European Urology Today Vol. 33 No.5 – October 2021/ January 2022

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European Urology Today Official newsletter of the European Association of Urology

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EAU Policy Office expands Prof. Van Kerrebroeck joins as Vice-Chair

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Vol. 33 No. 5 - October 2021/January 2022

ESU Urology Boot Camp in Lisbon Basic technical skill for first year residents

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EMUC21 in Athens Full report inside!

Crafting a winning scientific programme Scientific Congress Office making final preparations for EAU22 By Loek Keizer

asked to propose names of young, talented, scientifically outstanding people to support the EAU, also beyond composing our annual meeting’s scientific programme. We received dozens of names and we will continue to promote this way of actively recruiting members to our SCO.

The 37th Annual EAU Congress is nearing its final stages of preparation and is due to take place in Amsterdam, the Netherlands on 18-21 March, 2022. Amsterdam was previously the location chosen for EAU20, but the onset of the worldwide pandemic first postponed and then cancelled the in-person congress in 2020. Since then, the EAU has held EAU20 and EAU21 in a largely virtual setting. EAU22 is set to be the first in-person annual congress since EAU19 in Barcelona.

It is obvious that not everyone can already start participating in the next round, since there are only one or two positions open per year. But year by year we actively will change the important decisionmaking groups towards younger and more diverse members. This will also reflect upon the composition of congress faculty. Finally, for the EAU, quality and scientific engagement leads every decision but as a society we have the responsibility to open ourselves to all members that want to be active.

We spoke to Prof. Peter Albers (Dusseldorf, DE), Chairman of the Scientific Congress Office (SCO), who is overseeing the design and content of the scientific programme of Europe’s largest urology event. Here, he speaks about the various considerations for this year’s congress, and what some priorities are for the Annual Congress in the coming years. Most notably, this year we will see a four-day Annual Congress, not five as in previous years. How did the SCO come to this decision? The main reason for condensing the programme was to create a meeting which fits better into everyone’s schedule. We start on a Friday and the last day is now Monday, and not Tuesday. We have learned from questionnaires and surveying our membership that our attendees don’t like to lose too much of their working time. Therefore, we composed a programme that prioritises the days at the end of the week. This way, we hope that we end up with more participants per day. The programme now counts eight plenary sessions, also more than usual. That’s right, and this is a direct consequence of condensing the programme into four days. We realised that eight slots were available for plenary sessions and we decided to use them. Plenary sessions are the most attended ones at the congress and this is why we try to compose very lively and interactive plenary sessions with case discussions and more panel discussions than in the past.

"The Annual EAU Congress has become an attractive occasion for many researchers to first present their outstanding findings." Currently, a lot of room is reserved in the programme for “Game Changing Sessions”, is this a new development? We have noted in recent years that the Annual EAU Congress has become an attractive occasion for many researchers to first present their outstanding findings for example from large phase III trials in oncology and non-oncology. This is a quite recent development and we acknowledge this by extending the slots for so called “game-changing” research. In urology, a lot of things change, for example the indications for perioperative systemic treatment in most of our cancers have been extended. Patients now benefit from the combination of surgery and

Prof. Albers (Chairman of the Scientific Congress Office) speaking at a previous edition of the EAU Annual Congress

Friday, 18 March systemic treatments around the surgical procedure in onco-urology. We are proud that large phase III trials, also in screening and new treatments, are discussed at the EAU annual meeting now. The format is a presentation followed by an expert discussant who puts the research finding into perspective. This is very attractive for our attendees. Of course, the definitive number of these sessions depends on the amount and the quality of late-breaking, game-changing abstracts that are submitted before 4 February! What are some other new session types or other developments in the programme this year? Something we’ve changed over the last two years is how experts of the Scientific Congress Office now organise the sessions into topic-related “tracks”. We have decided to work with about eight tracks and the attendees of the meeting can easily find out what is important in their special field of expertise. We continue to present the “Best of EAU” abstracts as selected by the “track members”, discussions of the best 20 abstracts in (non-)oncology. This is independent of the award-winning abstracts because we felt that attendees would like to easily identify the highest quality abstracts from our congress. Again, those findings will be explained and discussed by the “track leaders” of the SCO. Another thing that makes our congress attractive is the active participation of urology patients. To my knowledge we are one of the few scientific medical societies worldwide who support active patient participation even in plenary sessions. This year we’ll present for example a special lecture for a new way of organising follow-up after treatment from a patient’s perspective. We have learned that a well-organised follow-up will save more lives than some of the new systemic treatment options in oncology. The EAU, as a medical society, is proud of this new way of patient participation in a scientific meeting. We think this is the way forward in non-oncology as well as oncology. As for what I would consider particular highlights this year… I would leave this decision to the

October/January 2022

Some Highlights from the EAU22 Scientific Programme

attendees. I think the programme covers all aspects of urology and major topics are always organised in major sessions. I encourage everyone to keep checking back on www.eau22.org as the programme becomes definitive! Is it true that you are looking at new ways to present abstracts at the Annual EAU Congress? In the past few years, we’ve had very good experiences with expert-guided tours of posters, with a lot of discussions. In pandemic times we do not want to proceed with exactly this format. But we will merge the positive experience from the past with the new demands. We will group 4-5 abstracts, as selected by the session composers of the sessions, and discuss them related to the specific topic. This gives much more time for discussion because we only ask for a “flash presentation” of the content, lasting 2 minutes. This way we’ll end up having sessions with in total 40 minutes of presentations, and 50 minutes of discussion time. This should work very well but it demands presenters to be exactly in time. Therefore, we will ask for pre-recorded talks.

"This is one good example where we moved to the next level in applying positive developments from the virtual meetings to the in-person meeting." This is one good example where we moved to the next level in applying positive developments from the virtual meetings to the in-person meeting. The same is true for the “hybrid” elements of our congress. We will transmit live from 3 major session rooms, including every plenary session. All other lectures will be webcasted and offered on-demand through the Virtual Platform. I understand there is a conscious effort within the SCO to have a more diverse representation of urologists as faculty members, how do you approach this desire for more diversity in the congress faculty? For the first time, we have created a transparent process within the EAU to actively recruit new members for the SCO. All sections of the EAU and especially the Young Academic Urologists have been

• Game changing sessions • Plenary Session 1: Challenges in RCC • Plenary Session 2: Going Viral in Urology • Urology Beyond Europe Sessions • Abstract and Video Sessions • EAU Special Sessions • ESU Courses and Hands-on Training

Saturday, 19 March • Plenary Session 3: Nightmares in surgery of retroperitoneal disease • Plenary Session 4: Perioperative treatment of urothelial cancer in 2022 • YUORDay22 • Section Meetings • Live Surgery Session of ESUT, ERUS and EULIS • Abstract and Video Sessions • EAU Special Sessions • ESU Courses and Hands-on Training

Sunday, 20 March • Game changing sessions • Plenary Session 5: PCa high risk local treatment • Plenary Session 6: Personalised surgical management of LUTS/BPO • Thematic Sessions • Abstract and Video Sessions • EAU Special Sessions • ESU Courses and Hands-on Training • Video Award Session

Monday, 21 March • Game changing sessions • Plenary Session 7: Liquid biomarkers in 2022 and beyond: Ready for prime time? • Plenary Session 8: Stones: The sky is the limit • Thematic Sessions • Abstract and Video Sessions • EAU Special Sessions • EAU Patient Day • Best of EAU22 • ESU Courses and Hands-on Training For all the latest news around the 37th Annual EAU Congress, the full scientific programme, and more details about registration please visit www.eau22.org. The discounted early fee ends on 19 January. Late-breaking abstracts can be submitted until 4 February. Read all about EAU22 on pages 4 and 5

European Urology Today

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Update from the Guidelines Office Novel strategies to effectively disseminate the EAU Guidelines The European Association of Urology (EAU) guidelines provide evidence-based recommendations for best clinical practice to effectively achieve better safer care with improved patient outcomes. Translating guidelines into practice is a complex task and takes considerable efforts at both the individual and organizational level. [1,2] The EAU Guidelines Office Dissemination Committee has created a strategic plan to spread clinical practice guidelines to a wide and diverse audience (Figure 1). In the digital era, knowledge can be shared instantly and people are able to access information quicker and easier than ever before through social media (SoMe). [3] The Dissemination Committee will explore three different communication channels to reduce barriers to knowledge use in Urology: podcasts, video-clips and Instagram. The strategy behind the projects takes into account both passive and active learning strategies, in order to customize the communication strategy to meet the needs and values of specific target audiences. In fact, passive strategies, such as videos and podcasts, have a structured and engaging format and complement the development of urological knowledge outside of academia and hospital settings.

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

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European Urology Today

Integrating podcasts technology into traditional health care communication or dissemination models will be an effective and practical strategy not only for delivering quality health-related information to the public, but also for creating content engagement opportunities and promoting communication between researchers, community members and other stakeholders. The podcasts will be released on the most widely used SoMe platforms (Buzzsprout, Amazon Music, Spotify, Apple Podcast, Google Podcast, and Stitcher) and on the EAU website. They will become a regular appointment for all those who want to increase their knowledge by listening to the most authoritative experts in the field.

“An important step in involving patients in the selection of outcomes for clinical trials, clinical audits, and real-world evidence is the development of a core outcome set ....”

Figure 1: The relationship between essential aspects of dissemination that contribute to knowledge use

Although clinical practice guidelines have a great potential to support implementation of evidencebased care, they are globally suffering from inefficient dissemination and implementation. A carefully and systematically planned and well-designed dissemination strategy might help ameliorate access to this fundamental tool, and lead to improvement in health outcomes. References 1. Bhatt N R et al. Eur Urol Focus. 2020 Nov 7;S24054569(20)30292-3. doi: 10.1016/j.euf.2020.10.008. 2. Pradere B et al. Eur Urol Focus – 2021 In press 3. Loeb S et al. Eur Urol Focus. 2020 May 15;6(3):605-608. doi: 10.1016/j.euf.2019.07.004. Epub 2019 Jul 24.

New EAU Guidelines Office lead research project aims to improve treatment for patients with prostate, breast and lung cancer through artificial intelligence

OPTIMA (www.optima-oncology.eu) stands for Optimal Treatment for Patients with Solid Tumours in Europe Through Artificial intelligence. It is a € 21.3 million public-private research programme that will seek to use artificial intelligence (AI) to improve care for patients with prostate, breast and Blogging and video blogging have become a new way lung cancer. OPTIMA’s goal is to design, develop for scientists to share their work with the general and deliver the first interoperable, GDPR-compliant public and the EAU Guidelines Office needs to take real-world oncology data and evidence generation advantage of these platforms. Each year, when the platform in Europe, to potentially advance new guidelines are released, the panel chairs will treatment for patients with solid tumours in the endeavour to produce audio/video content with the three cancers. aim of easily defining the major scientific achievements of the urological community. The plan The OPTIMA consortium consists of 36 multiis to provide short and essential information to those disciplinary private and public stakeholders in the who are interested in quick and passive learning as clinical, academic, patient, regulatory, data sciences, well as to users that are interested in “diving deeper” legal and ethical and pharmaceutical fields and is and want to read more about the topic in the being jointly led by Prof. Dr James N’Dow from the long-form of extended guidelines. European Association of Urology and Academic Urology Unit at the University of Aberdeen and In addition, the Dissemination Committee will monitor Dr Hagen Krüger, Medical Director Oncology, Pfizer the knowledge use through an instructional strategy Germany. where learners take an active role in their own For the latest news follow OPTIMA on Twitter: education by participating in activities and reflecting @OPTIMA_oncology on their learning. Instagram, a SoMe channel created for sharing images and videos, is rapidly becoming a For a more detailed explanation on the project: platform that welcomes scientific research and its www.optima-oncology.eu promotion and, when used correctly, it can be an excellent place to disseminate scientific knowledge. Through this channel, it will be possible to educate Big Data: The Key Role of Patient Involvement in younger people, especially in terms of primary and the Development of Core Outcome Sets in Prostate secondary prevention. Moreover, through the Q&A in Cancer Instagram Stories the audience will be engaged in the learning process by developing knowledge and Patients are the stewards of their own care and understanding through a fully-fledged participation hence their voice is important when designing and and an interactive session (Guidelines CUP). The use of implementing research. An important step in Instagram Stories and Instagram Reels, a new format involving patients in the selection of outcomes for for short and creative video content, will reach a wider clinical trials, clinical audits, and real-world evidence audience and increase interactivity. is the development of a core outcome set (COS) that is relevant to all stakeholders. The PIONEER Finally, data from Q&A, Reels insights and Consortium, an international multistakeholder Interactions, and Story views will be analysed collaboration lead by the European Association of (outcome evaluation) in order to understand which Urology, has developed a core outcome set (COS) for topics need to be further explored and properly localised and metastatic prostate cancer relevant to disseminated. all stakeholders in particular patients. Read the report that highlights the patient participation throughout the PIONEER COS development: Guidelines Office https://bit.ly/3EA64qA

Recent publications from Panels We are very pleased to announce that several papers from Guidelines Panels have been accepted for publication in 2021: • EAU-ESPU pediatric urology guidelines on testicular tumors in prepubertal boys. Stein R, et al. J Pediatr Urol. 2021 Aug;17(4):529533. • European Association of Urology Guidelines on Urethral Stricture Disease (Part 2): Diagnosis, Perioperative Management, and Follow-up in Males. Campos-Juanatey, F, et al. Eur Urol. 2021 Aug;80(2):201-212. • European Association of Urology Guidelines on Urethral Stricture Disease Part 3: Management of Strictures in Females and Transgender Patients. Riechardt S, et al. Eur Urol Focus. 2021 Aug 12:S2405-4569(21)00193-0.

• EAU Working Group on Male Sexual and Reproductive Health. European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction. Salonia A, et al, Eur Urol. 2021 Sep;80(3):333-357. • EAU Guidelines Office Dissemination Committee. A Systematic Review of the Use of Social Media for Dissemination of Clinical Practice Guidelines. Bhatt NR, et al. Eur Urol Focus. 2021 Sep;7(5):11951204. • European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (Ta, T1, and Carcinoma in Situ). Babjuk M, et al. Eur Urol. 2021 Sep 9:S03022838(21)01978-3 • EAU Muscle-invasive, Metastatic Bladder Cancer Guidelines Panel. The 2021 Updated European Association of Urology Guidelines on Metastatic Urothelial Carcinoma. Cathomas R, et al. Eur Urol. 2021 Nov 3:S03022838(21)02056-X. • EAU Working Group on Male Sexual and Reproductive Health. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility. Minhas S, et al. Eur Urol. 2021 Nov;80(5):603-620.

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The power of SoMe for dissemination of clinical practice guidelines Latest findings by the EAU Guidelines Office Dissemination Committee Dr. Nikita Bhatt East of England Deanery Cambridge (GB) On behalf of the EAU Guidelines Office Dissemination Committee nikitarb89@ gmail.com The European Association of Urology (EAU) Guidelines Office has appointed a Dissemination Committee to increase awareness of the guidelines with the ultimate aim of improving adherence to them, and advancing patient care. The Committe is composed of a scientific committee, a marketing expert, and a community manager (Figure 1). Through the work of this committee, the EAU became the first scientific association to systematically convert clinical practice guidelines (CPG) into social media (SoMe) posts for dissemination. This was published in the form of a proof-of-principle study on the use of Twitter as a platform for the dissemination and Figure 1: Infographic illustrating the strategy of the European Association of Urology (EAU) Guidelines Office Dissemination real-time evaluation of clinical guidelines in 2017. [1] Committee. It was recommended that other professional societies use these strategies to increase the reach and obtain rapid feedback on guidelines recommendations. The committee has now expanded its reach to include other SoMe platforms, such as Facebook and Instagram. However, the current role of SoMe for this purpose is not well known. CPG, such as the EAU Guidelines, are invaluable to clinical practice as they help in clinical decisionmaking using evidence-based medicine along with patient’s personal circumstances, values and preferences. However, despite their utility and advantages, the compliance to clinical guidelines is variable. In urology, adherence to various international guidelines issued by EAU, American Urology Association and National Comprehensive Cancer Network leaves room for improvement. CPG uptake does not occur spontaneously and requires active execution, especially for long-term implementation. Information dissemination in the medical field has been transformed by the advent of SoMe. These new communication technologies enable rapid and global information exchange among physicians, patients, organizations and other stakeholders. SoMe use can also have its limitations, including ethical implications for use in a healthcare setting with a need to protect patient privacy and confidentiality. However, if the power of SoMe is harnessed correctly, it can pave the way to unprecedented opportunities for CPG dissemination. CPGs represent an ideal source of information to promote on these platforms. However, there is a knowledge gap in the medical literature concerning existence and effectiveness of digital dissemination strategies for CPGs. With this context in mind, the EAU Guidelines Office Dissemination Committee conducted a systematic review on the role of SoMe in CPG dissemination across different medical specialties, which has been recently published on European Urology Focus. [2] Medline, Embase and Cochrane databases and the general platform Google were searched for all relevant publications using PRISMA guidelines. Only 5 studies were included after full text review. SoMe use for CPG dissemination is, in fact, a relatively new concept and all our included studies were published in the last 5 years. The specialties using SoMe for CPG dissemination included Neurology (complementary and alternative medicine in Multiple Sclerosis), Gastroenterology (Helycobacter pylori treatment), Anaesthesia (guidelines on National Tracheostomy Safety Project), Cardiology (Chronic Heart Failure) and Urology (EAU Guidelines). The included studies were a mixture of observational studies and pre/post interventional studies. The search strategy did not identify comparative, randomised or non-randomised trials, testing SoMe-based or other digital methods of CPG dissemination or implementation. There was a significant improvement in knowledge, awareness, compliance, and positive behaviours with respect to the CPG with use of the SoMe dissemination Guidelines Office

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Adapted from Pradere B, Esperto F, van Oort IM, et al. Dissemination of the European Association of Urology Guidelines Through Social Media: Strategy, Results, and Future Developments. Eur Urol Focus. 2021 Nov 10:S2405-4569(21)00289-3. doi: 10.1016/j.euf.2021.10.010. Online ahead of print.

compared to traditional methods. Owing to the recent application of SoMe in the context of CPG dissemination, there is no standardized format for its use. All studies included in the review reported very different methods of SoMe use and similarly variable methods of analysing the outcomes. As a common finding, a large audience (healthcare professionals and patients) viewed, and engaged with, the SoMe process of CPG dissemination, and expressed an intent to engage in this method in the future, further affirming its vital role in CPG dissemination.

“There was a significant improvement in knowledge, awareness, compliance, and positive behaviours with respect to the CPG with use of the SoMe dissemination compared to traditional methods.” In conclusion, the EAU Guidelines Office have pioneered the use of SoMe in dissemination of clinical guidelines. In order to investigate this in other specialties the Dissemination Committee published a first of its kind systematic review on use of SoMe for dissemination of CPG. This showed that SoMe use has an impact as it led to significantly increased awareness of the CPG, knowledge of the CPG and change in attitude with regards the CPG with no negative outcomes reported so far. Based on this publication, a pragmatic method of using SoMe for CPG dissemination has been proposed (Figure 2). Considering the importance of CPG in practice and

the ever-increasing role of SoMe in our professional lives, a new role for SoMe in CPG dissemination could be established. In the future, as the SoMe use in this context expands, comparative studies and randomized trials comparing SoMe to traditional methods of dissemination would be useful to determine its impact on dissemination and implementation. In the meantime, the EAU Guidelines Office Dissemination Committee continues its work in introducing novel ways and improving the application of SoMe in the dissemination of EAU Guidelines internationally. References 1. Loeb S, Roupret M, Van Oort I, N'dow J, Van Gurp M, Bloemberg J, Darraugh J, Ribal MJ. Novel use of Twitter to disseminate and evaluate adherence to clinical guidelines by the European Association of Urology. BJU Int. 2017 Jun;119(6):820-822. doi: 10.1111/bju.13802. Epub 2017 Mar 10. 2. Bhatt NR, Czarniecki SW, Borgmann H, van Oort IM, Esperto F, Pradere B, van Gurp M, Bloemberg J, Darraugh J, Rouprêt M, Loeb S, N'Dow J, Ribal MJ, Giannarini G; EAU Guidelines Office Dissemination Committee. A Systematic Review of the Use of Social Media for Dissemination of Clinical Practice Guidelines. Eur Urol Focus. 2021 Sep;7(5):1195-1204. doi: 10.1016/j. euf.2020.10.008. Epub 2020 Nov 7.

Appendix Current members of the European Association of Urology Guidelines Office Dissemination Committee are: Nikita R. Bhatt, Vito Cucchiara, Esther Garcia Rojo, Benjamin Pradere, Jeremy Y. Teoh, Elisabeth Hesston, Jarka Bloemberg, Julie Darraugh, Marc Van Gurp, Maria J. Ribal and Gianluca Giannarini (chair).

Crafting a winning scientific programme . . . . 1 Update from the Guidelines office . . . . . . . . . 2 The power of SoMe for dissemination of clinical practice guidelines. . . . . . . . . . . . . . . 3 EAU policy update . . . . . . . . . . . . . . . . . . . . . 6 ERN eUROGEN Exchange . . . . . . . . . . . . . . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11 Patient Information: What have we learned?. 12 History of face masks in medicine. . . . . . . . . 13 Obituary: Christopher Griffith Wood. . . . . . . 13 ESUO: The impact of the COVID-19 pandemic in urology. . . . . . . . . . . . . . . . . . . . . . . . . . . 14 ESU section: An overview of ESU masterclasses in 2021 . . 15 Hybrid 8th CEUEP delivers urolithiasis, BCa & PCa updates. . . . . . . . . . . . . . . . . . . 16 E-BLUS course in Gijón: A new model for online evaluation . . . . . . . . . . . . . . . . . 17 “The virtual ESU courses are a way out during a pandemic”. . . . . . . . . . . . . . . . . . 17 ESU Urology Boot Camp Serbia 2021. . . . . . . 19 21st RSU congress offers expansive urology fundamentals. . . . . . . . . . . . . . . . . . . . . . . 19 Virtual ESU-ESFFU Masterclass on Functional Urology. . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Virtual ESU course focuses on upper tract laparoscopy. . . . . . . . . . . . . . . . . . . . . . . . 20 ESU Urology Boot Camp Lisbon 2021. . . . . . 21 GPC: “Improving urological education in the developing world”. . . . . . . . . . . . . . . . . . . . 22 PCombi adds data to potential role for estrogens in PCa. . . . . . . . . . . . . . . . . . . . . . 22 YAU: More opportunities for young urologists in PCa research . . . . . . . . . . . . . . 23 YAU meets at EMUC21. . . . . . . . . . . . . . . . . 23 PI: The right information at the right time can save lives. . . . . . . . . . . . . . . . . . . . . . . . 24 ESUR21: An excellent platform to discuss urology research. . . . . . . . . . . . . . . . . . . . . . 26 European Board of Urology welcomes new President . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Virtual PCa21 delivers vital updates on PCa management . . . . . . . . . . . . . . . . . . . . . . . . 27 Obituary: Sergio Musitelli. . . . . . . . . . . . . . . 27 ERUS 2021: A Breakthrough year for new robotic systems. . . . . . . . . . . . . . . . . . . . . . 29 EMUC21: Multidisciplinary updates from diverse fields . . . . . . . . . . . . . . . . . . . . . . . . 30 ESFFU: Management of post-prostatectomy incontinence. . . . . . . . . . . . . . . . . . . . . . . . . 31 Urology Week 2021: International effort against incontinence taboo. . . . . . . . . . . . . . 32 ESOU22: Principal topics, expectations and COVID-19. . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Introducing UROtech22: A new meeting for 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Obituary: Stefan Loening . . . . . . . . . . . . . . . 34

Figure 2: Pragmatic approach to a SoMe campaign for CPG dissemination based on the summary of systematic review findings. CPG = clinical practice guideline; Q + A = question and answer; SoMe = social media

EAUN section: “We have fought for an independent nursing framework". . . . . . . . . . . . . . . . . . . 34 Prostate cancer care and exercise . . . . . . . . 35 Sexocorporel: Clinical sexology in urological context . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Post-EAUN webinar . . . . . . . . . . . . . . . . . . 36

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#EAU18

EAU22: An eco-friendly congress Thanks to its relatively small size for a European capital, Amsterdam is naturally suited to ecofriendly ways of getting around. The city has a dense public transport network and is easily traversed on foot or by bicycle. To support that sustainable character of Amsterdam, the EAU will offer several eco-friendly features during its 37th Annual Congress (EAU22) from 18 to 21 March 2022 in the RAI Amsterdam congress venue. If you travel from Belgium, France, Germany, or England to Amsterdam, consider taking one of the many high-speed rail options. Amsterdam is connected to several Belgian, French, and German cities by convenient high-speed services. Plus, Amsterdam has a Eurostar terminal with a direct train connection to London. Due to Amsterdam’s public transport network, travelling from Amsterdam Central Station to your accommodation will not be a problem; you can use the Dutch application 9292 or its equivalent website www.9292.nl/en/, also available in English, to plan your public transport trip. Equally, public transport is the more sustainable, cheaper, and faster option for travelling from Amsterdam Airport Schiphol to the city.

