused on laparoscopic radical prostatectomy, four 2h-modules on laparoscopic partial nephrectomy and 4h-modules on laparoscopic nephrectomy. The philosophy of the course was to maintain small groups for each procedure, favouring a modular rotation regulated by the tutor. Thus, not only surgical techniques are taught but also non-technical skills such as team building, a fundamental requirement in the operating room and in real life. Gap between simulation and live surgery IAMS has always embraced the philosophy of ESUT and appreciates that surgical training is very delicate. For ethical reasons, it cannot be performed directly on the patient but requires a structured modular training on dry lab first and then on animal models. The participants concluded that the cadaveric model bridges the gap between simulation and live surgery and facilitates a faster learning curve in complete safety for the patient. In the past, surgical training was essentially based on the ‘see one, do one, teach one’ concept, but we are gradually moving towards the development of specific modular training, standardised curricula, and an increasingly prevalent use of simulators before directly practising surgery on the patient2. Therefore, simulation and teaching are acquiring a fundamental role, further supported by the surgical ethics that implementation of a surgical procedure on a patient should only be allowed after a surgeon has reached notional and surgical skills that ensure adequate standards in terms of quality and safety3. Most reliable and realistic While the main limitations of synthetic models often lie in their limited realism, the greatest drawback of in vivo and ex vivo biological models (in particular porcine and canine) is once again the ethical dilemma they generate because of being alive. Since nothing can simulate human anatomy as well as a real human body, human cadaver models remain undoubtedly the most reliable and realistic version on which to perform surgical training or test new techniques.

“The modules were focused on laparoscopic radical prostatectomy, and partial and radical nephrectomy.” Since the birth of medicine and surgery centuries ago, human cadavers have been used as models of anatomical training and experimentation and to test new procedures. In recent decades, more strict regulations with regard to their use seem to have reduced their availability in surgical departments4. Nevertheless, their use might be fundamental nowadays to learn about anatomy, reduce the

Clockwise: Dissection of renal pedicle during laparoscopic partial nephrectomy; Anastomosis after nerve-sparing laparoscopic radical prostatectomy; Tutors of the resident faculty and trainees in the anatomy department of the University of Malta.

learning curve, improve patient safety and experiment with new surgical techniques5. They might be much more than ‘a look back into the past’, they might be the answer to both ethical issues concerning in vivo animal models and the need for realistic and ideal training models. Future meetings The 3-day event in Malta was concluded with a night of friendship in the historic district of Malta, which is full of restaurants and clubs with live music. IAMS and ESUT were delighted to organise this inspiring workshop and are now working on a brand new meeting which will be held in October 2020, again in collaboration with EAU. A future perspective of IAMS is to make training even more realistic by mimicking a real surgical environment through a live cadaver model. The anatomy department of the University of Malta is set out to work on the provision of a cadaver perfusion system. The model will combine the realistic conditions of a living body with real human anatomy

in one model and is the only training model available that provides such a combination. References 1. Thiel, W. Die Konservierung ganzer Leichen in natürlichen Farben. Ann. Anat., 174:185-95, 1992. 2. Somani BK, Van Cleynenbreugel B, Gozen A, Palou J, Barmoshe S, Biyani S, et al. The European urology residents education programme hands-on training format: 4 years of hands-on training improvements from the European School of Urology. Eur Urol Focus 2018. 3. Teoh JY, Cho CL, Wei Y, Isotani S, Tiong HY, Ong TA, Kijvikai K, Chu PS, Chan ES, Ng CF; Asian urological surgery training & education group. A newly developed porcine training model for transurethral piecemeal and en bloc resection of bladder tumour. World J Urol. 2018 Dec 17. 4. Gürses IA, Coskun O, Öztürk A. Current status of cadaver sources in Turkey and a wake-up call for Turkish anatomists. Anat Sci Educ. 2018 Mar;11(2):155-165. 5. Yiasemidou M, Gkaragkani E, Glassman D, Biyani CS. Cadaveric simulation: a review of reviews. Ir J Med Sci. 2018 Aug;187(3):827-833.

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

paul.meria@ sls.aphp.fr

Reconstructive and aesthetic genital surgery As many other topics, genital surgery is a multidisciplinary topic which is currently expanding thanks to the efforts of several urologists. Many surgical procedures have been developed. Some of Book reviews

European Urology Today

them require in-depth knowledge of the anatomy of the genitalia combined with a special training in expert centres. Patients with various congenital or traumatic problems and/or tumours can be eligible for reconstructive procedures.

and other vulvovaginal operations are extensively described and followed by the description of penis augmentation techniques. Surgical procedures of sex-reassignment are described, covering male-tofemale and female-to-male aspects.

In this original textbook, editor Philip H. Zeplin aims at assembling practical information in the field of genital aesthetic surgery with the help of more than 25 European experts from various departments of plastic, aesthetic and reconstructive surgery, urology and gynaecology.

This outstanding textbook is richly illustrated and intended for urologists, gynaecologists and plastic surgeons. It is of great interest to certified urologists and trainees anxious to increase their knowledge of genital surgery.

The first part is dedicated to plastic reconstructive surgery and addresses the foundations of skin grafting and flap techniques. The author covers vulvovaginal and penoscrotal reconstructive operations in adults and children in an exhaustive chapter. Most clinical situations in the field of challenging reconstructions are addressed. For each flap the authors consider the surgical principle, vascular supply, innervation, size and indications.

Author : P.H. Zeplin Published : October 2019 Publisher : Thieme Publishers eBook : 978-3-132-41306-1 Cover : Hardcover EAN : 978-3-132-41289-7 Edition : 1st The second part of the book is dedicated to functional Pages : 180 aesthetic surgery in males and females and includes a Price : € 149,99 (DE) special chapter about transsexualism. Labiaplasties Illustrations : 381 illustrations in colour October/December 2019

A discussion of what we consider to be office urology Remarkable results of ESUO Section surveys on office urology in European countries Prof. Helmut Haas Chairman, ESUO Heppenheim (DE)

Office Urologists in Europe hf.haas-hp@ t-online.de

Percentage office urologists

Exploring office urology in Europe is an important goal of the EAU Section of Urologists in Office (ESUO). It was founded nearly three years ago to represent and promote the interests of office urologists in Europe beyond national structures. The designation ‘office’ seemed to be appropriate to characterise the difference between office urologists’ field of work, that is mainly treating outpatients, and clinical urologists’ field of work, the treatment of inpatients. Key characteristics of office urologists were thought to be “self-employment” and the “privately conducted office”. However, as we have learned, and as you’ll see below, these properties may not be comprehensive enough to address all the urologists who are predominantly treating outpatients. Investigating the essence of office urologists’ work in the European countries is one core task of the ESUO section - besides conducting educational meetings at EAU meetings and invited lectures at national congresses. Therefore, we made a survey two years ago that explored the number of office urologists and the diagnostic and therapeutic methods office urologists used. The results were published in European Urology Today, issue October/December 2018, p. 23, and the EUT Congress News, 18 March 2019. Afterward, we received information from more countries. We learned that there are more than 10,000 office urologists in Europe (fig. 1). The percentage share of office urologists in the individual countries ranges from 2% to 78%. The average share of office urologists in all responding countries is 38%. This surprisingly high proportion is explained by the large absolute number of office urologists in Russia and Germany. But our knowledge is still incomplete, because we lack information from several countries, as can be deduced from the white spots on our map. Recently, we have conducted a second survey, this time about the working conditions and the working environment of office urologists in different European countries. This survey was done through a questionnaire in September 2019. Section members in 11 countries* who considered themselves to be office urologists reported the numbers. These numbers are estimations, because many official databases used different criteria. So, the figures don’t claim to be representative, but they give a strong impression of the diversity of outpatient urology in European countries. The results are remarkable - also for us - and make us think about a re-definition of what we consider to be office urology. Plus, they encourage us to cross boundaries in our comprehension of office and outpatient urology, because we see that this field in urology probably has a much wider range than we imagined. The results of the surveys Approvals: The health care sector is mostly under the control of state authorities. In work areas where the urologist is not alone in deciding what to do, one or more institutions must approve. These authorities are public and private health care institutions, medical self-administration and government administration. Local hospitals or local urologists may influence the urologist’s decision only in the fields of outpatient surgery, inpatient treatment and – occasionally – medical devices. Starting an office: 65% of the office urologists in the replying countries are allowed to start offices at any location they want. 10% need the approval of health insurance organisations, 20% of their medical administration, and 25% of government authorities.

*) Georgia, Germany, Greece, Italy, the Netherlands, Poland, Russia, Serbia, Sweden, Switzerland, United Kingdom EAU Section for Urologists in Office (ESUO)

October/December 2019

Absolute number of office urologists

Methods and equipment (fig. 2): Oncological treatment is in most of the countries controlled by official institutions. From our first survey, we know that in nearly all countries oncological drug treatment can be carried out in office; at least treatment of prostate cancer with classical ADT (LHRH and anti-androgens). In half of the countries, therapy using enzalutamide, abiraterone, and instillation therapy for bladder cancer is given in office as well. The in-office use of new substances in renal cancer or chemotherapy is solely allowed in a few countries (e.g. Germany) through a special individual qualification. On the other hand, office urologists are extensively free in administering other drug treatments. The use of certain medical equipment (e.g. ultrasound) has to be approved in only a few countries. In Poland, urologists need no approval at all if they have passed the FEBU exam. Patients: On average, 50% (range: 10% - 100%) of the patients visit the office urologist by their own decision. 30% (range: 10% - 60%) are referred by their general practitioners, 15% (range: 10% - 25%) by other specialists. In 5% mentioned other reasons unknown.

urologists. By now, we have learned that office urology has a significant larger spectrum. Not only because of office urology’s wide range between office-only urologists on the one hand and office urologists regularly treating inpatients on the other, including flowing transitions and differences from country to country, but also with respect to the kind of their employment and the institutions they work at. Our recent survey shows that only in one half of the countries office urologists work in privately conducted offices (self-employed) or medical centres (employed). The same proportion is employed in hospitals, with some of them running a private office self-employed in addition. For instance, in some countries, office urologists are hospital-based but self-employed. Moreover, colleagues from other countries have told us that some urologists do the same labour as office urologists hospital-based, but refuse this designation and demand the name “outpatient clinic” to characterize their institution. In summary, we see that what we simply call “office urology” is in reality, country-dependent, a different and complex structure of institutions, employment, payment, and patientand-specialties relations. Also, we have to consider that we might exclude urologists from other countries from our section because of the word "office".

Medical associations: In only 2 countries, Italy and A prudent course of action would now be to extend Sweden, associations have been established which our target group through a redefinition of office are fully dedicated to office or private urologists exclusively. In about 50% of the responding countries, urology to ensure that we include all urologists in this we find local networks of office urologists, some of them collaborating with general practitioners.

EAU section who fulfil the same tasks as (we thought ‘only’) office urologists do. This could boil down to European urologists who treat outpatients in their main profession in more than 50% of their working time within the context of an established professional profile no matter whether they are office- or hospital-based, who do so not only temporarily, and who are part of an institutionalised link between general medicine and clinical inpatient urology.

The discussion is open! Please send an email to esuo@uroweb.org What about the future? Some countries tell us that changes in the hospital and office landscape will lead to changes in the patients’ care. When full departments (of urology) in small hospitals are shut and relocated into those of larger clinics they often are substituted by medical outpatient centres to ensure the nearer-to-home care of outpatients. Private practices are increasingly being bought up by supra-regional commercial enterprises and operated with employed urologists. These are new challenges for the office and outpatient urology.

Salaries of office urologists: Nearly 50% (range: 15% - 100%) of the office urologists’ income comes from public, another 18% (range: 5% - 100%) from private health insurances. 28% (1% - 95%) is covered by the patient her/himself, and 5% by hospitals. The employment of office urologists: Our data show that in 40% of the countries the office urologists work self-employed in own offices, another 10% are employed in private medical centres. 40% are employed by and based in a hospital. 10% work as part-time employees in a hospital, but have an own office as well and work there during more than half of their working time. Uncertainties in defining “office urology” When we started our ESUO project three years ago, we had the impression (maybe influenced by our home countries) that “self-employment” and “privately conducted office” were the core characteristics of office

Figure 2: Who/which institution has to decide/agree which methods you may use in your office? Multiple answers possible

European Urology Today

SATURN Registry recruitment ahead of schedule EAU RF extends recruitment number and registry period Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ uroweb.org

Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ uroweb.org

The SATURN Registry evaluates the cure rate of surgical procedures for treatment of male stress urinary incontinence with medical devices. The study has started in 23 sites in Belgium, Czech Republic, Germany, the Netherlands, Norway, Spain, the United Kingdom and Italy. New sites in Belgium, Finland, France, Germany, Italy, Norway, Spain, United Kingdom and Sweden will become active soon. To date (14 October 2019), 19 sites recorded a total of 461 patients in the e-CRF. This may be an underestimation of the actual number of recruited patients as not all included patients are recorded in the e-CRF yet. Extension recruitment number and registry period The number of planned participating centres was increased from 20 to 35 and the number of planned registry participants was increased from 500 to 1000. This was done to obtain more variability in type of devices and to better comply with the new regulation post-marketing surveillance medical devices. To be able to study the long-term effects better, the registry period was increased from 5 to 10 years. EAU Research Foundation

We have reached an agreement with the funder, have prepared a protocol amendment for ethical approval and started to recruit new sites interested in participating. Participating Centres Belgium • University Hospitals, Leuven • University Hospital, Gent • Jessa Hospital, Hasselt • General Hospital Groeninge, Kortrijk Czech Republic • Thomayer Hospital, Prague Germany • University Hospital Münster, Münster • University Hospital Mainz, Mainz • University Medical Center Hamburg Eppendorf, Hamburg Italy • San Raffaele, Milan • ASST Valle Olona, Busto Arsizio • Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome The Netherlands • Radboud UMC, Nijmegen • University Medical Centre, Utrecht Norway • Oslo University Hospital, Oslo Spain • Hospital Universitario Puerta De HierroMajadahonda, Madrid • Hospital Universitario 12 Octubre, Madrid • Hospital Universitario de Canarias, Santa Cruz de Tenerife • Hospital Universitario Virgen de las Nieves, Granada • Hospital Universitario Germans Trias i Pujol, Barcelona • Hospital General Universitario Gregorio Marañón, Madrid • Hospital Universitario y Politécnico de La Fe, Valencia United Kingdom • Royal National Orthopaedic Hospital, London • Addenbrooke's Hospital, Cambridge

Is this study open to new sites? Yes. Institutions that perform surgical procedures for treatment of male stress urinary incontinence can participate with medical devices. There is no restriction on the number of patients enrolled but they need to be consecutive. Primary objective: To evaluate the cure rate of procedures for treatment of male stress urinary incontinence with medical devices. Secondary objective: To determine other outcomes of surgical treatment of male stress urinary incontinence for a variety of devices and to perform a prognostic factor analysis to identify clinical and surgical variables that correlate with (in)continence or revisions. For more information, please visit the EAU RF website http://uroweb.org/research/projects/. If you are interested in participating in this registry, please fill out the Feasibility Questionnaire at https://www.surveymonkey.com/r/9X9HRHP or contact the study coordinator, Dr. Raymond Schipper, at r.schipper@uroweb.org as soon as possible. Your site must be able to complete the approval process promptly.

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 (UK) Protocol Writing and Steering Committee: • Rizwan Hamid (UK) • Nikesh Thiruchelvam (UK) • Frank Van Der Aa (BE) • John Heesakkers (NL) • Wim Witjes, EAU Research Foundation (NL) 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

NIMBUS trial to end in 2020 Safety analyses show reduced frequency schedule is inferior for primary endpoint By Raymond Schipper and Wim Witjes, EAU RF Research Foundation

EAU Research Foundation: • Anders Bjartell, Chairman • Wim Witjes, Scientific and Clinical Research Director • Raymond Schipper, Clinical Project Manager • Christien Caris, Clinical Project manager • Ilse Christ, Clinical Research Associate • Joke Van Egmond, Clinical Data manager • Xandra Helmonds, Financial Officer • Hans Noordzij, Marvin Management Assistant

The EAU Research Foundation’s randomised phase III clinical trial NIMBUS has stopped recruitment due to the results of a safety analysis. The trial, which ran from 2013 and studied reduced frequency BCG instillations in NMIBC, included nearly 360 patients in five countries. The EAU RF NIMBUS study assessed whether a reduced number of BCG instillations was inferior to the standard number and dose in intravesical BCG treatment in patients with high grade non-muscle invasive bladder cancer (NMIBC). The primary endpoint was time to first recurrence. The target was to enrol 824 patients with high grade Ta-T1 urothelial carcinoma of the bladder, with or without CIS, who did not receive any previous BCG intravesical instillation therapy. Reduced frequency schedule Safety analyses by the independent data monitoring committee (IDMC) showed that the reduced frequency schedule of BCG was inferior to the standard frequency schedule for the primary endpoint according to the previously defined stop criterion. Recruitment was immediately stopped, and all participating sites were instructed to inform their patients. The patients in the reduced frequency treatment arm were offered the possibility to switch to the standard frequency. The follow-up period, which was initially 3 years, will be shortened until all patients have at least 6 months of follow-up. At the time recruitment was stopped, a total of 359 patients were randomised (see recruitment graph below). EAU Research Foundation

European Urology Today

Study Principal Coordinators: • Levent Türkeri Marmara University Medical School Istanbul (TR) • Marko M. Babjuk Charles University 2nd Faculty of Medicine Prague (CZ) Important scientific questions The EAU Research Foundation wishes to thank the patients who participated in NIMBUS and the many centres in Europe for their dedicated and hard work to enrol patients in this study. Despite the premature ending of the trial, the data collected in this trial may answer some important scientific questions concerning the use of BCG intravesical therapy in the management of high-grade Ta/T1 bladder tumours.

Study team

Also, biospecimens were collected for (a) the identification and validation of association signals in relation to BCG recurrence and progression, using genome-wide DNA analyses (DNA substudy) and (b) mechanistic insights into the relevance of specific immune response processes and evaluation of immune-related BCG response biomarkers (cytokine substudy).

National Coordinators: • Germany: Marc-Oliver Grimm • The Netherlands: Toine Van Der Heijden • France: Marc Colombel • Spain: Luis Martinez-Piñeiro • Belgium: Tim Muilwijk • Italy: Andrea Gallina • Turkey: Levent Türkeri

Protocol Committee: • Marko Babjuk, Prague (CZ) • Luis Martinez-Pineiro, Madrid (ES) • Joan Palou Redorta, Barcelona (ES) • Anup Patel, London (UK) • Levent Türkeri, Istanbul (TR) • Marc-Oliver Grimm, Jena (DE) • Wim P.J. Witjes, Arnhem (NL)

To find out more about the EAU RF and its ongoing projects, please visit www.uroweb.org/research, check Twitter (#EAUrf) for updates, or contact: EAU RF Central Research Office PO Box 30016, 6803 AA Arnhem, The Netherlands Email: researchfoundation@uroweb.org Phone: +31 (0) 26 38 90 677

October/December 2019

Opportunity to join for hospitals in smaller EU countries eUROGEN: European Reference Network on rare urological disease Jen Tidman eUROGEN Business Support Manager

jen.tidman@ radboudumc.nl

The current call by the European Commission (EC) for new healthcare providers to join existing European Reference Networks (ERNs) has reached its deadline of 30 November 2019, but there is still time for interested hospitals to apply to join eUROGEN (eurogen-ern.eu), the ERN for rare uro-recto-genital diseases and complex conditions, for which the European Association of Urology is a Supporting Partner. ERNs have been a huge political success for the EC. 24 ERNs were established in 2017, following a call for applications published in 2016, with over 950 clinical units, hosted in around 300 hospitals, becoming members. However, the geographical coverage of the ERNs showed an imbalance between Western and Eastern Europe, where the participation of smaller countries appeared to be more limited or, in certain cases, absent. The call for new members to join existing ERNs aims to overcome these gaps, offering the possibility for underrepresented EU member states to designate new full members for the existing ERNs. At present, with two weeks to go until the deadline, an additional 1,000 specialised units have applied to join.