The RAI is very easy to reach by public transport. ©Vervoerregio Amsterdam

Reaching the RAI congress venue from your hotel will be an excellent opportunity to get your daily exercise by walking or cycling to and from the venue. Cycling is popular among locals, and you can rent a bike throughout the city. Alternatively, the RAI is also very easy to reach by public transport; for instance, it is a stop on the North-South metro line (metro line 52, stop ‘Europaplein’) that goes straight through the city’s historic centre and comes and goes every eight minutes. Use the aforementioned 9292 application or website to plan your journey. The EAU is providing free four-day Transportation Passes to congress delegates. These can be picked 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 travel card includes metro, bus, and tram services within Amsterdam. No need to ever use a taxi during your stay! Eco-friendly tips Before EAU22 commences, make sure to download the EAU Association App. From mid February 2022, the EAU22 event will be available within the Association App. In this feature of the app, you can browse the EAU22 scientific programme and create your personal programme using the planner. Find session rooms and exhibitor booths by scrolling through the floor plans. Using the personal congress bag icon, you can save relevant links to digitally retrieve or review after the congress. Offline use of the app is possible. Download the EAU Association App for free in the Play Store (Android) or App Store (iOS). Please note that the traditional 600-page programme books will not be available anymore. You can collect your EAU22 tote bag (goodies included) in the Registration Area in the congress venue. These bags are reusable, made of 100% organic cotton and, for the first time, printed with amusing urology-themed slogans. There are five

Reaching the RAI Amsterdam congress venue from your hotel will be an excellent opportunity to get your daily exercise by walking or cycling to and from the venue

different bags, so keep an eye out for one that tickles you. RAI Amsterdam uses recycle bins. The bins are divided into paper, plastic, and organic waste. Please separate your waste so it can be recycled and/or disposed properly. Finally, did you know that tap water in the Netherlands is safe to drink? Bring a bottle and refill it as many times as you want without the need for buying bottled waters with the associated waste. Don't have a bottle? Go to the EAU booth in the Exhibition Hall to buy a special EAU collector's item. The EAU aims to make your experience in Amsterdam as eco-friendly as possible. By following these tips, we will be well on our way!

Tap water in the Netherlands is safe to drink

Educating and empowering patients in extraordinary times Looking forward to an in-person EAU22 Congress in Amsterdam The EAU22 Congress is optimistic to have an in-person, physical event from 18-21 March 2022 in Amsterdam, the Netherlands. After almost two years into the pandemic, the EAU and its Patient Office have continuously sought innovative ways to connect and collaborate with patients and patient advocate groups. A testament of this commitment is the resounding success of the Patient Day held last 9 July 2021 at the EAU21 Virtual Congress. Last year’s success served as a springboard for another meaningful and inclusive initiative this year. The EAU Patient Day which will be held on Monday, 21 March 2022 in Amsterdam with the primary goal of creating a platform for patients, their care support systems, and healthcare professionals to engage in a dialogue. It highlights the needs of patients and how their care support system and health care professionals address these needs and in turn improve their quality of life. Preparations for the Patient Day are well underway as early as November 2021. Aside from the urological cancer-specific thematic sessions, a more general session is dedicated to quality of life and survivorship issues. A session on functional urology is also dedicated to incontinence concerns. Programme The EAU22 Patient Day will include the following sessions: Bladder Cancer Session – led by the World Bladder Cancer Patient Coalition (WBCPC), the session will focus on developing patient information and support resources; 4

European Urology Today

Kidney Cancer Session – headed by International Kidney Cancer Coalition (IKCC), the session will bring together the importance of clinical trials and the improvement of communication between health care providers and kidney cancer patients;

WFIPP Roundtable Discussion on Incontinence - the session will focus on future innovations in care and sustainability.

www.eau22.org/patient

The information provided is still subject to change as the programme is still being finalised. Please keep Prostate Cancer Session – managed by Europa Uomo, an eye on the EAU22 or Patient Information website the session will discuss the many aspects of for more updates and we hope to see you in revolution and/or evolution in prostate cancer Amsterdam in March 2022! diagnosis and care; Life after Cancer Treatment Session – the session primarily aims to create a more holistic view of urological cancer, and how other stakeholders can take part in improving the quality of life of patients by promoting awareness about these issues that they face on a daily basis; Functional Urology Session – led by World Federation for Incontinence and Pelvic Problems (WFIPP), the session will discuss sustainable continence care, living with incontinence, and reaching out to patients who lack digital and literacy skills. Patient Poster Session – this year’s theme will be Addressing Unmet Needs, and will revolve around the following themes: • Physical and Psychological well-being; • Finance and Work; • Patient involvement in clinical research, and development of care pathways and clinical practice guidelines; and • Patient engagement/advocacy in healthcare policy You may also want to check the Patient Poster Session page on the EAU22 website for more information;

For more information www.eau22.org www.patients.uroweb.org/eau22

Patient Day Monday, 21 March • Bladder Cancer Session • Kidney Cancer Session • Prostate Cancer Session • Life After Cancer Treatment • Functional Urology Session • Patient Poster Session • WFIPP Roundtable Discussion on Incontinence Visit www.eau22.org/patients for more information.

Follow us: @EAUPatientInformation @EauPatient @EAU Patient Information

Patient Day will have seven sessions. More information can be found on www.eau22.org/patients October/January 2022


Join us in Amsterdam! Stellar lineup: Your guide to ESU courses The European School of Urology (ESU) continuously develops its educational activities to parallel the ever-expanding field of urology. For two decades now, the ESU has been vigilant in providing training essentials to young and experienced urologists. At EAU22, you can expect popular hands-on trainings (HOTs) on MRI fusion biopsy, MRI Reading, sacral neuromodulation, robotics, and abdominal ultrasound. What’s also in store for you are in-demand ESU courses. Found below is a preliminary overview of topics and course sessions. Individual lectures per session, as well as, more details on the HOTs will be made available in the online scientific programme soon.

Neurogenic and non-neurogenic voiding dysfunction

Adrenals

• M ale Genital Diseases (Chair: Prof. Suks Minhas) • Testicular cancer (Chair: Prof. Peter Albers)

• Percutaneous nephrolithotripsy (PCNL) (Chair: Prof. Evangelos Liatsikos) • Update on stone disease (Chair: Prof. Bhaskar Somani) • Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips, tricks and indications (Chair: Prof. Olivier Traxer) • Metabolic workup and non-surgical management of urinary stone disease (Chair: Dr. Thomas Tailly) • Advanced endourology in the non-standard patients with urolithiasis (Chair: Dr. Guido Kamphuis)

Prostate cancer

Urological surgery

• Adrenals for urologists (Chair: Prof. Ali Serdar Gözen)

Andrology • O ffice management of male sexual dysfunction (Chair: Prof. Christian Stief) • The infertile couple – Urological aspects (Chair: Dr. Marij Dinkelman-Smit)

• C hronic pelvic pain in men and women (Chair: Dr. Bert Messelink) • Practical neuro-urology (Chair: Prof. Francisco Cruz) • Lower urinary tract dysfunction and urodynamics (Chair: Prof. Hashim Hashim)

Paediatric urology • P ractical approach to paediatric urology (Chair: Asst. Prof. Fardod O'Kelly)

Penile and testicular cancer

• R obot-assisted laparoscopic prostatectomy (Chair: Dr. Pierre-Thierry Piéchaud) • Retropubic radical prostatectomy: Tips, tricks and pitfalls (Chair: Prof. Oliver Hakenberg) Female urology • Focal therapy in prostate cancer • Advanced vaginal reconstruction (Chair: Dr. Eric Barret) (Chair: Prof. Dmitry Pushkar) • Prostate cancer imaging: When and how to use • Prolapse management and female pelvic floor it (Chair: Dr. Jochen Walz) problems (Chair: Prof. Ervin Kocjancic) • Prostate cancer screening and active surveillance – Where are we now? General Urology (Chair: Prof. Alexandre R. Zlotta) • How to proceed with hematuria • Prostate biopsy: Tips and tricks (Chair: Mr. Hugh Mostafid) (Chair: Prof. Peter Hammerer) • Ultrasound in urology • Metastatic prostate cancer (Chair: Prof. Tillmann Loch) (Chair: Prof. Karl Pummer) • Improving your communication and presentation • Oligometastatic prostate cancer skills (Chair: Prof. Giovanni Cacciamani) (Chair: Dr. Robert Jeffrey Karnes) • How to write the introduction and methods • Prostate cancer update: 2021-2022 (Chair: Prof. James Catto) (Chair: Prof. Francesco Montorsi) • How to write results and discussion • Surgery or radiotherapy for localised and (Chair: Prof. Catto) locally advanced prostate cancer • Practical aspects of cancer pathology for urologists. (Chair: Prof. Jeroen Van Moorselaar) The 2022 WHO novelties • Prostate cancer challenges and controversies (Chair: Prof. Eva Compérat) from guidelines to real-world (Chair: Prof. Francisco Gómez Veiga) • Theranostics in prostate cancer Infections • Dealing with the challenge of infection in urology (Chair: Prof. Boris Hadaschik) (Chair: Prof. Florian Wagenlehner)

Kidney transplantation • R enal transplantation: Technical aspects, diagnosis and management of early and late urological complications (Chair: Prof. Francisco Javier Burgos Revilla)

Male LUTS • M anagement of BPO: From medical to surgical treatment, including setbacks and operative solutions (Chair: Mr. Vijay Ramani)

Renal tumours

• A dvanced course on laparoscopic renal surgery (Chair: Dr. Alberto Breda) • Treatment of small renal masses (Chair: Prof. Paolo Gontero) • Robot renal surgery (Chair: Prof. Alexandre Mottrie)

Trauma • U rinary tract and genital trauma (Chair: Dr. Noam Kitrey)

Urethral strictures • Advanced course on urethral stricture surgery (Prof. Luis Martinez-Pineiro)

Urolithiasis

• Surgical anatomy for laparoscopic and roboticassisted radical prostatectomy and cystectomy (Chair: Prof. Jens-Uwe Stolzenburg) • Laparoscopy for beginners (Chair: Prof. Xavier Cathelineau) • Advanced course on upper tract laparoscopy: Kidney, ureteropelvic junction (UPJ), ureter and stones (Chair: Prof. Francesco Porpiglia) • Peno-scrotology and basic lower urinary tract endoscopy – Questions you are scared to ask (Chair: Mr. Chandra Shekhar Biyani) • Prosthetic surgery in urology (Chair: Mr. Asif Muneer) • Lymphadenectomy in urological malignancies (Chair: Prof. Agostino Mattei) • Practical tips for pelvic laparoscopic surgery: Cystectomy, radical prostatectomy adenomectomy and sacrocolpopexy (Chair: Dr. Jose Maria Gaya Sopena)

#EAU22

YUORDay22: EAU Guidelines Cup, nightmare cases, and more Tailored to the educational needs of residents, the European Society of Residents in Urology (ESRU) and the Young Urology Office (YUO) organised the YUORDay22 session, which will take place on 19 March 2022. The session will offer surgery tips and tricks such as how to master flexible ureteroscopy, incontinence surgery, and more; nightmare cases with Q&A; hot updates such as new evidences in prostate cancer, and bladder cancer, to name a few. Then YUORDay22 will conclude with the live finale of 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 final top three participants will compete on YUORDay22 overseen by experts and Guidelines masters Prof. Dr. Maria Jose Ribal Caparros (ES), Dr. Giulio Patruno (IT), and Dr. Juan Luis Vásquez (DK). To join the EAU Guidelines Cup, wait for an invitation sent to your email address with a personalised link. Click the link then answer the questions as best and fast as you can. You will receive immediate feedback on how many answers you got correct. You could be the next EAU Guidelines Cup champion. Are you up for the challenge?

Urothelial tumours • Practical management of non-muscle invasive bladder cancer (NMIBC) (Chair: Prof. Alfred Witjes) • How we manage upper tract tumours (Chair: Prof. Shahrokh Shariat) • Robot-assisted laparoscopic radical cystectomy (Chair: Prof. Peter Wiklund) • Management and outcome in invasive and locally advanced bladder cancer (Chair: Prof. Bernard Malavaud) • Nerve-sparing cystectomy and orthotopic bladder substitution. Surgical tricks and management of complications (Chair: Prof. Arnulf Stenzl) • How will immunotherapy change the multidisciplinary management of urothelial bladder cancer (Chair: Assoc. Prof. Andrea Necchi)

How to add ESU courses to your registration You can enrol for the ESU courses online when you register for EAU22 via www.eau22.org/registration. You can also register for the ESU courses onsite during the congress but please note that participation is subject to availability. Many courses are fully booked prior to the congress.

Guidelines Cup at EAU19 Barcelona attracted talented young urologists

YAU Special Session: Hot topics and awards The Special Session: Meeting of the Young Academic Urologists (YAU) will commence on 18 March 2022 and be led by YAU Chair Dr. Juan Gómez Rivas (ES). To promote high-quality studies and to provide strong evidence for the best urological practice, YAU members and key opinion leaders in urology will focus on the scientific and educational aspects. The session will feature hot topics such as the potential use of robotic surgery in complex urological conditions, penile augmentation, updates on the Intraoperative Complication Assessment and Reporting with Universal Standards (ICARUS) project, current clinical trials in the field of renal cell carcinoma, and many more. The YAU Awards will also take place where the following accolades will be bestowed: Best paper published in 2021 by a YAU group, Best poster presented at EAU 2021 by a YAU group, and YAU reviewer of the year 2021.

October/January 2022

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EAU policy update A new addition to the EAU Policy Office and news from the European Union Mrs. Sarah Collen EAU Policy Coordinator Brussels (BE)

The European Commission has also appointed its chief scientific advisors to give their opinion on the most up-to-date scientific information on the potential new cancers to be addressed by early detection or screening guidelines. This includes prostate cancer, and we have been working with the scientific community to promote the EAU scientific recommendations on early detection.

s.collen@uroweb.org

The EAU remains active as a member of the European Commission’s stakeholder group on the EU Cancer Plan implementation.

Further to the formal establishment of the EAU Policy Office, the Executive Committee has appointed Prof. Philip Van Kerrebroeck (BE) as vice-chair of the Policy Office, meaning he will support Prof. Hein Van Poppel (BE) in the leadership of this new office. Why the need for an EAU Policy Office? The Policy Office works on six complementary and overlapping themes: • U ro-oncology and Europe’s Beating Cancer Plan (EU Cancer Plan) • R esearch and innovation • D igitalisation of health care and data-driven technologies • R egulation of medicines and medical devices • R are and complex urological conditions • P atient advocacy Prof. Van Kerrebroeck has been chosen for his wealth of experience and expertise to strengthen and develop the advocacy of the EAU outside of urooncology, which is primarily led by Prof. Van Poppel. It is also important that Prof. Van Kerrebroeck lives close enough to the EU institutions to be able to come to Brussels to engage regularly with EU decision makers. Prof. Van Kerrebroeck has over 37 years of experience as a medical doctor/urologist, including as chair of the Department of Urology at the University Hospital Maastricht from September 1997 until September 2012. He is also Professor of Urology at the University of Maastricht, a position in which he started in November 1998 (emeritus status since 1 November 2019). During his career, his specific interests have been in functional urology and neuro-urology. Prof. Van Kerrebroeck will continue in his role of Chair of the EAU History Office.

European Cancer Summit On 17 and 18 November, the cancer community met in Brussels and online for the European Cancer Summit organised by the European Cancer Organisation (ECO, an umbrella organisation of which the EAU is a member). Prof. Arnulf Stenzl (DE) attended as a member of the ECO Board, Prof. Van Poppel as chair of the EAU Policy Office, Mrs. Sarah Collen (BE) as EAU Policy Office manager, and Mrs. Corinne Tillier (NL) as board member of the EAUN. It was exciting to see that our advocacy on early detection of prostate cancer has been taken up by ECO and that our recommendations to the European Commission are echoed in their report on early detection, which was published on the first day of the summit at www. europeancancer.org/resources/. There were many interesting and informative sessions on topics of key interest to the EAU, such as early detection, affordable and equitable access to treatments, quality care, the multidisciplinary cancer workforce, harnessing data for better cancer outcomes, inequalities, and research and innovation. Mr. Alberto Costa (IT) from the European School of Oncology even promoted the EAU as an example of innovation in its use of Proficiency-Based Progression with digital tools to map training outcomes. The event was attended by patient advocates, multidisciplinary clinical experts, scientists, and researchers, along with high-profile EU decisionmakers such as the EU Commissioner for Health,

The Hellenic Urological Association has also done incredible work by reaching out to a Greek MEP, Anna-Michelle Asimakopoulou, who has not only asked a parliamentary question to the Health Commissioner, but has also gone on to write an article for ‘The Parliament Magazine’ to echo our advocacy views.

Ms. Corinne Tillier (l) and Prof. Hein Van Poppel (r) EAU Policy Office

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European Urology Today

hands-on experience of sharing data for healthcare purposes and has developed a patient registry. The EAU leadership over Prostate PIONEER and OPTIMA on the use of Big Data and Real-World Evidence has given the EAU a unique and detailed experience of the challenges and opportunities of data sharing. This experience and expertise are allowing us to feed into the European Commission as they draft the legislative proposal and into EU governments as they prepare for the EHDS through an EU-funded initiative. We at the EAU are also active participates in this network of EU government agencies, and we are helping to shape their thinking. We are also active members of the European Medicines Agency (EMA) Healthcare Practitioners Working Party and are working with their EMA Big Data Taskforce as they think through the use of big data and real-world evidence for regulatory purposes. This is a very exciting and dynamic policy space, and the EAU is providing leadership from the medical professional perspective in how Europe can meet the challenges and opportunities to help us deliver better outcomes for our patients.

Ultimately it was argued that this lack of harmonisation across the EU led to delays in technologies reaching patients. It was also considered a question of equity across the EU, particularly for patients living in countries where HTA agencies are not fully developed and where decisions can lag many years behind other EU member states. The compromise does not go as far as many would have liked, but it will provide the framework for cooperation across the EU on the scientific assessment of technology, leaving the economic assessment to each member state individually. Although the clinical assessment will be performed at EU level, EU governments will still have quite a lot of flexibility in how they use it. In spite of the compromises made, it is quite a significant step forward for the EU and a sign of greater harmonisation on this important issue. The EAU joined advocacy on this piece of legislation with our colleagues from the BioMed Alliance to push for its successful completion.

ERN eUROGEN Exchange

He will be helping the Policy Office in particular to develop a strategy for policy engagement with and awareness raising among decision-makers on urological care outside of uro-oncology, strategies that he will be developing with patient advocates and organisations. We look forward to working with him! News from the European Union EU Cancer Plan The EU Cancer Plan implementation is ongoing as the European Commission has recently published the implementation roadmaps for both the EU Cancer Plan and the EU cancer research mission. The European Parliament special committee on cancer will vote on a report on the EU Cancer Plan in December, and the EAU has conducted joint advocacy with patient organisations to MEPs to ensure that early detection of prostate cancer will be given sufficient attention and that realistic, tangible, and measurable targets are set.

Prof. Philip Van Kerrebroeck (BE), the newly appointed vice-chair of the EAU Policy Office

Health Technology Assessment Health Technology Assessment (HTA) is a multidisciplinary process which addresses social, economic, and ethical factors to assess the impact and effects of a new piece of technology or invention. This process is traditionally performed by individual government HTA agencies, which give guidance on if and how technologies can be implemented across a certain country. After almost 4 years of negotiating, the EU has found a compromise on a proposal for the regulation of HTA at EU level. The European Commission published the proposal for a regulation in January 2018, but it caused quite a storm within large EU member state governments with well-established HTA agencies, who wanted to keep the role of the EU to a minimum in this area. The pharmaceutical industry was very keen on a joint approach, however, because the industry spends time and money gaining HTA approval from each EU member state authority instead of a more harmonised approach.

Successful visits in the Netherlands and Italy

Prof. Hein Van Poppel chairs the Inequalities session at the European Cancer Summit.

Stella Kyriakides, and Members of the European Parliament. The EU has a chance through the EU Cancer Plan and the EU Research Mission on Cancer to focus on meaningful actions that will impact the lives of patients living with urological cancers and the lives of their families and friends. The EAU believes working together with the cancer community is crucial for addressing policy, legislative, and funding challenges which impact care for our onco-urology patients. European Health Data Space Plans for the European Health Data Space (EHDS) continue at pace, with an aim to support data sharing for health purposes across the EU. A first EHDS will facilitate the sharing of records for health purposes, so that things like Electronic Health Records and e-Prescriptions can be used by EU citizens in other EU countries when they travel abroad on holiday or to live. It will also support telemedicine and collaboration between expert clinical teams across borders. The second data space will facilitate ‘secondary purposes’ such as research, policymaking, and regulatory purposes. This initiative aims to support governance and infrastructure that will reinforce the sharing of data across the EU. This is quite a daunting task with many technical and legal barriers while keeping in mind ethical principles and maintaining trust of citizens. The EAU has much experience in this field; the EAU Research Foundation (EAU RF) has lots of practical experience from our medical device registries and clinical trials, and the eUROGEN network also has

The first three ERN eUROGEN Exchange Programme visits took place very successfully and further exchanges are planned so the European Reference Network for rare uro-recto-genital diseases and complex conditions can fully benefit from the opportunities provided by the European Commission. Lasma Lidaka, Paediatric Gynaecologist at Bērnu Klīniskā Universitātes Slimnīca (LV) and Vytis Kazlauskas, Paediatric Surgeon at Vilniaus Universiteto Ligoninė Santaros Klinikos (LT) visited Radboudumc (NL), the ERN eUROGEN coordinating centre. Dr. Kazlauskas said: "It was a great opportunity to visit one of the ERN centres actively involved in the management of rare diseases, which has great clinical experience in paediatric urology and their own scientific viewpoint on urogenital problems based on their original research. It was useful to see how the patient follow-up and treatment is organized in another hospital. It was also interesting to finally meet people I have only known from virtual conversations, but never seen eye-to-eye."

Dr. Lidaka visiting Prof. Feitz in Nijmegen (NL)

Gregory Apap Bologna, Higher Specialist Trainee in Urological Surgery at Mater Dei Hospital (MT) visited Azienda Ospedale Università Padova (IT). He reported: "I am very grateful for the opportunity to follow the different activities of the clinic and observe a wide array of the complex surgeries carried out regularly at this tertiary centre. I enjoyed watching a complex ureteric reimplant in a neo-bladder performed by Dr. Mariangela Mancini, different robotic-assisted laparoscopic surgeries, and was able to participate in ‘’hands-on’’ training on the Padoan Ileal Neobladder technique. I will take what I learned back to Malta to improve my clinical practice. This has been an important step in my urological training." The current call for visits is open to members of ERN eUROGEN and other ERNs until 1 February 2022. Check the information on our website for eligibility and visit our online tool to apply. https://bit.ly/ERNexchange

Dr. Gregory Apap Bologna in Padua, Italy

October/January 2022


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

Oliver.Hakenberg@ med.uni-rostock.de

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

Case study No. 70

A 28-year-old man has undergone several hypospadias repairs since childhood. Nevertheless, he is still complaining of dysuria and physical examination shows a meatal stenosis which only admits a guidewire (Fig. 1). His voiding urethrogram is also shown (Fig. 2).

Somehow, the stent was “forgotten”. A urologist now tried to take the stent out but was unsuccessful. Therefore the patient was referred to us.

This 61-year-old woman was referred with an incrustated ureteral stent on the left side for further management (fig.1). The stent had been in situ for almost four years and had been inserted because of symptomatic lower calyx stones. The patient suffers from severe cardiac insufficiency (NYHA 3-4) due to coronary artery disease, rheumatoid arthritis with prednisolone medication and COPD (Gold 4) requiring permanent oxygen treatment. For those reasons the symptoms of left stone disease were at the time treated just by stent insertion.

Case study No. 71

Discussion point • Which management and treatment is advisable?

Case provided by Oliver Hakenberg, Rostock, Germany. email: oliver.hakenberg@ med.uni-rostock.de Figure 1 Fig. 1

As minimally invasive as possible Comments by Dr. Mariela Corrales Paris (FR)

Dr. Alba Sierra Del Rio Paris (FR)

Prof. Olivier Traxer Paris (FR)

Encrusted stents are, without a doubt, every urologist’s nightmare. One of the causes of this undesired scenario is when stent removal has been missed for months or even years, as it was in this patient’s case.

So, how to deal with this problem? There is a wide range of treatment options. For instance, some may say that perhaps the percutaneous access is the way to go, others may say that it could be treated by flexible and/or semi-rigid ureteroscopy and finally, there is the group that will select a combined approach, using percutaneous access and ureteroscopy to treat simultaneously the encrustations of the renal and ureteral segments of the stent. In this case, all these approaches are feasible and could work. However, we need to remember two crucial points. The first one is that we are dealing with a fragile patient with several comorbidities. It is of utmost importance to take into account the patient’s condition before choosing the treatment that is best suited. The second one, with the improvements in the ureteroscopy field and the experience gained in flexible ureteroscopy, cases like this could be treated by ureteroscopy alone. That being said, for this patient, we recommend a session of flexible ureteroscopy by using the laser to cut the stent itself and to fragment the encrustations on the stent. Nowadays, we have two different laser technologies on the market, the thulium fiber laser (TFL) and the holmium yttrium aluminum garnet (Ho:YAG) laser; both are safe and effective. The TFL brings a more precise cut, when compared to the

Ho:YAG laser and would be the laser of choice, if available. After ablating the stent, a control ureteropyelography must be performed to reveal any contrast media extravasation and a control ureteroscopy also needs to be done to show the integrity of the ureteral mucosa. Additionally, it seems that only the retrograde approach does not increase the risk of severe complications when compared to combined procedures. Nonetheless, as encrusted stents are usually covered by biofilms and have resistant bacterial colonisation, all precautions should be taken against urinary sepsis. References 1. Thomas A, Cloutier J, Villa L, Letendre J, Ploumidis A, Traxer O. Prospective Analysis of a Complete Retrograde Ureteroscopic Technique with Holmium Laser Stent Cutting for Management of Encrusted Ureteral Stents. J Endourol. 2017 May;31(5):476-481. doi: 10.1089/end.2016.0816. 2. Barghouthy Y, Wiseman O, Ventimiglia E, Letendre J, Cloutier J, Daudon M, Kleinclauss F, Doizi S, Corrales M, Traxer O. Silicone-hydrocoated ureteral stents encrustation and biofilm formation after 3-week dwell time: results of a prospective randomized multicenter clinical study. World J Urol. 2021 Sep;39(9):3623-3629. doi: 10.1007/s00345-021-03646-0.

Fig. 2

Discussion point • What surgical procedure is advisable?

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

The ‘Forgotten’ ureteric stent management Comments by Dr. Abdelfttah Omran Doha (QT)

Dr. Abdulkader Alobaidy, Doha (QT)

Prof. Omar Aboumarzouk, Doha (QT)

The missed stent or ‘forgotten’ stent is a urological disaster and a treatment nightmare for any urologist. Missed stents occur for many reasons: poor patient compliance in that the patient does not return for change or removal or poor counselling by the practitioner if the patient does not understand follow-up. No matter the cause, this highlights the importance of a stent registry which needs to be regularly updated and monitored.

October/January 2022

Encrustations in stents that have been left in situ for years occur in various forms. However, generally it concerns either segmental incrustation of the coiled parts of the stent, or along the whole length of the stent. Management in these scenarios can be challenging. A step-by-step, multi-disciplinary and multimodality and even multi-sessional approach might be required. Generally, endourologists might require the use of all the modalities at their disposal, including SWL, ureteroscopy (rigid and flexible), PCN, PCNL, cystolitholapaxy, even open or laparoscopic/ robotic surgical techniques, including nephrectomy if the kidney is non-functioning. Therefore, a CT scan and a functional nuclear renogram are required. Given the fact that the patient was deemed unfit for endoscopic intervention at the time due to extensive co-morbidity, options for treatment are limited. Therefore, we would seek an anaesthetic opinion. Spinal anaesthesia could be the most appropriate method. We also do not tend to insert a second stent in these patients, as we found no additional benefit and there is a risk of the second stent becoming encrusted as well, even in short intervals. We would initially treat the upper coil encrustation and any large bulky encrustation along the stent with shock wave lithotripsy. This allows for

fragmentation of the heavily encrusted segments and potentially allows for the stent to straighten as well as giving more mobility. Then, we would deal with the lower coil encrustation with a cystolitholapaxy with all endourological safety measures such as the use of contrast media and a safety wire. Following that, we would use rigid ureteroscopy and a pneumatic lithoclast or laser fragmentation to deal with the encrustations along the stent. We would fragment the encrustations along the whole stent length, especially the large encrusted segments. Throughout the procedure, we would assess stent mobility as we progress upwards inside the ureter. Once all impacted areas have been desintegrated and the stent has more mobility without any impacted areas remaining, and with upper coil flexibility, the stent will come out without further problems. In our experience dealing with complete total stent encrustations, we found that using this multi-modality technique is successful. Important points: 1. It is vital to have and maintain a stent registry 2. Patient and family counselling of stent management and potential complications is essential

3. A multi-disciplinary approach, by a radiological, anaesthetic and urological team is needed 4. A multi-modality approach utilising all technical options is needed 5. A step-wise approach is the key to solving the problem, first debulking the upper coil encrustations and then working from below upwards.

Case study No. 70 continued In this severely ill patient we chose to perform ureteroscopy only under peridural anesthesia with sedation. Using a combination of rigid and flexible ureteroscopy, the stent was completely freed from all encrustations and finally, after a long procedure, the stent could be removed completely. All debris was cleared and a new stent was inserted for the lower pole stones still present. A second procedure to remove the remaining stones was planned but the patient refused and went home.

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

serdartekgul@ gmail.com

Do modern disposable diapers stimulate better bladder control in children? Over the last decades, the availability of modern disposable diapers (DD) has changed the way we manage our children. They are safe, easy to use, comfortable and easy to dispose, compared to cloth diapers used previously. Meanwhile, this has also changed our attitude to toilet training. Initiation of toilet training usually starts later compared to the past. Diapers play an important role in the management of enuresis-related issues and have significantly increased the quality of life of children as well as their family. Although many people will disagree, there is no evidence that the use of DD postpones the time of bladder control attainment, or that removal of the DD leads to resolution of enuresis. Yet many would recommend against using DD, as a first measure towards night-time dryness training. The NICE guideline on enuresis proposes trying non-diaper periods to assess any effect on enuresis frequency.

challenge. Parents have less time for TT, which makes the DD even more convenient, and necessary to cope with incontinence in small children.

were needed and performed in 11 patients. Eight patients were eventually diagnosed with a bulbar stricture, either isolated (n = 5) or combined with a distal stricture (n = 3), without significant relation The studies presented in this review show conflicting with the initial position of meatus. results. Several studies believe firmly in the association between diapering and prolonged Bulbar strictures represent more than 25% of the enuresis, other studies do not find this link. Whether overall strictures diagnosed in adult patients treated or not DD use has different effects on enuresis for hypospadias during childhood, independent of compared to daytime urinary incontinence is hard to the original site of urethral reconstruction. assess from the included studies, as all daytime cessation of DD is combined with some kind of TT. The study did not discuss length and exact location For the children with enuresis, avoidance of night of bulbar strictures, because of absence of data in diapers may lead to discomfort awakenings of both some patients. It was, however, observed that child and parents, interrupted and poor sleep symptomatic bulbar strictures do exist in adults in quality, further motivating the on-going use of DD the long term after penile hypospadias repair during until spontaneous resolution of symptoms occurs. childhood, independent of the initial site of hypospadias, initial success of primary repair, and It is possible to try to see whether children could the type of surgical reconstructions performed actually gain continence just by stopping the use of during childhood. DD, but there is no good evidence to support this Source: Adults with previous hypospadias practice.

Source: Does the development and use of modern disposable diapers affect bladder control? A systematic review. Breinbjerg A, Rittig S, Kamperis K. J Pediatr Urol 2021

Journal of Pediatric Urology, published online November 11 2021.

Aug;17(4):463-471.

High rate of bulbar strictures in patients treated for hypospadias

Although the subject is still insufficiently studied, increasing data appear in literature addressing the The aim of the review by the authors was to evaluate long-term complications of hypospadias repair. The the scientific knowledge on DD use in children with relationship with the initial procedure is a urinary incontinence, to assess whether DD use is challenging process of exploring the frequency of related to continence attainment. complications and understanding the variations. A systematic literature search looked at 400 studies which were eligible for screening. Finally, 12 abstracts and only eight studies were eligible for review. No prospective intervention studies specifically evaluating the effect of a diaper on enuresis were identified.

surgery during childhood: beware of bulbar strictures. Faraj S, Loubersac T, Bouchot O, et al.

There will always be a selection bias in such data, as it is almost impossible to have a good and strict follow-up of children into adulthood. Often we only see patients with problems, but not all the others who had a satisfactory outcome. Additionally, the information available about past surgical history and technique employed is not good enough to draw any conclusion on causative factors.

Outcomes analysis of the phase III ACIS trial for mCRPC In the present article, the authors reported the outcomes analysis of the phase III ACIS trial, comparing abiraterone acetate with or without apalutamide, in addition to androgen blockage, in metastatic, castration-resistant prostate cancer (PCa) patients. So far, no combination trial has proven any survival advantage at the mCRPC stage. The PLATO study, assessing the maintenance of enzalutamide at progression in addition to abiraterone, failed to demonstrate strong efficacy of the new hormonal agent combination, but this trial was conducted in the second-line setting.

In the ACIS trial, the primary endpoint was radiographic progression-free survival. Overall, 982 mCRPC, first-line, chemo-naive patients were included in this combination trial between 2014 and 2016. Secondary endpoints were overall survival, The general idea is that disposable diapers have time to initiation of cytotoxic chemotherapy, time to made a significant impact on toilet training in chronic opioid use, and time to pain progression. children, however, based on the available literature Treatment with apalutamide plus abiraterone led to Bulbar strictures are unexpectedly no secure conclusions can be drawn. There does a significant improvement in radiographic common among patients treated for progression-free survival compared with abiraterone seem to be some proof that diaper use is related to a delay in obtaining continence in children. (plus placebo) at the primary analysis (HR 0.69, 95% hypospadias and later presenting CI 0.58–0.83; p < 0.0001). At the final analysis (4.5 with urethral strictures …. years of follow-up), the significant radiographic … a robust correlation between progression-free survival benefit persisted (HR 0.70; Long-term hypospadias complications leading to p < 0.0001). Thus, despite the use of an active and diaper use and continence adult urologist consultation typically include established therapy as the comparator, apalutamide attainment cannot be found. stricture, cosmesis dissatisfaction, abnormal position plus abiraterone– prednisone improved radiographic of the meatus, urethrocutaneous fistula, and progression-free survival. The concordance between The use of DD is increasing as they become more persistent penile curvature. Urethral strictures stand central and investigator review of radiographic safe, reliable and accessible. DD have several as the most frequent long-term complication after progressive disease was 75%, with a high positive advantages in terms of comfort; newer materials hypospadias surgery during childhood. Urethral correlation coefficient for both treatments. decrease the risk of diaper dermatitis, and many strictures are more common at the site of the initial argue that they increase sleep quality in children surgery or along the neo-urethra. No overall survival benefit was achieved by the with enuresis. Along with the development of better combination. The median overall survival surpassed DD, there is a concern about an increase in age of The management in adult men remains challenging, 3 years with apalutamide plus abiraterone (36.2 initiating TT as well as an increase in the prevalence with several surgical strategies available and versus 33.7 months). At progression, about twoof LUTS in children, including enuresis. Although it is inconsistent results. This is especially true in men thirds of the patients who discontinued treatment tempting, a robust correlation between diaper use with a personal history of multiple stages of urethral received subsequent life-prolonging therapy. and continence attainment cannot be found, as no reconstruction during childhood. large randomised prospective studies have been Positive signal for combined performed evaluating only diapering as intervention. Bulbar strictures are unexpectedly common among hormone therapy in mCRPC The evidence on the effect of DD on enuresis and TT patients treated for hypospadias and later is not clear. It is not possible to draw any presenting with urethral strictures in adulthood. conclusions, although it seems that DD use might Moreover, none of the other secondary endpoints of have a negative influence on continence attainment. In this study, the authors look into a cohort of time to initiation of cytotoxic chemotherapy, time to One study reports a better chance of success when a patients who had hypospadias surgery in childhood chronic opioid use, and time to pain progression child wears diapers, but these findings were in and presented with urethral strictures. Hence there reached significance. Analyses of prespecified children > 11 years of age, and therefore not is a potential bias in the recruitment pattern and the biomarker subgroups based on molecular signatures comparable to the other cohorts described. lack of knowledge of the denominator (namely the (PAM50-luminal and androgen receptor signalling Therefore, impact of DD on TT is debatable. A number of hypospadias patients treated during activity) did not find any significant correlation with common assumption would be that the more childhood) and unavailability of medical detail in radiographic progression-free survival. Overall comfortable and convenient a diaper gets, the more ancient operative records. incidence of adverse events was similar between it takes to motivate the child and the parents to stop groups. Serious adverse events occurred in 40% using them. Of the 42 consecutive adults eligible, a total of 28 versus 37% of patients receiving apalutamide plus patients had a persistent urethral stricture. During abiraterone versus placebo plus abiraterone. Grade Because of the lack of comfortable and convenient adulthood, initial urethral assessment revealed 29 3-4 adverse events were reported in 60% versus diapers or better alternatives, TT was initiated at an urethral strictures in 28 patients (penile urethra 51% of patients receiving apalutamide plus earlier age in the past. The fact that more parents 23/29, bulbar urethra 8/29). The early initial success abiraterone versus placebo plus abiraterone. The both have full-time jobs and children spend the rate of stricture treatment was 50% (median most common adverse event was hypertension largest part of the day in day-care is an extra follow-up: 4 years). Additional surgical procedures (10%-17%). Cardiac disorders occurred with similar Key articles

8

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com

frequency in both groups (19%) leading to 1% of deaths in both groups. Globally, safety was consistent with the previously reported tolerability profiles. Quality-of-line maintenance was equivalent in both arms. This trial is the first combo phase 3 study in castration-resistant prostate cancer that has met its primary endpoint. Nevertheless, no benefit was observed in terms of overall survival. Such a combination probably does not lead to changes in current guideline treatment recommendations. However, subgroup analyses may help to identify patients that would be more likely to benefit. A positive signal was seen in patients aged 75 years and older. For this specific population who may be unfit to receive subsequent therapy sequences, the initial combination of two active drugs could be interesting to consider. Future trials are awaited to better define combinations and sequencing at the mCRPC stage, in the era of the use of new hormonal agents in the metastatic castration-sensitive prostate cancer stage.

Source: Apalutamide plus abiraterone acetate and prednisone versus placebo plus abiraterone and prednisone in metastatic, castrationresistant prostate cancer (ACIS): a randomised, placebo-controlled, double-blind, multinational, phase 3 study. Saad F, Efstathiou E, Attard G, et al; ACIS Investigators. Lancet Oncol. 2021 Sep 30:S1470-2045(21)00402-2

STAMPEDE trial: Comparison of quality-of-life outcomes Intensified systemic treatment is currently the standard treatment in metastatic prostate cancer. The choice is mainly based on new generation hormone therapy or docetaxel in addition to androgen therapy (ADT). Recently, after the presentation of the preliminary results of the PEACE1 trial during ESMO, the combination of abiraterone and docetaxel therapy has also been found to have an additional favourable impact. However, these different treatments may induce clinically meaningful side effects which may impact on the patient’s quality of life. In the present study, Rush et al report quality of life outcomes of men included in the same period in the Stampede trial, who were assigned to hormonal therapy plus docetaxel versus hormonal therapy plus abiraterone. Quality of life (QoL) was measured using the QLQ-C30 and PR25 questionnaires during a 2-year period.

This data, derived from a randomised controlled trial, provides important insight in a field where not much level 1 evidence is available. Interestingly, patients who received ADT plus abiraterone were found to have a more favourable global quality of life score than men who received upfront docetaxel, mainly during the first year after treatment initiation. Thereafter, the differences in QoL between the arms decreased with little differences in the second year. The toxicity of docetaxel mainly explained the QoL scores differences. Short-term differences in fatigue, pain, physical functioning, social functioning, and role functioning were also observed, favouring abiraterone treatment over docetaxel. This data, derived from a randomised controlled trial, provide important insight in a field where not much level 1 evidence is available. Patient-reported

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Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

outcomes measurements should play an increasingly important role in assessing the value of therapy for prostate cancer, given the large number of available life-prolonging drugs. Several studies have also proven that QoL assessment can largely vary between the patient and the physician perspective. The cancer-specific and overall survival benefit should not be a stand-alone factor when deciding which drug is more suitable for an individual patient. Comorbidities, medical history, and own perspectives should be integrated into a patient-tailored decision-making process. Indeed, a patient may be more interested in side effects and impact on quality of life of the treatment options. As main limitation, we could highlight that even statistical differences were seen between both treatments in the present study, the thresholds described here remain subjective. Moreover, differences were totally amended after the first year, without sustainable benefit from long-term hormone therapy versus short-term chemotherapy.

Source: Quality of life in men with prostate cancer randomly allocated to receive docetaxel or abiraterone in the STAMPEDE trial. Rush HL, Murphy L, Morgans AK, et al. J Clin Oncol. 2021 Nov 10.

Role of adjuvant cisplatinbased chemotherapy in treatment of muscle-invasive bladder cancer The recommendation of performing neoadjuvant chemotherapy is mainly based on individual participant data meta-analysis, showing a 5% reduction in mortality. The same analyses have been performed for the adjuvant setting but were limited by the small number of trials and patients. Since the initial publication, 5 additional randomised controlled trials have been completed and reported. In the present article, the authors aimed to investigate the role of adjuvant cisplatinbased chemotherapy in the treatment of muscleinvasive bladder cancer. Eligible trials were those aimed to compare adjuvant cisplatin-based chemotherapy plus local treatment versus the same local treatment alone or the same local treatment and then adjuvant cisplatin-based chemotherapy on recurrence. Local treatment could include surgery with or without preoperative radiotherapy, or radical radiotherapy ± salvage cystectomy for local failure. The ten included trials (n = 1,183 participants) accrued between 49 and 284 participants, and radical cystectomy was the local treatment in all cases. The median follow-up was 6 years. Overall survival results showed a significant benefit of adjuvant chemotherapy (HR = 0.82; 95% CI:0.70–0.96, p = 0.02). This corresponded to a 6% absolute improvement in overall survival at 5 years. Results were the same when a randomeffects model was used. Recurrence-free survival (615 events) results were only based on nine trials (1,075 participants) and demonstrated a benefit of adjuvant chemotherapy (HR = 0.71, 95% CI = 0.60–0.83, p < 0.001). This translates to an 11% improvement at 5 years. Metastasis-free survival results were based on six trials (884 participants, 425 events) and showed an 8% absolute improvement in metastasis-free survival. This individual participant data meta-analysis confirmed a 6% absolute benefit of cisplatin-based adjuvant chemotherapy in 5-year survival of patients with muscle-invasive bladder cancer who received radical cystectomy as primary local treatment. Moreover, no clear evidence that the effect varied by trial or participant characteristics was reported. Adjuvant chemotherapy also improved recurrence-free survival, locoregional Key articles

October/January 2022

recurrence-free survival, and metastasis-free survival. Although neoadjuvant chemotherapy is currently recommended, the 5% absolute improvement in survival achieved by this preoperative regimen was no different from that reported here after adjuvant chemotherapy. Without high-level data comparing these two regimens, this meta-analysis demonstrates that adjuvant chemotherapy may be discussed and may become a new option. It may be part of the patient counselling and could be favoured depending on circumstances and clinician and patient preference. However, it is worthy to note that almost one-third of the participants in these trials did not receive all the chemotherapy cycles as planned (fewer cycles, lower total doses). Thus, the completeness of chemotherapy may be more difficult in the adjuvant setting compared with neoadjuvant chemotherapy due to complications and impaired renal function after radical cystectomy and urinary diversion. Last point, immunotherapy may also be considered as a new competitive option in this setting, with potentially higher complete tumour response rates and better safety profile.

Source: Adjuvant Chemotherapy for Muscleinvasive Bladder Cancer: A Systematic Review and Meta-analysis of Individual Participant Data from Randomised Controlled Trials. Burdett S, Fisher DJ, Vale CL, et all; Advanced Bladder Cancer (ABC) Meta-analysis Collaborators Group. Eur Urol. 2021 Nov 18:S03022838(21)02058-3

Comprehensive evaluation of psychological distress, erectile function in patients recovered from COVID-19 The psychological and sexual health of different populations are negatively affected by the coronavirus disease (COVID-19) pandemic. However, little is known about long-term psychological distress and erectile function of male patients who recovered from COVID-19. The authors aimed to evaluate these aspects in the mid to long term. The investigators recruited 67 eligible male patients recovered from COVID-19 and performed a follow-up twice within approximately 6 months after their recovery. The psychological distress and erectile function were assessed by validated questionnaires.