ERNs are virtual networks bringing together healthcare providers across Europe with specialised expertise to tackle complex or rare medical conditions that require highly specialised care and a concentration of knowledge and resources, as well as making it easier for patients to access information on healthcare and thereby increase their treatment options. A rare disease, as defined by the EC, is a disease affecting less than 1 in 2,000 people, however, some urological conditions have an incidence of less than 1 per 250,000 people. The complex and rare conditions that are part of eUROGEN are divided into 3 different workstreams (WS): • WS1: rare congenital uro-recto-genital anomalies • WS2: functional urogenital conditions requiring highly specialised surgery • WS3: rare urogenital tumours Rare congenital uro-recto-genital conditions often require following a patient throughout their life span. Many patients have reported lack of adequate care when transitioning from paediatric to adult uro-rectogenital care, but eUROGEN will ensure that as many patients as possible can receive high quality specialist care from birth through to end of life. Indeed, patients are at the heart of eUROGEN, and European Patient Advisory Groups (EPAGs) are included in governance and decision making for the network. The main focus of the ERNs is on holding virtual European Multi Disciplinary Team (MDT) case discussions (with informed consent) using a custombuilt online IT tool, the Clinical Patient Management System (CPMS), which allows the secure upload and sharing of patient histories, x-rays, investigations, and so on. Leading experts in multiple healthcare providers are then able to access these and discuss cases in a real-time videoconference, and then provide written reports on diagnosis and treatment options, including detailed advice on recommended surgical procedures for the treating clinicians.

The eUROGEN Steering Group during the annual meeting in Noordwijk, last June

ERNs are about more than just MDTs though. eUROGEN will also be involved in developing independently-evaluated best practice clinical guidelines for rare and complex urogenital diseases, providing education and training for the next generation of surgeons to increase skill levels and improve outcomes, developing research programmes and fostering innovation to fill gaps in current diagnosis or treatments, and developing registries to track long-term outcomes for patients. Indeed, as the initiative progresses, all of the ERNs will help to develop new innovative care models, eHealth tools, medical solutions and devices. They will boost research through large clinical studies and contribute to the development of new pharmaceuticals. They will lead to economies of scale and ensure a more efficient use of costly resources, which will have a positive impact on the sustainability of national healthcare systems, and for tens of

thousands of patients in the EU suffering from rare and/or complex diseases and conditions. Healthcare providers who wish to apply to join eUROGEN can find all the relevant information on the EC’s dedicated webpage (https://ec.europa.eu/health/ ern/consultations/2019_call_membership_en) and need to submit their application through a specific IT tool provided there. Two manuals have been published to provide guidance to applicants on the use of the online application form and on the assessment and the application process. FAQs are also available to answer the most frequent concerns. If you have any questions, please do not hesitate to contact me via: jen.tidman@radboudumc.nl

'Let's talk Prostate Cancer' campaign launches EU Call to Action to improve prostate cancer care across Europe By Sarah Collen, EAU Policy Coordinator On Tuesday 12 November a new campaign ‘Let’s talk prostate cancer’ was launched. An EU multistakeholder expert group on prostate cancer came together to set out recommendations on how the care for people affected by prostate cancer across Europe can be improved. “My life has changed in unimaginable ways since being diagnosed as a prostate cancer patient”, explained Robert Greene from the European Cancer Patient Coalition(ECPC) during his speech at the launch of the ‘Let’s Talk Prostate Cancer campaign’. Despite catching prostate cancer at an early stage, and with a positive diagnosis of the condition being manageable for the time being, Greene still finds life

Policy Paper on

PSA SCREENING FOR PROSTATE CANCER Has the time come to reconsider structured population-based PSA screening for prostate cancer?

is full of ‘what ifs’. What if his recent MRI scan reveals progression of the disease? What if he suddenly suffers from sexual dysfunction or loss of libido? What if he becomes incontinent? These sorts of questions are rarely openly discussed in EU policy forums. Compared to cancers such as lung, colorectal, cervix or breast cancer, prostate cancer is relatively low down the political and policy agendas in the EU and its member states. That is why Astellas asked a number of experts on prostate cancer to join together to formulate a policy platform to talk openly about prostate cancer, with a focus on advanced prostate cancer, and to develop some recommendations to the EU. In the European Union over 2 million people are living with prostate cancer, the most frequently diagnosed cancer in men. More men die from prostate cancer than women from breast cancer and, in men, prostate cancer mortality ranks second after lung, and before colorectal cancer. Around 450,000 new cases were diagnosed in Europe in 2018, compared to an estimated 345,000 in 2012. Each year, prostate cancer accounts to around 25% of all new cancers and 10% of male cancer deaths, with over 107,000 people estimated to have died from the disease in 2018. Unfortunately, prostate cancer is increasingly diagnosed at an advanced stage with studies showing an increasing proportion of individuals diagnosed with metastatic or late stage disease. Given the decrease in quality of life especially in later stages of the disease, it is crucial that the needs of people with prostate cancer are addressed at the earliest opportunity.

October/December 2019

Professor Hein Van Poppel was invited to present the new campaign and used his talk to stress the necessity of screening programmes. Although the early stages of the disease are without symptoms, PSA testing can be used in parallel with a number

MEP Tiemo Wölken (l) and Professor Hein Van Poppel (r) at the launch of the campaign

of clinical tools to diagnose prostate cancer early and at a manageable stage. The EAU has gold standard clinical guidelines on PSA testing agreed by all 28 EU member states and beyond. However, instead of using this tool, EU member states are using PSA less, leading to a worrying trend of men being diagnosed with advanced stage prostate cancer becoming the norm. Van Poppel blamed the rise in men being diagnosed with advanced stage prostate cancer on the ‘propaganda’ against PSA testing. The criticism on PSA testing has been focused on the problems with over-treatment, which, although having been a problem 20 years ago, are no longer inhibitors due to the combined use of new diagnostic tools, such as multiparametric MRI and active surveillance strategies. Van Poppel warned that less PSA screening will inevitably lead to higher numbers of patients that

need to be treated for advanced an metastatic disease in the years to come. Hopefully, with implementation of well-structured screening programmes these numbers and the prostate cancer mortality will come down dramatically. The ‘Let’s Talk Prostate Cancer’ initiative was introduced by Tiemo Wölken who is the MEP leading this campaign. He said: “As one of the most pressing health issues of our time, the fight against cancer unites us all – no matter where we live or what language we speak.” In the next mandate of the European Commission, the EU Health Commissioner, Stella Kyriakides has been tasked with drawing together a European plan to beat cancer. The EAU will be working tirelessly to ensure that prostate cancer gets the prioritisation and attention it deserves. European Urology Today

Report

New masterclass receives praise for 1st edition Erectile restoration and Peyronie's disease masterclass off to a good start By Erika De Groot The ESU-ESAU-ESGURS Masterclass on Erectile Restoration and Peyronie's Disease marked a solid launch with its first edition. The masterclass garnered tremendous positive feedback and anticipation for its future editions. The two-day masterclass commenced on 3 October 2019 in Leuven, Belgium. It was the culmination of efforts and dedication of the European School of Urology (ESU), the EAU Section of Andrological Urology (ESAU), and the EAU Section of Genitourinary Reconstructive Surgeons (ESGURS), endorsed by the European Society for Sexual Medicine (ESSM). In this article, Masterclass Directors Dr. Maarten Albersen (BE) and Dr. Juan Ignacio Martínez Salamanca (ES), together with esteemed psychologist Asst. Prof. Marieke Dewitte (NL) and masterclass participant, Dr. Paul Soava (FR) share their masterclass experiences. First (edition) impressions “As a whole, we’re very pleased with the first edition. The feedback was overwhelmingly positive. The programme covered male sexual dysfunction in depth. The masterclass was comprehensive, in fact, maybe even too comprehensive for the days allotted for it. In the next edition, the programme will have a balance of lectures and discussions,” stated Dr. Albersen. Prof. Dewitte shared, “Although the delegates and the programme were mainly medically oriented and highly specialised, the delegates have shown openness and interest in multiple aspects of sexual functioning, including the psychosocial part. The sessions were informal and the social cohesion among participants was high.”

A full house at the new masterclass

The panels were made up of esteemed experts

Dr. Martínez Salamanca said, “The survey results from participants were encouraging. The faculty and the organisers put great value on feedback to see what works and what can be improved. This way, the quality of the masterclass can only get better.” He added, “The overall vibe during the masterclass was good. We even had participants from countries outside Europe. The live surgeries were delivered with outstanding moderation with tips and tricks for the beginners as well as for the experts.” Dr. Soava agreed, “The live surgery session offered helpful insights on how the procedures are effectively carried out. For a novice such as myself, the techniques were clearly explained, including the pros and cons. It is far from the ‘See One, Do One, Teach One’ situation but it certainly gave me the confidence to get started.” “I applied for this masterclass because I noticed that other urological trainings don’t completely cover Peyronie’s disease and there is lack of knowledge on how to efficiently manage it. This masterclass offered extensive coverage and the opportunity to learn from top experts in the field,” disclosed Dr. Soava.

patient counselling, she provided us with a perspective of a psychotherapist that enriches our own approaches. The lecture led to lively discussions.”

“Prof. Dewitte’s lecture gave us a wake-up call,” said Dr. Albersen. “She stated that sexual satisfaction is not necessarily dependent on good erection, and intercourse is overrated. She referred to the latter as dessert and not the main course. Her lecture left the moderators flushed and speechless. It was a great moment!”

“We will continue to work hard to make the programme even more conducive to learning and attractive to future participants.” Dr. Albersen concluded.

Future masterclass editions There is plenty to look forward to in the second edition, according to Dr. Martínez Salamanca. “We She emphasised the biopsychosocial nature of erectile plan to enhance next year’s masterclass with new dysfunction (ED) and the importance of addressing educational innovations with the objective to boost the psychological aspects of ED (e.g. dysfunctional knowledge-sharing. macho beliefs, performance anxiety, hampered sense of masculinity, lack of spontaneity, sense of artificial “This masterclass is a great initiative. It helps bridge intimacy, impact of and on the partner). According to different views on sexual problems, brings people Prof. Dewitte, a combination approach yields the best together and broadens their views on sexual function treatment results. and pleasure,” stated Prof. Dewitte.

The lecture of Prof. Dewitte also left an impression on Dr. Soava. He said, “When her lecture touched on

For updates on the next edition of the ESU-ESAUESGURS Masterclass on Erectile Restoration and Peyronie's Disease, and information on other masterclasses, please visit the www.esu-masterclasses.uroweb.org/.

www.esunmibc20.org

www.esuerectile20.org

ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer

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

20-21 February 2020 Prague, Czech Republic

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

Memorable lecture “I gave a talk on counselling patients who have erectile dysfunction with a specific focus on those who are therapy-resistant, have permanent damage and/or needing consultation for a penile prosthesis,” said Prof. Dewitte.

European Urology Today

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

October/December 2019

Report

Renal transplantation: "An inspiring activity" A report on the 2nd edition of the ESU-ESTU masterclass By Erika De Groot Extensive coverage on kidney preservation, emerging technologies, immunosuppression, immunology, and oncological issues of donor-receptor were the prime focus of the recent 2nd edition of the ESU-ESTU Masterclass on Kidney Transplant. Organised by the European School of Urology (ESU) and the EAU Section of Transplantation Urology (ESTU) together with Course Directors Prof. Francisco Javier Burgos Revilla (ES) and Prof. Enrique Lledó García (ES), the masterclass was held from 24 to 25 October 2019 at the Gregorio Marañón Hospital in Madrid, Spain. What was it like to be at the masterclass? What new knowledge did the delegates bring home with them? In this report, faculty member Dr. Julien Branchereau (FR) and delegates Dr. Grazia Bianchi (IT) and Dr. Riccardo Campi (IT) disclosed these and more. Addressing a need “The ongoing shortage of donor organs for transplantation, and changes in the demographics of donors have created the drive to achieve an optimal approach for kidney transplantation,” stated Dr. Branchereau. He added that kidney transplantation is still a developing activity, and that there are different ways to increase the donor pool such as extending the donor acceptance criteria and retrieving kidneys from living donors. “I applied to this masterclass because we don't perform kidney transplants at my hospital at the moment,” shared Dr. Bianchi. “I wanted to improve my knowledge because we often have to treat patients who are waiting for a kidney or just received a new kidney.”

Faculty members and delegates of the masterclass

Dr. Campi explained, “I applied to the masterclass because I wanted to learn about the state-of-art practices such as transplantation from living donors, donors after brain death and donors after circulatory death; and the best practices in the use of robotic technology. I wanted to know more about the current options for ex-situ organ preservation, the management of challenging clinical situations and basic knowledge on immunosuppressive therapies, as well as how to deal with tumours of the genitourinary tract after kidney transplantation.”

excellent learning environment. I remember having fun, lively discussions with them that continued even during dinner,” stated Dr. Branchereau.

Dr. Campi enumerated his masterclass highlights. “Beyond the technical details, in my opinion the highlights include: 1) The importance and impact of urologists in the field of kidney transplantation 2) The current status of kidney transplantation in Europe from an ethical standpoint 3) The significance of building a close-knit To Dr. Campi, renal transplantation is an “inspiring multidisciplinary team involving urologists, activity”. He said that, although highly demanding, it nephrologists, radiologists and transplant can be truly rewarding from both clinical and surgeons for the ultimate quality of the kidney personal standpoints. transplantation program (and therefore, patient outcomes) Personal highlights 4) The emergence of robotic kidney transplantation as a minimally-invasive technique with several “Together with the rest of the faculty, we felt honoured potential advantages for both recipients and and had the pleasure to contribute to the masterclass. surgeons, despite the technical and logistical It provided delegates updated information in an

www.urobestt.org

challenges in the setting of deceased donors 5) The benefit of evidence-based discussions on real-life cases, which allow experts and trainees to share perspectives on controversial issues 6) The importance of being updated with the latest evidence on all aspects of kidney transplantation as a key factor for a comprehensive patient care. “The meetings and masterclasses organised by the ESU are always high level, with tutors who are the best in the field to share their knowledge. I found the relationship between kidney transplants and cancer, both in the donor and in the recipient, the most interesting because this is what I expect to see in my daily practice someday,” said Dr. Bianchi. Dr. Campi concluded, “One can receive updates of kidney transplantation from articles, peer-reviewed journals and books but despite all of that, I believe nothing can replace the first-hand, learning experience at a masterclass.”

www.esubpo20.org

ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction 16-18 April 2020, Berlin, Germany

Application deadline: 1 February 2020

October/December 2019

7-8 May 2020, Heilbronn, Germany An application has been made to the EACCME® for CME accreditation of this event

European Urology Today

Report

SET-UP Programme recap of 2018 and 2019 By Erika De Groot Imagine enriching your laparoscopic and endoscopic skills under the guidance of top experts. Picture a realistic setup as your learning environment. The Standardized Endoscopic Training in Uro Procedures (SET-UP) Programme offers this ultimate experience and more. What is the SET-UP Programme? The SET-UP programme is a joint venture of the European School of Urology (ESU), the EAU Section of Uro-Technology (ESUT), the EAU Section of Urolithiasis (EULIS), the Urological Association of Asia (UAA) and KARL STORZ, with support from Cook Medical. The curriculum is designed to enhance proficiency in laparoscopy and endoscopic stone treatment. The programme protocol follows a strict process to prevent risks of complications related to the learning curve. The SETUP programme is composed of a three-step training programme aptly referred to as s1, s2 and s3 in laparoscopy and in endoscopic stone treatment. Preceding the SET-UP programme requires review and analysis of videos found on the Endoscopic Stone Treatment (EST) webpage https://bit.ly/2Q8t622 and the basic laparoscopy training (E-BLUS) webpage https://bit.ly/2CE496r. This article offers an overview of the Step 1 Training in laparoscopic urological skills (E-BLUS) and of Step 1 and 2 Training in Endoscopic Stone Treatment (ESTs1 and ESTs2) which took place in 2018 and 2019. Overview of 2019 activities This year, the European-Basic Laparoscopic Urological Skills (E-BLUS), ESTs1 and of ESTs2a were held in Singapore, Beijing, Shanghai and Bangkok. Each training was comprised of 24 participants, 6 working stations, the following activities and topics: • • • • • •

Hands-on training Introduction of the ESU training programme Semi-live surgeries Operating-area (OR) setup and organisation Equipment management Standardised technical approach of a urological procedure • Surgical strategy and benchmarks for certain urological indications • Management of critical details related to a urological procedure Prof. Ali Serdar Gözen (DE), the international coordinator of the E-BLUS courses was one of renowned faculty members of the E-BLUS training held from 28 to 29 September 2019. The E-BLUS was comprised of case discussions; lectures such as innovations in laparoscopy, avoiding complications, and anaesthesiology; and the practical E-BLUS exam. The theoretical course and exam are available online via www.uroweb.org/course/e-blus/. The practical E-BLUS exam measures a participant’s skills in laparoscopy (e.g. depth perception, bimanual dexterity, efficiency, etc.) His/her speed and accuracy are tested with the peg transfer, circle cutting, needle guidance, and knot tying tasks.

Prof. Gözen shared his programme highlights, “Seeing the insatiable quest for knowledge of the young urologists, and the increasing acceptance of the programme from the urological community were rewarding.” An esteemed faculty member, Dr. Guido Kamphuis (NL) helped coordinate and mentor during ESTs2a, which took place from 10 to 11 October 2019 at the Siriraj Hospital Mahidol University. ESTs2a included lectures on the operation room set-up (e.g. positioning the patient/surgeon/C arm etc.), dealing with residual stones to name a few, as well as, exercises on ureteral and kidney stone fragmenting, stone relocation, and stent placement. Dr. Kamphuis foresees standardisation through the SET-UP Programme, expansion of its exercises and evaluation exams.

“SET-UP Programme fortifies skills in laparoscopy and endoscopy” A look back at 2018 Last year, the ESTs1 trainings took place from 25 to 26 October in Bangkok, and from 15 to 16 December 2018 at the Tsinghua Changgung Hospital in Beijing, China. The ESTs1 lectures included topics such as the history and future of URS; techniques in stone treatment, OR setup and equipment; flexible URS indications; updates on URS treatment; the importance of intrarenal pressure during flexible URS; avoiding complications; and how to use a laser. The hands-on trainings commenced with participants performing the ESTS1 exercises without any preparation which served as the baseline per individual. A tailored hands-on training based on the first ESTs1 attempt followed. Then the last part of the training took place wherein tips and tricks are acquired by the participants. Finally, the participants tested their proficiency via the ESTs1 exams. Participant Dr. Supachai Sathidmangkang (TH) said, “I remember my first impressions on the tips and tricks in flexible URS such as the operator's position. It helped me relieve muscle pain after a long operation. And I’ve also learned more about the concept of intraluminal pelvic pressure.” Dr. Sathidmangkang suggested to have the SET-UP Programme in the last year of residency training. He added that the exam was challenging due to the time constraints but educational nonetheless. Dr. Sathidmangkang commended the dedication and valuable contributions of the faculty members. Dr. Ekkarin Chotikawanich (TH) was local Chair and one of the respected faculty members of the ESTs1held in Bangkok. He disclosed, “The most fulfilling part of ESTs1 for me was seeing the progress in the skills of our participants especially during the hands-on training in flexible ureteroscopy (URS).” For more information on all educational activities offered by the ESU, please visit www.uroweb.org/education/.

ESU Event Calendar Date

Event name

Location

JANUARY 2020 11-12 18

ESTs1/ESTs2 during SET-UP Programme ESU course Immunotherapy for the treatment of urological cancers during the 17th meeting of the EAU Section of Oncological Urology (ESOU)

Beijing (CN)

Dublin (IE)

FEBRUARY 2020 10-12 20 20-21

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

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

MARCH 2020 20-24

ESU Courses, Hands-on Training Courses during the 35th Annual EAU Congress

Amsterdam (NL)

APRIL 2020 4 9 16-18 tbd tbd

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

Limassol (CY) Vrnjacka Banja (RS) Berlin (DE) Singapore (SG) Bangkok (TH)

MAY 2020 7-8 7-9 22-23

ESU-ESUT Masterclass on Operative management of Benign prostatic obstruction ESU EST workshop - step 2 ESU course on PCNL during the 7th Baltic Meeting in conjunction with the EAU

Heilbronn (DE) Prague (CZ) Minsk (BY)

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

ESU course during the national congress of the Spanish Urological Association ART in Flexible - step 1 ESU course on Trauma in urology and reconstructive urology during the national congress of the Ukrainian Urological Association ESU-ESUT Masterclass on Urolithiasis EAU Update on Bladder cancer (BCa) and Renal cell cancer (BCa) ESU - Weill Cornell Masterclass in General urology

Burgos, (ES) Berlin (DE)

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

SEPTEMBER 2020 4-9 11-12 15-19 tbd 23-26 tbd

18th European Urology Residents Education Programme (EUREP) EAU Update on Prostate cancer (PCa19) ESU course during the national congress of the Russian Society of Urology ESU course during the national congress of the German Association of Urology

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

OCTOBER 2020 1-2 21-24

ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie's disease 7th Confederación Americana de Urologia Residents Education Programme (CAUREP)

Leuven (BE) Guayaquil (EC)

NOVEMBER 2020 5-7 12-15

ESU-ERUS courses during the 18th Meeting of the EAU Robotic Urology Section (ERUS) ESU courses during the 12th European Multidisciplinary Meeting in Urological Cancers (EMUC)

Dusseldorf (DE) Athens (GR)

DECEMBER 2020 2-4

ART in Flexible - Step 2

Berlin (DE)

ESTs1 training in the Thai capital

European Urology Today

October/December 2019

Report

ESU Course delivers PCa essentials in Hungary Latest EAU Guidelines, role of mpMRI, updates on CRPC and mHSPC Dr. Tamás Somogyi Dept. of Urology University of Debrecen Debrecen (HU)

dr.somogyi.tamas@ gmail.com More than 50 Hungarian urologist residents and numerous specialists attended the compact yet comprehensive course “Prostate Cancer”, which was organised by the European School of Urology (ESU). The course was held during the 24th National Congress of the Hungarian Urological Association on 12 October 2019 in the picturesque Hungarian city of Eger. Internationally-known Mr. Vijay Ramani (GB) was the Course Chair who welcomed the participants to a half

a day of intensive learning. Mr. Ramani spoke about the objectives, philosophy, and achievements of the ESU. His lecture was followed by Dr. Roderick Van Den Bergh (NL) who presented a frontline lecture on PCa based on the newest EAU Guidelines. Afterwards, Mr. Ramani emphasised the role of multiparametric imaging (mpMRI) in the diagnosis of PCa. In another presentation, he shared his expert insights on when and how to use boneprotective agents, as well as, the treatment options in metastatic hormone-sensitive prostate cancer (mHSPC). Dr. Van Den Bergh presented interesting lectures on new treatment options in castration-resistant prostate cancer (CRPC), and a state-of-the-art update on active surveillance in localised PCa.