…second-visit patients showed no significant difference with controls in ED prevalence. During the first visit, COVID-19 patients with a median recovery time of 80 days presented the following positive symptoms: obsessivecompulsive, additional items (ADD), hostility, interpersonal sensitivity, depression, and somatisation; while the dimension scores in somatisation, anxiety, ADD, and phobia were higher than male norms. Besides, the prevalence of erectile dysfunction (ED) in the first-visit patients was significantly higher than controls. In the second visit, the primary psychological symptoms of COVID-19 patients with a median recovery time of 174 days were obsessive-compulsive, ADD, interpersonal sensitivity, and hostility, while all dimensions scores of symptom checklist 90 were lower than male norms. Moreover, second-visit patients showed no significant difference with controls in ED prevalence. The study showed the changes in psychological symptoms and erectile function in patients recovered from COVID-19 and provided reference on whether psychological and sexual support is needed after a period of recovery. With less impact of COVID-19, the impaired erectile function and psychological distress improved in recovered patients, with a recovery time of approx. half a year.

Source: A Mid-to-Long Term Comprehensive Evaluation of Psychological Distress and Erectile Function in COVID-19 Recovered Patients. Bintao Hu, Yajun Ruan, Kang Liu, , et al. J Sex Med. 2021 Nov;18(11):1863-1871. doi: 10.1016/j.jsxm.2021.08.010.

Association of physical activity and urinary incontinence in US women

Prof. Oliver Hakenberg Section Editor Rostock (DE)

The authors aimed to evaluate the relationship between physical activity, both work and recreational, and urinary incontinence in women.

Oliver.Hakenberg@ med.uni-rostock.de

Women aged 20 years and older were assessed in 2008-2018 NHANES (National Health and Nutrition Examination Survey) cycles and answered selfreported urinary incontinence and physical activity questions. A weighted, multivariate logistic regression model was used to determine the association between incontinence and physical activity levels after adjusting for age, body mass index, diabetes, race, parity, menopause and smoking.

depressive symptoms (all p < 0.05). Furthermore, a worse quality of life and higher IPSS score were associated with RE-related distress (all p < 0.05). The above results were confirmed even when patients using drugs that possibly interfere with ejaculation or those without a stable relationship were excluded from the analysis.

Increasing levels of RE-related …more time spent on participating distress were associated with in moderate physical activity a progressively worse sexual is associated with a decreased functioning, higher risk of ED… likelihood of stress, urge and mixed incontinence… Self-reported RE is common in European men A total of 30,213 women were included in the analysis, of whom 23.15% had stress incontinence, 23.16% had urge incontinence, and 8.42% had mixed incontinence (answered "yes" to both stress and urge incontinence). Women who engaged in moderate recreational activity were less likely to report stress and urge incontinence (OR 0.79, 95% CI 0.62-0.99 and OR 0.66, 95% CI 0.48-0.90, respectively). Similarly, women who engaged in moderate activity work were less likely to report stress, urge and mixed incontinence (OR 0.84, 95% CI 0.70-0.99; OR 0.84, 95% CI 0.72-0.99; and OR 0.66 95% CI 0.45-0.97, respectively). Moderate physical activity and more time spent on participating in moderate physical activity is associated with a decreased likelihood of stress, urge and mixed incontinence in women. This relationship holds for both recreational and work-related activity. The authors hypothesise that the mechanism of this relationship is multifactorial, with moderate physical activity improving pelvic floor strength and modifying neurophysiological mediators (such as stress) involved in the pathogenesis of incontinence.

Source: The Association of Physical Activity and Urinary Incontinence in US Women: Results from a Multi-Year National Survey. Kim MM, Ladi-Seyedian S-S, Ginsberg DA, et al. Urology. 2021 Oct 10;S0090-4295(21)00915-8. doi: 10.1016/j. urology.2021.09.022.

Study on self-reported shorter than desired ejaculation latency

aged over 40 years. The reported limited RErelated distress may explain the relatively low number of medical consultations for RE. RErelated distress is associated with worse sexual function, couple impairment, and more LUTS, resulting in a worse quality of life and mood disturbances.

Source: Self-Reported Shorter Than Desired Ejaculation Latency and Related DistressPrevalence and Clinical Correlates: Results From the European Male Ageing Study. Corona G, Rastrelli G, Bartfai G, et al. J Sex Med. 2021;18(5):908-919. doi: 10.1016/j.jsxm.2021.01.187.

Nonlinear relationship between body mass index and clinical outcomes after kidney transplantation A high body mass index (BMI) is a risk factor for complications in renal transplantation. The exact dose-response relation between body mass index at transplantation and clinical outcomes after kidney transplantation, however, remains unclear, and no specific body mass index threshold and pretransplant weight loss aims have been established. The authors did a meta-analysis of the available literature after searching PubMed, Embase, Web of Science and the Cochrane Library for all relevant publications published until 31 December 2019. The two-stage, random-effect meta-analysis was performed to estimate the dose-response relation between BMI and clinical outcomes after kidney transplantation.

Few studies have looked at the occurrence and clinical correlation between self-reported shorter than desired ejaculation latency (rapid ejaculation, RE) and its related distress in the general population.

Analysis of BMI, graft outcomes suggests clear margins for pre-transplant weight reduction

The subjects were recruited from population samples of men aged 40-79 years across 8 European centres. Self-reported RE and its related distress were derived from the European Male Aging Study (EMAS) sexual function questionnaire (EMAS-SFQ). Beck's Depression Inventory (BDI) was used for the quantification of depressive symptoms, the Short Form 36 health survey (SF-36) for the assessment of the quality of life, the International Prostate Symptom Score (IPSS) for the evaluation of lower urinary tract symptoms.

Ninety-four studies were included for qualitative assessment and 50 for dose-response metaanalyses. There was a U-shaped relation between graft loss, patient death and BMI. The body mass index with the lowest risk of graft loss was 25.2 kg/ m2, and the preferred BMI range was 22-28 kg/m2. Referring to a BMI of 22 kg/m2, the risk of graft loss was 1.088, 0.981, 1.003, and 1.685 for a body mass index of 18, 24, 28, and 40 kg/m2, respectively. The BMI with the lowest risk of patient death was 24.7 kg/m2, and the preferred BMI range was 22-27 kg/m2. Referring to a BMI of 22 kg/m2, the patient death risk was 1.115, 0.981, 1.032, and 2.634 for a body mass index of 18, 24, 28, and 40 kg/m2, respectively. J-shaped relations were observed between BMI and acute rejection, delayed graft function, primary graft non-function, and de novo diabetes. Pair-wise comparisons showed that higher BMI was also a risk factor for cardiovascular diseases, hypertension, infection, longer length of hospital stay, and lower estimated glomerular filtration rate level.

About 2,888 community dwelling men aged 40-79 years (mean 58.9 ± 10.8 years) were included in the analysis. Among the subjects included, 889 (30.8%) self-reported RE. Among them, 211 (7.3%) claimed to be distressed (5.9% and 1.4% reported mild or moderate-severe distress, respectively). Increasing levels of RE-related distress were associated with a progressively worse sexual functioning, higher risk of ED and with couple impairment, along with a higher prevalence of

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Prof. Oliver Hakenberg Section Editor Rostock (DE)

authors of this study estimated the global, regional, and national incidence of sepsis and mortality using data from GBD 2017.

Oliver.Hakenberg@ med.uni-rostock.de

Multiple cause-of-death data from 109 million individual death records were used to calculate mortality related to sepsis among each of the 282 underlying causes of death in GBD 2017. The percentage of sepsis-related deaths by underlying GBD cause in each location worldwide was modelled using mixed-effects linear regression. Sepsis-related mortality for each age group, sex, location, GBD cause, and year (1990-2017) was estimated by applying modelled cause-specific fractions to GBD 2017 cause-of-death estimates. Investigators used data for 8.7 million individual hospital records to calculate in-hospital sepsis-associated case-fatality, stratified by underlying GBD cause. In-hospital sepsis-associated case-fatality was modelled for each location using linear regression, and sepsis incidence was estimated by applying modelled case-fatality to sepsis-related mortality estimates.

The authors conclude that underweight and severe obesity at transplantation are associated with a significantly increased risk of graft loss and patient death and suggest that a target BMI at kidney transplantation is 22-27 kg/m2. This analysis provides clear data on the aims that counselling of patients on the waiting list should have.

Source: Nonlinear relationship between body mass index and clinical outcomes after kidney transplantation: A dose-response meta-analysis of 50 observational studies. Yin S, Wu L, Huang Z, Fan Y, Lin T, Song T. Surgery, 2021, doi: 10.1016/j.

Study estimates 19.7% of all global deaths are sepsis-related

surg.2021.10.024, Online ahead of print.

Bioavailability of once-daily tacrolimus formulations in De Novo kidney transplant recipients Once daily administration of tacrolimus for immunosuppression is advantageous for patient compliance. In daily practice, pharmacokinetic data are often different from those observed in clinical trials. This is a multicentre, prospective, observational study to compare the relative bioavailability of once-daily tacrolimus formulations in de novo kidney transplant recipients.

In 2017, an estimated 48.9 million (95% uncertainty interval [UI] 38.9-62.9) incident cases of sepsis were recorded worldwide and 11 million (10.1-12.0) sepsis-related deaths were reported, representing 19.7% (18.2-21.4) of all global deaths. Agestandardised sepsis incidence fell by 37% (95% UI 11.8-54.5) and mortality decreased by 52.8% (47.7-57.5) from 1990 to 2017. Sepsis incidence and mortality varied substantially across regions, with the highest burden in subSaharan Africa, Oceania, South Asia, East Asia, and Southeast Asia.

Patients with urosepsis were characterised by a higher proportion of females, older age and a higher percentage of comorbidities. Patients with ESBL(+) Escherichia coli infection were more prone to shock. Mechanical ventilation, comorbidity with CKD, APACHE II score and lactate were independent risk factors for death in urosepsis patients, but lactate level and APACHE II score had better predictive value for prognosis.

Source: Clinical characteristics and prognosis in patients with urosepsis from intensive care unit in Shanghai, China: a retrospective bicentre study. Ying Sheng, Wen long Zheng, Qi fang Shi, et al. BMC Anesthesiology (2021) 21:296. h

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

tebj@medisin.uio.no

where a trend towards a potential association could be observed.

ttps://doi.org/10.1186/s12871-021-01520-5

Does mini-PCNL give higher risk of urosepsis in large renal stones? Urosepsis is amongst the most fearsome postoperative complication of an endourological procedure as it may potentially lead to a fatality. The risk of this complication may increase in relation to multiple variables, including the invasiveness of the endourological intervention. Percutaneous nephrolithotomy (PCNL) for the treatment of renal stones is regarded as the most invasive treatment and the risk of urosepsis may be as high as 7.6%, according to historical series published in literature.

Overall, regardless of its limitations, this study is the first of its kind to demonstrate that mPCNL for the treatment of large renal stones may increase the risk of urosepsis. Unfortunately, this study could not address which actual stone size should be considered the upper limit to be approached by means of mPCNL.

Source: Analysis of pre-operative risk factors for post-operative urosepsis following minipercutaneous nephrolithotomy in patients with large kidney stones. Yirixiatijiang Amier, Yucong Zhang, Jiaqiao Zhang, et al. J Endourol . 2021 Sep 25. doi: 10.1089/end.2021.0406. Online ahead of print.

Identifying better and safer training processes in endourology

Surgical training is a very challenging issue nowadays, due to the complexity and variety of the technological instrumentation that has been introduced in the last Despite declining age-standardised incidence and decades. The ‘old-style’ method of mentor training in mortality, sepsis remains a major cause of health theatre without any skills preparation beforehand is loss worldwide and has an especially high healthknown to expose patients to a relevant risk of related burden in sub-Saharan Africa. Nevertheless, some concerns have been raised about complications, a significant amount of additional the potential higher risk of post-operative infection stress to the supervising operator, and an increased Source: Global, regional, and national sepsis during an mPCNL: the higher intrarenal pressure amount of surgical time that might alter surgical De novo kidney transplant recipients who started a incidence and mortality, 1990-2017: analysis for and longer surgical time may facilitate the spread of planning. tacrolimus-based regimen were included 14 days bacteria trapped in the stones, evolving eventually to post-transplant and followed up for 6 months. Data the Global Burden of Disease Study. Rudd KE, Johnson SC, Agesa KM, et al. Lancet 2020 Jan urosepsis. This may occur regardless of an Simulation-based training (SBT) models have been from 218 participants were evaluated: 129 in the appropriate pre-surgical screening - including ‘extended release’ group (Envarsus®) and 89 in the 18;395(10219):200-211. doi: 10.1016/S0140developed in several surgical disciplines to obviate ‘prolonged release’ group (Advagraf®). 6736(19)32989-7. PMID: 31954465 PMCID: PMC6970225 antibiotic targeted courses - to sterilise urine. these issues, and their effects have been explored in few trials. Nevertheless, the robustness of available Recently, a group of scholars from China have Patients in the ‘extended release’ group exhibited studies is quite weak, due to the complexity and reviewed their series of mPCNL in large renal stones, difficulties in identifying measurement tools, higher relative bioavailability (Cmin /total daily dose [TDD]) vs. ‘prolonged release’ tacrolimus (61% defined as > 3 cm in terms of overall maximum standardised models and assessment protocols to Clinical characteristics and increase; p < 0.001) with similar Cmin and 30% length, performed in the span of six years. verify the transfer of simulation-based skills in real-life prognosis in patients with lower TDD levels (p < 0.0001). The incidence of interventions. treatment failure was 3.9% in the ‘extended release’ According to the inclusion/exclusion criteria, a total urosepsis in China group and 9.0% in the ‘prolonged release’ of 171 patients were included in the study. Urosepsis A group of researchers from the UK has been able to design a randomised clinical trial that could satisfy all tacrolimus group (p = 0.117). Study discontinuation was defined according to the 2001 International rates were 6.2% in the ‘extended release’ group and The purpose of this study was to retrospectively Sepsis Definitions Conference as: fever > 380 or the desired criteria: they recruited urological residents 12.4% in the ‘prolonged release’ tacrolimus group (p analyse clinical characteristics and prognostic risk from different training centres across Europe, hypothermia < 360; tachycardia > 90 bpm; = 0.113). Adverse events, renal function and other factors of urosepsis patients admitted to two intensive tachypnoea > 20/min in presence of signs of hypoxia; North-America and Asia. Main inclusion criteria included: they did not receive any significant prior complications were comparable between groups. care units in Shanghai (CN). Clinical data from leucocytosis (WCC > 12,000 cells/µl) or leucopoenia surgical or simulation exposure in the field of The median accumulated dose of tacrolimus in the patients diagnosed with urosepsis were retrieved (WCC < 4,000). extended release group from day 14 to month 6 was retrospectively and analysed from ICU in two regional ureteroscopy for the treatment of either ureteric or renal stones by means of semi-rigid and flexible 889 mg. Thus, the ‘extended release’ tacrolimus medical centres from January 2015 to December 2019. Mini-PCNL were performed by placing an Amplatz group showed higher relative bioavailability, similar sheath of 20 ch in order to use a 12 ch nephroscope. ureteroscopy, respectively. effectiveness in preventing allograft rejection, Two hundred and two patients were included in the Lithotripsy was realised by means of Holmium laser final analysis. The average age was 72.02 ± 9.66 A sample size of 44 residents per arm was calculated comparable effects on renal function, safety, fibres. years, 79% of the patients were female and the in order to satisfy the primary outcome, consisting of a adherence, treatment failure and premature mortality rate was 15.84%. The proportion of reduction of 33% of procedures (i.e. ≤ 10 operations) discontinuation rates. … this study is the first of its kind patients with underlying chronic diseases, such as needed by the SBT group in order to achieve Source: Bioavailability of once-daily tacrolimus diabetes and hypertension, was 56.44% and to demonstrate that mPCNL for the proficiency in the intervention of interest. Simulationformulations used in clinical practice in the 49.50%, respectively, and the incidence of shock was based training included dry-lab, virtual reality and treatment of large renal stones may wet-lab models, which were available in differing 41.58%, correspondingly. management of De Novo kidney transplant recipients: the better study. Fernandez Rivera extents in the recruiting centres. Proficiency was increase the risk of urosepsis. CF, Rodríguez MC, Poveda JL, Pascua J, et al. Clin defined as the ability of a trainee to score 28 (out of a Chinese study on urosepsis shows Transplant 2021, doi: 10.1111/ctr.14550. Online ahead of maximum score of 35) or above in three consecutive print. The overall urosepsis rate was 17% (29/171), a value operations according to the Objective Structured that lactate level and APACHE II by far higher than those available in literature. By Assessment of Technical Skill (OSATS) assessment score had excellent predictive value analysing all the clinical variables of interest at scale, without any complications. The complication univariate analysis pre-operative urine-leukocytes rate was considered as secondary endpoint. for prognosis. count, urine nitrite, stones in adjacent calices on the Global, regional, and national coronal plane, the maximum cross-sectional area of Resident’s development skills were followed up for a sepsis incidence and mortality, The most common pathogen isolated was Escherichia stones, the diameter of hydronephrosis and number maximum of 25 surgery sessions or 18 months spent in coli (79.20%), of which the extended-spectrum of stones were found to be associated with the surgical theatre. 1990-2017 β-lactamases (ESBL)(+) accounted for 42.57%. events. Other factors, such as proportion of multiple tracts, surgical time or medical history of diabetes An overall of 65 participants (SBT = 32, non-SBT = 33) Sepsis is life-threatening organ dysfunction due to a In multivariate analysis, the strongest predictors were not found to be associated to the events. completed the overall curriculum, as 29 (SBT = 14 and dysregulated host response to infection. It is for death were mechanical ventilation (OR 7.260, NSBT = 15) were lost in follow up, which consisted of considered a major cause of health loss, but data for 95% CI 2.200–23.963; p = 0.001), chronic kidney Furthermore, at multivariate analysis only the more than the 10% drop-off rate expected at the time the global burden of sepsis are limited. As a disease (CKD)(OR 5.140, 95% CI 1.596–16.550; p = pre-operative urine-leukocytes count (≥ 450/μl) the study was designed. On the other hand, nearly syndrome caused by underlying infection, sepsis is 0.006), APACHE II score (OR 1.321, 95% CI remained statistically correlated to the urosepsis (OR 1,200 operations were evaluated for the residents’ not part of standard Global Burden of Diseases, 1.184–1.473; p = 0.001) and lactate (OR 1.258, 95% = 5.514, CI [1.866–16.795], p = 0.002). All these curricula. Injuries, and Risk Factors Study (GBD) estimates. CI 1.037–1.527; p = 0.020). Both APACHE II score results could be attributed to the small number of Accurate estimates are important to inform and and lactate showed excellent predictive values, the sample size, especially with regard to the Although no statistical difference was identified in the monitor health policy interventions, allocation of with areas under the ROC curve (AUC) of 0.858 and presence of nitrite in the urine, stones in adjacent overall proficiency rates achieved in the two groups, a resources, and clinical treatment initiatives. The 0.805, respectively. calyx, and maximum cross-sectional area of stones, sub-analysis regarding the proficiency in flexible URS Key articles

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Miniaturised PCNL (mPCNL) has been introduced in an attempt to reduce the overall risk of complications of a standard PCNL, by reducing the loss of functional renal parenchyma and reducing the risk of bleeding and pain as well.

EAU EU-ACME Office

European Urology Today

October/January 2022


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

fsangue@ hotmail.com

– a more complex procedure - showed statistically significant better proficiency outcomes in favour of the SBT group. Similar outcomes were found for other metric units in observation, including OSATS mean score and number of cases with scores above 28. Furthermore, complication rates favoured the SBT group, confirming that a simulation-based training model may serve as a safer programme for patients.

Source: Effect of Simulation-based Training on Surgical Proficiency and Patient Outcomes: A Randomised Controlled Clinical and Educational Trial. Aydın A, Ahmed K, Abe T, et all; SIMULATE Trial Group. Eur Urol. 2021 Nov 14:S03022838(21)02133-3. doi: 10.1016/j.eururo.2021.10.030.

Supine versus prone percutaneous nephrolithotomy in complex renal stones The prone position is the most common worldwide approach to perform a percutaneous nephrolithotomy (PCNL) for the fragmentation of large renal stones. Supine PCNL has been introduced in the eighties and became more popular in the last two decades, thanks to the possibility to perform a combined retrograde ureteroscopy at the same time. Nevertheless, there are concerns about the efficacy of supine PCNL for complex/challenging renal stones. Traditionally, the initial access to the upper tract via a prone PCNL was considered the standard of care.

The statistical difference of the immediate SFR was not significant… so that the non-inferiority supine approach was confirmed. Evidence in literature is contrasting, but mostly based on retrospective studies. In order to shed some light on this matter, a randomised controlled trial has been conducted to compare stone-free rates at day 1 and day 90 post-op in patients harbouring complex renal stones, defined as Guy’s Stone Score (GSS) 3 and 4 and treated via a supine or prone PCNL. Basal stone burden and stone free rate (SFR) at the two time points were evaluated with a non-contrasted CT scan. SFR at day 1 included residual fragments < 4 mm, while at day 90 post-op it was defined as lack of any fragments. The RCT was designed as a non-inferiority trial for supine PCNL to have an immediate (i.e. at day 1 post-op) SFR no worse than 15% as a non-inferior margin. Sample size calculation to test the null hypothesis resulted in the need of recruiting 56 patients per arm. Secondary outcomes included complication rates. Patients were recruited in the span of 13 months, and demographics of basal conditions were comparable among the two groups. The statistical difference of the immediate SFR was not significant - 62.5% and 57.1% for the supine and prone PCNL, respectively (p = 0.563) - so that the non-inferiority supine approach was confirmed. The difference of SFR at day 90 post-op was also not statistically significant: 55.4% and 50% for supine and prone PCNL, respectively. Regardless of the fact that first renal puncture was attempted more frequently in the lower pole via a supine approach (87.3% vs. 39.3%, p = 0.001), the overall proportion of patients requiring a supracostal puncture was similar. The latter data may be explained by a larger proportion of patients in the supine PCNL group requiring more than 1 access (although this is statistically not significant). Complication rates were higher in the prone PCNL Key articles

October/January 2022

group, with more septic shock (n = 4) and hydrothorax Source: Prostate cancer screening using a (n = 3) observed in the prone PCNL patients. combination of risk-prediction, MRI and Nevertheless, the study was not powered for the complication rate, so that no definitive conclusion on safety profile could be drawn by the authors. Overall, both approaches showed similar efficacy meaning that both options should be equally considered for the treatment of complex renal stones via a PCNL.

Source: Supine versus Prone Percutaneous Nephrolithotomy for Complex Stones: A Multicenter Randomized Controlled Trial. Rodrigo Perrella, Fabio C Vicentini, Eliane D Paro, et al. J Urol. 2021 Oct 25;101097JU0000000000002291. doi: 10.1097/ JU.0000000000002291. Online ahead of print.

Improving prostate cancer screening The use of MRI in men eligible for prostate biopsy has been established as a means to avoid unnecessary biopsies whilst increasing detection of clinically significant prostate cancer. There are also several emerging blood-based tests to estimate prostate cancer risk that have shown potential to reduce the harm compared with using PSA alone for biopsy referral. Among these emerging tests is the Stockholm3 test, which incorporates clinical variables (age and previous prostate biopsy), plasma protein concentrations (PSA, free PSA, human kallikrein 2, β-microseminoprotein, and growth differentiation factor-15), and a polygenic risk score derived from single-nucleotide polymorphisms to yield a percentage risk of clinically significant prostate cancer, defined as ISUP group 2 or higher. The question is: would the combination give added value, especially in a screening scenario? This study invited a randomly allocated cohort of men aged 50-74 years living in Stockholm county to participate in screening. those with an elevated risk of prostate cancer, defined as either a PSA of 3 ng/mL or higher or a Stockholm3 score of 0.11 or higher were eligible for randomisation. Men with a previous prostate cancer diagnosis, who had undergone a prostate biopsy within 60 days before the invitation to participate, with a contraindication for MRI, or with severe illness were excluded. Eligible participants were randomly assigned (2:3) using computergenerated blocks of five, stratified by clinically significant prostate cancer risk, to receive either systematic prostate biopsies (standard group) or biparametric MRI followed by MRI-targeted and systematic biopsy in MRI-positive participants (experimental group). The primary outcome was the detection of clinically significant prostate cancer at prostate biopsy, defined as a Gleason score of 3 + 4 or higher.

This approach using Stockholm3 testing followed by MRI-targeted biopsy, improved the detection of clinically significant prostate cancers Between 5 February 2018 and 4 March 2020, 49,118 men were invited to participate, of whom 12,750 were enrolled and provided blood specimens, and 2,293 with elevated risk were randomly assigned to the experimental group (n = 1,372) or the standard group (n = 921). Compared with PSA of 3 ng/mL or higher, a Stockholm3 of 0.15 or higher provided identical sensitivity to detect clinically significant cancer and led to fewer MRI procedures (545 vs. 846; 0.64 [0.55–0.82]) and fewer biopsy procedures (311 vs. 338; 0.92 (0.86–1.03). Compared with screening using PSA and systematic biopsies, a Stockholm3 of 0.11 or higher combined with MRI-targeted and systematic biopsies was associated with higher detection of clinically significant cancers (227 [3.0%] men tested vs. 106 [2·1%] men tested; RP 1.44 [95% CI 1.15–1.81]), lower detection of low-grade cancers (50 [0.7%] vs. 73 [1.4%]; 0.46 [0.32–0.66]) and led to fewer biopsy procedures. Compared with the screening approach used in ERSPC, this approach using Stockholm3 testing followed by MRI-targeted biopsy, improved the detection of clinically significant prostate cancers and reduced the detection of low-grade cancers. These findings should lead to a re-evaluation of populationbased prostate cancer screening in countries with high prostate cancer mortality.

targeted prostate biopsies (STHLM3-MRI): a prospective, population based, randomised open label, non-inferiority trial. Nordstrom T, Discacciati A, Bergman M, et al. Lancet Oncol

Mr. Philip Cornford Section editor Liverpool (GB)

2021; 22: 1240-9. philip.cornford@ rlbuht.nhs.uk

VISION: Does it let us see clearly? As an increasing number of treatments developed in men with mCRPC are used earlier in the disease, there is a need for new options when men progress. Radioligand therapies offer an alternative mechanism to destroy cancer cells whilst sparing most normal tissues. Prostate-specific membrane antigen (PSMA) is a transmembrane glutamate carboxypeptidase that is highly expressed on prostate cancer cells. Metastatic lesions are PSMA-positive in most patients with castration-resistant prostate cancer. 177Lu-PSMA-617 delivers beta-particle radiation selectively to PSMA-positive cells and the surrounding microenvironment. The VISION trial was a phase 3 trial investigating the efficacy and safety of 177Lu-PSMA-617 plus protocol-permitted standard care in a population of previously treated patients with metastatic castration-resistant prostate cancer who were selected for PSMA positivity on the basis of PSMA positronemission tomographic (PET) imaging. VISION is an open-label phase 3 trial evaluating 177Lu-PSMA-617 in patients who had metastatic castration-resistant prostate cancer previously treated with at least one androgen-receptor–pathway inhibitor and one or two taxane regimens and who had PSMA-positive 68Ga–PSMA-11 PET-CT scans. Patients were randomly assigned in a 2:1 ratio to receive either 177Lu-PSMA-617 (7.4 GBq every 6 weeks for four to six cycles) plus protocol-permitted standard care or standard care alone. Chemotherapy, immunotherapy, radium-223 (223Ra), and investigational drugs were excluded. Of the 1,170 patients screened, 1,003 underwent 68Ga–PSMA-11 PET-CT scanning and 831 met all the trial eligibility criteria and were randomised. However, just 581 were included in the data on image-based progression-free survival. In this sub-group of patients, the median imaging-based progression-free survival was 8.7 months in 385 men in the 177Lu PSMA-617 group, as compared with 3.4 months in the 196 men in the control group (HR, 0.40; CI, 0.29 to 0.57; p < 0.001). Overall survival was also longer in the treatment group, median, 15.3 vs. 11.3 months; (HR, 0.62; 95% CI, 0.52 to 0.74; p < 0.001). Quality of life was maintained in the 177Lu-PSMA-617 group although the incidence of grade 3 adverse events was higher (52.7% vs. 38%). Issues include an extremely high incidence of withdrawal in the control arm (56%), initially suggesting a lack of equipoise. Although this dropped to 16.3% after enhanced trial-site education this was much higher than in the 177Lu-PSMA-617 arm (3.2%). In addition, this trial elected to compare against standard of care rather than cabazitaxel. It was recorded that 38% had already had the drug, but for the rest this option with proven efficacy was delayed. Other data does suggest 177Lu-PSMA-617 is more effective at delaying radiographic progression, but data on survival will have to be implied. Lastly other studies have used 2 PET scans to ensure the majority of metastasis are PMSA positive. This study did not, but we are likely to see further refinement in selecting appropriate patients. Despite all of this, 177LuPSMA-617 is likely to be an important new therapeutic option for men with mCRPC

Source: Lutetium=177-PMSA-617 for metastatic castration-resistant prostate cancer. Sartor Q, de Bono J, Chi KN, et al. NEJM 2021; 385: 1091-103.

Increased prostate cancer risk: Variants in mismatch repair gene? Lynch syndrome is an autosomal, dominantly inherited, multicancer syndrome caused by a germline pathogenic variant in one of the mismatch repair genes: MLH1, MSH2, MSH6, or PMS2. Each gene has a different cancer incidence spectrum, with colorectal and endometrial cancers being the predominant phenotype. These pathogenic variants are also

associated with an increased risk of other cancers including those of the ovary, stomach, small bowel, ureter, kidney, and brain. It has been reported to increase the risk of prostate cancer by two to ten times. Most evidence has come from studies of men with prostate cancer from families with mismatch repair pathogenic variants. Tumour testing has shown loss of expression of mismatch repair proteins and microsatellite instability. However, mismatch repair deficiency does not conclusively prove that a tumour is caused by a germline variant and not all studies show an increased risk of prostate cancer with Lynch syndrome. The IMPACT study is prospectively assessing PSA screening in men with germline mismatch repair pathogenic variants. In this paper, they report the usefulness of PSA screening, prostate cancer incidence, and tumour characteristics after the first screening round in men with and without these germline pathogenic variants. Men aged 40–69 years without a previous prostate cancer diagnosis and with a known germline pathogenic variant in the MLH1, MSH2, or MSH6 gene, and age-matched male controls who tested negative for a familial pathogenic variant in these genes were recruited from 34 genetic and urology clinics in eight countries and underwent a baseline PSA screening. Men who had a PSA level higher than 3.0 ng/mL were offered a transrectal, ultrasound-guided, prostate biopsy and a histopathological analysis was done. All participants are undergoing a minimum of 5 years’ annual screening. The primary endpoint was to determine the incidence, stage, and pathology of screening-detected prostate cancer in carriers of pathogenic variants compared with non-carrier controls. Between 28 September 2012 and 1 March 2020, 828 men were recruited (644 carriers of mismatch repair pathogenic variants [204 carriers of MLH1, 305 carriers of MSH2, and 135 carriers of MSH6] and 184 noncarrier controls [65 non-carriers of MLH1, 76 noncarriers of MSH2, and 43 non-carriers of MSH6]), and in order to boost the sample size for the non-carrier control groups, they randomly selected 134 noncarriers from the BRCA1 and BRCA2 cohort of the IMPACT study, who were included in all three non-carrier cohorts. Men had a mean age of 52.8 years (SD 8.3). Within the first screening round, 56 (6%) men had a PSA concentration of more than 3.0 ng/mL and 35 (4%) biopsies were done. The overall incidence of prostate cancer was 1.9% (18 of 962; 95% CI 1.1–2.9). The incidence among MSH2 carriers was 4.3% (13 of 305; 95% CI 2.3–7.2), MSH2 non-carrier controls was 0.5% (one of 210; 0.0–2.6), MSH6 carriers was 3.0% (four of 135; 0.8–7.4), and none were detected among the MLH1 carriers, MLH1 non-carrier controls, and MSH6 non-carrier controls. Prostate cancer incidence, using a PSA threshold of higher than 3.0 ng/mL, was higher in MSH2 carriers than in MSH2 non-carrier controls (4.3% vs. 0.5%; p = 0.011) and MSH6 carriers than MSH6 non-carrier controls (3.0% vs. 0%; p = 0.034). The overall positive predictive value of biopsy using a PSA threshold of 3.0 ng/mL was 51.4% (95% CI 34.0–68.6), and the overall positive predictive value of a PSA threshold of 3.0 ng/ mL was 32.1% (20.3–46.0). IMPACT has found a significantly higher incidence of prostate cancer in men with pathogenic variants in MSH2 and MSH6 compared with non-carrier controls, supporting the theory that the risk of prostate cancer is increased with Lynch syndrome, and specifically with MSH2 and MSH6. The overall incidence of cancer for our study cohort was 1.9%, which is similar to the 2.4% reported in the BRCA1 and BRCA2 cohort of IMPACT. Urologists will need to consider PSA screening for these men.

Source: A prospective prostate cancer screening programme for men with pathogenic variants in mismatch repair genes (IMPACT): initial results from an international prospective study. Bancroft E, Page EC, Brook MN, et al. Lancet Oncol 2021; https://doi.org/10.1016/ S1470-2045(21)00522-2

EAU EU-ACME Office

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What have we learned? Key messages from the EAU Patient Poster Session EAU21 Dr. Sara MacLennan Deputy Director of the Academic Urology Unit University of Aberdeen Aberdeen (GB) s.maclennan@ abdn.ac.uk

Dr. Lydia Makaroff Director World Bladder Cancer Patient Coalition (WCPC) Chinnor (GB) lydia@ fightbladdercancer. co.uk

Prof. Eamonn Rogers Chair EAU Patient Office Galway (IE)

highest ranking were selected for an award. The selected abstracts were classified under 5 subheadings: bladder cancer, kidney cancer, prostate cancer, general oncology, functional urology, and COVID-19. Each poster presentation was recorded (webcast) and made available on the EAU21 Resource Centre website within 24 hours: https://bit.ly/3zJXXpB. The Patient Poster Session took place as part of the inaugural EAU Patient Day of the EAU21 Virtual Congress on July 9, 2021. Key messages The Patient Poster Session outlined several important messages for clinicians, healthcare providers, and the healthcare industry (see table 1). These messages were about patient involvement and engagement, communication, collaboration, support, finance, and procedures. Each set of key messages highlights the clear unmet need for those living with and beyond a urological condition and proposes ways in which healthcare professionals and the healthcare industry can better work with patient advocates to address these. Conclusion In all articles submitted to the EAU for the Patient Poster Session 2021, the patient’s voice was expressed in many forms: from typical scientific articles to patient stories – and even beautiful artwork. All have value. It is hoped that the EAU can build on this pioneering initiative, which will undoubtedly shape and improve the future management of urological diseases.

emacruairi@me.com

Ms. Esther Robijn Sr. Coordinator EAU Patient Office Arnhem (NL)

e.robijn@uroweb.org Since 2012, the EAU has sought to meaningfully involve patients and their families in its mission to raise the level of urological care in Europe. Wellinformed patients are better equipped to talk about their conditions and treatments, and this fosters more meaningful dialogue between the doctor and the patient, leading to better care. The concept of a Patient Poster Session was developed, supported by an unrestricted grant from Pfizer. The main purpose of the Patient Poster Session was for healthcare professionals to engage directly with patients and to provide a platform (the Annual EAU Congress) where the patient’s perspective is heard, to identify any disconnects, improve communications and, ultimately, to improve patient outcomes.

Figure 1: Dr. Lydia Makaroff and Prof. Eamonn Rogers chaired the virtual Patient Poster Session

Patient involvement and engagement

Communication

“The theme for the EAU22 Patient Poster Session will be addressing the unmet needs identified in the EAU21 poster session.” EAU Patient Poster Session 2021 Studies have shown that there is often a gap between what the physician recommends, based on scientific evidence combined with experience, and what patients prefer in terms of outcome, side effects, and maintaining a good quality of life. A patient’s personal values and opinions may not be taken into consideration or may not be compatible with the recommended treatment. As a result, healthcare professionals (HCPs) may appear to be out of sync with health-related quality-of-life matters that a patient wants to discuss. The Poster Session theme for 2021 was: Disconnect between the physician and patient. The aim of the session was to discuss topics from a patient perspective, to encourage discussion between experts and patients, and to identify any patient-physician disconnect. Patients and patient advocates were encouraged to submit abstracts to this session, and in March 2021, 13 abstracts were selected for presentation. The top-5 abstracts which received the 12

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Strengths and limitations The session was well-attended; there were 110 delegates. This compared favourably to delegate numbers attending scientific presentations by clinicians. The virtual format, however, was a challenge to patient presenters, some of whom had little experience presenting at a major international medical meeting (the EAU21 Virtual Congress). While the session concluded on time, there were some technical difficulties with presentations and answering questions, as well as little time to answer questions. A reduced number of oral presentations in 2022 will allow more time for questions. Submitted abstracts that meet selection criteria but are not presented will be displayed in the Patient Information kiosk for attendees, located adjacent to the EAU Booth on the congress exhibition floor. Looking ahead: EAU22 Patient Poster Session The theme for the EAU22 Patient Poster Session will be addressing the unmet needs identified in the EAU21 poster session. EAU PI encourages all patients and patient advocates to present solutions, novel approaches and best practices revolving around:

1. Physical and psychological well-being 2. Finance and work 3. Patient involvement in clinical research, and development of care pathways and clinical practice guidelines 4. Patient engagement /advocacy in healthcare policy EAU22 will take place from 18 to 21 March 2022: https://www.youtube.com/watch?v=jUof5HRw3Fo

Figure 2: Each category was given one verbal question for the Q&A, while the rest were sent through the Q&A box and Twitter using the hashtag #EAU21

• There are clear benefits of involving patients and engaging with patient advocacy groups when designing products that optimise urological care, when designing clinical care pathways and supportive care pathways, and when identifying and addressing unmet needs. The EAU should consider using patient focus groups in designing EAU Patient Information (PI) and patient education. • Patients will participate in clinical research if they see its relevance and see that the benefits of participation outweigh the risks; however, HCPs generally do not encourage their patients to participate (40%) nor do they inform them about clinical trials and associated benefits and risks, and this is even more the case with African American male patients (80%) • The involvement of patient representatives in the development of clinical studies will ensure that the relevance to patients is incorporated in clinical study designs. • Peer-to-peer contact is an excellent means of increasing participation in clinical trials. • Study participation should aim to have a minimal impact on work, childcare commitments, and other critical aspects of patients’ lives, and participation should be appropriately costed. • Patient engagement in the design and delivery of care also holds direct benefits for patients, e.g. increased emotional well-being, improved physical well-being, and improved self-care in terms of adherence to guidelines and treatment plans. • Improved communication between the physician and patient lessens a cancer patient’s stress, improves their quality of life, and facilitates better participation in care. • Patients have additional needs that are not addressed in the disease-orientated focus of the physician, such as the quality of life. Patient-reported outcomes may differ from those reported by clinicians. • There is often a disparity between what information a doctor considers important for patients and what the patient and their families consider to be important, e.g. survival rates and clinical trials. This can lead to poor rates of satisfaction with information about disease diagnosis and management. • Healthcare providers (HCPs) communicating information to patients must ensure that the information is tailored to patients’ needs, takes patients’ goals and aspirations into account, uses simple language, and is delivered at a pace that allows patients to process information. • Clinicians need to inform patients about clinical trials, and HCPs and representative bodies like EAU PI must support clinicians to direct patients to clinical trial websites or should ask patient peers, volunteers, and advocates to bring the subject up. • Almost 75% of patients continue to prefer face-to-face consultations especially for critical parts of their care pathway, e.g. initial diagnosis, discussion of treatment options, and when a disease recurs requiring second-line treatment options. • Although often described as impersonal, telephone consultations are still favoured by elderly patients living remotely from hospitals. • Healthcare providers need to listen to patients and provide products that work for patients rather than cheaper generic products, e.g. absorbent aids in urinary incontinence. • Organisations advocating for patients with a urological disease should also network with other international patient advocacy groups e.g. the Global Cancer Coalitions Network (GCCN). Such links assist the EAU as they attempt to lobby with healthcare providers on behalf of patients and urologists, and the EAU has a major role to inform and lobby with healthcare providers to address these global needs. • Collaboration is needed to restore cancer services safely and effectively without delay while a global plan of action for cancer is required to meet the challenges of future healthcare crises. • Almost 100% of patients experienced clinical anxiety at the time of cancer diagnosis, which can persist in almost 50% of responders. This emphasises the need for psychological support. • All patients surveyed wanted supplementary information available to them concerning their disease e.g., web-based support such as EAU PI. Patients also value access to patient advocates and to their family and care givers to help them understand the information and to provide emotional support. They also report a need for a consistent “Go To” person. • Emergency support is needed by patient advocacy organisations and affiliated associations to ensure the needs of cancer patients are met during the pandemic, especially as long delays in accessing treatment are reported in a number of countries. • A significant number of patients report financial hardship as result of cancer diagnosis, which increases anxiety and impacts on adherence to treatment; only half of this group of patients are given the opportunity to discuss this issue with their doctor. • Some urological diseases need to be recognised as a chronic illness by healthcare providers and patients should be reimbursed accordingly. The EAU should lobby for improved drug reimbursement. • Doctors must improve neobladder surgical techniques to prevent severe incontinence rates reported by patients.

Table 1: Key messages from the Patient Poster Session 2021 October/January 2022


History of face masks in medicine How face masks became the symbol of medical health professionals Dr. Mohammad Rahnama'i Uniklinik RWTH Aachen Aachen (DE)

srahnamai@ ukaachen.de In September 2021, the Dutch government abolished the compulsory wearing of face masks in the public area as one of the first European countries. Hopefully it was the beginning of a post-COVID-19 era which will take us back to our ‘normal’ living situation of before 2020. The COVID-19 era, however, was visibly marked by the fact that everybody was wearing medical masks in public areas. During this pandemic, medical face masks became a topic of their own. In the media, they were described as “A Powerful Symbol Of Expression In Dark Times”. Modern times This raises the question of when medical face masks first appeared in history. Since early modern times, the coverage of nose and face was an essential part of medical cultures in Europe. This protected people from “miasmas” i.e. bad odours, which were seen as health threatening and the cause of the plague by the scientific theory of the time. The Italian doctor‘s mask with its typical, long nose was described in the Commedia della arte. However, there is no proof that these plague doctors with their beak-like masks really existed. Microscopically small In 1867, the British surgeon Joseph Lister postulated that wound disease was caused by the germs of the microscopically small, living EAU History office

entities that Louis Pasteur had recently described. Lister suggested eliminating these germs through the use of antiseptic substances. In the 1880s, a new generation of surgeons devised the strategy of asepsis that aimed to stop germs from entering wounds in the first place. Since the works of Lister and Pasteur in the last quarter of the 19th century, the so called surgical ward and the developing special disciplines such as urology were confronted with the trendsetting discourse about wound infections and their prohibition and containment. Spanish flu A study of more than 1,000 photographs of surgeons in operating rooms of hospitals in the United States and Europe between 1863 and 1969 indicate that, by 1923, over two-thirds of surgeons wore masks. By 1935, most of them were using masks. During the Spanish flu pandemic in 1918, the masks (called muzzles, germ shields and dirt traps) became a symbol of medical health professionals outside the operation room for the first time.

Left: Commedia dell'arte mask “dottore” Right: Coloured version of a copper engraving of Doctor Schnabel (i.e. Dr. Beak), a plague doctor in seventeenth-century Rome, circa 1656. Source: Wikipedia

"During the Spanish flu pandemic in 1918, masks became a symbol of medical health professionals outside the operation room for the first time."

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Act of solidarity There is no absolute agreement in literature about the efficacy of masks in reducing surgical wound infections. In addition, in the urological practice for endoscopic procedures, the benefit of wearing a surgical mask is disputable. Nowadays, the face mask is part of the professional identity of physicians in general and of the urological ontology of urologists. Moreover, wearing a medical mask represents an act of solidarity, displaying that the citizens of the world are on board with the preventive measures needed to control COVID-19 contagion.

(Inter)National Urological Associations and the CME providers (organisers of CME activities) are invited and encouraged to send in requests to register accredited CME activities or requests for accreditation. Corona crisis in Spain. Source: https://taz.de/Coronakrise-in-Spanien/!5742758/

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Christopher Griffith Wood 1963 - 2021 Engaged kidney cancer expert who inspired the global kidney cancer community On Wednesday, 3 November 2021, Dr. Christopher Wood sadly and unexpectedly passed away. Dr. Wood was a professor of urology and genitourinary cancer surgeon at the University of Texas MD Anderson Cancer Centre and a pioneer in advanced kidney cancer surgery. According to his own account, he was initially employed at the MD Anderson to focus on prostate cancer but switched interest to manage patients with kidney cancer early in his career. Whoever met him could not but notice how passionate he was about developing and teaching advanced kidney cancer surgery and mentoring the next generation of urologic oncologists. At a time devoid of prognostic scores for patients facing advanced kidney cancer surgery he studied how to select patients for complex procedures to ensure the best outcome. The first time I heard him present was at a Kidney Cancer Association meeting in Chicago, more than 2 decades ago where he questioned a statement one of his teachers made, that ‘the only thing that cures cancer is stainless steel and a good template’. Recognising the limits of surgery while pushing the boundaries, he was one of the first to study medical therapy prior to planned nephrectomy to select patients with metastatic kidney cancer

October/January 2022

the MD Anderson and continues to motivate researchers around the globe as can be witnessed in the recent international trials on deferred cytoreductive nephrectomy after immune checkpoint inhibitor combination therapy.

likely to benefit from this approach. At that time, MD Anderson was the global leader in offering this concept to patients, and their publications laid the foundations for similar studies in Europe. Both the improved selection criteria for surgery and the concept of deferred cytoreductive nephrectomy answered to an unmet clinical need and inspired clinical kidney cancer research in Europe to test the sequence of medical therapy and cytoreductive nephrectomy in the randomised SURTIME trial. Dr.