From left to right: Dr. Tamás Fazekas (HU), Dr. Roderick Van Den Bergh (NL), Dr. Vijay Ramani (GB), Prof. Péter Nyirády (HU), Dr. Péter Molnár (HU), Dr. Dániel Juhász (HU), Dr. András Hüttl (HU)

The lectures were well-prepared and were wellexecuted by experienced urologists who provided interesting and useful tips and tricks for the residents and young urologists in the audience.

The highly-informative presentations were enriched with interactive case discussions which marked the end of the ESU course. The young Hungarian

urologist, Dr. András Hüttl (HU) of the Department of Urology at Semmelweis University, presented an eye-opening case report. ESU Courses The ESU offers 50 courses from current developments, core theoretical knowledge to best practices in urology. These courses deliver top-quality, clinicallyoriented information for immediate use in daily practice. The ESU aims to offer insights of experienced mentors and faculty members, and ensures that participants will receive the best practices that are vital in optimal patient care, first-hand. Together with national societies, the ESU also conducts post-graduate accredited courses.

Dr. Vijay Ramani (GB), Course Chair, welcomes the participants

Interesting interactive case discussions enhance the engagement of the participants

For more information on ESU courses, please visit www.uroweb.org/education/live-events/courses/.

EAU Edu Platform

Education Online

The online learning platform for Lower Urinary Tract Symptoms

Improve your skills: e-learning at your own convenience

EAU Education Online introduces 2 new courses:

Guidelines on Urological Infections Guidelines on Urinary Incontinence Get a complete view on clinical aspects, diagnoses and treatments of Urological Infections and Urinary Incontinence: • Understand the diverse natures of Infections and Urinary Incontinence • Arrive at the right diagnoses • Make risk assessment of cases • Decide on a treatment and follow-up strategy

2 CME c

redits

Dr. Panagiotis Kallidonis, Prof. Gernot Bonkat

uroluts.uroweb.org

Dr. Tom Marcelissen, Dr. Arjun Nambiar

uroweb.org/education October/December 2019

European Urology Today

Cancer patient advocacy

Guidelines collaboration

EPAG: Bolstering patients' empowerment

EAU-CUA panel develops joint MIBC guidelines

The EAU Patient Advocacy Group (EPAG) was established to bolster patients’ empowerment and to increase patients’ involvement in EAU activities.

By Emma Jane Smith

• Professor Francesco De Lorenzo, European Cancer Patient Coalition (ECPC) • Mr. Ernst-Günther Carl, EUomo • Mr. John Dowling, EUomo Moreover, EPAG develops and disseminates • Dr. Rachel Giles, International Kidney Cancer information essential for patients and supports Coalition (IKCC) educational events for patients and patient advocates. • Ms. Berit Eberhardt, International Kidney Patient advocates play a crucial role in supporting and Cancer Coalition (IKCC) informing cancer patients and caregivers. • Dr. Lydia Makaroff World Bladder Cancer Additionally, they provide valuable input into Patient Coalition (WBCPC) healthcare decision-making processes. As a result of • Dr. Wendy Yared, Association of European this, education of patient advocates is critical to Cancer Leagues (ECL) ensure that patients are provided with accurate information and that their input into healthcare By organising special Sessions for patients during decision-making processes is relevant. the EAU Annual Congress, the EAU Patient Information Committee tries to fulfil an important role in disseminating knowledge to advocacy groups, patient organisations and the lay public. In collaboration with EPAG, a programme is under development that revolves around follow-up programmes for cancer patients. How do follow-up programmes impact quality of life? Can web-based follow-ups provide useful insights? Does it have the potential to modify postoperative treatment?

EPAG completed its 2nd general assembly in Vienna last month

EPAG consists of the following HCPs and representatives of GU-cancer patient organisations: • Prof. Hein Van Poppel, EAU Executive for Education • Dr. Mark Behrendt, EAU Patient Information • Mr. Philip Cornford, EAU Guidelines Office • Dr. Sara Maclennan, EAU Guidelines Office • Prof. Joan Palou, EAU Education Office • Ms. Corinne Tillier, EAU Nurses (EAUN) • Dr. Antonella Cardone, European Cancer Patient Coalition (ECPC) Patient Information

During the 35th Annual EAU Congress (EAU20) a session, titled ‘Living With and Beyond Cancer’, will be hosted by the EPAG. This session is interesting for both HCPs as well as patients and aims to expand your knowledge about the growing popularity of web-based follow-ups and will make you see remote surveillance in experts’ and patients’ perspective.

The EAU and Chinese Urological Association (CUA) Guidelines Offices have steadily been building a strong collaborative working relationship culminating in the first pilot programme for the production of a joint EAU-CUA Guidelines focusing on Muscle Invasive Bladder Cancer (MIBC). The origins of this project began in August 2016 when the EAU Guidelines Methodology Committee ran a highly successful systematic review and Guidelines methodology training course in Guangzhou, China, at the invitation of Prof. J. Huang, President Elect of the CUA. This course was followed by a second one in Shenzhen, China in 2018. Both workshops were extremely well attended by members of the CUA Guidelines Office with excellent overall participation and active engagement from both the faculty and the attendees. During the Shenzhen meeting both Guidelines Offices also participated in a highly productive joint meeting to discuss potential collaborative projects, the result of which was the launch of a pilot joint MIBC Guidelines. The Shenzhen meeting was followed by a working group meeting at EAU19 which effectively established the joint EAU-CUA Guidelines Panel and defined the development method and workflow for the production of the joint MIBC Guidelines.

EAU Patient Information Special Session Sunday 22 March, 14h00 - 17h00 Follow us: Twitter: @EauPatient Facebook: @EAUPatientInformation Website: http://www.patients.uroweb.org

Guidelines Office

EAU-CUA Guidelines Office Collaboration – going strong

During the recent CUA annual congress Prof. F. Witjes, chair of the EAU MIBC Guidelines panel, supported by Prof. C. Chapple, Secretary General EAU, met with the CUA joint panel delegates to discuss the project’s progress (Picture 1). Both Guidelines Offices are pleased to report that the project is firmly on track and it is envisaged that the joint Guidelines will be launched during EAU20. Overall, it has been an enlightening experience for both Guidelines Offices, with both panels particularly interested in the potential implications that Chinese and European data, previously not considered by the respective Guidelines, may have for the joint Guidelines. Both the EAU and CUA Guidelines Offices are eager to deliver on this pilot project and look forward to tackling the upcoming challenges regarding the drafting of joint recommendations. Once complete the joint Guidelines will exist alongside the CUA and EAU guidelines; therefore, it is important that all three align with each other on the recommendations appropriate to Europe and China, respectively. The meeting at CUA Annual Congress was pivotal for the continued growth of the EAU-CUA Guideline Offices’ collaboration and it is hoped that moving forward both Offices can build on the success of the joint MIBC Guidelines project to work collaboratively on assessing the impact of Guidelines on healthcare and healthcare systems across Europe and China.

www.esuurolithiasis20.org

www.esusalzburg20.org

ESU-ESUT Masterclass on Urolithiasis

ESU - Weill Cornell Masterclass in General urology

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

29 June- 3 July 2020, Salzburg, Austria An application has been made to the EACCME® for CME accreditation of this event

European Urology Today

October/December 2019

EUSP scholarship: A catalyst to acquiring my PhD Fellowship and endourology-centred training at Tenon Hospital Dr. Esteban Emiliani Dept. of Urology Fundació Puigvert Barcelona (ES)

My experience there enabled me to learn surgical techniques and receive exposure to a wide spectrum of clinical research, in-vitro and laboratory studies that the best of the field of endourology can offer. The fellowship truly gave me a wider perspective on this subspecialty which is more vast that I had ever imagined.

I dedicated many hours and hard work for my project and priming for the interview for the application. This thorough preparation benefitted me then and will benefit me in what was to come.

Obtaining my doctorate The programme gave me the opportunity to participate in a one-year fellowship wherein I started several projects in different lines of research, including the evaluation of holmium laser settings in different scenarios i.e. lithotripsy and its effect in soft tissue ablation. This resulted to several published papers which allowed me to pursue my doctorate at the Autonomous University of Barcelona under the tutelage of Dr. Joan Palou (ES) and Dr. Félix Millán-Rodríguez (ES), who later also guided me through the complex process of acquiring my PhD.

The programme offered me numerous benefits such as guidance from the internationally-known Prof. Olivier Traxer (FR), and the opportunity to have my fellowship at one of the most important centres in endourology, the Tenon Hospital, which is located in Paris, France.

A wide variety of research I worked with Dr. Michele Talso (IT), who was my partner during the clinical and surgical activities in a wide variety of research. Following the lead of Prof. Traxer, Dr. Talso and I immersed ourselves in endourology-focused activities.

emiliani@gmail.com Applying for the European Urological Scholarship Programme (EUSP) scholarship was one of the best opportunities I have ever had, as well as, one of the best challenges I have ever encountered.

We performed clinical research evaluating the clinical outcomes and reviewing surgical techniques such as use of apnoea during ureteroscopy, tips and tricks to get access in patients with Cohen reimplantation or analysis of reperfusion syndrome after ureteroscopy.

Gathering during the fellowship; pictured from left to right: Dr. Talso, Prof. Traxer, and Dr. Emiliani European Urological Scholarship Programme Office

We carried out an expansive in-vitro and laboratory research. With the help of the laser laboratory, we examined how the holmium cavitation bubble could impact the ureteroscope. Dr. Talso and I also performed an in-depth evaluation of the image quality of all flexible ureteroscopes available. This included image-enhancing

Together with PhD directors and judges after the dissertation (left to right): Dr. Palou, Prof. J. Morote Robles (ES), Dr. P. Kallidonis (GR), Dr. Emiliani, Dr. M.P. Luque Galvez (ES) and Dr. Millan

technologies; efficiency of laser fibre passage if the tip of the fibre was cut; the single-use cystoscope to grasp and remove double-J stents. With regard to lithotripsy, we evaluated the holmiumlaser setting to look for the most efficient popcorn technique. I am fortunate to have had a fellowship at Tenon Hospital, access to a laser laboratory (one of the biggest metabolic laboratories for stone analysis) and to hospital facilities which included the radiology and pathology units during collaborative studies. I encourage residents to apply for the EUSP scholarship for an excellent start of their academic career. The EUSP has given me the opportunity to partake in the fellowship which allowed me to

perform the research for my PhD in an optimal setting. About the EUSP The aim of the EUSP is to stimulate clinical and experimental research in Europe and to promote exchange amongst European urologists. Knowledge exchange is the keystone of the progress of European urology care and research standards. Individuals interested in the EUSP scholarship must be a urologist, a urologist in training or urologyassociated scientist with an EAU membership. Further conditions can be found in the description of different programmes. All projects and/or visits must be conducted in a European institution outside the home country. For more information, please visit www.uroweb.org/education/scholarship/ about-the-eusp/.

YUO leadership course sharpens key competences Tailor-made course for young urologists at EAU20 The YUO leadership course aims to give expert recommendations to urologists and health care professionals aged 45 and younger on how to develop leadership and management skills. For Sunday 22 March 2020, during the 35th Annual EAU Congress in Amsterdam, the EAU Young Urologists Office (YUO) has again arranged for a specialist management-and-communications team to help participants acquire effective management skills. During EAU19 in Barcelona, many urologists attended the course. One of them was Dr. Bernhard Haid (AT).

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

What have you learned from the YUO Leadership course? “Taking part in the YUO Leadership course provided me with a comprehensive insight into important principles of leadership in general. By means of pre-course questionnaires, the contents were adapted to the individual participants, allowing for a more tailored focus on personal weak spots. In my case, identifying my weak spots and tackling the associated skills was a main takeaway which provided me with new resources to improve my daily practice. Another highlight was working on challenging questions concerning leadership in urology together with people in a similar leadership situation. The excellent tutorship of the course leaders Mr. Herman Rijksen (NL), Mr. Michiel Evers (NL), Mr. Thijs Quakkelaar (NL), and Dr. Michiel Sedelaar (NL) opened up the invaluable opportunity to exchange views and make contacts. The course alone was too short to cover all relevant aspects; however, with the reading material, the pre-course reading, and the mailings over a longer period of time, I could clearly extend my theoretical knowledge and thus have acquired applicable, relevant new skills.” How have you applied these skills in your daily practice? “I have put my focus on more effectively identifying

October/December 2019

tasks to delegate and to assign those tasks in a more efficient way. Furthermore, I took on the offer of the course leaders to contact them per email with questions arising from daily work. Not only did I get valuable advice whenever I needed it, but I was also recommended helpful literature which later on had a practical impact.” How was the course taught? “It was a delightful experience of learning together in a relaxed atmosphere. The course leaders employed a well-balanced mix of lectures and tasks assigned to groups of participants. One example was to analyse one’s own leadership profile based on the pre-course questionnaire and derive concrete measures applicable in daily life from that.” Do you feel you have become a better urologist because of this course? “The course was a beacon pointing the right way to sharpening key competences. Building leadership skills and reflecting on one’s role within a team is essential for being a good clinician, scientist, surgeon, colleague, and leader. Therefore, probably yes.” To know more about the YUO leadership course, please visit EAU20’s website at www.eau20.org. The deadline for applications is 1 February 2020.

Dr. Bernhard Haid (AT, centre) at EAU19 in Barcelona

European Urology Today

Latest developments in penile cancer EAU supports projects that harness potential to improve future therapies Dr. Maarten Albersen Laboratory of Experimental Urology Dept. of Development and Regeneration KU Leuven (BE) maarten.albersen@ uzleuven.be

Joren Vanthoor Resident in Urology Laboratory of Experimental Urology Dept. of Development and Regeneration KU Leuven (BE) vanthoorjoren@ gmail.com

Anita Thomas Dept. of Urology and Paediatric Urology University Medicine Mainz (DE)

anita_thomas3@ hotmail.com

In collaboration with the European Reference Network for rare urogenital diseases and complex conditions (eUROGEN) Penile cancer (PeCa) is a squamous-cell carcinoma emerging from the upper layers of the inner prepuce or glans. Several histological characteristics of PeCa resemble other malignancies deriving from the superior epithelial layers, such as cutaneous squamous cell carcinoma, carcinoma of the pharynx, uterus, vagina, vulva or anus. PeCa is a rare disease with an incidence of less than 1.00 per 100,000 males in Europe1. About 40% of PeCa cases are at least in part attributable to Human Papilloma Virus (HPV), although there is inconclusive evidence to prove HPV is a prognostic factor1. PeCa exhibits a very aggressive course marked by an early lymphatic and visceral dissemination necessitating rapid diagnosis and treatment in order to provide curative therapy1. Although surgery alone can cure approximately 80% of patients without or with only limited lymph node involvement (pN0-1), advanced or metastatic PeCa requires systemic treatment in the neoadjuvant, adjuvant or palliative setting to improve outcomes compared to a single modality approach, although the evidence base for these options is still very low. Patients with lymph node-positive disease without distant metastasis have a 5-year overall survival rate of approximately 50%2, hence underscoring an unmet need to improve the multidisciplinary approach. Cytotoxic regimen Once metastasised, no curative treatment is currently available for PeCa. At present, limited data from studies of up to 40 patients exist for the palliative management of the disease with platinum-based approaches3-6. In Europe, a cytotoxic regimen with 3 cycles of cisplatin combined with 5-fluorouracil ± taxane is often used in clinical routine. However, resistance to these therapies develops rapidly, resulting in an ORR of up to 30% and progressionfree survival of up to 20 weeks at most. Currently, there is still a limited understanding of the biological mediators that may play a part in prognosis and therapy. We need research that leads to a better understanding of the molecular basis of the disease, its relationship with the stroma and immune systems and its genetic backbone. To this end, we have applied for a seeding grant of the EAU Research Foundation in 2018 and a scholarship of the EAU-EUSP for 2020. We need these resources to establish animal models for penile cancer suitable for preclinical personalised trials and research into mechanisms of chemoresistance in order to provide a platform for novel therapy development. 24

European Urology Today

Fig. 1A: image showing PDTX in nude mouse displaying a cystic area and a solid mass. Fig. 1B: image showing [18F]-FDG uptake during PET-MRI (from left to right: FDG-PET, MRI and fusion image. * marks the graft, other hotspots include the heart, eyes, kidneys and bladder) in the solid tumour in the nude mouse model. Fig. 1C: image showing perfusion in a viable rim of tissue (X) around a central necrotic core in the penile cancer PDTX nude mouse. Left: before contrast, right: after contrast.