Wood and his team pioneered neoadjuvant treatment concepts for high-risk and locally advanced kidney cancer and he was the first to lead and report an international randomised controlled trial of adjuvant heat shock protein-peptide complex for use as a patient-specific vaccine. Dr. Wood authored more than 400 peer reviewed journal articles and book chapters. His work will leave a legacy behind reaching far beyond the confines of

Above all, Dr. Wood was driven to deliver the best care for his patients and he engaged very early on with the Kidney Cancer Association, a global community dedicated to serving and empowering patients and caregivers, and leading change through advocacy, research, and education. During his successful career he was a member of the KCA’s Medical Steering Committee and then as the Chair of the Kidney Cancer Association’s Board of Directors until his death. At the annual meetings of the KCA his rapid-fire educational case discussions were legendary and became known as ‘Woodfire’ sessions in which he challenged multidisciplinary panels of international kidney cancer experts. Dr. Wood leaves behind his wife Colleen, his daughter Sarah and his son Chris Jr. He will not only be greatly missed by his family and friends but by colleagues and the entire kidney cancer community. Prof. Axel Bex

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The impact of the COVID-19 pandemic in urology Reflections on changed practice and risks from an office urologist perspective Prof. Ayhan Verit ESUO Member Fatih Sultan Mehmet Hospital Dept. of Urology Istanbul (TR) veritayhan@yahoo. com Despite the title of this article, there is no such thing as an ‘office urologist’ in Turkey, as there is in most European countries. The practice of ‘office urology’ is part of the general urological work performed by all urologists in variable degrees, just like, for example, in Spain (an EU country). Office urology practice is the first line of urology and, as we know, demands close and frequent contact with the patient. This type of healthcare service had to change because of the demands of the COVID-19 (C19) situation. I would like to present some examples of modifications in office urology and the care provided by the urologist. Furthermore, I will discuss the legal rights of the urologist in pandemic Turkey, compared to other parts of the world. Weakened medical care systems The extraordinary impact of this health event has weakened every aspect of the world’s medical care system and tested its long-term strength with regard to budgets. Naturally, the professional rights of the main ‘actors’ - the healthcare staff at the battlegrounds of this war have gained importance and are worth being reinvestigated in the light of a pandemic situation, also seen in national context with their socio-cultural, economic differentiations [1]. As a striking example, the funeral costs for the healthcare workers who are victims of C19 is now an expense that is a concern, even reported in medical literature [2,3]. While funeral procedures are a free municipal service not only for healthcare workers but for all citizens in Turkey, it may be a significant expenditure for the relatives of South African healthcare employees. Thus, I think that cultural, legal, and economical factors should be rediscussed in each country separately, based on the needs of the community. Satisfactory solutions for health care professionals will in the end serve the public interest best. Even more so if healthcare staff will stay motivated and be prepared to fight in possible similar health battles in future. (see Figure 1) Occupational disease Philosophically, while the universal definition of work accident is ‘an unexpected/unplanned event that causes harm or injury’, the term occupational disease is defined as ‘temporary or permanent illness, either physical or mental, due to the nature of the job or condition of the business’[4]. Depending on these explanations, the legal situation of healthcare staff who are exposed to C19 can easily be placed under the terms of both concepts: work ‘accident’ and ‘disease’. This dilemma may result in a different impact on the professional rights of healthcare workers in their legal environments1. So far, the ‘Turkish Labour Act’ views the situation of healthcare employees who become infected with C19 as an ‘occupational accident’. However, there is a heated ongoing discussion among social platforms about the present legal terminology. So far, it has not resulted in an answer that satisfies the expectations of the healthcare professional community, despite some current improvements [4,5]. Working area On the other hand, Prof. Olaf Michel claimed in his paper that, without a doubt, a C19 contamination can be categorised under the terminology of a pandemic. This means that all public levels present equal risks of viral exposure and, therefore, it cannot be seen as a work accident, based on investigation of the German law system. However, he emphasised that ophthalmologists and especially Ear-Nose-Throat physicians are exposed to a greater risk of C19, due to the fact that the colonisation site is close to their working area. Thus, for them an infection should be defined as occupational EAU Section for Urologists in Office (ESUO)

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European Urology Today

disease [6]. In addition, dentists should also be categorised under this definition. All things considered, it is no exaggeration to state that office urology should be considered the riskiest part of the urology field due to the need for close contact with the patient. It starts with patient admission and continues with the determination of an approach to the problem by drawing up detailed patient history and a physical urological examination. Furthermore, the urologist uses diagnostic instruments and asks for frequent patient office admissions. COVID-19 adjustments Moreover, there have been special changes in office urology because of the pandemic. Below you will find some examples about the modifications in office urology practice in Turkey: - There have been restrictions for appointment intervals between patient visits in connection with the severity of local C19 peaks in public hospitals, which are entirely supported financially by the state insurance system covering 80% of the health workload [7]. Turkey is a populated country and there have been high office admissions per hospital. In addition, there are no strict hospital referral chains in the Turkish system. Patients can be admitted to any hospital and thus, this system increases the urological office workload of all hospitals. - Some of the postponed workload, caused by the restrictions during transient intense local pandemic periods at the clinical urology departments in public hospitals, has been taken over by office urologists working in private medicine and insurance systems. - Several medical treatments by office urologists, for example BPH and stone patients who need operations, continued during this period. - The regular control cystoscopy in patients with bladder cancer became irregular due to the lack of appointment opportunities with hospital office urologists or due to patient concerns. This may result in increasing communication between the physician and patient via telephone or other distant communication methods. There are no standard intervals for control cystoscopy for individual patients supported by scientific data and thus, longer intervals may lead to oncological risk. - In polyclinics, staff switched to initial cystoscopy under local anaesthesia as an office urological procedure more frequently, instead of a procedure in the operating room in clinical urology. - In my opinion, patients and office urologists hesitate to have prolonged contacts with each other in the form of e.g. counselling, physical examination and diagnostic instrumentation during office visits. This may present another factor that results in ineffective diagnostical procedures. Generalisations All of the above irregularities may lead to medical and legal frustrations in the future. The Italian insurance system confirmed that corona virus infections of MDs, nurses and all other health employees are now considered occupational disease. They announced that the causal link between work and the infection would be automatically established for these groups in their advantage in case of conflict [8]. Actually, these kinds of general rules can simplify the formal procedures and prevent troublesome discussions in favour of healthcare staff. Nevertheless, in the related official definitions, possible lifelong health deformations have not even been considered yet. I think that C19 may become a chronic disease in healthcare staff with chronic detrimental effects on several human organ systems, such as central nervous, cardiovascular, renal and respiratory, via a long-term sequel of scarring/fibrosis in the vessels [9-11]. These totally unexpected effects can lead to a severe burden on the healthcare system, possibly lasting for many years after the current pandemic. Critical health problems Although these possible chronic health effects have not yet been confirmed, it is logical to presume that they can lead to critical health problems, such as mental-motor sequels, chronic renal insufficiency that may extend to chronic haemodialysis, renal transplantation and chronic respiratory insufficiency. All these discouraging scenarios may pose a pessimistic view on the future of healthcare staff and their relatives by

protection of human resources as a qualified, irreplaceable ingredient in the struggle in unexpected public health disasters, such as the C19 pandemic.   References

Figure 1. A cartoon from late Ottoman times (5 Jan 1911, Comedy journal “Kalem-Pencil”) about the cholera pandemic. The woman with her stomach-ache has been applying atomizer for the suspicion of cholera clinics, however, she has just given birth to the second scene (not shown here). Reference: Kazım Cihan Can (“Birikim Dergisi” Journal of Backlog, 2020) Corona-Fear-Comedy-Cholera. https:// birikimdergisi.com/guncel/10061/korona-korku-komedi-kolera

means of moral and financial concerns related to professional rights. It is essential to reach consensus with regard to the legal position of healthcare staff, in order to formulate their legal rights in the struggle with C19. Independent of the quibble in the terminology of national law and economic systems, states should solve this paradox in favour of healthcare workers in view of the need for long-term general public health care provision, which also affects the economy, both nationally and globally. As a result, in my opinion, the main goal should be the

1. Mega E, Verit A. A critical dilemma for the rights of healthcare staff exposed with Covid-19: Occupational “Accident” or “Disease”? – A clinician view. Rom J Leg Med (RJLM) (on publish). 2. George R, George A. COVID-19 as an occupational disease? S Afr Med J. 2020; 110(4): 12874. 3. George R, George A. COVID-19 in South Africa: An occupational disease. S Afr Med J. 2020;110(8):12985. 4. Mega E.COVID-19: Meslek hastalığı iş kazası ikilemi (article in Turkish) (COVID-19: Dilemma of occupational accident or disease). Sağlıkçıyız (We are healthcare professionals). 2020, April 02. Available in Turkish website: http://www.saglikciyiz. com.tr/2020/4/ covid-19-meslek-hastaligi-is-kazasi-ikilemi-m1182. html 5. LBF partners. http://www.lbfpartners.com/tr/yayin/ covid-19-occupational-disease-or-work-accident .html 6. Michel O. BK 3101: COVID-19-Infektion des HNOArztesist Berufskrankheit, kein Arbeitsunfall [BK 3101: COVID-19 infection of the ENT physician is an occupational disease, not an occupational accident]. HNO. 2020;68:444-6. 7. https://data.tuik.gov.tr/Bulten/Index?p=HealthExpenditure-Statistics-2019-33659 8. ISSA excellence in social security. https://ww1.issa.int/ news/can-covid-19-be-considered-occupationaldisease. 9. Fraser E. Long term respiratory complications of covid-19. BMJ. 2020;370:m3001. 10. Ogier M, Andéol G, Sagui E, Dal Bo G. How to detect and track chronic neurologic squeal of COVID-19? Use of auditory brainstem responses and neuro imaging for long-term patient follow-up. Brain Behav Immun Health. 2020;5:100081. 11. Gan R, Rosoman NP, Henshaw DJE, Noble EP, Georgius P, Sommerfeld N. COVID-19 as a viral functional ACE2 deficiency disorder with ACE2 related multi-organ disease. Med Hypotheses. 2020;144:110024.

The open access member of our family of journals: European Urology Open Science

Now indexed in PubMed Central® European Urology Open Science is a member of the European Urology family of journals. The journal is dedicated to the publication of high quality, innovative research that benefits patients with urological conditions and serves the world-wide community of urologists in academia and practice. Now accepted for indexing in PubMed Central® (PMC), all articles published will be fully indexed in PMC and discoverable via PubMed. European Urology Open Science is a broad-scope, gold open access journal published on behalf of the European Association of Urology (EAU) and the European Board of Urology (EBU). All articles are immediately and permanently accessible online-only for everyone to read, download, copy and distribute. Submit your paper www.editorialmanager.com/euros

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October/January 2022


Report

An overview of ESU masterclasses in 2021 Vital key messages, diverse topic coverage, and testimonials By Erika De Groot Not even the advent of the COVID-19 pandemic impeded the quest for knowledge of young and experienced urologists. This year, the European School of Urology (ESU), together with key opinion leaders in urology in Europe, forged ahead and even redesigned some of the masterclasses into virtual events to cater to the increasing demand for educational activities. This report is a compilation of key messages from the faculty and impressions from the participants of the following five ESU masterclasses that took place later this year: • E SU-Weill Cornell Masterclass in General urology 2021 • Virtual ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie's disease 2021 • E SU-ESTU Masterclass on Kidney transplant 2021 • Virtual ESU-ESFFU Masterclass on Functional Urology 2021 • ESU-ESUT Masterclass on Lasers in Urology 2021 On general urology From 12 to 16 July 2021, the ESU-Weill Cornell Masterclass in General urology 2021 covered a myriad of topics such as nephrectomy, upper urinary tract urothelial carcinoma (UTUC), diagnosis of testis cancer, and muscle-invasive bladder cancer (MIBC) staging, to name a few. ESU faculty member and former ESU Chair, Prof. Joan Palou (ES), provided the following important key points of the masterclass: 1. With regard to small renal masses – from surveillance or minimally-invasive treatment, to partial nephrectomy – the factors to be considered are age, comorbidities, location and size of the tumour. 2. Opting for partial nephrectomy or enucleation is still debatable. However, there is enough indirect evidence showing similar results related to recurrence. 3. TURB a very important step in the management of bladder cancer; always go for more external and deeper than you initially think!

Learning by doing, laparoscopy training during ESU-Weill Cornell Masterclass

Participant Dr. Aurore Mattlet (BE) shared, “The masterclass was a great opportunity for me. The planning for everything – from the lectures, accommodation, travels, to meals – was perfect. There is no comment about that except thank you. I enjoyed and learned a lot during all the lectures on MIBC and renal mass. However, I found one lecture difficult to follow and needing more clarity, and the paediatrics presentations were at a basic level. Overall, I want to express my appreciation for this opportunity and for the participation of experts in urology.”

and the partner. 2. A lways measure penile length in a standardised fashion and with the patient awake before embarking on penile curvature correction: subjective penile shortening is one of the most prevalent complaints after this type of surgery and an important determinant of patient satisfaction. 3. Modesty is important when combined surgery is employed for complex penile curvatures: do not use large grafts on top of penile implants and do not overstretch the corpora after dissection of the urethra and the neurovascular bundle. Participant Dr. Fadi Dalati (BE) stated, “The presentation on non-surgical options by Dr. Albersen made the most impact. The slides were very informative and was presented in an orderly fashion. All statements were combined with reliable references, as well as, with the personal experience of the user, which has an important added value. It’s a shame the meeting was not face-to-face as we would have much benefited from rich discussions during and after the presentation.”

On-site during the masterclass on lasers

According to participant Dr. David Andrés Castañeda Millán (CO), the insights he gained from the two lectures of Dr. Vital Hevia Palacios which were entitled “Evaluation of oncological disease in the donor” and “Incidence and treatment of urological tumors in KT recipients” will benefit his daily practice. He added, “The oncological issues surrounding the kidney transplant (donor and recipients) covered by the masterclass were useful and changed some paradigms related to the acceptance and use of kidney grafts with small renal masses for transplantation. These presentations gave the participants important and relevant clinical knowledge in management in terms of the urooncological aspects after kidney transplantation.” Hypothermic renal perfusion demonstration

On kidney transplant The ESU and the EAU Section of Transplantation Urology (ESTU) organised the ESU-ESTU Masterclass on Kidney transplant 2021 which was held from 28 to 29 October 2021 in Madrid, Spain. The masterclass delivered updates on kidney donors and rejection consequences during the pandemic; kidney preservation practices and strategies, and more together with hands-on trainings on hypothermic renal perfusion.

On functional urology From 3 to 4 November 2021, experts of the ESU and EAU Section of Female and Functional Urology (ESFFU) comprised the faculty of the Virtual ESUESFFU Masterclass on Functional Urology 2021. They provided vital insights on neuroanatomy and physiology, bladder pain syndrome, interstitial cystitis, and urinary diversion, to name a few. The lectures were interspersed with step-by-step videos, commonly-encountered and unique patient cases.

Participant Dr. Florine Schlatmann (NL) shared, “The topic that will have the biggest impact on my daily ESU faculty members Prof. Dr. Enrique Lledó García clinical practice was the coverage on complications (ES) and Prof. Francisco Javier Burgos Revilla (ES) after tape surgery. As a resident in the last phase of encapsulated the key messages of the masterclass: her training, not being able to prevent or causing a 1. Transplantation is an essential part of urology. complication is obviously a big fear. Learning how to Organ procurement techniques, bench surgery and deal with possible complications is of great added complex vascular surgery associated with kidney value. The good visuals, interactive discussions with transplant activity increase the skills of the the faculty and colleagues, and time for questions urologists to face major oncological surgeries. made this masterclass very informative!” 2. Donor profile is changing with a higher number of Please go to page 20 for the expanded report of expanded criteria and non-beating heart donors. fellow participant, Dr. Martina Beverini (IT). Normothermic reperfusion in the donor and pulsatile hypothermic perfusion of the graft are On lasers important to prevent delayed graft function. From 18 to 19 November, the ESU-ESUT Masterclass 3. Robotic kidney transplant is an innovative on Lasers in Urology 2021 kicked off in Barcelona, technique feasible in living donor kidney Spain. Faculty members, who are experts from the transplant. At present, recipients with iliac ESU and the EAU Section of Uro-Technology (ESUT), atheromatosis is a limitation for this approach. delivered laser fundamentals and developments

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ESU faculty member, Dr. Alberto Breda (ES), shared the following key points of the masterclass: 1. Thulium fibre lasers are more and more used in the field of stone fragmentation and dusting. 2. The combination of Holmium and Thulium-YAG lasers is possibly the best treatment for upper tract tumour ablation. 3. N o matter what laser is used, prostate enucleation is the standard of care for BPH treatment.

Apply to an ESU masterclass now! Searching for opportunities to enrich your knowledge with what’s new in urology? Eager to finetune your skills and enhance your clinical practice? Let leading experts guide you through ESU masterclasses. Visit www.esu-masterclasses.org for more information, to check your eligibility and to apply.

Access the scientific content

On erectile restoration and Peyronie's disease Participants from 31 countries from around the world attended the Virtual ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie's disease 2021, which took place from 6 to 7 October 2021. The collaborative efforts of the ESU, EAU Sections of Andrological Urology (ESAU) and Genitourinary Reconstructive Surgeons (ESGURS) paid off when the evaluation report showed that majority of the participants felt that the masterclass increased their professional knowledge and could benefit their patient care. ESU faculty member, Dr. Maarten Albersen (BE), offered the following take-home messages of the masterclass: 1. If pharmacotherapy does not work, there are various options in terms of erectile prosthesis to allow penetrative intercourse. Advantages and disadvantages of the two commonly used types of implants (malleable and three-piece inflatable) should be thoroughly discussed with the patient

which included videos on lasers for UTUC, stones, and benign prostatic hyperplasia. One remarked that the masterclass was of high calibre and “the best in the world” in terms of scientific content. In the evaluation report, participants stated that it was “a high-level masterclass that was relaxed which made it an excellent forum for engagement” and “a must-attend for endourologists.”

Explore and (re)view the scientific content of the masterclasses that took place this year via UROsource, the EAU learning library for urologists. Simply go to www.uroweb.org/ masterclass-content-on-urosource or scan the QR code with your smartphone.

Faculty and delegates of the masterclass on erectile restoration and Peyronie's disease

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Hybrid 8th CEUEP delivers urolithiasis, BCa & PCa updates A Wu Jieping Medical Foundation, EAU and ESU collaboration By the International Communication & Education Department of Wu Jieping Medical Foundation The 8th Chinese European Urology Education Programme (CEUEP) took place from 14 to 16 October 2021. It was co-organised by the European Association of Urology (EAU), the European School of Urology (ESU), the International Communication & Education Department of Wu Jieping Medical Foundation. Via a real-time video transmission, 32 participants in Beijing and 42 participants in Guangzhou took part in the courses simultaneously. More than two thirds of the participants were from primary hospitals or remote areas. As a non-profit organisation, the Wu Jieping Medical Foundation offered free registrations for all participants, traveling arrangements for some, and accommodation for all. This programme aimed to promote founder of China’s urology Prof. Wu Jieping’s tenets “gracious medical ethics, excellent medical skills, and specific services” and to develop China’s urology with more qualified professionals through education. HOT sessions In the afternoon of 14 October 2021, participants fine-tuned their skills during the hands-on training (HOT): 58 participants trained on pigs and the rest practised on box trainers. The HOT tutors were Dr. Wenfeng Zhao (CN) from the Peking University Wu Jieping Urology Center, Dr. Jianhua Deng (CN) from the Peking Union Medical College Hospital, Dr. Cheng Hu (CN) from the Third Affiliated Hospital, Sun Yat-Sen University, and Dr. Bing Yao (CN) from the Six Affiliated Hospital, Sun Yat-Sen University.

“This programme aimed to develop China’s urology with more qualified professionals through education.” Most of the participants, who have fewer opportunities of HOT sessions were eager to make good use of every minute to sharpen their skills during the four-hour training, and made strong appeals for more HOT sessions in the future programme. Support and collaboration The morning of October 15 commenced with a welcome speech by Mrs. Yang Ren (CN), Director of International Communication & Education Department, Wu Jieping Medical Foundation. She introduced the foundation’s mission as a non-profit organisation, and expressed deep gratitude to the faculty for their contributions to this programme. The CEUEP has received great support from the EAU and ESU for years. In a pre-recorded speech, EAU Secretary General Prof. Christopher Chapple (GB) wished the 8th CEUEP success, reviewed the good collaboration between the EAU and the Wu Jieping Medical Foundation, and introduced publications, educational activities, and events of the EAU. Then ESU Chair Prof. Evangelos Liatsikos (GR) expressed his best wishes to the CEUEP in his pre-recorded speech. Finally, all ESU and Chinese faculty members extended their greetings to the participants in their pre-recorded talks.

Hands-on training on box trainers

Faculty rings bells to declare the programme is officially open

Guangzhou faculty moderate discussions and give interpretations of ESU lectures

Prof. Palou offers key insights on NMIBC management

The faculty in Beijing and Guangzhou venues rang bells to declare the programme open. Programme topics The 8th CEUEP covered three themes: urolithiasis, bladder cancer and prostate cancer. Urolithiasis The urolithiasis module was comprised of three lectures: “Tips and tricks of flexible ureteroscopy” by Prof. Yi Zhang (CN) from Peking University International Hospital; “Tips and tricks in PCNL” by Prof. Andreas Skolarikos (GR) from the National and Kapodistrian University of Athens; and “Complications of endoscopic procedures for stone treatment” by Prof. Qingquan Xu (CN) from the Peking University People’s Hospital. Prof. Wenqi Wu (CN) from the Second Affiliated Hospital of Guangzhou Medical University interpreted the key points of the ESU lecture, moderated the discussions and interactions among all the attendees in Beijing and Guangzhou venues. Bladder cancer The bladder cancer module consisted of three lectures as well which were “The chain of excellence in the management of NMIBC” by former ESU Chair Prof. Joan Palou (ES) from Fundació Puigvert; “Radical cystectomy and urinary diversion” by Prof. Ningchen Li (CN) from Peking University Wu Jieping Urology Center; “Non-operative aspects of MIBC management” by Prof. Kexin Xu (CN) from Peking University People’s Hospital. Prof. Rongpei Wu (CN) from the First Affiliated Hospital, Sun Yat-sen University interpreted the core messages of the ESU lecture and supervised discussions and interactions among all the attendees in various venues.

Prostate cancer The three lectures of the prostate cancer module were “The optimal way to evaluate a patient with elevated PSA” by Prof. Gang Song (CN) from the Peking University First Hospital; “Individualized treatment of the patient with proven prostate cancer” by Prof. Andrea Minervini (IT) from Careggi Hospital, University of Florence; “Treatment strategies in recurrent PCa” by Prof. Wei Wang from the Beijing Tongren Hospital, Capital Medical University. Prof. Cao Cai (CN) from the First Affiliated Hospital of Guangzhou Medical University interpreted the key points of the ESU lecture and guided the discussions and interactions among all the attendees in the different venues. Valuable feedback About 65 participants completed the feedback questionnaires after the training, 88% of whom rated the 8th CEUEP with a 9 or 10 with 10 being the highest. Impressions from the participants included the following statements:

• “The programme is extensive. It was great that the training was organised virtually and face to face.” • “The moderators’ simultaneous interpretations of ESU lectures were impressive.” • “I hope there would be more time for discussions and interactions in the future since the lectures have taken most of the time.” • “I wish the lectures could cover more case discussions, surgery skills, and management of complications.” • “I learned a lot from this programme. Both my knowledge and surgery skills have improved after the training. I now have a more systematic understanding of urology with standardised instructions.” • “I wish urologists like us from primary hospitals could have more opportunities like this to take part in this training programme to learn how to make better diagnosis, treatment options, improve surgery skills, and know about cutting-edge knowledge in the world.”