Molecular background of penile cancer and implications for new systemic therapies The use of treatment modalities such as cisplatinbased chemotherapy regimens and consolidation surgery methods has increased. Nevertheless, the trends of OS seem to be constant, thus the impact of multimodality therapy options on survival in locally advanced disease remains unclear. Understanding the molecular biology of penile SCC could help to clarify the role of various treatment options in penile cancer. Chronic inflammation is a well described mechanism in the pathogenesis of penile cancer7. Reactive oxygen/nitrogen species (ROS/RNS) produced by inflammatory cells cause DNA damage. The tumour suppressor (TP) gene p16 reacts to this DNA damage by inducing cell arrest and/or apoptosis. It is believed that this p16 pathway plays a critical role in penile cancer development. Other modulators in inflammation-induced carcinogenesis are cyclooxygenase-2 (COX-2) and prostaglandin E2 (PGE2). Overexpression of COX-2 results in an upregulation of PGE2, which leads to proliferation, angiogenesis, and activation of epidermal growth factor receptor (EGFR). Research demonstrated an overexpression of EGFR in the majority of penile SCC8. Additionally, PGE2 activates the PI3K pathway, which is consequently responsible for cell migration and invasion. Indeed, in 29% of the 28 penile tumours, the PI3K pathway was altered9. Anti-inflammatory mediators As COX-2 has been shown to be strongly expressed in penile carcinoma, anti-inflammatory mediators may become important targets of tumour therapeutic approaches. HPV infection is another pathway for carcinogenesis in penile cancer. The HPV oncogenes E6 and E7 inactivate p53, which leads to an inactivation of the p21/Retinoblastoma cascade. This results in an unregulated cell cycle and uncontrolled proliferation. Peter et al. showed in 2006 that inserted HPV DNA leads to up-regulation and amplification of the proto-oncogene MYC leading to uncontrolled proliferation and progression of disease in a penile cancer specific cell line10. It should be noted that penile cancer shares many similarities with other squamous cell carcinomas (e.g. head/neck, oesophageal, cervix SCC), including the activation of COX-2, PGFE2 and EGFR. Antiepidermal growth factor receptor (EGFR) targeted therapies have been used as second-line therapy in refractory cases. Panitumumab, an anti-EGFR monoclonal antibody, showed to be active and safe in highly pre-treated cases of penile cancer. However, this seemed to be without long-term response11. Dacomitinib Dacomitinib is an irreversible, pan-epidermal growth factor (HER) inhibitor. A recently published phase 2 study of Necchi and colleagues included 28 patients with advanced penile SCC treated with dacomitinib in the first line setting12. An ORR of 32.1% (80% CI, 21.0-43.0%), a 1-year progression free survival (PFS) of 26.2% (95% CI, 13.2-51.9) and a 1-year OS of 54.9% (95% CI, 36.4-82.8) were observed. High risk HPV-positive tumours and EGFR amplification was only found in two and four cases respectively. They concluded that dacomitinib was active and well tolerated in the first line setting in patients with penile SCC. The authors highlighted the importance of patient selection for such targeted compounds, based on the downstream effector of EGFR signalling. Mutations of the PI3K-Akt-mTOR pathway were found in 42.9% of responders to 8.3% of non-responders. The prognostic value of this PI3K-AKT-mTOR pathway13 was further evaluated by Azizi et al. In their tissuebased study of 57 patients with invasive PSCC, Akt was up-regulated in 47%. They showed that a low

expression of Akt had an increased risk of recurrence (HR 3.95; 95% CI, 1.47-10.59; p = 0.02). Additionally, they reported HPV as an independent predictor of overall survival as well (HR = 6.99; 95% CI, 2.42-20.16; p < 0.001). Consequently, mTOR pathway biomarkers along with HPV status may represent prognostic factors for the risk stratification of penile SCC13. Frequent mutations Comprehensive targeted next-generation sequencing of several cohorts of advanced treatment naïve primary and metastatic PeCa samples identified a median of two relevant somatic mutations and one high-level copy-number alteration per sample14. Findings of frequent mutations in CDKN2A, NOTCH1, PIK3CA as well as activating mutations in CCND1 and EGFR (all in excess of 20%) point to potential therapeutic direction. In a cohort of refractory and metastatic penile and nonpenile cutaneous squamous cell carcinoma, alterations in the mTOR and DNA repair pathways and tyrosine kinase signalling including FGFR3, EGFR, and ERBB2 were observed15. Furthermore, VEGFR-3 and VEGF-C were upregulated and played a role in chemoresistance in cell line studies. The tumour mutational burden was determined on 1.1 Mbp of sequenced DNA and microsatellite instability was determined on 114 loci15. Further evidence points to a high percentage of tumour cells and tumourinfiltrating leukocytes expressing programmed death ligand 1 (PD-L1) in samples of the primary tumour and in metastases. Importantly, an unfavourable prognostic value of the PD-L1 expression for lymph node metastases and disease-specific survival has recently been highlighted for PeCa patients16. To that end, an interesting ongoing phase 1 trial demonstrated objective responses of the combination of cabozantinib and nivolumab in squamous cell genitourinary tumours, including penile cancer. Cabo-Nivo seems to be well tolerated with no dose-limiting toxicity. Another ongoing phase 2 trial investigates the use of pembrolizumab for advanced penile SCC following failure of chemotherapy. In total, there appears to be a plethora of druggable mutations and amplifications as well as an opportunity for immune checkpoint inhibition meriting evaluation in PeCa. However, the effects of these drugs in PeCa have been understudied due to the rarity of the disease. Thus, there is an urgent need for preclinical translational research to elucidate molecular mechanisms of resistance, figure out potentially effective agents and evaluate counteracting of emerging resistance by combining drugs of different classes and mode of action. EAU support invaluable for eUROGEN driven translational research In the current body of literature, there is a lack of studies utilising patient-derived tumour xenograft (PDTX) nude mouse models for preclinical investigation of PeCa biological behaviour and treatment response. In Leuven and in collaboration with eUROGEN, we have been allocated an EAU-RF seeding grant with which we have developed the first penile cancer PDTX displaying platinum resistance, derived from a post-chemo inguinal recurrence displaying HRAS and NOTCH1 mutations. This model will hopefully pave the way for preclinical testing of novel systemic therapies and is only the first of a planned series of PDTXs with different genetic and expression profiles. Since these tumours display central necrosis and, in some cases, cystic compartments, an adjunct to estimated tumour volume is animal imaging using PET CT and/or MRI which proves to be feasible and provides valuable output on tumour growth and

metabolic activity which can be used as proxies for therapeutic efficacy. In 2020, we will host a one-year EAU-EUSP scholar from Mainz (DE), Anita Thomas, who will further develop these animal models, including humanisation of mice to be able to test immune therapies, and initiate preclinical trials with radiation, systemic agents and combinations of those. We would hereby like to express our gratitude to EAU for supporting projects that harness the potential to improve future therapeutic approaches for PeCa. References 1. Hakenberg OW, Comperat EM, Minhas S, Necchi A, Protzel C, Watkin N, et al. EAU guidelines on penile cancer: 2014 update. Eur Urol. 2015;67(1):142-50. 2. Pandey D, Mahajan V, Kannan RR. Prognostic factors in node-positive carcinoma of the penis. J Surg Oncol. 2006;93(2):133-8. 3. Hussein AM, Benedetto P, Sridhar KS. Chemotherapy with cisplatin and 5-fluorouracil for penile and urethral squamous cell carcinomas. Cancer. 1990;65(3):433-8. 4. Shammas FV, Ous S, Fossa SD. Cisplatin and 5-fluorouracil in advanced cancer of the penis. J Urol. 1992;147(3):630-2. 5. Roiner M, Maurer O, Lebentrau S, Gilfrich C, Schafer C, Haberl C, et al. [Management of penile cancer patients: new aspects of a rare tumour entity]. Aktuelle Urol. 2017. 6. Zhang S, Zhu Y, Ye D. Phase II study of docetaxel, cisplatin, and fluorouracil in patients with distantly metastatic penile cancer as first-line chemotherapy. Oncotarget. 2015;6(31):32212-9. 7. Protzel C, Spiess PE. Molecular research in penile cancer-lessons learned from the past and bright horizons of the future? International journal of molecular sciences [Internet]. 2013 Sep 26 [cited 2019 Sep 8];14(10):19494–505. 8. Gou H-F, Li X, Qiu M, Cheng K, Li L-H, Dong H, et al. Epidermal Growth Factor Receptor (EGFR)-RAS Signaling Pathway in Penile Squamous Cell Carcinoma. Viglietto G, editor. PLoS ONE [Internet]. 2013 Apr 24 [cited 2018 Nov 29];8(4):e62175 9. PIK3CA, HRAS and KRAS gene mutations in human penile cancer. Andersson P, Kolaric A, Windahl T, Kirrander P, Söderkvist P, Karlsson MG. J Urol. 2008 May;179(5):2030-4. 10. Peter M, Rosty C, Couturier J, Radvanyi F, Teshima H, Sastre-Garau X. MYC activation associated with the integration of HPV DNA at the MYC locus in genital tumors. Oncogene 2006;25(44):5985–93. 11. Necchi A, Giannatempo P, Lo Vullo S, Raggi D, Nicolai N, Colecchia M, et al. Panitumumab Treatment for Advanced Penile Squamous Cell Carcinoma When Surgery and Chemotherapy Have Failed. Clinical Genitourinary Cancer 2016 Jun;14(3):231–6. 12. Necchi A, Lo Vullo S, Perrone F, Raggi D, Giannatempo P, Calareso G, et al. First-line therapy with dacomitinib, an orally available pan-HER tyrosine kinase inhibitor, for locally advanced or metastatic penile squamous cell carcinoma: results of an open-label, single-arm, single-centre, phase 2 study. BJU International 2018 Mar;121(3):348–56. 13. Azizi M, Tang DH, Verduzco D, Peyton CC, Chipollini J, Yuan Z, et al. Impact of PI3K-AKT-mTOR Signaling Pathway Up-regulation on Prognosis of Penile Squamous-Cell Carcinoma: Results From a Tissue Microarray Study and Review of the Literature. Clinical Genitourinary Cancer 2019 Feb;17(1):e80–91. 14. McDaniel AS, Hovelson DH, Cani AK, Liu CJ, Zhai Y, Zhang Y, et al. Genomic Profiling of Penile Squamous Cell Carcinoma Reveals New Opportunities for Targeted Therapy. Cancer Res. 2015;75(24):5219-27. 15. Jacob JM, Ferry EK, Gay LM, Elvin JA, Vergilio JA, Ramkissoon S, et al. Comparative Genomic Profiling of Refractory and Metastatic Penile and Nonpenile Cutaneous Squamous Cell Carcinoma: Implications for Selection of Systemic Therapy. J Urol. 2019;201(3):541-8. 16. Ottenhof SR, Djajadiningrat RS, Thygesen HH, Jakobs PJ, Jozwiak K, Heeren AM, et al. The Prognostic Value of Immune Factors in the Tumor Microenvironment of Penile Squamous Cell Carcinoma. Front Immunol. 2018;9:1253.

October/December 2019

Young Urologists/Residents Corner Evidence-based medicine: Training is lacking Perception, attitude, and skills among European Urology residents - results from a survey Dr. Daniel GonzálezPadilla 12 de Octubre University Hospital Dept. of Urology Madrid (ES) Daniel.mx@ gmail.com Evidence-based medicine (EBM) is an important part of contemporary medical practice, yet while much importance has been given to evidence-based practice, there is no data available that tell us that young urologists can fully comprehend the published data. Therefore we decided to determine the current EBM perception among Urology trainees, determine the current prevalence of formal training, evaluate self-appraised skills, and the perceived need for further training.

The main results we found were: • 90% and 84% agreed that EBM is important for daily medical and surgical practice, respectively. • 89% agreed that EBM improves patients care. • 90% agreed that EAU guidelines are a trusted source of information when making evidencebased decisions. • 57.3% have received prior formal training in EBM or epidemiology/statistics of whom only two-thirds received it as part of the residency program. • 75% agreed that the training received (if any) is not enough for daily practice. • Only 51% agreed on feeling confident performing critical appraisal of scientific articles and barely 30% agreed on feeling confident interpreting the methodology and statistics of such papers. The results from the self-assessed understanding of EBM terms are summarised in the next figure.

With our survey, we can conclude that most of the participants think EBM is useful for daily practice and We performed an ESRU (European Society of Residents most of them agree that it improves patient’s outcomes. in Urology) coordinated internet survey distributed through direct invitation, e-mail and twitter, inviting Urology residents training in European countries. About one-third of the respondents have received formal EBM training during their residency programme. Only 25% consider their training The survey included 28-items including ten Likert sufficient for their daily practice and 92% would like scale questions. to receive further training. We gathered 110 valid responses from 18 European countries. The sample was homogeneous with Hopefully, this study has shed some light on this highly important topic and help promote EBM training answers from residents of all years of training, among the European Urology residency programmes, 71% were male and the mean age was 31 years which may subsequently improve patient’s care. old.

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

even worse case yourself? If so…

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

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

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

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

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

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

Personal monetary costs of urology residency An overview of the first results from an ESRU survey Dr. Mário Pereira Lourenço NCO (ESRU) Dept. of Urology Portuguese Institute of Oncology Coimbra (PT) mariolourenco88@ gmail.com A residency in urology is academically, personally and financially demanding. During a residency period, young doctors must attend congresses, courses, buy literature and publish articles, among other costs that are sometimes not noticed by society in general. The personal costs associated with the urology residency have not been studied at a European level before.

(55.3%), were married/ with partner (66.1%) and had no children (74.6%). Some of the most interesting results are presented in the table below: Sponsors The results allow for a general characterisation of the personal costs spent by residents. First, we notice that most residents have training costs of up to € 1999 (63.9%), with a monthly salary below € 1500 in 70.4% of cases. Regarding sponsorships, 24.1% of residents report no sponsors, although 43.8% report more than half of the expenses is paid by sponsors. The largest source of sponsorships is notably the pharmaceutical industry (74.1% of residents had sponsorships in the previous 12 months). Most residents agreed with sponsorship by the pharmaceutical industry and did not feel any commercial pressure.

ESRU survey In November 2018, the European Society of Residents in Urology (ESRU) launched a 34-question survey entitled ‘Personal monetary costs of urology residency’. As the name implies, this survey aimed to evaluate personal expenses during urology residency and their relevance to the quality of medical training. Other more specific objectives were to evaluate the most expensive training areas, the existence of sponsorships, their distribution among residents and to fully understand the importance of personal monetary costs in the personal and professional lives of residents. Finally, the comparison of results between different countries is also important in order to increase the homogeneity of urology residency at a European level.

Low contribution by hospitals The distribution of sponsorships deserves thorough reflection regarding all entities involved in medical education. Results show that the ‘sense of justice’ within the urology departments is 44.6% and only 29.5% in a national perspective. In addition, contrary to what is happening today, most residents (56.7%) argue that monetary support for training should be provided by hospitals/urology departments. These results should alert health authorities: there is a significant amount of training expenses paid by different entities without fair distribution. This fact may create significant differences in access to training opportunities. It is also important to emphasise that hospitals and urology department pay low contributions to training expenses, while the skills acquired by residents have a direct benefit in their activities in daily care.

Survey results The survey ended in June 2019, with a total of 224 responses (male: n = 188/80.4%; female: n = 36/19.6%). Responses were obtained from 25 different countries. The countries with the highest response rates were Poland (14.7%), Greece (13.4%), Portugal (13.0%), Italy (11.2%) and Spain (9.2%). Most residents were in the third year of training (21%), worked in public university hospitals

Objective survey It is difficult to compare between different countries due to the sample characteristics (25 different countries), all with their distinct socio-economic and cultural particularities. However, it is interesting for each country (individually) to compare with other European countries. Therefore, ESRU is available to share the results with the international collaborators.

October/December 2019

European urology residents (n = 224) Monetary spending on urology education in the last 12 months • € 0-999 • € 1000-1999 • € 2000-2999 • € 3000-3999 • € ≥4000

86 (38.4%) 57 (25.5%) 30 (13.4%) 22 (9.8%) 27 (12.9%)

Amount of sponsored spending • 0% • < 20% • 20-49 % • 50-79 % • 80-100 %

54 (24.1%) 37 (16.5%) 35 (15.6%) 45 (20.1%) 53 (23.7%)

Biggest sponsor • No sponsor • Hospital/urology department • Pharmaceutical industry • National Association of Urology • International Association of Urology • Other

54 (24.1%) 27 (12.1%) 126 (53.0%) 11 (4.9%) 3 (1.3%) 3 (1.3%)

In which of the following do you need to spend more personal money on your training? • Courses • Congresses • Literature • Professional internships • Academic formations • Publications of articles • Others Would you be a better urologist if you had more sponsorships? • Yes • No

79 (35.3%) 56 (25.0%) 51 (22.8%) 17 (7.6%) 14 (6.3%) 6 (2.7%) 1 (0.5%)

189 (84.4%) 35 (15.6%)

Do you consider that the distribution of sponsorships in your urology department is fair? • Yes • No Do you consider that the distribution of sponsorships in your country is fair? • Yes • No

100 (44.6%) 124 (55.4%)

66 (29.5%) 158 (70.5%)

Do you agree with the existence of sponsorships by the pharmaceutical industry? • Yes • No

183 (81.7%) 41 (18.3%)

Do you experience any type of coercion or commercial pressure when you accept a sponsorship from the pharmaceutical industry? • Yes • No • Not applicable

42 (18.8%) 157 (70.1%) 25 (11.2%)

What is your monthly base net salary as a urology resident? • € < 500 • € 500-999 • € 1000-1499 • € 1500-1999 • € 2000-2499 • € ≥ 2500 “I do not want to answer” •

13 (5.8%) 58 (28.9%) 80 (35.7%) 31 (13.8%) 15 (6.7%) 22 (9.8%) 5 (2.2%)

Ideally, who do you think should sponsor your training? • Hospital/urology department • National urology association • Pharmaceutical industry • Other • No one

127 (56.7%) 65 (29.0%) 25 (11.6%) 6 (2.7%) 1 (0.45%)

Table 1: Most interesting results of ESRU Survey ‘Personal monetary costs of urology residency’ In conclusion, this survey makes residency expenses and the source and distribution of monetary support (partly) objective. These results may contribute to a serious discussion about the source of sponsorship,

the role of hospitals/urology departments in the training of their professionals and even the prices charged to residents at different courses and congresses. European Urology Today

EUREP19 17th European Urology Residents Education Programme 6-11 September 2019, Prague, Czech Republic

Prof. Palou bids EUREP farewell His legacy, the programme’s aims, and the future For almost two decades now, the European Urology Residents Education Programme (EUREP) has developed into an unparalleled programme for final-year residents popular even beyond Europe. Its participants – past and present – have come to know the dedicated and distinguished experts as their mentors, one of whom is the respected Prof. Joan Palou. More than a decade ago, Prof. Palou began as a EUREP faculty member who later became Chairman of the European School of Urology (ESU). His main responsibilities at EUREP involved overseeing its

Prof. Joan Palou

coordination together with organisers from the ESU; and facilitating the development of the programme.

“To maintain the high standards and quality of education that EUREP provides, we the faculty put great value in the feedback we receive from the residents. We aim for improvement and innovation,” said Prof. Palou.

familial atmosphere,” shared Prof. Palou. “After intensive days of teaching and learning, we spend a few hours of relaxation, bonding and enjoyment such as dinner get-togethers, karaoke and for me, wine-tasting with the faculty.”

Prof. Palou also helped ensure the influx of new faculty members since there is a five-year term of service, and evaluated their performance as well.

EUREP is known for its intensive six-day programme jam-packed with essentials on urological cancer, prostate cancer, andrology, and functional urology to name a few. However, numerous social activities are incorporated into the programme as counterbalance. “EUREP is not solely about developing the knowledge and skills of the residents, it is also about creating a

As Prof. Palou steps down as ESU Chair in March, he looks forward to what the future will bring and feels fulfilled in providing his service to the programme. “I hope to have left a legacy for the future ESU activities such as the next editions of EUREP. My only aim was to help provide and improve the educational activities that would benefit the next generation of urologists.”

Profs. Ahyai and Karsenty join the EUREP team New mentors share aspirations and impressions of the programme This year, two new faculty members, Prof. Sascha Ahyai (DE) of the University Medical Center Göttingen and Prof. Gilles Karsenty (FR) of Aix-Marseille Université, have joined the ranks of the programme’s esteemed mentors.

Prof. Sascha Ahyai

Prof. Gilles Karsenty

Nobel Peace Prize laureate and previous SecretaryGeneral of the United Nations, Kofi Annan, once said “Knowledge is power. Information is liberating. Education is the premise of progress, in every society, in every family.” Through frontline education provided by an expert faculty, EUREP continues to enrich the capabilities of young urologists, encourage innovation and help the advancement of the field.

Prof. Karsenty was one of four mentors in the Functional Urology panel. His responsibilities involved raising the residents’ interests on the importance of evaluation and terminology in functional urology and on the management of neurogenic bladder. Through daily lectures on the diagnosis, medical and surgical therapies of benign prostatic enlargement, Prof. Ahyai shared his valuable insights with the residents during Module 2 “Prostate cancer and male voiding LUTS”. The two new expert mentors also shared their most memorable and rewarding moments. Prof. Ahyai stated, “It was the time spent together as a group during and after the lectures. I appreciate the lively interactions with the residents, and the camaraderie

among fellow faculty members and programme organisers.”

“To continuously work on becoming a better mentor year after year is one of my main objectives,” said Ahyai.

“To continuously work on becoming a better mentor year after year is one of my main objectives..”

Enhancing his presentations is a goal for Prof. Karsenty. “I would like to make my lectures more interactive with more visual aids such as video demonstrations, for instance.” He added, “I would also like to encourage more French urologists in training to apply for EUREP, and to take the European Board of Urology (EBU) exams.” Prof. Karsenty will suggest to his academic colleagues to promote the programme more and to recognise the EBU Fellowship within their national board of urology.

For Prof. Karsenty, there were many noteworthy moments, which included the reaction he received after his first presentation. “I remember my students applauding. Then as I looked over to my colleagues, I could see that they were truly interested in what I had to say and were satisfied with the way I gave the lecture. I enjoyed the many informal talks I’ve had with the residents. They asked a lot of intelligent questions which showed their interest for functional urology. They also gave me good feedback.” He added, “What was also memorable was when well-known faculty members welcomed me during the wine and cheese dinner.” Profs. Ahyai and Karsenty did not join the EUREP faculty to only teach but to learn as well.

Prof. Somani takes on new role at EUREP19 Noteworthy moments, his tasks and plans for the programme Esteemed EUREP tutor of five years, Professor and Consultant Urological Surgeon at the University Hospital Southampton, Prof. Bhaskar Somani (GB) shares his experiences as the new Coordinator for the hands-on training (HOT) sessions and his aspirations for the programme.

drive to improve were extraordinary,” said Prof. Somani. “One notable example was when one of the tutors in the laparoscopy station stayed behind to help a trainee complete all the E-BLUS training tasks. They finished at 9:30PM, which was well beyond the routine completion time. The tutor knew that he would miss dinner with rest of the EUREP group, but New tasks and tutor responsibilities he still decided to put his trainee’s needs first. This The responsibilities of a HOT Coordinator begin before gesture showed true dedication and commitment as the sessions start. “I select the tutors, and I liaise with an educator.” a company to ensure that the correct equipment and kits are provided for the four Transurethral resection Prof. Somani mentioned another trainee who, instead (TUR) stations, five endoscopic skills stations and 15 of taking her lunch break, went through the training laparoscopic skills stations,” stated Prof. Somani. exercises to prepare for the E-BLUS exams instead. “Her hard work paid off. Not only did she pass but His role involves discussions with the tutors on she did well in her exams.” what could be improved and the troubleshooting of trainee- or equipment-related issues, on a daily Objectives reached basis. The tutors were also asked to identify the EUREP has grown since its inception, with its trainees who performed well during the HOT standardised training format and dedicated faculty sessions, and encourage said trainees to take the providing a solid programme. According to Prof. European training in basic laparoscopic urological Somani, the trainee demographics, filled slots, skills (E-BLUS) and Endoscopic Stone Treatment evolution of protocols and technologies applied show step 1 – basic (EST-s1) exams. that EUREP’s objectives are being achieved. Memorable EUREP19 moments “The hard work and passion for teaching shown by tutors; the trainees’ hunger for learning and their 26

European Urology Today

“Even though majority of the trainees are from Europe, participation from non-European countries suggests further collaborations between the ESU and

Prof. Bhaskar Somani

national societies, and wider dissemination of simulation training worldwide,” said Prof. Somani. He added that due to massive interest in HOT courses and exams, all training and exam slots during EUREP19 were filled.

Prof. Somani stated that the standardised training protocols allow for more accurate and measurable training based on the trainees’ needs. “While basic models are more useful to novices, more advanced models will allow complex and more realistic training. A combination of didactic teaching and a supervised HOT improve surgical ability as well as provide real-life, operating-room environments.” Aspirations for the programme Prof. Somani describes EUREP goals in the next two years which will also deliver long-term results. “We will further improve the programme with endoscopic stone treatment step 2a (EST-2a), laparoscopic intermediate skills and endoscopic lower-tract

“I’m truly impressed with the EUREP programme and I feel so proud to be part of it,” he added. “The dedication and effort for education are exactly what motivates me.” “My overall impressions of the programme is nothing but positive. I believe it needs to continue what it does for so many young and promising residents: to educate and to inspire,” said Prof. Ahyai.

curriculum development. We aim to maintain EUREP’s high standards that were achieved over the last decade through thorough tutor selection, curriculum updates that meet the trainees’ needs, and continuous improvement based on received feedback.” Acknowledgements Prof. Somani would like to thank all the HOT tutors who put in their effort to make EUREP a success. The vision of European School of Urology and their "Training and Research group" has led to one of the most successful simulation training programmes of all time. References 1. Somani BK, Van Cleynenbreugel B, Gozen A, et al. The European Urology Residents Education Programme Hands-on Training Format: 4 Years of Hands-on Training Improvements from the European School of Urology. Eur Urol Focus. 2018 Mar 14. pii: S2405-4569(18)30080-4. doi: 10.1016/j.euf.2018.03.002. [Epub ahead of print] 2. Veneziano D, Ploumidis A, Proietti S, et al. Evolution and Uptake of the Endoscopic Stone Treatment Step 1 (EST-s1) Protocol: Establishment, Validation, and Assessment in a Collaboration by the European School of Urology and the Uro-Technology and Urolithiasis Sections. Eur Urol. 2018 Sep;74(3):401-402. 3. Somani BK, Van Cleynenbreugel B, Gözen AS, et al. Outcomes of European Basic Laparoscopic Urological Skills (EBLUS) Examinations: Results from European School of Urology (ESU) and EAU Section of UroTechnology (ESUT) over 6 Years (2013-2018). Eur Urol

Focus. 2019 Jan 17. pii: S2405-4569(19)30007-0. doi:10.1016/j.euf.2019.01.007. [Epub ahead of print]. October/December 2019

Zambia represents at EUREP19 via Urolink New insights gained to benefit clinical practice back home Dr. George Soko University Teaching Hospital Lusaka (ZM)

george1soko@ gmail.com I participated at the 17th European Urology Residents Education Programme (EUREP19) in Prague, Czech Republic which was an experience that I will always cherish in my urology career. The generous efforts of Urolink’s Mr. Chandra Shekhar Biyani (Consultant Urologist) and Mr. Nicholas Campain, together with my chief/consultant urologist Dr. Nenad Spasojevic and Dr. Victor Mapulanga, ensured that a Zambian resident attended the coveted programme which is a first for my country. On Friday, 6 September, I joined fellow final-year residents from other countries at the Clarion Congress Hotel Prague in Vysocany. It was extremely exciting to interact with other highly-motivated and enthusiastic residents. The participants were divided into five groups in accordance with the five programme modules. These covered in-depth topics spanning from urological cancers (testicular, penile, renal and urothelial), male voiding lower urinary tract symptoms (LUTS), andrology, stones and upper tract urology, functional urology, paediatric urology, trauma, to infection. The lectures delivered by internationally-known experts were compact yet covering all the major

components of the latest EAU Guidelines in a lively, interactive and cordial atmosphere. They encouraged open participation, debate on clinical scenarios, publications and evidence that provided basis for the guidelines.

I was guided through the proper URS approach and manoeuvres for a successful procedure, particularly the use of Ureteral Sheaths (US). The US are not available at our hospitals. It was eye-opening to learn how US can aid good ureteroscopic procedures.

The presentations also included videos and multiplechoice questions which affirmed what the faculty members taught. The participants had an opportunity to give their feedback after every lecture session. The lecture sessions were complimented with coffee breaks enabling participants to converse with colleagues from other countries, exchanging ideas on how to deal with urological cases, progression in urological career, and views on how certain practices vary in different centres.

The tutors explained and coached me basic laparoscopic skills; on how to handle the instruments; and operation techniques in a clear, understandable manner. The simulators for urological surgery training are not available in Zambia. Exposure to complex models for effective learning was momentous. It is also prudent clinical practice to make decisions relying on evidence-based guidelines.

I must admit that before the lectures started, the prospect of absorbing a plethora of urological information in just six days appeared daunting. The experience was far better than anticipated. The presentations were stimulating and riveting, particularly the case reports which were very interesting. The key learning points of EUREP19 emphasised evidence-based urology and the sharpening of one’s skills to critically appraise publications. We also learned the importance of clinical acumen in applying proper diagnosis and management to achieve high-quality patient care. HOT sessions The Hands-on training (HOT) sessions were superb. We, residents, had the opportunity to interact with expert tutors one-on-one. They helped us improve our skills. We learned tricks applicable in routine practice.

Meeting residents from Europe

The sessions included transurethral resection, ureteroscopy (URS), and laparoscopy. I participated in URS and laparoscopy trainings. They were marvellous and rewarding experiences. They bridged the gap in terms of training facilities of what we have in my country. The HOT sessions also offered a possibility for participants to take the European training programme in Basic Laparoscopic Urological Skills (E-BLUS) assessment exam.

Ultimately, the programme had a positive impact on how I should manage urology patients in my daily clinical practice. I hope more residents, especially from countries such as mine, will have the opportunity to attend future EUREP programmes.

Extending my appreciation I wish to express my profound gratitude to Urolink through Mr. Biyani for the support rendered in ensuring my successful participation at EUREP19. The continued support of Urolink to urology in Zambia Balanced programme will have a lasting impact on good urology practice EUREP19 was an excellent, well-balanced conference; for many years to come. I am currently compiling the organisers integrated social events into the some easy-to-use resource materials based on what programme. The karaoke and barbecue on Sunday evening was a fun way of making new friends, enjoying was learned at EUREP, to share with other Zambian Urology residents. performances from various national residents’ teams, and faculty members’ team. The party extended to I am grateful for the invaluable experience at EUREP James Deen Prague, which is a popular club in the city. and would like to thank the organising committee and European School of Urology (ESU). It will EUREP19 take-home messages I have gained numerous insights which I am pleased to hopefully go a long way in inspiring a revamp of training facilities for urology trainees in Zambia. bring back to my country.

EUREP19 meets great expectations Learning from top experts, forging bonds with fellow residents Dr. Emilien Seizilles de Mazancourt Hôpital Edouard Herriot Lyon (FR)

This intensive six-day programme is aimed at last-year residents and almost covers the full spectrum of urology e.g. urological cancers, andrology, stones, endourology, paediatric, traumatology, infection, male voiding LUTS and functional urology.

The lectures were delivered by European experts who were then evaluated by the participants afterwards. Lecturers who do not receive satisfactory grades will not be invited the following year. This ensures the high-quality of the comprehensive EUREP lectures. We were comprised of 360 residents from 47 different Also, I think the secret of the experts was their countries at the 17th edition of the European Urology enthusiasm! Residents Education Programme (EUREP19), which was hosted in Prague. It was definitely a not-to-beEUREP is also an ideal programme to prepare missed week! one’s self for the European Board of Urology, as emilien. mazancourt@ hotmail.fr

both the course and the exam are based on the guidelines of the European Association of Urology. The experts had the ability to condense the guidelines and offer the essentials to the participants. HOT courses We had the opportunity to follow some handson-training (HOT) courses on laparoscopy and endourology, either transurethral resection of the bladder (TURB) or ureteroscopy. Each student was assigned to a “Hotty”(also known as a HOT tutor) and together, had more than an hour to work on practical skills with very useful trick and tips. We also had the liberty to sign up for the E-BLUS and EST1 exams which were rewarded with certificates.

Before the lecture commences

Bonding time We had the pleasure to attend the karaoke and barbecue night under the rain. I have to admit that we, French people, are better at urology than singing! Overall, this week was an excellent event to forge bonds with fellow urology residents from other countries.

EUREP19 delivers excellent opportunity for residents Boost your knowledge and skills, meet new friends Dr. Zhivko Siromahov National Oncology Hospital Sofia (BG)

jsiromahov@mail.bg EUREP19 is the latest edition of the high-level training programme designed for urology residents from all over the Europe. It is an excellent opportunity for every young urologist to find new friends and to acquire new skills. I think that the host city, Prague, is perfect place for this event. It is a beautiful and very hospitable city located in heart of Europe. I wonder why the EUREP programme is not popular in my country. Only two participants from Bulgaria attended this year, myself included. October/December 2019

I just signed up as an EAU member when I read about EUREP. One of my colleagues recommended the programme with great enthusiasm. On that day, I was sure that I will be a participant someday. And I was right.

endoscopic stone treatment. In addition, the meeting with the members of European Board of Urology (EBU) was the most important for me. At the registration desk, you can purchase the tests of the EBU exam. To be a Fellow of the EBU is one of my biggest dreams.

The six-day intensive programme started on Friday and covered the whole spectrum of urology. Before lunch, we made a lot of group photos. I thought that the lectures would be a passive intake of facts. I was pleasantly surprised that I was completely wrong. The format of interactive seminars with questions from the lecturers is probably the best. The multiple-choice questions were so important and so useful.

Best group name This year, the winning group name “HYDROCELES”, which stands for “Hot Young Dynamic Residents Obtaining Certified Education, Leading to Excellent Surgeons” describes the course format and the spirit of the participants very well. Congratulations to the Danish group!

On Sunday evening, we had a barbecue party. It was rainy but it was probably the most colourful and multinational party that I ever had. I made a lot of new friends. On Monday after the lectures, I attended the hands-on training course for flexible ureteroscopy. The tutor at

Happy to be at EUREP19

my station was well experienced and I learned a lot from him. He shared his tips and tricks with me. Career opportunities In EUREP, every resident had a wonderful opportunity to boost his/her career. There was possibility to take European training in basic laparoscopic skills and

Participate in EUREP EUREP19 was great event for me. I highly recommend it to everyone! I am very grateful to all organisers, lecturers, tutors an participants. It was great experience and it was a pleasure for me to be part of it. To summarize my feelings about the course, I say: New friends, new skills, new knowledge and new opportunities. European Urology Today

Peyronie’s disease 20 years of evolution in surgical techniques and penile prosthesis implants Prof. Nikolaos Sofikitis ESAU Chair University of Ioannina Medical School Dept. of Urology Ioannina (GR) v.sofikitis@ hotmail.com

According to the 2019 EAU Guidelines, penile prosthesis implantation is typically reserved for the treatment of Peyronie’s disease in patients with erectile dysfunction, especially when they do not respond to treatment with PED5Is. In cases of severe deformity, intra-operative ‘modelling’ of the penis over the inflated cylinders has been introduced as an effective treatment. Furthermore, the EAU Guidelines 2019 indicate that if

there is a residual curvature of less than 30˚ no further treatment is recommended, as the prosthesis will act as a tissue expander which will result in complete correction of the curvature after a few months of cycling the prosthesis. On this page, Professor Castañé presents a state-ofthe-art article about penile prosthesis implants. Professor Kadioglu presents the evolution in surgical techniques for the management of Peyronie’s disease during the last 20 years.

Lessons from 20 years Peyronie’s surgery Prof. Ates Kadıoglu Section of Andrology, Istanbul Faculty of Medicine University of Istanbul (TR) kadiogluates@ ttmail.com Co-author: Dr. Nusret Can Çilesiz Peyronie’s surgery has undergone a significant evolution over the last two decades. This article aims at summarising the cornerstones of the evolution.

under loop magnification is required for this technique3. For patients with hourglass and hinge deformity, the NVB is dissected from the urethral ridge toward the medial side (lateral dissection). One longitudinal graft is required for one-sided deformity and two separate longitudinal grafts are required for hourglass deformity4 (see Figure 2). Geometrical principles Until the introduction of the geometrical principles, H incision was preferred over plaque incision (see Figure 3). Geometrical principles (Egydio technique) with double-ended incision helps to determine to exact site of the incision and the shape and size of the defect to be grafted. It also describes the exact length of the width and height of the triangle at the end of

In the past the gold standard was to completely excise the Peyronie’s plaque. Recent advances in understanding the pathophysiology of Peyronie’s disease showed that the plaque is not localised near the curvature site, it affects the entire tunica albuginea. Therefore, incision became preferred over excision in the last two decades. By avoiding excision the defect size is decreased and erectile dysfunction (ED) is also avoided1,2. Medial dissection One of the newer approaches is to perform medial instead of lateral dissection (see Figure 1). The deep dorsal vein is removed at the prominent side of the curvature and the dissection is carried out from the medial to the lateral side. Medial dissection allows for shorter operation time, less mobilisation of the bundle and better restoration (to clean the bundle from the plaque) of the neurovascular bundle (NVB). Meticulous dissection

the incision. By using geometrical principles the surgeon can easily predict the defect size which provides better straightening of the penis5. The graft type has also changed over the last two decades; from autologous material to allografts or xenografts. Both allograft and xenograft materials provide similar success rates in terms of straightening of the penis and de novo ED rate6. Implantation For patients with refractory ED and penile deformity, implantation of a penile prosthesis with remodelling is the treatment of choice. After the penile prosthesis is implanted and the plaque is excised, the defect can be covered with Buck’s fascia only and graft material is avoided. In two series with large numbers of cases satisfactory anatomic and functional successes were achieved7,8.

Figure 2: Incision site of a patient with Hinge deformity

4. 5.

Peyronie’s surgery will continue to evolve with the development of surgical techniques and with the research on the aetiology and pathophysiology of the disease. So far, the ideal graft material does not yet exist. But we can look forward to materials which mimic the tunica albuginea and will replace the currently used graft materials in the future.

Nesbitprocedure in congenital penile curvaturepatients: medialorlateral? Asian J Androl. 2014 MayJun;16(3):442-5. doi:10.4103/1008-682X.123667. Chang JA, Gholami SS, Lue TF. Surgicalmanagement: saphenousveingrafts. IntJ ImpotRes. 2002 Oct;14(5):375-8. Egydio PH, Lucon AM, Arap S. A singlerelaxingincision to correctdifferenttypes of penile curvature: surgicaltechniquebased on geometricalprinciples.BJU Int. 2004 Nov;94(7):1147-57. Review. Hatzichristodoulou G, Osmonov D, Kübler H, Hellstrom WJG, Yafi FA.ContemporaryReview of GraftingTechniques for the Surgical Treatment ofPeyronie'sDisease. SexMedRev. 2017 Oct;5(4):544-552. doi:10.1016/j. sxmr.2017.01.006. Djordjevic ML, Kojovic V Penile prosthesis implantation and tunicaalbugineaincision without grafting in the treatment of Peyronie'sdisease with erectiledysfunctionAsian J Androl. 2013 May 6; 15(3): 391–394. Kadıoglu A, Salabas E, Özmez A, Ural AF, Yücel ÖB, Ortaç M, Pazır Y, Ermeç B. Peyronie'sdiseasesurgery: Surgicaloutcomes of 268 cases. Turk J Urol. 2018Jan;44(1):10-15. doi: 10.5152/tud.2018.87405.

References

Figure 1: Medial dissection technique

1. Leungwattanakij S, Bivalacqua TJ, Reddy S, Hellstrom WJ. Long-termfollow-upon use of pericardialgraft in the surgicalmanagement of Peyronie'sdisease. IntJ ImpotRes. 2001 Jun;13(3):183-6. 2. Gelbard MK, Hayden B. Expandingcontractures of the tunicaalbugineadue toPeyronie'sdisease with temporalisfasciafreegrafts. J Urol. 1991Apr;145(4):772-6. 3. Akbulut F, Akman T, Salabas E, Dincer M, Ortac M, Kadioglu A. Neurovascularbundledissection for

Figure 3: Double-Y forked incision

State-of-the-art in penile prosthesis implants Dr. Eduard Ruiz Castañé ESAU Board Member Director Andrology Dept. Fundació Puigvert Barcelona (ES)

cases, regardless of aetiology. There are two types of penile prosthesis implants: inflatable (IPP) and non-inflatable (semi-rigid or malleable prosthesis) types. Usually, the non-inflatable prosthesis consists of a pair of rods made of either spiral wire core or silicone material, wrapped in fabric such as silicone or polyurethane jacket.

A variety of semi-rigid prostheses are currently commercially available worldwide. Unlike the inflatable penile implant, no pump is needed to initiate an erection. The penis can be manipulated Erectile dysfunction (ED) is a multifactorial disorder into the “erect” position for sexual activity. A that is defined as the inability to attain and maintain malleable penile implant can be maintained in this a penile erection which is sufficient for sexual position for as long as the patient desires. Other intercourse. The prevalence of ED increases advantages of the semi-rigid prosthesis are the ease significantly in elderly men; ED is seen in over 50% of of implantation, the cost and the fact that the patient does not need to learn how to activate it. men older than 70 years. eruiz@fundaciopuigvert.es

These devices have been shown to be inferior regarding infection. The main complication of the wrong cylinder size, such as the use of an oversized cylinder, mechanical reliability and patient satisfaction rate may result in an S-shaped deformity and buckling. An compared to other hydraulic prostheses. oversized cylinder is responsible for constant pain and exposes the patient to the risk of erosion. The The two-piece IPP consists of a pair of cylinders, connected with tubes to a pump, which are placed in opposite problem is an undersized cylinder, which will have the effect of a ‘concorde deformity’ with the scrotum. The advantages of this device are the excess mobility of the glans. In the era of hydraulic ease of implantation and the cost compared to the three-piece prostheses. The main disadvantage is that inflatable devices, erosions are considered a rare complication. Migration of the reservoir seldomly the degree of rigidity is not 100%, so the risk of occurs, usually when the space that is created through erosion increases. the fascia to access the Retzius space is too big. Three-piece IPP Penile prosthesis implantation is associated with high A three-piece IPP consists of two intracorporal cylinders, a scrotal pump, and a fluid reservoir that is patient satisfaction and improved sexual quality of life. Penile prosthesis implants offer the patient a high placed in the abdomen (Retzius' space or ectopic placement). Postoperative complications are rare and degree of satisfaction when compared to other modalities of treatment of erectile dysfunction, include mechanical failure, infection, wrong sizing, because sex is more spontaneous and the consistency erosion and migration of the component of the and rigidity of the erection is improved. More than prosthesis. The most common mechanical 80% of men and their partners were satisfied with complications are fluid loss, cylinder rupture, the results of surgery. auto-inflation and mechanical breakage.

Currently, the use of oral phosphodiesterase type-5-inhibitors are the mainstay of treatment. However, up to 35% of ED patients may fail to respond to this therapy or it cannot be used due to systemic side effects and drug-drug interactions. Therefore, alternative therapies are required (alprostadil topical cream, intracavernosal injections, vacuum erectile devices or penile prosthesis).

Inflatable The IPP was developed to stimulate normal penile erection, and it consists of a pair of cylinders implanted in the corpora cavernosa which are connected to a pump. When the pump is squeezed and released several times, the cylinders are filled with sterile normal saline, simulating the corpora cavernosa blood filing during physiologic erection.