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

Submission deadlines: 1 March - 1 July - 1 November Please check our website for details regarding the eligibility criteria and application procedure: www.uroweb.org/education/young-urologists-office-yuo/yau or contact the office via yau@uroweb.org

European Urological Scholarship Programme (EUSP) Don't forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme before 1 May. For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website www.uroweb.org/education/scholarship/ Group photo at the Guangzhou venue

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Report

E-BLUS course in Gijón: A new model for online evaluation Simultaneous onsite and remote training Dr. Sergio Fernández-Pello Cabueñes University Hospital Gijón (ES)

spello84@ hotmail.com The European Basic Laparoscopic Urological Skills (E-BLUS) course and dry-lab workshop took place from 29 to 30 April 2021 in Gijón, Spain. The course was organised under my supervision, as well as, Dr. Domenico Veneziano’s (IT). Our urology departments actively collaborated during the hands-on training (HOT), live surgeries, and examinations. These practical and HOT courses are generally part of the EAU Annual Congress or the European Urology Residents Educational Programme (EUREP). The aim of the course is to provide the delegates with the basic theoretical lessons and laparoscopic training through simulators in two intensive days. At the end of the course, the participants will have the opportunity to test their skills under the guidance of an E-BLUS tutor, and adhering to the E-BLUS certification The course helps enhance surgical quality criteria. dexterity

Due to the COVID-19 pandemic, the initial course in Gijón was cancelled twice. Together with the ESU, we worked on a mixed modality which combines the essence of E-BLUS courses, a restricted number of participants, and the online supervision by an E-BLUS tutor. Following this model, we abided by the COVID-19 rules and regulations while including a new way of online supervision called teletraining. Dr. Veneziano defined teletraining as “a digital transposition of the classic hands-on training, where the expert teaches and consults remotely.” He added, “The tutor and trainees use the same equipment including the laparoscopy box and training tasks, which allows everyone to actively perform the procedure in real-time. This way, the tutor can teach multiple trainees and also provide advice and suggestions to each one. With the advent of COVID-19, teletraining became a good option to optimise costs and efficiency, as well as, to deliver practical surgical training.”

fourth- and fifth-year urology residents. During the two days, they practised on the workstations and received interesting theoretical lessons in laparoscopy. They learned about the laparoscopic operating room set-up with live laparoscopic surgeries at our theatres. After the course, they presented the online E-BLUS examination in this new modality.

Testimonials Participants Dr. Laura Modrego Participants finetuning their skills on workstations Ulecia (ES) and Dr. Pelayo Suárez Sal (ES) shared their experiences and impressions of the course. Dr. Suárez Sal shared that after the course, he clearly noticed an improvement in his day-to-day life in the Dr. Modrego Ulecia stated, “After a year of coping operating room. “I changed my mentality. Every day, I do my best to practise on my pelvic trainer at home with the pandemic and complying with protective health measures, I enjoyed being able to share for half an hour. Being able to take a course to update, improve, and practise movements is one of clinical experiences in urology with colleagues from The structure other hospitals. It was very rewarding for me. the best ways to grow in your learning curve of We set up a room with six workstations comprising of laparoscopic surgery. Karl Storz pelvi-trainer, tele-pack and instruments. “Training our skills through simulation models was Each workstation was connected to a webcam and “It has been a great experience to participate in the overseen by an E-BLUS tutor. The tutor could watch the very important for our learning and clinical practice. E-BLUS course. The opportunity for expert urologists The course taught basic skills on urological exercises, correct the participants if needed, and to guide us was one of the course’s best aspects, as provide tips and tricks in real-time from his own home. laparoscopic surgery: needle handling, cutting, suturing, and knot tying techniques which well as, being able to enjoy it with fellow residents. I To evaluate the performance of the participants, we encouraged us to use both hands, thereby enhancing was pleased with the organisation and materials to prepared an additional working station with two surgical dexterity. carry out the exercises.” cameras: one to broadcast the exercises and the other to broadcast the participant. The E-BLUS tutor, “The equipment we used was of very high quality and Final remarks the online connection was perfect. Additionally, the It was such a pleasure to work together with the ESU together with the assistance of the local tutor onsite, could watch the exercise/instruments inside the box small number of attendees allowed the faculty to help and Dr. Veneziano and to explore this initiative in the and the face/body/arms outside the box of a us more optimally. E-BLUS setting. Even though having this on-site is important for an E-BLUS course, this alternative workstation. “I would like to thank Hospital of Cabueñes, its would make these courses possible for small groups, urology service and especially Dr. Fernández- Pello for venue issues, and/or mobility restrictions of the Six participants from La Coruña, León, Oviedo, and tutors. Gijón took part in the course. They were comprised of the wonderful reception.”

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“The virtual ESU courses are a way out during a pandemic” A recap of the ESU course in Tashkent, Uzbekistan Dr. Bekhzod Ayubov ISC Republican Specialized Center of Urology Secretary of the SUU Tashkent (UZ) bekzod.ayubov@ gmail.com Together with the European School of Urology (ESU), we organised the virtual ESU course “Modern technologies and equipment in diagnosis of urologic diseases” which took place on 8 November 2021 in Tashkent, Uzbekistan in conjunction with the meeting of the Society of Urologists of Uzbekistan (SUU). We have had these highly-educational ESU courses in Tashkent intermittently since 2007. Our aim was to improve the education and knowledge of our local urologists and it was successful. When we learned that internationally-known experts Profs. Prokar Dasgupta (GB), Silvia Proietti (IT), and Morgan Rouprêt (FR) will present virtually at our meeting, we were pleased. Interest to the ESU course was high among our local urologists and exceeded their expectations. We initially planned 100 participants, but at day of the meeting, we counted more than 200 urologists offline and 250 online. The conference hall was full but we made sure to create extra places so everyone enjoyed high-quality lectures safely. After the welcome speech of the Chairman of the Scientific Society of Uzbekistan Prof. Farkhad Akilov (UZ), and the Director of the Republic Center of Urology Prof. Shukhrat Mukhtarov (UZ) during the opening ceremony, Prof. Dasgupta introduced the October/January 2022

aims of the EAU and ESU, as well as, benefits for participants when partaking in their programme and activities. Prof. Proietti presented “New technologies in the diagnosis and management of urolithiasis”. She addressed the problem with regard to the necessity of single-use digital flexible ureterorenoscopes for getting stone-free rates and cleaning calyces in the kidney. She also discussed the pros and cons of holmium and thulium lasers for the fragmentation of urinary tract stones. Prof. Proietti also mentioned that nowadays, the simultaneous bilateral endoscopic surgeries for patients with bilateral upper urinary tract stones have good outcomes. The second presentation was a pre-recorded lecture by Prof. Declan Murphy (AU). He discussed PSMA/PET imaging for primary staging of prostate cancer and PSMA theranostics for advanced prostate cancer. He also informed the participants about the LuTectomy trial wherein neoadjuvant LuPSMA prior to radical prostatectomy has been found effective in the destruction of metastatic lymph nodes. We also discussed the interesting case reports prepared by our young urologists Dr. Muzaffar Tukhtamishev (UZ) and Dr. Khusniddin Nuriddinov (UZ). They asked the ESU faculty on tactics and treatment options of difficult clinical situations and compared ways of management. The faculty answered and explained in detail. Discussing these case reports was an interesting tool that helped us see that we are treating our patients the same way as recommended by the EAU Guidelines and by experts in this field. Then Prof. Rouprêt presented “Alternatives to white light cystoscopy in the diagnosis of bladder cancer” which was an excellent lecture. The participants were informed how to deal with endoscopic invisible lesions

through new photodynamic agents 5-ALA or HAL, photodynamic diagnostics (PDD) visualization, narrow band imaging (NBI), SPIEs, confocal laser endomicroscopy (CLE) or optical coherence tomography (OCT). These could be helpful in reducing the tumour recurrences and leaving unnoticed residual The ESU faculty shares insights to delegates online and on site tumours in comparison with white-light resection. The ESU faculty shared their own experiences on how to deal with difficult bladder cancer cases (e.g. carcinoma in situ, residual or recurrent) prevent complications, and how to treat them. The last presentation was by Prof. Dasgupta which was entitled “Technologies in the treatment of BPO.” He explained each method used at present. He discussed transurethral resection of the prostate (TURP); photoselective vaporization of the prostate (PVP); anatomical endoscopic enucleation of the prostate (AEEP) e.g. HoLEP, ThuLEP, DiLEP, BipLEP, GreenLEP; iTIND; UroLift; Rezum; Warejet; robotic or laparoscopic simple prostatectomy and prostate artery embolization, including the advantages and disadvantages of each method. The take-home message from the ESU was: “AEEP offers the greatest long-term improvement in maximum flow-rate, while International Prostate Symptom Score (IPSS) and prostate volume reduction with lowest re-treatment rate. Then these are followed by PVP, TURP, and Aquablation. Urolift, Rezum and prostatic artery embolization (PAE)

have similar efficacy for prostate volume up to 80cc, and are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anaesthesia”. During the closing speech, Prof. Dasgupta expressed his satisfaction how the course went and the quality of questions. He also welcomed the continued cooperation of the Scientific Society of the urologists of Uzbekistan and the EAU. The Head of Scientific Society of Uzbekistan Prof. Akilov thanked the EAU for the support and introduction of new technologies which we plan to integrate into our practice in the near future. We would also like to extend our appreciation for the huge efforts of the ESU, especially the Board Members, Mrs. Jacobijn Sedelaar-Maaskant, and Ms. Sophie Mills. The ESU courses guide us in moving forward and enhancing our knowledge and skills, which in turn will benefit our patients. European Urology Today

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Check your understanding of the EAU Guidelines New courses on the EAU Guidelines are available now. • Understand the diverse natures of subjects such as Paediatric Urology, Bladder Stones and Testicular Cancer • Arrive at the right diagnoses • Make risk assessments of cases • Decide on a treatment and follow-up strategy Dr. Nicolaos Grivas Dr. Panagiotis Kallidonis Dr. Henk Van Der Poel

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ESU Urology Boot Camp Serbia 2021 Skills training for residents from Serbia and the neighbouring countries By Prof. Aleksandar Vuksanovi and Dr. Tiago Oliveira Over the last years, the European School of Urology (ESU) has developed a series of standardised and validated hands-on training activities in collaboration with the European Association of Urology (EAU), the EAU Section of Uro-Technology (ESUT), and the EAU Section of Urolithiasis (EULIS). In view of the clear success of these activities, the ESU, the ESUT and the EULIS have created the Standardization in Surgical Education (SISE) programme, which is a collaborative venture that aims to implement a comprehensive approach to all training activities within the ESU. SISE encompasses a series of structured, standardised and validated training curricula targeted at all trainee levels. ESU Urology Boot Camp project The ESU Urology Boot Camp is a standardised course that provides first-year residents with high-quality technical skills training. The boot camp is designed within the framework of a standardised and integrated ESU training programme. This is to enable every urology resident in Europe to acquire the necessary technical skills to perform the most frequent urological procedures before they start working with patients.

equipment, trainees are provided with standardised hands-on trainings on laparoscopy, flexible and semi-rigid ureterorenoscopy, transurethral resection of the prostate (TURP), transurethral resection of bladder tumour (TURBT), flexible and rigid cystoscopy, bladder catheterisation, suprapubic catheter placement, and scrotal examination. ESU Urology Boot Camp Serbia 2021 Following the great success of the courses organised in Portugal and Belgium, the ESU and the Serbian Association of Urology organised the first ESU Urology Boot Camp in Belgrade, Serbia on 16 September 2021. It was the first step in introducing the ESU Urology Boot Camp in the region. In line with the procedures established for previous courses, the day before the boot camp, a “Train the Trainer” course was organised with all the faculty to optimise and standardise training activities. In accordance to the structure of the ESU Urology Boot Camp, the course comprised a full day of

The ESU Urology Boot Camp comprises a full day of intensive hands-on trainings organised into separate training modules. One of the most important hallmarks of the boot camp is the 1:1:1 training model: one trainee with his/her own training station under the tutelage of an experienced trainer for the entire duration of each module, therefore maximising the learning experience. With a series of different high-fidelity models and a considerable amount of state-of-the-art urological

Practising on high-fidelity models under the tutelage of an expert

intensive hands-on training activities organised into several modules including: laparoscopy, upper urinary tract endoscopy, lower urinary tract endoscopy, scrotal examination and circumcision. A total of six residents from Serbia and the neighbouring countries had the opportunity to participate, thus complying with the Serbian Association of Urology’s objective of extending all training opportunities to the neighbouring countries. Testimonials Delegate Dr. Ilija Nikčević (MNE) shared, “The boot camp was a truly enriching experience. The laparoscopy module included basic laparoscopic manoeuvres, the explanation of pneumoperitoneum establishment followed by peg transfer, circle cutting, needle guidance, and suturing. The upper and lower urinary tract endoscopy modules consisted of rigid and flexible cystoscopy, semi-rigid and flexible ureteroscopy, ureter cannulating, guidewire manipulation, and visualisation of labelled renal calices. And last but not the least, the reconstructive surgery module encompassed circumcision techniques alongside with scrotum models for palpation and theoretical explanation of diverse testicular pathology. In conclusion, ESU Urology Boot Camp was a perfect chance to gain significant insight into the existence of various advanced endoscopic and reconstructive surgery methods, which could be a game changer for residents in terms of manual skills improvement.” Faculty member Prof. Otaš Durutović (RS) stated, “The 1:1:1 model was more than well adopted by residents, who expressed that it had surpassed all their expectations. This was also the impression of the tutors, who considered the one-on-one training to be the most important hallmarks of the course.

Meet the boot camp faculty and participants

“I would like to express my gratitude to the ESU, Prof. Evangelos Liatsikos (GR), and our dear friends who have joined us in Belgrade to do such an excellent course, Dr. Tiago Ribeiro de Olivera (PT) and Mr. Ton Brouwers (NL). “We hope this ESU Urology Boot Camp is just the beginning of a solid tradition, not only by organising it on a yearly basis but also with other ESU training activities during the annual meetings of the Serbian Urological Association.” Given the complete success of this first course, the ESU and the Serbian Association of Urology are organising a second edition for May 2022.

Report

21st RSU congress offers expansive urology fundamentals Delivers crucial updates and hosts virtual ESU course Prof. Igor Korneyev Dept. of Urology Saint Petersburg State Pavlov Medical University Saint Petersburg (RU)

urology, presented by Prof. Glybochko and Prof. Pushkar respectively. The EAU and RSU honorary member Prof. Vladimir Tkachook presented a historical retrospective of the development of the RSU, starting from its inception in 1907 in St. Petersburg through the initiative of Prof. Sergey Petrovich Fedorov, until the present day.

iakorneyev@ yandex.ru

The plenary session commenced with the EAU lecture of Prof. Chapple on surgical management of female urethral disorders which garnered attention of more than 1,300 urologists online. Another guest lecture, “Pros and Cons in kidney-sparing treatment of upper tract urothelial carcinoma” was conducted by Prof. Oliver Hakenberg.

The 21st Congress of Russian Society of Urology (RSU) took place online on 23 to 25 September 2021 with the “Fundamental scientific aspects of urological practice” as the key theme. It highlighted the latest research and state-of-the-art sessions covering a wide breadth of urological topics which were presented by key opinion leaders. The congress was organised in conjunction with the European Association of Urology (EAU) and hosted the course organised by the European School of Urology (ESU). The opening ceremony started with a warm welcome from the RSU Chairman Prof. Yuri Alyaev, and the Rector of Moscow Sechenov University Prof. Petr Glybochko, followed by the EAU Secretary General Prof. Chris Chapple. They concluded that in the times of COVID-19 pandemic when the delegates were unable to meet in person, implementation of the virtual format brings a solid platform for continuation of professional growth, knowledge exchange and promotion of international co-operation for the future. The welcome messages were also presented Chief urologist of Russia Prof. Dmitry Pushkar, the Executive Director of the RSU Prof. Magomed Gazimiev, as well as, Prof. Boris Komyakov and Prof. Salman Al-Shukri from St. Petersburg. The first session covered the key issues of education and scientific research in Russian and international October/January 2022

The second day of the congress highlighted the virtual ESU course chaired by Prof. Marek Babjuk. In his welcome speech, he gave an overview of the structure, role and goals of the ESU and emphasised the importance of close co-operation between the EAU and the RSU. The ESU course consisted of presentations on the management of muscle-invasive and metastatic bladder cancer and renal cell carcinoma (RCC) treatment. The EAU Guidelines on both topics were discussed and presented by Prof. Babjuk and Dr. Umberto Capitanio respectively. Prof. Bernard Malavaud discussed the controversial topic of bladder preservation strategies as an alternative to radical cystectomy in patients with muscle-invasive bladder cancer stressing out careful patients selection for both options. He also presented a report on systemic chemotherapy and check-point inhibitors in metastatic bladder cancer. For years the cisplatin-based chemotherapy has been the standard first-line treatment for this kind of patients, more recently immune checkpoint inhibitors have become available. Studies have shown that combining of

these approached can lead to potentiating effects with discussed the treatment options with the audience promising results. and the ESU Faculty. The ESU course attracted more than 1,600 participants and gave them an excellent updated overview of practical and challenging Dr. Oscar Rodríguez Faba’s follow-up lecture was devoted to the role of surgery in metastatic RCC. approaches in managing of these common malignancies. Surgery remains a valuable tool in patient management in the time of immunotherapy or agents targeting the vascular endothelial growth The following days of the congress included training seminars of the RSU and thematic sessions in factor. Surgical treatment can be offered as palliative nephrectomy for symptomatic patients, as well as, oncourology, reconstructive urology, benign prostatic hyperplasia (BPH)/ lower urinary tract symptoms cytoreductive nephrectomy before starting systemic therapy or as consolidative procedure after therapy (LUTS), imaging in urology, urolithiasis, for intermediate- and poor-risk patients. In selected neurourology, UTI, andrology and reproductive urology. patients resection of metastatic lesions could be performed, its feasibility depends on the organs More than 3,300 participants who followed the involved and the extent of resection that is achievable. Dr. Rodriguez proceeded with the sessions online were from 78 regions of Russia and discussion and presented options for systemic also from Armenia, Belarus, Estonia, Germany, Georgia, Israel, Kazakhstan, Kyrgyzstan, Latvia, treatment for patients with metastatic RCC. Moldova, Spain, Tadzhikistan, Turkmenistan, Ukraine and Uzbekistan. The 21st Congress of RSU organised At the end of the session, Dr. Sergey Reva and Dr. Viktor Ochelenko demonstrated challenging and in close co-operation with the EAU and the ESU has interesting cases of muscle-invasive bladder cancer become a successful meeting and the highlight of the and RCC complicated by thrombus formation. They scientific calendar.

Prof. Malavaud discusses bladder preservation strategies

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Report

Virtual ESU-ESFFU Masterclass on Functional Urology A comprehensive coverage on functional and neurourology Dr. Martina Beverini IRCCS University Hospital San Martino Genoa (IT)

martina.beverini@ live.it The 3rd and 4th November saw the 2022 edition of the annual ESU-ESFFU Masterclass on Functional Urology. Just like last year, this edition was also online. Nonetheless, enthusiasm and participation were not lacking. Although the virtual edition influenced the group’s spirit that has always characterised the meetings of the European School of Urology (ESU) and the EAU Section of Female and Functional Urology (ESFFU), there were constructive debates. The opportunity for growth and comparison was enormous. Interestingly, more than 40 participants from and outside Europe actively participated in the dense succession of interesting lectures.

must have. Right after, Prof. Hashim presented “How I do urodynamics: Video with explanations” which was focused on the good practices as stipulated by the International Continence Society in order to perform and correctly interpret this examination. This series of interesting slideshows were interspersed with clinical cases presented by the participants. Finally, the day ended with an afternoon dedicated to bladder pain syndrome, interstitial cystitis and a stunning lecture on “Sexual dysfunction” by Prof. Costantini. The first day was dedicated to theory; the second day was full of lessons with step-by-step videos on how to perform delicate surgical procedures. In “Operation of Vesicovaginal fistula (VVF): Video of method,” Prof. Chartier-Kastler and Prof. Heesakkers explained in detail the indications and techniques to repair a vesicovaginal fistula. In addition, they clarified the steps to carry out this intervention to avoid complications. Thereafter was the presentation on stress incontinence surgery by Prof. Costantini, who explained the steps of a transobturator tape surgery. The attendees appreciated these step-by-step videos because these allowed young urologists to fully understand the tips and tricks in performing surgery.

Chaired by Prof. John Heesakkers (NL), the faculty was comprised of excellent specialists recognised worldwide for their skills and experiences in this field of urology such as Prof. Elisabetta Costantini (IT), Prof. Emmanuel Chartier-Kastler (FR), Prof. George Kasyan (RU), Prof. Hashim Hashim (GB), Prof. Frank Van Der Aa (BE) and Dr. Nikesh Thiruchelvam (GB).

Following Prof. Costantini’s presentation was the lecture entitled “Complications video: How to solve a urethral erosion of tapes” by Prof. Van Der Aa and Prof. Kasyan who showed how to manage terrible complications related to this kind of interventions. They demonstrated how to manage the dramatic event of a urethral erosion.

The first day was mainly designed to provide participants with a solid base then cover more complex subjects later. Consequently, the beginning of this masterclass was dedicated to anatomy and physiology, which are foundations that every urologist

Hereinafter, Prof. Van Der Aa illustrated the indications for urinary diversion in functional urology and artificial urinary sphincter, and supported the discussion with a useful video “Video of AMS800: The way I do it”.

Some of the enthusiastic faculty and participants of the masterclass

After a short lunch break, the afternoon was dedicated to neurological patients with three exciting slideshows by Dr. Thiruchelvam and Prof. ChartierKastler which were “Overactive bladder in neurogenic patients”, “Surgery management of Overactive bladder: Botox video SNS video: Step by step”, and “Augmentation video: Step by step”. It is certainly important to devote time to the topic of neurourology, as this kind of patients require special attention and will benefit from a multidisciplinary and personalised management. To wrap up two days of full immersion in functional and neurourology, Prof. Kasyan reported a summary of special and extraordinary cases from Russia which amazed all the participants. It was surely a great way to end two intensive days.

Prof. Hashim provides definitions of urodynamics terminologies

opportunity to learn. It is also important to note that these lectures contain accurate and up-to-date information based on the latest literature and guidelines, step-by-step videos, and interesting comparisons among the experts. Moreover, the survey carried out before and after has also shown the excellent training the masterclass has provided; the improvement shown by the results was apparent. We just have to wait for the next edition with the hope that we can finally meet in person. More ESU masterclasses For more information about upcoming masterclasses and how to apply, please visit www.esu-masterclasses.org.

In addition, the second day was also marked with numerous presentations of clinical cases highlighted by the participants, which led to a discussion and a constructive debate on the best management of patients that we visit every day. To conclude, I advise every urologist interested in these topics to participate in the ESU-ESFFU Masterclass on Functional Urology as it is an excellent

One of the extraordinary cases presented by Prof. Kasyan

Report

Virtual ESU course focuses on upper tract laparoscopy Advanced course report at the Tunisian Association of Urology congress Dr. Ahmed Said Zribi Vice President, Tunisian Association of Urology Tunis (TN)

zribi.ahmedsaid@ yahoo.fr

mostly used by surgeons as this would avoid local recurrence. He also shared his feedback and impressions of the course: “Laparoscopy in urology remains one of the leading surgical treatment modalities. I realise that the educational role of the EAU and especially the ESU is mandatory and essential. Implementation of EAU Guidelines and modern approaches is the cornerstone of equal relation between each urological society.” He added that the delegates were eager and enthusiastic, and thought that the scientific content and level of the presentations were appropriate for the delegates.