Penile prosthesis A penile prosthesis offers a surgical solution that restores erectile function in the most refractory of

There are three types of IPP devices: single, two and three-piece prostheses:

As penile prostheses become increasingly developed and technically advanced, the mechanical survival of a three-piece IPP is found to be 81.3% after 10 years. The infection rate is approximately 3%, but this rate increases in case of prednisone prescription (20%), revision surgery (10%), spinal cord injuries (9%), or diabetes (8%).

The single-piece IPP has a small reservoir at the end of each cylinder, that allows for the transfer of a small volume of fluid into a non-distensible central core.

Risk of infection The use of antibiotic coatings such as InhibiZone and hydrophilic material has minimised the risk of

EAU Section of Andrological Urology (ESAU)

European Urology Today

Effective, safe and durable In my experience over the last 30 years, penile prosthesis surgery remains an effective, safe and durable treatment option for male ED. It is no longer the first choice therapy, but is very often the last chance for impotent patients if oral and intracavernosal therapies have not been successful. While the ideal penile prosthesis is probably yet to be developed, scientific advances in prosthesis design, device technology and surgical techniques have made the penile prosthesis a more natural, durable and reliable device. October/December 2019

ERUS19: New steps in live robotic surgery Meeting has lasting impact Hospital Da Luz urology department By Loek Keizer On 11-13 September, Lisbon hosted the 16th meeting of the EAU Robotic Urology Section (ERUS19). Mainland Europe’s westernmost capital was a suitable city for an event that likes to be “on the edge” when it comes to robotic technology. We spoke to Dr. Kris Maes, head of the Da Luz Hospital Urology Department and Chairman of the meeting’s Local Organising Committee. It was Dr. Maes’s department that hosted the event’s trademark live surgery sessions, at some points broadcasting three sessions simultaneously to the congress centre. Reflecting on the meeting as it came to a close, Dr. Maes described himself as “a very happy man. The organisation and venue were perfectly suited to our meeting’s requirements. I’m also very happy that we managed to display the da Vinci SP single port system, as far as I know it’s the first time that it was on display, and we’re very proud of that.” As a novelty for ERUS19, the case presentations that precede each live surgery procedure were filmed in advance and not presented live from the OR by a member of the team. Maes: “This ensured that the presentations had a uniform and informative character. Of course this meant that we could only record the presentations once all the patients were

selected, and we also had to include every back-up case. I am very pleased with the result as it helps to clearly introduce the case to the audience.” Live surgery ERUS19 featured 18 live surgery procedures, spread over six sessions. Procedures included cystectomy with pelvic lymph node dissection and ileal conduit, RARP and NeuroSAFE, Prostatectomy for HBP, Neobladder reconstruction after prostate sparing cystectomy and Colpopromontofixation. “I was in surgery for most of the day,” said Dr. Maes. “I’m very happy with the coordination of my staff at the hospital, who helped develop the live surgery programme. One benefit of concentrating the procedures in a single centre was the simplified logistics: we were able to reserve a small room in the OR so that we could see all the surgeries as they happened and also follow along with the activities in the congress centre.” “The first day of surgery went well, the visiting surgeons were happy. This morning we started on time. There were no complications with patients from the day before. The programme was a good mix of easy and difficult cases, this helped us keep time. Organising the ERUS meeting and its complex live surgery schedule was a challenge for Da Luz Hospital Urology Department. “For three simultaneous operations and visiting surgeons and staff, you need to manage a lot of people and everything needs to fit together,” Maes explained. “Preparations started years ago and since ERUS18 I had a lot of help from Dr. Jochen Walz, who was the host in Marseille. I think it’s a good idea to create a “How to Organise…” manual for ERUS meetings, that will help future ERUS meetings.

ERUS19 could boast live surgery from three operating theaters simultaneously, creating an immersive programme

The hospital and OR staff rose to the challenges, as Maes emphasises that all the surgeons were happy with the quality of the staff.

11-13 September 2019 Lisbon, Portugal

A post-ERUS hospital It’s not every hospital that can host and broadcast three procedures at once. “It’s quite rare that centres have three ORs with robots that are also suitable for broadcasting,” said Maes. “This may be easier for the broadcasting logistics but more difficult for the hospital. In terms of responsibility, it’s also all in our hands should something go wrong.” “I don’t know what the European public opinion is on the state of Portuguese medicine, but I fear it may be underestimated. We have many highly-trained doctors and professionals, but sometimes the conditions in which they work are sub-optimal. In our hospital, this is certainly not the case.”

“An event like ERUS is a good way to get the most out of your team.” The case could be made that by organising an ERUS meeting, a robotic urology department is pushed to find new methods and streamline protocols, leaving it improved after the meeting ends. “An event like ERUS is a good way to get the most out of your team. We’ve seen it now: I knew my team could do it, but now they know it themselves too. We will have a ‘post-ERUS’ hospital, one that is better than it was before. The staff members are better attuned to each other, and strategies have been developed to streamline and not lose valuable time.”

Dr. Kris Maes was head of the local organising committee and head of the Da Luz Hospital Urology Department where the surgery was performed

their choosing, often presenting the progress that they are making. When asked on his view of the impending future for robotic surgery, Maes was intrigued: “I’ve tested the CMR Versius [which was on display at ERUS19]: it has some good features. In my opinion it’s not yet going to convince current da Vinci users to switch. But it might help hospitals who are now just starting with robotic surgery. Possibly it will offer a lower entry price but that remains to be seen. In terms of functional outcome, I don’t think it’s going to be a big difference. If the costs are substantially lower, we might see a (further) democratisation of robotic technology.”

How will future ERUS meetings and educational programmes integrate upcoming robotic systems? Dr. Maes points out that the ORSI Academy, Europe’s foremost robotic surgery training centre has already “As my staff said to me: ‘You brought ERUS here, and we did it.’ I think that’s a good summary of how the made arrangements for a larger diversity of systems. “The ERUS board discusses this topic often. I imagine hospital has risen to the challenge.” that we will have a transitionary period, when the ERUS meeting will work with streams from different Technology forum A recent and significant addition to the ERUS meeting’s hospitals using the different systems. Once the systems programme is the Technology Forum. The forum allows are being put in use, we will certainly endeavour to speakers from robotic companies to speak on a topic of stream and demonstrate their use at our events.”

www.erus20.org

ERUS-DRUS20

Robotic Live Surgery

17th Meeting of the EAU Robotic Urology Section in conjunction with the 12th meeting of the German Society of Robotic Urology 5-7 November 2020, Dusseldorf, Germany

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

Registration opens on 2 March, 2020

October/December 2019

European Urology Today

EULIS19 delivers vital stone updates in Milan Live surgeries, emerging technologies, and expert insights Prof. Emanuele Montanari EULIS Board Member Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Milan (IT) emanuele. montanari@unimi.it

Dr. Alberto Trinchieri Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Milan (IT) alberto.trinchieri@ gmail.com From 3 to 5 October 2019, the 5th Meeting of the EAU Section of Urolithiasis (EULIS19) took place in Milan, Italy with great success. Prior to EULIS19, the well-attended ESU Hands-on Training in Endoscopic stone treatment – step 1 was offered to 36 residents. The course is supported by KARL STORZ and Cook Medical, and organised by Dr. Domenico Veneziano and Mr. Kamran Ahmed.

Four retrograde intra renal surgeries (RIRS) were performed by Dr. Vitor Cavadas, Dr. Esteban Emiliani, Dr. Oriol Angerri Feu, and Prof. Olivier Traxer. They demonstrated the use of reusable digital and single-use endoscopes. Two pre-recorded surgical procedures were presented: RIRS by Prof. Bhaskar Somani and 3D reconstruction for planning of stone treatment by Prof. Francesco Porpiglia. Plenary sessions The first two Plenary Sessions featured the miniaturized instruments for PCNL and ureteroscopy (URS), new lasers for lithotripsy, and complications of the endourological treatment of renal stones. The other Plenary Sessions were dedicated to the most recent technological innovations for the endourological treatment of urinary calculi e.g. ureteroscopic disposables, devices to prevent retropulsion, augmented reality, robotics arm for puncturing renal cavities, and 3D printing. In addition, the sessions also addressed the emerging problem of radiation exposure of patient and surgeon during endourological procedures, as well as, radiation exposure of patients in imaging follow-up.

Thematic Session 5: Stones course for nurses was a EULIS first; it was a course specifically organised for nurses in Italian which included a poster presentation. This session was organised by the European Association of Urology Nurses (EAUN) and acknowledged by the Italian Federation of Nursing Boards (FNOPI). Other notable sessions EULIS19’s Scientific Programme was also comprised of notable sessions which included a video session,

12 moderated poster sessions and five unmoderated poster sessions. During these sessions, more than 150 posters were presented by residents, young endourologists and nurses who addressed the medical and surgical treatment of urinary stones in adults and children, as well as, basic research related to the pathogenesis of urinary stones. On the last EULIS19 day, joint sessions were held in collaboration with other societies involved in stone research such as the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA), International Alliance of Urolithiasis (IAU), and South-Eastern European Group for Urolithiasis Research (SEGUR).

Awardees EULIS19 recognised frontline clinical and research work. The awardees were the following: • Prof. Guohua Zeng received the Basic Research Award on behalf of Dr. Yang Liu for their team’s research which was entitled “Androgen receptor (AR) increases intrarenal CaOx crystal deposition via increasing urinary oxalate through differentially regulating renal SLC26A6 expression and intestinal SLC26A6 expression.” • Dr. Eugenio Ventimiglia was granted the Best Resident Poster for his team’s poster “Is the introduction of single use flexible ureteroscopes capable of preventing reusable scopes breakages? Results from a high-volume center.”

Around 600 attendees participated at EULIS19. Some hailed from countries outside Europe such as China, Egypt, Japan, Pakistan, South Korea, to name a few. Live surgeries The two live surgery sessions were the main and most followed events, broadcasted in high definition from the operating rooms of the Urology Department of the Packed room during Thematic Session 5: Stones course for nurses Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico located in Milan. In the three operating rooms, eight surgeons took turns performing endoscopic procedures for the treatment of kidney stones. On the first day, Prof. Evangelos Liatsikos presented his puncture technique to access the renal cavities to perform the standard percutaneous nephrolithotomy (PCNL) in prone position. Prof. Guohua Zeng demonstrated the supermini-PCNL in prone position using the instrument he developed himself.

The Italian Society of Urolithiasis (CLU), chaired by general secretary Prof. Domenico Prezioso, organised Thematic Session 4 which covered the European guidelines on urolithiasis and practical applications.

• Dr. Amelia Pietropaolo and her team were recognised for their research with the Clinical Research Award. Their research was entitled “Endourological management (PCNL) of stones in solitary kidney - A systematic review from European Association of Urologists (EAU) Young Academic Urologists (YAU) and Uro-Technology (ESUT) groups.” • Dr. Raffaele Vitale and his team received the CLU Best Poster Award for their poster “Osteoporosis is a risk factor for nephrolithiasis in an adult Caucasian population”. • Dr. David Esteban Díaz-Pérez and his team were recipients of the Peter Alken Award for their research “Sepsis after ureterorenoscopy: Development of a predictive model”.

Esteemed experts shared their insights during these Plenary Sessions such as Prof. Peter Alken on PNL in Europe; Prof. Palle Jörn Sloth Osther on the evolution of ureterorenoscopes; Prof. Bernhard Hess on the medical management of stones; Dr. Jan Halbritter on genetics and stones; Dr. Giovanni Battista Fogazzi on urinary sediments in stone patients; and Prof. William Robertson on basic research in stone disease. Thematic sessions Multidisciplinary sessions focused on the pathogenesis of calcium and non-calcium stones in the treatment of ureteral and renal stones using different procedures.

Prof. Montanari’s TV interview with Studio Aperto 1 during EULIS19

On the second day, Prof. Michael Straub carried out a mini-PNL in prone position for a complex stone. Prof. Montanari demonstrated a PCNL in supine position using the vacuum-assisted mini (16.5 Ch) ClearPetra system. In the course of various procedures, different kinds of energies were used for lithotripsy and litholapaxy.

In Thematic Session 1 Paediatric stone management, paediatric nephrologists and urologists presented various reports on the genetics of rare stones; and the medical, extracorporeal and endoscopic treatment of urinary stones. Thematic Session 2 Resident corner: Petra Group focused on the technological, clinical and educational topics. Thematic Session 3 Clinical and metabolical evaluation of stone forming patients discussed hypercalcemic diseases, screening of monogenic defects, metabolic syndrome, the contribution of physical activities, the effects of stress, and many more.

Prof. Zeng receives the Basic Research Award on behalf of Dr. Liu.

Dr. Pietropaolo is recipient of the Clinical Research Award

Technological innovations in endourological stone treatment Dr. Elisa De Lorenzis Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Milan (IT) elisa.delorenzis@ policlinico.mi.it During the 5th Meeting for the EAU Section of Urolithiasis (EULIS19) in Milan, plenty of technological innovations have been presented foreseeing an easier endoscopic treatment of urolithiasis in the future. For patients who are candidates for endourological treatment during the live surgery sessions, 3D reconstruction of the stone, urinary tract, renal parenchyma and adjacent organs were prepared to allow an accurate planning of

percutaneous puncture. 3D-printed models were available for the PCNL cases during live surgery. This is a first step towards augmented reality based on the projection of a hologram on the skin making the patient "transparent". The first experiences in this field were shown using an iPad and a HoloLens viewer by Prof. Jens Rassweiler and Prof. Francesco Porpiglia, respectively. Other interesting news is the clinical application in mini-PCNL of vacuum-assisted technologies (super-mini perc and ClearPetra). This transformed PCNL from an open system to a semi-closed system aiming to have better vision, shorter operating time, lower pressure inside the kidney reaching more consistent results, by Prof. Alken underlined as stone-free, which meant no stone was left behind. These innovations, together with other improvement of robotics, imaging and laser technology are promising in facilitating and reducing morbidity of endourological procedures.

Prof. Liatsikos performs PNL standard prone live during Plenary Session 1

European Urology Today

October/December 2019

ELUTS19: Recap and highlights A fusion of andrology, GU reconstruction and functional urology

By Erika De Groot

According to Prof. Kluth, there is a lack of guidelines and consensus on perioperative algorithms. He Around 300 participants from 40 countries joined the emphasised the importance of publishing institutional recently-concluded 3rd edition of the European Lower standards as these are the basis for evidence-based Urinary Tract Symptoms (ELUTS19) meeting. medicine, especially in rare diseases and surgeries. Organised in collaboration with the International He added that large multi-centre studies could Continence Society (ICS), ELUTS19 kick-started on 31 provide sufficient number of patients to allow for October 2019 in the historic city of Prague, Czech statistical power as prospective (randomised Republic. controlled) trials are needed. In addition, institutional standardised voiding trial has a high predictive value Day one launched with a simultaneous to identify those patients at high risk for early stricture commencement of the section meetings of the EAU recurrence. Section of Andrological Urology (ESAU) and the EAU Section of Genito-Urinary Reconstructive This was followed by the “Radiotherapy Surgeons (ESGURS), as well as, a masterclass reconstruction LUTS” session, which was chaired by organised by the European School of Urology (ESU) Ms. Tamsin Greenwell (GB). The session examined and the EAU Section of Female and Functional ureteric issues, sphincter replacement with regard to Urology (ESFFU). male stress urinary incontinence (SUI), and more. The session was succeeded by the “Ureteric Masterclass coverage Reconstruction” session, which included the Course Director Dr. John Heesakkers (NL) welcomed point-counterpoint deliberations on open versus delegates for the first part of the ESU-ESFFU robotic ureteral reimplantation in children. Masterclass on Functional Urology. The programme was comprised of deliberations under guidance of Prof. Mesrur Selçuk Silay stated that open ureteral Prof. Elisabetta Costantini (IT), Prof. Hashim Hashim reimplantation remains the gold standard for (GB), and Prof. George Kasyan (RU), who are correcting vesicoureteric reflux. However, roboticrenowned for their clinical and scientific experience assisted laparoscopic ureteral re-implant (RALUR) is a in functional urology, investigations on the valuable alternative and should be performed in developments in stress incontinence, sexual experienced centres. According to Prof. Silay, the dysfunction, neuroanatomy, and bladder pain standardisation of the RALUR technique increases the syndrome, to name a few. The second part of the success of the procedure. masterclass resumed the following day.

Some of the notable lectures included the presentations of Prof. Thorsten Diemer (DE) on the effects of Selective Serotonin Reuptake Inhibitors (SSRIs) on male reproductive potential. Prof. Diemer stated that endocrine disruptors may cause testosterone deficiency. He also expressed caution in usage of SSRIs in men of reproductive age, and in pregnant females as it might affect their male offspring. This lecture was followed by Prof. Ates Kadioglu’s presentation “Lessons learned over 20 years in Peyronie’s surgery”. According to Prof. Kadioglu (TR), incision is preferred over excision in the last two decades. By avoiding excision, the defect size is decreased and erectile dysfunction is also avoided. He added that by using the geometrical principles such as that of the Egydio technique, the surgeon can easily predict the defect size which provides improved straightening of the penis.

Prof. Sofikitis (left) and awardee Prof. Dohle (right)

During the ESAU section meeting, Prof. Gert Dohle (NL) was recognised as an esteemed Honorary Member of the ESAU. He is the third recipient of the award. Prof. Sofikitis described Prof. Dohle as “A person who acts as a stimulatory factor that inspires young residents and colleagues from all over the world to love urology and to become better clinicians.” ESGURS section meeting recap The ESGURS section meeting lead with a session on urethral surgery chaired by Ass. Prof. Roland Dahlem (DE) and Ass. Prof. Luis Alex Kluth (DE). This session covered semi-live surgeries on strictures and presentations such as Prof. Kluth’s “Improving results of buccal mucosal graft urethroplasty by standardised perioperative algorithms”. October/December 2019

ESU-ESFFU masterclass faculty and delegates

He stated that the key symptoms are best identified by the International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS), due to the inclusion of Urge Urinary Incontinence (UUI), post-micturition dribble (PMD) and individual symptom bother. Joint sessions and workshop The Joint Session of the ESFFU, ICS, and ESGURS entitled “Male Incontinence. What is new in 2019?” concentrated on topics on post-prostatectomy incontinence, sling, artificial sphincter, and more.

Updates at the ESAU section meeting The ESAU meeting delivered relevant updates on varicocele and azoospermia, genetic factors in male infertility, priapism, therapeutic pharmaceutical agents, and more. The meeting was overseen by ESAU Chair Prof. Nikolaos Sofikitis (GR), and Chair of the EAU Section of Urologists in Office, Prof. Helmut Haas (DE) co-chaired the initial sessions of the meeting.

Great turnout at the ESGURS meeting

To Dr. Beatriz Bañuelos, open ureteral reimplantation is considered “safe and sound”. Parents of the young patients chose open surgery 74.9% of the time as the parents perceived no difference in preference for the cosmetic outcome of open versus minimally-invasive surgery. Moreover, the length of the submucosal tunnel is an important factor in the success of ureteral reimplantation which could explain why extravesical techniques with shorter tunnels have less rate of resolution. The state-of-the-art lectures by Young Academic Urologists (YAU) Reconstructive Working Group concluded the ESGURS meeting. ELUTS19’s second day Esteemed faculty members EAU Secretary General Prof. Chris Chapple (GB), Prof. Sherif Mourad (EG) of the ICS, Prof. David Manuel Castro Díaz (ES) and Prof. Francisco Cruz (PT) welcomed delegates on day two of ELUTS19. During the first session of the meeting “Management of LUTS in men”, Chairman of the History Office of the EAU Prof. Philip Van Kerrebroeck (NL) shared his expert insights in the management of nocturia. He stated that more than 80% of male patients with nocturia have nocturnal polyuria (NP), and emphasised that NP comorbid with benign prostatic obstruction (BPO) and/or overactive bladder (OAB) must be addressed.

31 October - 2 November 2019 Prague, Czech Republic

In his presentation “Role of conservative therapy of post-prostatectomy incontinence,” Assoc. Prof. Bary Berghmans (NL) stated that pelvic floor exercises are useful after radical prostatectomy. "There is indeed a significant impact on the duration and degree of the incontinence. However, in many countries, it is still unclear how to organise these in terms of when to start and which type of pelvic floor exercises,” said Prof. Berghmans. The Joint Session of ESAU and ESGURS focused on surgery for erectile dysfunction with lectures on approaches on the treatment of post-prostatectomy incontinence; procedures for the inflatable penile prosthesis; and management of the infected penile prosthesis, to name a few. The second part of the ESU-ESFFU Masterclass on Functional Urology resumed and focused on overactive bladder and evolution in male LUTS. Through the guidance of Mr. Nikesh Thiruchelvam (GB) and Prof. Frank Van Der Aa (BE), the masterclass delivered case-based approaches regarding performance and dealing with complications of urinary diversions. Prof. Salvador Arlandis (ES), Prof. Hashim and Prof. Enrico Finazzi Agrò (IT) lead the Urodynamic Workshop, which was centred on essentials in UDS and discussions on urodynamic traces. Twenty-one abstract presentations concluded the second day of ELUTS19. Final day of ELUTS19 ELUTS19 concluded on 02 November 2019 and imparted delegates with developments on Pelvic Organ Prolapse (POP), female SUI, neuro-urology insights, applications of laparoscopy and robotic

laparoscopy, and presentation of abstracts selected for the “Best of the ICS” session. The “POP Update” session was chaired by Prof. Elisabetta Costantini (IT) and Prof. Mourad. In this session, Dr. Alex Disgesu (GB) underscored the importance of specialised training for clinicians who would opt for surgical mesh in treating POP or SUI during his presentation “Pelvic pains after vaginal repair of POP”. Dr. Disgesu added that in most cases, POP can be treated successfully without mesh. If mesh it so be used for POP repair, transabdominal mesh placement may result in lower rates of mesh complications. In the following session, “Female stress urinary incontinence”, which was chaired by Prof. Tufan Tarcan (TR) and Dr. Nikolaus Veit-Rubin (AT), Prof. Karl Dietrich Sievert (DE) stated that bulking agents may be offered to female patients as therapy for recurrent or persistent SUI following antiincontinence surgery. However, the outcomes are likely inferior to repeat anti-incontinence surgery in the long term. During the session on practical neuro-urology chaired by Mr. Rizwan Hamid (GB) and Prof. Sievert, Prof. Mourad stated that enterocystoplasty continues to be an effective tool in decreasing bladder pressure, preventing or reversing upper-tract deterioration, and managing socially unacceptable incontinence in some patients. According to Prof. Mourad, complications following cystoplasty are frequent and related to the use of intestinal segments. He added that overall reported outcomes are remarkable for a high-continence rate and acceptable patient satisfaction; however complications are evident in approximately a third of the patients. Session Chairs Prof. Cruz and Prof. Castro Díaz presented selected abstracts for the “Best of ICS 2019” session, which marked the completion of ELUTS19. To all the participants of ELUTS19, thank you very much and see you in the next edition!

According to Prof. Van Kerrebroeck, desmopressin can successfully and safely treat nocturia in men caused by NP. He stated that combination therapy (desmopressin + anticholinergics/β 3 agonists + α1- blockers) is feasible to improve nocturia in men with BPO and/or OAB with NP. This lecture was followed by Prof. Hashim Hashim’s presentation “Can urodynamics improve the functional outcome of TURP? Lessons from the UPSTREAM study”. According to Prof. Hashim (GB), if assessed properly (i.e. through symptom score, a bladder diary, flow rate, and sexual function assessment), urodynamics (UDS) is optional in men principally bothered by voiding LUTS. He added that inclusion of UDS in male LUTS assessment will achieve the equivalent symptomatic outcomes following treatment.

Only standing room left at the ESAU meeting

European Urology Today

PCa19: "Practical conclusions for daily work" Imaging, surgery and drug options compared in case-based Prague meeting By Loek Keizer Organisers look back on a successful third edition of the EAU’s Update on Prostate cancer. Prof. Jeroen Van Moorselaar, who chaired the PCa19 Scientific Committee and participated in the meeting as a faculty member noted the dedication of the audience. “In most congresses, the participants come and go throughout the day, cherry picking the programme. In more educational meetings like this one, people stay for the whole programme and remain interested.”

11-12 October 2019 Prague, Czech Republic

EUREP course for many years,” said Van Moorselaar. “It is well suited to our purposes, as there is a large conference hall, and many smaller rooms for the case discussions.” “Most participants were urologists or residents in training from Europe. The presenters were not only urologists but from many more specialities in the field,” said Van Moorselaar. “EMUC might be a much larger multidisciplinary congress that addresses urological cancers, and together these congresses cover the whole field over prostate cancer.”

The meeting took place on 11-12 October in Prague. It is a cooperation between the EAU and the European School of Urology, making this a uniquely educational meeting. Prof. Van Moorselaar has been involved in making the scientific programme since PCa18. In Prague, he chaired the session on focal therapy on Saturday morning.

“But the major advantage that PCa19 has are the case discussion sessions. Cases are presented to small groups of delegates, and then the work-up and treatment of patients is discussed in the group. This gives much more interaction between the audience and the presenters.”

Educational character PCa19 welcomed 213 delegates and 20 faculty. “The congress hotel might have been familiar for some of the participants, as it has served as the venue for the

Hot topics Important topics that were covered in Prague were the new imaging options that are starting to become available in the participants’ hospitals like mpMRI

The session on focal therapy, as chaired by Prof. Van Moorselaar (right) and also featuring contributions from Profs. Joniau, De Meerleer and Palou

and PSMA-PET. New treatment options are becoming available for metastatic hormone sensitive prostate cancer, but also for non-metastatic castration resistant prostate cancer. These topics were covered in the presentations, as was the treatment of oligometastatic disease. The programme was designed to allow comparison between the various medical and surgical options available to PCa specialists. The case discussions in particular made this come to life for the delegates. Together, the case discussions and expert presentations “offered an up-to-date overview, with practical conclusions for daily clinical practice,” according to Prof. Van Moorselaar.

Some of the PCa19 faculty pose on the Vltava river

PCa19 drew 213 delegates to Prague, from a wide variety of disciplines and backgrounds

The EAU Update on Prostate Cancer will return in 2020. Check back on www.pca20.org as details will become available!

Leipzig welcomes "present and future of surgical technology" Registration still open for EAU’s uro-technology meeting “ESUT20 is THE event where experts and beginners can see the present and future of surgical technology,” says Dr. Bernardo Rocco, board member of the titular EAU Section of UroTechnology of the section’s upcoming 7th meeting in Leipzig, Germany. Delegates can look forward to two full days of the best of uro-technology, mainly demonstrated by means of live surgery broadcasts. Pre-recorded videos of special cases will fill the gaps in the live programme. The meeting will take place on 23-24 January 2020 and will be held in conjunction with the German Society of Urology’s (DGU) Working Groups of Endourology, Laparoscopy and Robotic-Assisted Surgery. Late registration is available until January 15th. Different fees are available for EAU Members, Nurses, Residents and Medical Students.

Register now for the late fee! Deadline: 15 January 2020 Upcoming technology Dr. Rocco gives a preview of what technologies can be expected in the OR in the near future, much of which will be demonstrated in Leipzig. Urologists can use meetings like ESUT20 to prepare for this future.

“That meeting saw experts in endourology, laparoscopy, robotics, all joined together for three days of live surgery in the comfortable setting of the high-tech city of Ferrari and Lamborghini. Dr. Bernardo Rocco, Modena (IT) Board member, EAU Section of Uro-Technology

New developments in laser and microscopy combine to form a potential breakthrough technique. Rocco: “With great interest I follow the increasing role of laser for upper tract urothelial carcinoma, together with in vivo microscopy. At the moment we are studying, with promising results, the ex vivo fluorescent microscopy for prostate biopsy and intraoperative frozen section. We will show very interesting results in Leipzig.” Far from reducing the surgeon to a cog in the machine, or a technician to the increasing number of devices in the OR, Rocco sees the surgeon as someone very much in charge. “I work a few minutes’ drive from the Ferrari factory in Modena, and it is easy for me to make parallels between surgery and car racing. Today more than in the past, technology is essential! But the skilled driver still makes the difference in a race.”

Working with the DGU ESUT20 is co-organised with the DGU Working Groups of Endourology, Laparoscopy and Robotic Assisted Surgery, specialised sections of the Germany Urological Society. What can ESUT20 delegates expect from the collaborative meeting?

Beyond robotics, “digital and disposable endoscopic devices are improving kidney stone treatment and furthermore new lasers are of great interest for prostate surgery.”

Dr. Rocco hopes to replicate the successful experience of the ESUT18 in Modena. “There, we integrated attendees from the ESUT with the those from the Italian Endourologic Association.”

European Urology Today

On a final note, Rocco adds: “In Leipzig there is a wonderful Porsche Centre, to keep the association between car racing and uro-technology going. We will be in good hands and I look forward to seeing all of our colleagues in Leipzig!”

ESUT20 7th Meeting of the EAU Section of Uro-Technology in conjunction with the German Working Groups of Endourology, Laparoscopy and Robotic Assisted Surgery 23-24 January 2020, Leipzig, Germany

Incl. Live Surgery

For the complete Scientific Programme visit www.esut20.org

“In the short term, the variety and amount of robots for prostate, kidney and reconstructive surgery will grow,” Rocco says. “With the expected advent of new competitors on the market, robotic surgery will become more widespread. Robotics training centres such as the ORSI Academy will be the key for today’s young urologists to prepare adequately for this.”

Similarly, ESUT20 will provide all of us -German, European and worldwide urologists– the best opportunity to share individual research and

expertise, and improve the common knowledge in uro-technology.”

www.esut20.org Arbeitskreis Endourologie

October/December 2019

ESOU20 to unveil GU fundamentals in Dublin New session, a battle of nations and potential breakthroughs By Prof. Morgan Rouprêt, ESOU Chairman

EUO links The ESOU has a strong collaboration with the European Urology Oncology (EUO) journal as EUO’s Editor-in-Chief, Prof. Alberto Briganti (IT) and Associate Editor, Dr. Gianluca Giannarini (IT) are both ESOU Board members. We will award the best oncological article by a young urologist published in the EUO to illustrate how young urologists are active and flourishing in the field of academic publications.

Expect a wide-range, accurate overview of current novelties in onco-urology at 17th Meeting of the EAU Section of Oncological Urology (ESOU20). Join us in Dublin, Ireland from 17 to 19 January 2020 for onco-urological fundamentals such as combined therapeutic sequences for advanced diseases (e.g. surgery + in locally perioperative systemic drug); the stratification of advanced diseases; the role of molecular and genetics medicine in the personalisation of the treatment management of our patients, to name a few. ESOU20 is also designed to address challenges such as the promotion of the role of European urologists as principal caregivers regarding genitourinary (GU) cancers. The meeting is the quintessential platform to demonstrate how substantial the network urologists actually is, and to expand it further with new connections with colleagues in the field of oncology.

Interactive session during ESOU19 meeting, Prague

natural history of cancer (focal, localised, advanced and metastatic); and to emphasise the importance of stepping back a bit from the purely technical aspects of surgery to get a more expansive understanding.

STEPS programme Young promising clinicians can look forward to the For urologists, it is important that they remain the Sessions To Evaluate ProgresS in the management of main advocates of large uro-oncological trials, urological cancers (STEPS) programme, which will especially in areas where low-level evidence exists, as offer them the opportunity to interact with the ESOU this will promote consensus statement articles and Board and other experts, and provide new will link the EAU with major uro-oncological societies. perspectives regarding a career in onco-urology. For ESOU20, we invited colleagues from American Society of Clinical Oncology (ASCO), European Society An ESOU Board member and a field expert will for Medical Oncology (ESMO), and European SocieTy oversee a table of participants. One participant from for Radiotherapy & Oncology (ESTRO) to participate. each table will be selected and granted the opportunity to give a presentation at a Plenary Core topics Session at the next ESOU meeting. The ESOU20 Scientific Programme will cover topics on prostate cancer, renal cell carcinoma, urothelial The STEPS programme will support ESOU in its cancer and rare tumours (e.g. penile carcinoma). We continued scientific and research-focused projects by will dive and dig in as much as we can in the strengthening existing ties and encouraging more substratification of these diseases based on the research projects.

ESU-ESOU session In collaboration with the European School or Urology (ESU), the new session “Immunotherapy for the treatment of urological cancers” was developed to offer participants an overview of what is underway; and what essentials from the latest phase II and phase III trials they can incorporate in their daily clinical practice. Battle of nations In the ESOU20 Plenary Session “Game of thrones: Battle of Nations”, three national research groups will assess major improvements in the field of onco urology in their countries; talk about how their groups are organised; and discuss their plans. These research groups will include the Comité de cancérologie de l'Association française d'urologie (CCAFU) of France, the Spanish Urology Association for Oncological Treatment (CUETO) of Spain, and the Scandinavian Prostate Cancer Group (SPCG) of Sweden. What the future holds In oncology, individual therapy and personalised medicine will transition from theory to practice very

rapidly. The treatment of cancer should focus on the treatment of cancer cells rather than on the surgical extirpation of an organ. Thus, in investing in medicine that uses information such as a patient’s genes, his/ her environment, and proteins is key for the prevention, diagnosis and treatment of diseases. In the coming years, some medical specialties such as radiology and pathology, might become obsolete. As urologists, we need to incorporate novelties in our practice not only from evidence-based medicine and pharmaceutical trials, but also from big data and artificial intelligence. The conflict between standardisation and individualisation has always been a characteristic of medical activity. The high cost of testing and treatments are among the most important factors that influence the integration of individualised medicine approaches in general practice. Some key areas for the future management of GU cancers include genetic polymorphism, the influence of environmental factors, chemoprevention and focal therapies.

Check out the Scientific Programme: esou.uroweb.org/ scientific-programme Explore the ESOU20 Scientific Programme Check out the rest of ESOU20’s dynamic programme. Visit www.esou.uroweb.org/scientific-programme/ for more information.

ESOU 20

17-19 Janua ry 2020 Dublin, Ireland

www.esou20.org

Fellowship Programme

www.baltic20.org European Association of Urology Nurses

BALTIC20 7th Baltic Meeting in conjunction with the EAU 22-23 May 2020, Minsk, Belarus An application has been made to the EACCME® for CME accreditation of this event

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

Call for Abstracts Deadline 1 April 2020

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

October/December 2019

European Association of Urology Nurses

European Urology Today

First MMISU meeting: Sharing MIS nursing skills Egypt successfully hosts international experts in minimally invasive surgery Harold Omana, RN, BSc, MSc Surgical Care Practitioner in Robotics Guy's and St. Thomas' Hospital TLondon (UK) Harold.Omana@ gstt.nhs.uk The first annual meeting of Mediterranean Minimally Invasive Surgery in Urology (MMISU 2019) was held in the beautiful city of Alexandria in Egypt from 18 to 20 April 2019. The meeting venue was in the convention centre of the iconic Bibliotheca Alexandrina, a prestigious and historical place in the heart of the magnificent Alexandria. Informative conference Prof. Evangelos Liatsikos, Honorary Chairman, alongside Prof. Ashraf Koraitem and Prof. Aly M. Abdel-Karim and a team of distinguished urologists organised this amazing and exceptionally informative conference. The meeting was organised in collaboration with the European Association of Urology (EAU), EAU Section of Uro-Technology (ESUT), EAU Section of Urolithiasis (EULIS), Society of Urologic Robotic Surgeons (SURS), Endourological Society (ES), International Continence Society (ICS) and International Urogynaecology Association (IUGA) and last but not the least, the European Association of Urology Nurses (EAUN).

MIS surgeries and open panel discussions which caught everyone’s attention. Through live surgeries, these eminent pioneering surgeons showcased their expertise and demonstrated various practices and advanced technical skills (mostly the ‘tips and tricks’) in numerous procedures in the field of minimally invasive urological surgery. These sessions were very beneficial for registrars and newly appointed consultant urologists in order to enhance their skills before performing their first operation. Nurses educational course for MIS in urology Prof. Aly M. Abdel-Karim, the conference’s General Secretary, has organised the educational programme for the nurses in collaboration with the EAUN to produce a suitable agenda for endourological nurses in Egypt. I was honoured to be invited to lead the programme and felt privileged to share my knowledge and expertise in minimally invasive surgery in the field of urology. The session was divided into two parts: laparoscopic and endoscopic sessions. Laparoscopic instruments In the laparoscopic section, we started with a brief discussion about the history of laparoscopy followed by recent technological advancements in MIS in urology. We pursued the session with safety checks and the significance of the WHO Surgical Safety Checklist before and after surgery. We also went through the standard and advanced lap stack system and instruments. Although the audio-visual presentation was great, it would have been better to

Up-to-date innovations As minimally invasive surgery (MIS) has evolved over the years, the urological world has been at the core of the latest developments, can be argued to be ‘above par’ from its MIS counterpart in other surgical specialties. The most up-to-date innovations and cutting-edge technology in the minimally invasive surgery world and the field of urology were presented at this meeting. The faculty consisted of well-known experts and top speakers from all over the endourological world. The scientific programme was thoroughly prepared and had the best combination of live and semi-live

The chairs of the nurses' workshop (left to right): Harold Omana, Prof. Aly Abdel-Karim, Prof. Ashraf Koraitem

Assembled delegates and faculty of the nurses educational course for MIS in urology

have the actual lap system and instruments at hand for demonstration purposes. Positioning during endoscopy Before the tea break, we had a prolonged and interesting discussion about the importance of endourological nurses and our role in surgery success. We all agreed that everyone has a specific role and should be acknowledged as an integral part of the perioperative team. In the endoscopic session, the speakers discussed further about the theatre set-up and the proper positioning during endoscopy. They have also highlighted the significance of the WHO Checklist and Time Out in theatres. This session was brilliantly presented by the local members of the Faculty of Nursing in Alexandria. Educational section successful Overall, the educational section for the nurses was indeed a success! Although it was only a half-day session, the nursing delegates were very enthusiastic about the presentation. They were very keen to learn and keep themselves up to date in the latest trends in minimally invasive surgery in urology. They truly understand the importance of updating oneself through training courses for their professional development. They suggested that during the upcoming MMISU in 2020 they would like to participate in practical sessions such as hands-on training (HOT) courses on the Lap Stack System or the current endourological innovations on the market.

EAUN membership At the end of the session, the delegates received detailed information about the EAUN, its advantages and benefits for its members. This has provided the nurses with a fantastic overview of how they can become member. The group showed great interest in applying and becoming international or associate EAUN member, in order to enjoy the advantages and benefits of a world-class organisation. Travelling to Alexandria was already a highlight of my trip to Egypt but chairing the session and deliberating with these excellent delegates was just sensational! I would like to take this opportunity to send my gratitude to Prof. Aly M. Abdel-Karim and his team for their hospitality and for inviting me. They provided the platform to share my knowledge and expertise in the field of MIS. Alexandria, where history meets the Mediterranean Sea.

Prof. Evangelos Liatsikos during live surgery

Educational framework to support urological nursing An update on the status - November 2019

jt.marley@ ulster.ac.uk During the 19th EAUN Congress in Barcelona earlier this year, delegates were informed about the progress made to date regarding the establishment of an Educational Framework for Urological Nursing (EFUN). This brief update explains the steps we have taken since then. Subgroup EFUN In Barcelona, the EFUN subgroup met to discuss the next steps to be taken in this important initiative. The subgroup is comprised of the Chairs of the European Association of Urology Nurses (EAUN), the British Association of Urological Nurses (BAUN) and the Australia and New Zealand Urological Nurses Society (ANZUNS) along with their Deputy Chairs. It is co-led by Julia Taylor, Immediate Past President of BAUN and Jerome Marley, EAUN Board member. Furthermore, the EFUN subgroup has had teleconference business meetings in recent months and met again during the BAUN Annual Conference in Liverpool (UK) from 11 to 12 November 2019. Third World Café meeting The subgroup also committed to organising a third World Café meeting at the ANZUNS meeting held in April 2019 and was to be a repetition of those organised in Glasgow (BAUN) and Copenhagen (EAUN). As with BAUN and EAUN cafés, the aim was 34

European Urology Today

to allow ANZUNS colleagues to lend their very important voice to the 4 questions posed regarding framework content, academic level, developmental collaboration and framework utilisation. Julia Taylor attended the ANZUNS in April 2019 and led delegates through the cafe, gathering a copious amount of data thanks to their very engaged and animated interaction. These data have now undergone a first analysis and are being reviewed, together with data generated by EAUN and BAUN. A presentation of the data has recently been supplied to ANZUNS for consideration by their members, as was the case for BAUN and EAUN members. International Journal of Urological Nursing The combined review of the data generated from all three cafés is now being used to complete two important tasks. Firstly, the data is the basis of a paper about the detailed findings which will be published in the International Journal of Urological Nursing (IJUN). This step is considered extremely important by the subgroup, as it is essential that the members of all three organisations are fully informed about the information gathered and how it is used to influence progress. The second task, by far the most challenging one, is to consider how the data gathered from nurses across multiple countries on two continents can be used to assist the construction of an educational framework that is relevant and useful to all. There is no doubt that this will be a monumental task. Structure and guidance Although urological nurses may have more tacit than explicit knowledge, they show great variation in their educational journey (initial and ongoing) as well as in how nurses practice in their own countries. The EFUN needs to speak clearly and with authority to all urology nurses, offering structure and guidance for development where required, in a manner that those who use it will find it helpful as they continue to lead

and support change. The EFUN subgroup is acutely aware of the needs of nurses and is committed to ensure that you, our urology nurse colleagues, are not only informed of developments but can also play your part in helping to shape our work. Education frameworks Lastly, the EFUN subgroup is evaluating existing

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

education frameworks used by several nursing groups (more than a dozen at present) to gain understanding of how others have addressed the challenges now before us. Analysis of these various approaches, along with the cafe data and our other deliberations, will allow us to develop a confidence on how we might construct our EFUN. Reporting progress on all of this to you will remain as one of our key drivers.

www.eaun.uroweb.org

Jerome Marley Lecturer in Nursing University of Ulster Newtownabbey (UK)

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

October/December 2019

National urological nursing congresses in Serbia and Turkey EAUN chair and chair-elect give lectures about importance of nursing One of the EAUNs main aims is to standardise urological nursing care across Europe. It also seeks to encourage and support urological nursing societies in their host nations, in order to share exemplary practices and act as a platform to develop evidencebased care using the EAUN guidelines. To help realise this purpose, Paula Allchorne (EAUN Chair Elect) and Susanna Vahr Lauridsen (EAUN Chair) were invited to give talks in Serbia and Turkey. Paula Allchorne, MBA, Dip, RGN Executive MBA EAUN Chair Elect London (UK)

p.allchorne@ eaun.org I felt honoured to attend the 6th national congress in Serbia entitled ‘History of nursing in the republic of Serbia’. By giving such talks, I hope to enhance understanding of nursing care throughout Europe and ensure that the EAUN continues to improve and standardise the quality of care across Europe and globally. The congress covered history through practice, work of professional organisations, education and heroines of our time, in recognition of the incredible efforts of nurses over the years to deliver the best healthcare possible. I was asked to deliver a keynote lecture on ‘History of nursing in Great Britain: the cradle of nursing?’.

She was an accomplished statistician, recognised by her mathematical peers and praised for developing a highly visual way of presenting complex annualised data sets on mortality and morbidity data. She did so to persuade generals and politicians of the fact that the impact of disease was crippling a nation’s army far more than injuries in battle. In doing so she improved general health conditions. She realised education was key and nursing needed to be developed as profession. General Nursing Council In 1860, the Nightingale Training School opened at St. Thomas’s Hospital in London. Her actions changed the face of nursing, from a mostly untrained profession to a highly skilled and well-respected clinical profession. In 1919, the General Nursing Council was established and adapted in 1983 to United Kingdom Central Council for Nursing, Midwifery and Health Visiting. In 2009 all nursing courses in the UK became degree level. Part of multidisciplinary team I continued my talk by drawing parallels with European nursing today. The UK was perhaps the spark that initiated nursing professionalism, but the profession is developing globally this millennium. Florence Nightingale, in her role as leader of quality improvement, would certainly have supported the aim of the EAUN: to ensure that all nations come together to standardise and improve care across the world. Nursing has evolved over the last twenty years, we have a stronger voice and presence, and our practice is evidence-based and integrated within the medical profession as a key part of the

multidisciplinary team. The most important thing is to ensure everything we do is patient centred and patients are at the heart of everything we do to improve quality of care. This is being enhanced by nurses taking on more and more advanced practices. This is particularly true in the field of urology over the last twenty years.

Özbas, current president of the Turkish Association of Urology Nurses, had arranged translators from the first day, so th,e delegates could understand my presentations about rehabilitation of bladder cancer patients undergoing radical cystectomy and about EAUN indwelling catheter guidelines to prevent urinary tract infections. I was happy to understand all Turkish presentations. The programme included Improve efficiency and quality of care presentations about both benign and cancer diseases Global attendance at the EAUN meetings in urology and about patient involvement and ethics demonstrates the collaboration and standardisation in in care of the urology patient. The delegates were the field of nursing. Everyone wants the same: to very interested in discussion about differences improve efficiency and quality of care. Improving between practices and how to overcome these. quality means addressing what matters to patients making pathways patient centred. Florence “EAUN Chair Elect: ‘Little can be Nightingale said: ‘Little can be done in a spirit of fear’. We need to ensure we speak up for our patients done in a spirit of fear” and provide standardised evidence-based practice. And like Florence, we must often persuade politicians and budget holders of the importance of nurses and Future collaborations exemplary nursing care to the health of the nation. I was very impressed by the great hospitality and the We should ask ourselves 3 questions: inspiration I found for future collaboration between • Where are we now ? the two societies. A meeting was arranged on day • Where are we going? one to discuss EAUN activities and benefits of • What has changed? membership with representatives from the Turkish Association of Urology Nurses, vice president Ates Kadıoglu from Türk Uroloji Dernegi and me. The meeting resulted in exchange of propositions for Susanne Vahr future collaborations, such as fellowship exchange, Lauridsen, RN, international multicentre studies and presentations at Master’s degree in the next EAUN meeting. I was invited to a friendship HRD, PhD dinner and a faculty dinner which I appreciated very EAUN Chair much. The EAUN looks forward to welcoming the Copenhagen (DK) Turkish nurses at the 21st EAUN Annual Meeting in Amsterdam in 2020. s.vahr@eaun.org

Florence Nightingale Using a historical example, I initially focused my lecture on Florence Nightingale in order to make comparisons with current nursing innovations. Florence Nightingales impact on nursing has often been simplified and merely shows the caring face of nursing, as epitomised by ‘the lady of the lamp’ image, when in fact she was an innovator in the complete care of patients. She was one of the first proponents of patient safety and quality improvement. Ms. Paula Allchorne with Ms. Natasa Dimoska from Belgrade

Inspiration for future collaboration between societies I was invited to talk at the 9th National Congress of Urology Nursing in Antalya (TR) from 11 to 12 October. The congress was held at the fabulous Rixos Sungate hotel and it was attended by about 50 nurses. It was a very well organised conference and a good example of the possibility to exchange knowledge about Ms. Susanne Vahr answering questions after the lecture on nursing practices when the interest is there. Ayfer rehabilitation

Nurses and PhDs - a new trend The EAUN board is on track to become the board with the most PhD holders and students Corinne Tillier Nurse Practitioner Uro-oncology Antoni Van Leeuwenhoek Hospital Dept. of Urology Amsterdam (NL)

causes of a high mortality rate among British soldiers in India. The powerful Royal Commission on the Health of the Army applied her research, and, thanks to her recommendations, the mortality rate was reduced. Data collection of hospitalized patients to carry out clinical studies, classification of diseases; both owe their use to her. Plus, she was behind the idea of the education of nurses by expert nurses.

c.tillier@eaun.org

The path Nightingale chose was not easy, and we cannot say it became easier for nurses to carry out research over the decennia that followed. In the USA, PhD programmes for nurses came up in the 1970s1; the evolution of such programmes went even more slowly in Europe. Since the early 2000s, nurses from all over Europa started to get their PhDs.

Franziska Geese, MScN Advanced Practice Nurse, Research Assoc. University Hospital of Bern Berne (CH) franziska.geese@ gmail.com Only few decennia ago, no one could have imagined nurses obtaining a PhD degree. However, it now seems that a trend for nurses to do a PhD has emerged. What motivates them to participate in a PhD programme? What are their goals, and what do they want to contribute with their PhD degree? When talking with those who chose to pursue a PhD degree, it becomes clear that the nurses’ motives are different. Florence Nightingale (1820-1910) was the one who showed the path of research to nurses. She was a pioneer in the field of statistics. For instance, after the Crimean War, she carried out statistical research on the European Association of Urology Nurses

October/December 2019

nurse all along the path to the thesis. The supervisor/ promotor could be a nurse, a doctor or anyone else such as a psychologist, an epidemiologist, and there are many differences between European countries. For the nurse her/himself, it is important to find a suitable topic and to put together a committee that is familiar with this topic and the necessary methodical procedure. The committee should impart knowledge, coaching in challenging situations, and support for the advancement of the project.

Although certainly not a requirement, these achievements will probably lead to the current EAUN board becoming the board with the most PhD holders and students in the history of the EAUN. Florence Nightingale would have been proud. Reference 1. H. Michael Dreher, PhD, RN, FAAN, Mary Ellen Smith Glasgow, PhD, RN, ACNS-BC, ANEF, FAAN. Role Development for Doctoral Advanced Nursing Practice. Springer Publishing Company. Edition 2011

Florence Nightingale would have been proud There are many nurses to be inspired by. In 2014, former EAUN chair Dr. Bente Thoft Jensen (DK) defended her PhD thesis about the efficacy of multimodal rehabilitation in radical cystectomy. She has presented the results of her work all around the Why nurses pursue a PhD degree world and gained the respect of many urologists. Another past chair of the EAUN, Dr. Stefano Terzoni Besides the increased opportunities, nursing care has (IT), obtained his PhD with research about the efficacy become more complex and multidisciplinary. The of and the quality of life after two conservative "Piled Higher and Deeper" by Jorge Cham increased demand for more quality and proven effectiveness (through nursing research) has resulted treatments for urinary incontinence after radical www.phdcomics.com in nurses who want to develop advanced skills in retropubic prostatectomy in 2011. Present EAUN chair Dr. Susanne Vahr (DK) defended her PhD thesis about carrying out research. For the most part, nurses do a the effects of tobacco and alcohol intake on PhD to gain more experience in research projects and postoperative outcomes in cystectomised patients in to develop a methodical understanding of qualitative 2017. Dr. Giulia Villa (IT), EAUN board member, has and/or quantitative research -- leading to the acquisition of more knowledge for the benefit of every developed two new tools of self-care for ostomy EAUN Board patient. Of course, they could have conducted research patients and obtained her PhD in 2019. And Mrs. without pursuing a PhD, but such a degree also brings Jeannette Verkerk-Geelhoed, chair of EAUN SCO and Chair Susanne Vahr (DK) another EAUN board member, will very soon begin them in a new dimension where their work and Chair Elect Paula Allchorne (UK) leadership are recognised, which also provides a with her PhD research on Peyronie’s disease. Lastly, Board member Jason Alcorn (UK) motive. Another reason for taking a PhD is to become a one of the authors, Mrs. Corinne Tillier, EAUN Board Board member Jerome Marley (GB) locomotive for other nurses. PhD-holding nurses pull member, has just started on the path of pursuing a Board member Tiago Santos (PT) the nursing care toward a higher evidence-based level, PhD degree. She will conduct research on individual Board member Corinne Tillier (NL) thereby taking all the other nurses with them. prediction of urinary incontinence and development of Board member Jeannette Verkerk (NL) an individualised algorithm to predict incontinence and Board member Giulia Villa (IT) It is not easy to embark on a PhD programme. severity of incontinence after robot-assisted radical Therefore, the nurse needs the support of the entire www.eaun.uroweb.org prostatectomy (RARP). team, above all from a supervisor who will guide the European Urology Today

Non-muscle invasive bladder cancer surveillance Development of the advanced nurse practitioner-led service in Ireland: Preliminary audit results Robert McConkey, RANP, MSc, BSc (Nursing), PGDip. Galway University Hospital Urology Outpatient Department Galway (IE) robert.mcconkey@ hse.ie I was invited to write this article in European Urology Today as a result of my successful presentation at the last International Meeting of the EAUN in Barcelona. I am happy to share with you the developments of the increasing role of the advanced nurse practitioner in bladder cancer care in Ireland. Bladder cancer in Ireland Bladder cancer is the 11th most common cancer worldwide, and there are more than 470 new diagnosis in Ireland annually. Approximately 75% of cases diagnosed are non-muscle invasive bladder cancer (NMIBC). It is one of the most expensive cancers to treat due to high recurrence rates, arduous invasive treatment regimens and surveillance follow-up schedules, which significantly impacts on patients’ quality of life and places a burden on healthcare systems. Ireland’s National Cancer Strategy 2017-2026 emphasises an increased role for the advance nurse practitioner (ANP) in urology to meet the healthcare needs of the population. Flexible cystoscopy is the cornerstone of non-muscle invasive bladder cancer surveillance. Nurse-led flexible cystoscopy emerged from the UK in the 1990s in response to increasing bladder cancer workloads of urologists. The role is well established internationally but has not yet been developed in the Republic of Ireland. For the patient, the benefits of the nurse cystoscopists include continuity of care and the provision of

psychological support. Experienced nurse cystoscopists can be involved in training of junior medical staff. The role also offers nurses wishing to remain in clinical practice the opportunity to advance their careers. Data from published service audits in Australia and the UK report that trained nurse specialists can safely and competently carry out this role, patient satisfaction is high and waiting times for access to care are shortened. Preparing for the role Preparation for the introduction of the role in Ireland was guided by the tenets of a model of change (adapted from the Health Service Executive Change Model). The ‘initiation and preparation for change’ stage examined the nurse cystoscopist role in the context of the domains of advanced nursing practice, as defined by the Nursing and Midwifery Board of Ireland to ensure congruence.

Mainstreaming the role requires its evaluation and ‘making it the way we do business’. Auditing appropriate measures and disseminating the learning and feeding back to colleagues helps to achieve this aim. Irelands Health Information and Quality Authority's (HIQA) ‘National standards for better and safer healthcare’ aim to improve services and protect patients by placing them at the centre of the care process. Focusing on quality and safety, the standards are useful for measuring output. The following standards formed the basis of the audit for the period 23/3/18 to 30/07/18 and are reported below.

Effective care and support • Measure: Urine for cytology to be sent for all patients with high-grade cancer in alignment with international best practice guidelines. • Population: Patients attending the ANP service for surveillance of high-grade bladder cancer. • Target: 100% will have sample sent for cytology. • Outcome: 18 out of 20 eligible samples sent: 90% “…benefits of the nurse compliance rate. cystoscopists include continuity • Action: A review of the two instances when cytology was not sent, identified that the patients of care and the provision of were unable to provide another voided prepsychological support” cystoscopy urine sample. • Plan: In future, patients with high-grade disease The ‘planning’ stage of the process included building will be contacted in advance of their appointment commitment, determining the details, and developing and a 2nd morning voided sample will be an implementation plan. Multidisciplinary stakeholder requested. meetings collaboratively defined the job description and patient caseload of the candidate advanced nurse Safe care and support practitioner (cANP). Governance structures, such as • Measure: Documented evidence of appropriate evidence-based policies, procedures, protocols and antimicrobial stewardship. guidelines were developed to ensure the delivery of • Population: Patients attending the cANP flexible quality and safe service. Formal mentorship for cystoscopy service. clinical supervision was agreed with a named • Criteria: Patient screened and reason for antibiotic consultant urologist, and formal education was prophylaxis identified. embarked upon to Masters level. I also participated in • Target: 100% documentary evidence. a flexible cystoscopy training workshop at the British • Outcome: 100% of patients who received a Association of Urology Nurses annual conference in prophylactic antibiotic (n=62) (18% of all patients Glasgow in November 2016. Following this, a period attending) had a documented valid reason for of formal flexible cystoscopy training and competency administration. assessment commenced. • Action: Target met; continued vigilance required.

Antimicrobial stewardship has both clinical and economic benefits. Use of resources • Measure: Time to complete an entire episode of care safely (including patient assessment, performance of procedure, care plan, documentation and communication). • Population: Patients attending the cANP flexible cystoscopy service. • Criteria: The standard to be achieved for the ANP is that of a competent urologist. • Target: Equivalent time to urology colleagues. • Outcome: No appreciable increase in the average time to complete an episode of care (26 minutes and 27 seconds (cANP) versus 26 minutes 12 seconds (urology colleagues in 2017)). • Action: Target met; continued vigilance required. The results of this measure lend support for the introduction of the service on a cost-neutral basis. Conclusion International experience of the nurse-led flexible cystoscopy service demonstrates that appropriately trained specialist nurses can deliver a safe and quality patient-centred service. Preparing for the role requires commitment from all multidisciplinary stakeholders to successfully deliver the initiative. The evaluation of the preliminary introduction of the role in the context of advanced nursing practice demonstrates evidence of compliance with national and international standards, aligned with delivering a safe and high-quality service, providing a tentative framework for its adoption in other centres. Award At EAUN19 I presented a poster on the first results of the above audit and was honoured to be awarded the first prize for the Best Practice-development Poster Presentation. I hope to present further results in one of the future meetings. See you in Amsterdam!

EAUN20: "A worthwhile and valuable experience" New knowledge, broader connections, better clinical practice Look forward to innovations in urological nursing and multidisciplinary collaborations at the upcoming 21st International EAUN Meeting (EAUN20). In this article, esteemed members of the EAUN Scientific Congress Office, Mr. Robert McConkey and Mrs. Hanny Cobussen-Boekhorst, and respected member of the EAUN Special Interest Group Bladder Cancer, Ms. Kathryn Chatterton, offer a sneak peek at the anticipated meeting.

The programme is so comprehensive and dynamic that it comprises of specialty sessions such as the “Best of urological nursing practice in Europe”. In this session, participants will receive valuable insights, tips and tricks, and clinical practice updates from top nurses who are awardees of the Best Nurse of the Year in their respective countries. Their contribution to urology, stoma or continence care is instrumental to achieving a high quality of nursing care.

“The meeting will cover vital topics such as bladder and bowel management; antibiotic resistance because within urology, high rates of catheter-associated urinary tract infections (CAUTIs) are causing concern; developments in endourology; nocturia in children and adults, and many more,” added Mrs. CobussenHe stated, “Some of the oncology lectures will examine Boekhorst. the salient issues affecting patients with muscleinvasive and non-muscle-invasive bladder cancers, and HOT courses Based on positive feedback received at EAUN19, the their quality of life. The lectures will also address ESU/ESUT - EAUN Hands-on Training (HOT) in Flexible sexual (dys)function of male cancer survivors, and the cystoscopy will precede the three-day meeting. emerging role of genomics in urological cancers. EAUN20 participants can expect the assessment and Ms. Chatterton stated, “This HOT course is management of skeletal issues in metastatic prostate specifically designed for nurses who aim to set up a cancer, as well as, interdisciplinary end-of-life care.” nurse-led flexible cystoscopy service. The outcome is Mr. McConkey added that the meeting will also touch to enable nurses to gain insight into what is required to set up the service within their on holistic approaches to urinary and bowel continence care; endourology and robotics; updates of hospitals.” the EAUN indwelling catheterisation guidelines and She added, “The course also includes theory and the proposed Urological Nursing Education Framework (Curriculum); and the critical nursing role practical basics. Under the guidance of experts, the participants will familiarise themselves with the in antimicrobial stewardship, to name a few. flexible cystoscope in a classroom-like environment.” Register now for the early fee! “Searching for educational urological updates focused on high-quality and safe care for patients? Interested to know more about inspiring clinical practice? EAUN20 promises to deliver these and more,” said Mr. McConkey.

Deadline: 16 January 2020 Dynamic programme “In healthcare, collaboration is of utmost importance to ensure top quality and safety. This is one of the core foundations in the development of EAUN20’s Scientific Programme,” said Mrs. CobussenBoekhorst. 36

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According to Ms. Chatterton, this HOT course will offer a comprehensive overview on anatomy and physiology to deepen nurses’ knowledge on identification and troubleshooting specific problems a patient may have. The course will also include a step-by-step guide to gaining learning competencies, and provide instruction on required protocols under the support/guidance of a urologist.

This in-demand course will take place on 20 March 2020, from 14:00 to 17:30 and will only have limited seats available. Interested participants can secure their place for a small fee.

For the complete Scientific Programme visit www.eaun20.org The EAUN20 Scientific Committee is also preparing a new HOT course “The Essentials of Urological Nursing Assessments” where participants can enrich their skills in nephrostomy care; bladder irrigation and manual washouts; catheter troubleshooting; uroflowmetry and bladder scanning; and stoma care. Participants will also review symptom and assessment questionnaires in this HOT course.

Making a difference “We aim for offer the EAUN20 experience that will inspire the delegates to apply the new knowledge they’ve gained to optimise their practice, and also help them build connections with other nurses across Europe,” stated Mrs. Cobussen-Boekhorst. “EAUN20 has a so much to offer; if each delegate could take home just one thing they’ve learned and make a small change to their practice, that could make a huge difference to patients under their care,” said Mr. McConkey. “Whether that means being inspired to develop a new service; reviewing and updating local guidelines based on new evidence learned; deciding to create and present your first poster at a local event; or sharing highlights from EAUN20 to your colleagues back home; these make attending the meeting a worthwhile and valuable experience.”

21st International EAUN Meeting

Join us in Amsterdam!

21-23 March 2020, Amsterdam

in conjunction with

www.eaun20.org

October/December 2019