The 21st congress of the Tunisian Association of Urology took place from 22 to 23 October 2021 in Hammamet, Tunisia. The participants were delighted Dr. Kallidonis took to the online stage once again and to finally meet in-person once again after the onset of provided different steps of laparoscopic ureteropelvic the COVID-19 pandemic. junction obstruction management in detail during his lecture “Pyeloplasty: Indication – techniques – The congress also hosted the virtual course of the problems”. The participants asked him why not insert European School of Urology (ESU) which was entitled a double-J stent by endoscopy prior to laparoscopy as “Advanced course on upper tract laparoscopy: Kidney, they think this is easier and might be a way to identify UPJ, ureter and stones”. ureter in recurrent cases. Dr. Kallidonis replied that the ureter and the ureteropelvic junction are more The course presentations were livestreamed on the elastic and better to manipulate without a double-J first congress day. Course Chair Dr. Panagiotis stent inside. Additionally, he also stated that a Kallidonis (GR) launched the course by putting the retrograde placement of a double-J stent might be a spotlight on the role of the ESU in providing unique cause of bacterial inoculation. opportunities in urological education. Dr. Kallidonis’s presentation was followed by a lecture by Assoc. Prof. He continued with his next lecture on partial Bogdan Petrut (RO) which summarised the EAU nephrectomy wherein he concluded that we can Guidelines of kidney cancer, then by Prof. David usually either perform better with or without a robot, Nikoleishvili (GE) who provided his expert insights and to perform the technique where we have the best during his presentation “Kidney: Nephrectomy, expertise in. Also during Dr. Kallidonis’s presentation, management of cysts”. it was shown that the presence of adherent perirenal fat seen in the computed tomography made the He explained how to deal with nephrectomy, radical laparoscopic partial nephrectomy difficult but it was and conservative treatment of upper tract urothelial not a contraindication in experienced hands. carcinoma. During the discussion on bladder cuff excision, Prof. Nikoleishvili underscored that although Afterwards, Prof. Petrut presented his lecture the endovesical approach ensures the removal of the “Complication management” which showed how to entire intravesical ureter, the extravesical excision is manage and avoid complications in laparoscopic 20

European Urology Today

The audience pays close attention during the ESU course

surgery. He demonstrated that an intrarenal pseudoaneurysm can be managed by laparoscopy. However, the standard management is embolisation.

antegrade than retrograde endoscopy. In fact, the inflammation and stricture are mostly below rather than above the stone.

Prof. Petrut also presented a challenging case of vena cava perforation. In this patient case, good visibility is needed and to stop bleeding, one must put a row of staples. An additional access port may be indicated for better intraoperative exposure.

Highly-regarded local faculty member Dr. Salem Braiek (TN) presented another case centred on a large pelvic stone managed by retroperitoneal laparoscopy. The presence of an adherent peripelvic fat made the dissection difficult. The indication of laparoscopic approach was when percutaneous nephrolithotomy is not possible for any reason.

Case discussions Concluding the ESU course, esteemed local faculty member Prof. Mehdi Jaidane (TN) presented a case of impacted upper ureter stone which was treated by retroperitoneal laparoscopy as an alternative to ureteroscopy. During the discussions, Dr. Kallidonis and Prof. Nikoleishvili agreed that prior drainage either by double-J stent or percutaneous nephrostomy might be safer in difficult cases or in the presence of cloudy infected urine. An impacted upper ureter stone with a dilated pelvicalyceal system is easier to treat with

The discussions were lively that we surpassed the time allotted. We are pleased that we were afforded an hour extra by our honourable presenters and organisers. The scientific content presented was apt and relevant. The overall atmosphere during the course was friendly, conversational and conducive to learning. We would like to extend our deepest gratitude to the EAU and to the ESU for this fruitful collaboration, and we hope to meet face to face in upcoming events. October/January 2022


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ESU Urology Boot Camp Lisbon 2021 Comprehensive basic technical skills training to 1st-year residents Prof. Ben Van Cleynenbreugel Dept. of Urology University Hospitals Leuven Leuven (BE) Ben. Vancleynenbreugel@ uzleuven.be

Mr. Chandra Shekhar Biyani Dept. of Urology St. James’ University Hospital Leeds (GB) shekharbiyani@ hotmail.com

Dr. Tiago Ribeiro De Oliveira Dept. of Urology Armed Forces Hospital Lisbon University Hospital Lisbon (PT)

Stone Treatment Step 1 (EST-S1) and the Certified Curriculum of ERUS (CC-ERUS). This has led to the implementation of several structured and integrated training curricula in urological laparoscopy, endoscopy and robotics In view of the clear success of these activities, the ESU, ESUT, ERUS and EULIS have created the Standardization in Surgical Education (SISE) program. This collaborative venture aims to implement a comprehensive approach to all training activities within the EAU, encompassing a series of structured, standardised and validated training curricula targeted at all trainee levels. The first step in the SISE programme is the ESU Urology Boot Camp. The ESU Urology Boot Camp project The Urology Simulation Boot Camp, developed in Leeds by Mr. Shekhar Biyani (GB) and Mr. Sunjay Jain (GB), is a revolutionary course that, over five days of intensive training, aims to provide basic technical and non-technical skills for urology registrars in the United Kingdom. From the ground-breaking evidence originating from this course, the ESU Urology Boot Camp project was developed to provide technical skills training to urology residents throughout Europe, within the framework of a standardised ESU training curriculum. At the basis of the SISE program, the ESU Urology Boot Camp is a standardised course for first-year residents, comprising a full day of intensive hands-on training and organised into four separate training modules, with the aim of providing high-quality technical skills training to enable every urology resident in Europe to acquire the necessary technical skills to perform the most frequent urological procedures before they start working with patients.

Intensive hands-on training

Boot Camp in Portugal, Belgium, and Serbia, a first edition of the course is planned for Greece and Germany.

The organisation of future ESU Urology Boot Camps will be initiated via the SISE Over the last decades, the traditional surgical training programme platform model faced several ethical and regulatory issues that One of the most important hallmarks of the ESU i.e. SISE website. The considerably impacted surgical education. In fact, Urology Boot Camp is the 1:1:1 training model, where ESU Urology Boot studies show that not only was there a subjective one trainee has a dedicated training station and an Camp Working Group decline in residents’ performance (perceived both by experienced trainer for the entire duration of each will analyse all new programme directors and residents themselves) but Enthusiastic participants and faculty members module, therefore maximising the learning Boot Camp requests there was also an objective decline in proficiency and experience. With a series of different low and and provide a autonomy levels at the end of residency programmes. high-fidelity models and a considerable amount of step-by-step manual, state-of-the-art urological equipment, trainees are a checklist, and a timeline for the implementation of planned to take place during our upcoming National Urology residency training remains quite provided standardised hands-on training on every course to support and guide the organising Congress in Athewns in 2022.” heterogeneous throughout the world, not only in the laparoscopy, flexible and semi-rigid ureterorenoscopy, committees throughout the entire process. The ESU total duration of training but also in the length of core transurethral resection of the prostate and bladder Urology Boot Camp Working Group will also prepare a Boot Camp trainee, Dr. André Ye (PT) of the Santa surgical training and specific urological training, tumours, flexible and rigid cystoscopy, bladder Train the Trainer course for all the faculty to ensure the Maria Hospital in Lisbon, stated “The ESU Urology research requirements, working hours, surgical catheterisation, suprapubic catheter placement, and highest quality of training. Bootcamp fills an essential gap in the education of exposure, and evaluation methods. Studies on the scrotal examination. first-year residents with an introduction to the most current status of urological training show a relatively To guide and facilitate the implementation of the essential urologic materials and skills, each one with low surgical exposure throughout the formal training Following a very successful pilot course in Portugal, in course, a previous visit as an external observer to its own complex characteristics. period, with only one third of residents satisfied with 2018, four additional courses have been organised in another Boot Camp will be part of the process. In line their surgical training and with most residents Portugal, Belgium, and Serbia. with this principle, Prof. Athanasios Delis (GR), the “The highlight of this course is its heavily based considering that training was inadequate and having Chairman of the Hellenic Association of Urology and hands-on approach with a unique one-to-one lack of confidence in independently performing ESU Urology Boot Camp Lisbon 2021 Boot Camp external observer, was present in the ESU guidance ratio with an expert in the field. Needless to surgical procedures at the end of their residency. After a forced one-year gap due to the restrictions of Urology Boot Camp in Lisbon to coordinate the say, the supervision and recommendations are Altogether, these results showed that current urology the COVID-19 pandemic, the third edition of the ESU implementation of the course in Greece in 2022. invaluable, with precious suggestions that will prove residency programmes have limitations that may Urology Boot Camp in Lisbon was organised in 2021. very helpful in the future. The quality of the realistic seriously compromise the quality of urological On October 30th, the course was organised by the ESU Testimonials from participants models is also worth noting, which succeed in training. and the Lisbon Faculty of Medicine Center for Prof. Delis (GR) shared, “I had the privilege to attend representing real-life scenarios thus allowing practice Postgraduate Training in Urology (CFU), in the 3rd Lisbon Urology Bootcamp, held in the Armed in a safe environment. In light of the limitations of traditional surgical collaboration with the Armed Forces Hospital and the Forces Hospital under the auspices of the ESU. Dr. training over the past decades, simulation-based Military Health Teaching, Training and Investigation Oliveira was responsible for the excellent organisation “This event is defined by its pedagogical excellence, training has been extensively explored and used as an Unit, with the scientific support of the Portuguese and hospitality and I do thank him for that. organisation, and carefully thought details to provide adjunct to traditional surgical training, namely for the College of Physicians’ Board of Urology and with the the best experience to the participants. It is safe to say development of technical skills via individual sponsorship of Karl Storz, Teprel, Janssen, Boston “Four modules were deployed for almost 10 hours of that the Boot Camp should be mandatory for everyone hands-on practice. In recent years, the European Scientific, Medtronic, and Mediplus. training and covered all aspects of training for who enters the Urology residency, as it inspires us to Association of Urology (EAU), the European School of first-year urology residents. Trainees were able to: be diligent and creates a strong foundation for the Urology (ESU), the EAU Section of Uro-technology The intensive course programme provided participants palpate and examine external genitalia, place a years ahead. To all the faculty and staff, my sincerest (ESUT), the EAU Robotic Urology Section (ERUS) and the opportunity to acquire and train several urological bladder catheter (transurethrally or suprapubically), thanks for this opportunity.” the EAU Urolithiasis Section (EULIS) have developed a skills in eight hours of hands-on training. Each perform rigid and flexible cystoscopies, place ureteral series of standardised and validated training participant had a dedicated model and individually stents, use rigid and flexible ureteroscopes to examine Boot Camp trainee, Dr. Guilherme Bernardo (PT) of the programmes. Examples are the European Basic guided by a trainer. This was a unique opportunity for the upper urinary tract, and even do transurethral Fernando Fonseca Hospital in Lisbon said, “The Laparoscopic Urological Skills (EBLUS), the Endoscopic first-year urology residents to learn a series of resections of prostatic adenomas and bladder Urology Boot Camp, in my opinion, was a tremendous different technical skills that are of paramount tumours. Furthermore, they had the chance to use success, for many reasons. First of all, it was very importance in daily clinical practice. The quality of the laparoscopic instruments and do their initial basic practical and hands-on, allowing junior residents to models and equipment, the motivation and steps in laparoscopy. This hands-on training course learn in top-of-the-notch simulation devices with competence of the faculty, and the use of ESU’s was focused on enhancing technical skills in a senior urologists, in a 1:1 ratio! validated training models warranted the clear success one-trainer-per-trainee ratio. of the course amongst the participants. “The fact that we had plenty of time to train and “Participating as an external observer, I was able to interact with our mentor in each of the four stations, Future perspectives feel the enthusiasm of the junior residents for allowed us to learn in a stress-free environment, The aim of the ESU Urology Boot Camp Working practicing basic technical skills within the framework giving a unique learning experience. The seniors Group is to implement an ESU Urology Boot Camp of a standardised ESU training programme. And this shared their “tricks” and skills, and we learned from course for first-year urology residents on a national is, according to my opinion, the key to the Boot Camp’s their vast experience. level and on an annual basis. The objective is to success: to give equal opportunities to all newcomers provide first-year urology residents a platform to to participate and perform basic simple steps, but first “I hope I can enrol in more Bootcamps, I believe in a acquire and train basic urological technical skills, to learn them in an optimal way. It is of utmost standardised method of learning, in which the seniors’ based on a standardised curriculum, prior to starting importance not to simply learn, but to learn properly! skillset is the goal to achieve, and only doing that urological clinical activities. The focused training can Additionally, the organising team provided me with every resident will end their residency programme help improve clinical proficiency and self-confidence. very important information to be better prepared for with the knowledge and expertise of a seasoned Finetuning laparoscopic skills In 2022, aside from a new edition of the ESU Urology the 1st ESU Urology Bootcamp in Athens, which is urologist.” tiagoribeirooliveira@ sapo.pt

October/January 2022

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“Improving urological education in the developing world” Spotlight on the Global Philanthropic Committee organisations, part 2: the EAU The year was 2010 when Dr. Robert Flanigan (US), then secretary of the American Urological Association (AUA), initiated the Global Philanthropic Committee (GPC). The AUA, the European Association of Urology (EAU), and the Société Internationale d'Urologie (SIU) united forces to support education initiatives in “areas where needs are important and resources limited.” Six years later, the International Continence Society (ICS) joined this collaboration. In this four-part interview series, we are putting the spotlight on each of these four organisations and their respective GPC projects. In part II, the EAU represented by its Secretary General Prof. Christopher Chapple (GB).

“Long-term improvements in urology care in underserved areas is the goal of this collaborative effort.” Why did the EAU join the GPC? Prof. Chapple: “The EAU Executive Board discussed the GPC initiative with Dr. Flanigan in 2010. We decided to join as the GPC is an important initiative which allows all four participating organisations to channel resources to support colleagues practising in less advantaged areas of the world. Through monetary funds and/or in-kind donations, including volunteer time, we have been able to support the training and continuing professional development of urologists on the other side of the globe. We are very proud to support the GPC.” What projects has the EAU added to the GPC? “The EAU has in particular provided support to a number of initiatives in Africa. The unit at the Kilimanjaro Christian Medical Centre (KCMC) in Arusha, Tanzania, for example, and its training programme for young urologists. These urologists are very grateful for the philanthropic support, which has provided equipment to facilitate the training programme.” What are the results of the support for all these initiatives? “The inaugural GPC project was the support for two urology training centres in Nigeria and Senegal that serve multiple countries. Thanks to the GPC’s support, those training centres have established formal academic training programmes and have significantly improved the urological care provided to patients.” “Since its inception, the GPC has supported educational efforts in Cameroon, Haiti, Nigeria, Senegal, and Tanzania.”

“As my colleague Dr. John Denstedt (US) from the AUA also mentioned in the previous issue, a perfect illustration of the results of the GPC’s support was presented by Prof. E. Oluwabunmi Olapade-Olaopa (NG), who reported that since the GPC had begun its support and equipment donations to his institution in Ibadan, Nigeria, they had seen a 30-40% increase in procedures. Prof. Olapade-Olaopa mentioned that there had also been an increase in multidisciplinary interactions between urologists, nurses, and general surgeons, which was an unexpected benefit from the GPC’s support. He felt that this had led to long-term improvements in urology care in underserved areas, which is exactly the goal of this collaborative effort.” “Over the last ten years, the EAU has been able to hold an annual regional educational symposium at KCMC, in addition to its continuing support of in-service training as noted earlier. If you would like to know more about our GPC project in Moshi, Tanzania, please read the story of Dr. Jacques Bogdanowicz at our website www.uroweb.org.”

“The GPC strives to provide funding mainly for education and generally will not provide funds for purchasing expensive equipment.” What is the EAU’s ultimate goal for the GPC? “The goal of the EAU in supporting this important philanthropic initiative is to provide philanthropic support to improve urological education in the developing world. The GPC strives to provide funding mainly for education and generally will not provide funds for purchasing expensive equipment. The primary goal is to help build the infrastructure for a sustainable and self-sufficient educational hub in areas of need, using a ‘train the trainer’ model.”

Prof. Christopher Chapple

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

What can the average urologist in the western world do to help remove the inequality between the western world and global south? “Contributing to initiatives such as the GPC, partnering with individual institutions for the gifting of equipment, and then volunteering one’s time to support educational activities is the most effective model.”

PCombi adds data to potential role for estrogens in PCa Larger and longer-lasting studies are needed to confirm the results of the trial By our editor Androgen deprivation therapy (ADT) is the standard treatment for locally advanced or metastatic prostate cancer (PCa). The aim of ADT is to reduce testosterone to castrate levels since testosterone is considered as the most important stimulator of progression of advanced and/or metastatic hormonesensitive PCa. Of course, ADT is not devoid of side effects. The PCombi study, recently published in European Urology Open Science [1], was a randomised, double-blind, phase-II trial involving patients with advanced PCa who started ADT treatment with luteinising hormonereleasing hormone (LHRH) agonists. The aim of the PCombi study was to assess the effects of high-dose Estetrol (E4) combined with ADT on hot flushes (HFs) and bone health and to assess the potential antitumour effects of this same combination on this same category of patients.

"Estrogens were used as a method for androgen suppression for several decades. However, the treatment was largely abandoned." “The use of estrogens as a mode of ADT is interesting as the side effects of ADT, which 22

European Urology Today

are caused by low estrogen levels and which can include HFs and loss of bone mineral density, are avoided,” says Dr. Peter Busch Østergren, associate professor urology at the University of Copenhagen (DK), who was not involved in the study. “In fact, estrogens were used as a method for androgen suppression for several decades. However, due to an observed increased risk of thromboembolic events, the treatment was largely abandoned. Estrogen affects liver metabolism and function including blood coagulation, which in part explains the association with thromboembolic events. This is particularly evident in oral estrogens that undergo first-pass hepatic metabolism.”

trial. Previously, the collaborators had shown that tE2 produce castrate levels of testosterone and improve the quality of life and reduce fatigue and HFs compared to LHRH agonists. The PCombi trial adds to these promising data about a role for estrogens in prostate cancer treatment.”

"The large randomised PATCH trial found no difference in cardiovascular morbidity or mortality between LHRH agonist treatment and tE2."

Overview Prof. Frans Debruyne, one of the authors of the article in European Urology Open Science and consultant for Pantarhei Oncology, the sponsor of the study, offered an overview of the study: “62 patients receiving LHRH agonist treatment for advanced PCa were randomised 2:1 to 40 mg E4 (n = 41) or placebo (n = 21) daily co-treatment for 24 weeks. Five patients dropped out early. Co-primary endpoints were the frequency and severity of HFs and levels of total and free testosterone. Secondary endpoints included the assessment of bone metabolism (osteocalcin and type-I collagen telopeptide [CTX1]), prostate-specific antigen (PSA), and follicle-stimulating hormone (FSH).”

“New clinical trials have awakened the interest in using estrogens. Transdermal estrogens (tE2) and other forms of estrogen, such as E4, may have better cardiovascular profiles,” Dr. Østergren explained. “The large, randomised PATCH trial found no difference in cardiovascular morbidity or mortality between LHRH agonist treatment and tE2.[2] 1694 men with prostate cancer were randomised in this

“The study results showed no E4-related serious cardiovascular adverse events. Weekly HFs were reported in 13.5% of the patients with E4 and in 60.0% of those with placebo (P<0.001). Daily HFs occurred in 5.9% versus 55%. Bone turnover parameters decreased significantly with E4 (P<0.0001). Furthermore, the total and free testosterone levels decreased earlier (P<0.05), and free testosterone was

suppressed further (P<0.05). PSA suppression was more profound and started earlier (P<0.005). FSH levels were suppressed by 98% versus 57% (P<0.0001). Estrogenic side effects were nipple sensitivity (34%) and gynecomastia (17%).”

"The results of this phase-II trial demonstrate that the addition of E4 to ADT treatment for advanced PCa has promising positive effects." “The results of this phase-II trial demonstrate that the addition of E4 to ADT treatment for advanced PCa has promising positive effects, especially in relation to HFs, which can tremendously improve a patient’s quality of life,” Prof. Debruyne continued. “Evidently, larger and longer-lasting studies, starting with a further 52-week randomised phase-III trial with more patients, are needed to confirm the results of the PCombi study.” References 1. Coelingh Bennink HJT, Van Moorselaar JA, Crawford ED, et al. Estetrol Cotreatment of Androgen Deprivation Therapy in Infiltrating or Metastatic, Castration-Sensitive Prostate Cancer: A Randomized, Double-blind, Phase II Trial (PCombi). Eur Urol Open Sci 2021; 28: 52-61. 2. Langley et al. Lancet. 2021 Feb 13;397(10274):581591. doi: 10.1016/S0140-6736(21)00100-8.

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Young Urologists/Residents Corner More opportunities for young urologists in PCa research YAU Prostate Cancer Working Party covers entire disease spectrum Dr. Giorgio Gandaglia Chairman San Raffaele Hospital Milan (IT)

gandaglia.giorgio@ hsr.it

Dr. Giancarlo Marra Member Molinette Hospital Turin (IT)

marragiancarlo@ hotmail.it

Translational and clinical research Since its foundation, the Young Academic Urologists (YAU) Prostate Cancer (PCa) Working Party is active in the field of translational and clinical research. A great deal of relevant multi-institutional studies and collaborative systematic reviews have been published over the last few years. The mission of the group is to promote high-quality work to fill current research gaps - via studies performed in our large multicentre network - and to have meaningful impact on everyday patient management. The group is currently composed of 15 extremely motivated members and 3 associates who have been selected after an evaluation of their track record of research activities in the field. Multidisciplinary environment Our Working Party pays particular attention to the creation of a multidisciplinary environment. Several specialists in patient management, such as nuclear medicine physicians, radiologists, radiation oncologists, medical oncologists and psychologists should be included or actively collaborate with the group. Over the last few months, the activities of the group expanded beyond the YAU and collaborations with other EAU offices have been implemented. This allowed us to coordinate our efforts to answer clinically meaningful questions in the field of PCa, to provide methodological and practical support to members involved in our research activities, and to facilitate the dissemination of our study results. Entire spectrum The research activities of the YAU PCa Working Party cover the entire spectrum of PCa. With regard to diagnosis, the group was invited to join the PRIME (PRostate Imaging using MRI +/- contrast Enhancement) study, a prospective trial comparing

bi-parametric MRI to multi-parametric MRI in the diagnosis of clinically significant PCa. This trial will assess the potential role of biparametric vs. multiparametric MRI and might lead to avoiding the use of contrast during MRI. This, in turn, would reduce the risk of side effects related to contrast administration as well as reduce the costs and duration of the examination. With regard to the prostate biopsy setting, we are investigating the impact of the introduction of mpMRI and MRI-targeted biopsies: has there been a temporal change in the risk of upgrading to radical prostatectomy after the introduction of these approaches? Another ongoing project aims at assessing the impact of the introduction of transperineal biopsies on the detection rate of clinically significant disease. A database including more than 5,000 patients who underwent a biopsy in one of the YAU centres has been implemented. PRECISE scoring system Regarding first-line treatment, the YAU PCa Working Party recently started a prospective study aimed at validating the PRECISE scoring system. It has been developed to assess progression of MRI lesions in men on active surveillance. Another important area of research is represented by the evaluation of preoperative risk tools in PCa patients who are candidate for curative-intent therapies. For example, we recently evaluated whether men with high-risk PCa and unilateral mpMRI lesion are suitable for contralateral nerve-sparing procedures. We were able to propose a tailored approach based on the characteristics of each patient. Lymph node dissection Another area of interest is lymph node dissection. YAU members actively contributed to the development of novel models based on MRI-targeted biopsy that may be used to identify candidates for an extended pelvic lymph node dissection at the time of radical prostatectomy. More recently, we systematically reviewed the literature to summarise single and multicentre cohort and registry-based evidence on the optimum management of patients with cN0M0 PCa and lymph node invasion at final pathology. Novel studies, aimed at defining the optimum treatment and follow-up strategies for the management of pN+ patients, have been proposed. The results are expected soon. Multi-institutional study Over the last few years, the introduction of PSMA PET imaging revolutionised PCa management. Thanks to the collaboration with nuclear medicine physicians, a multi-institutional study has started, aiming to assess the impact of the introduction of PSMA PET on the management of PCa patients at diagnosis and at the time of recurrence at a European level. When it comes to patients experiencing recurrence after curative-intent radiotherapy, a database with more than 1,000 salvage RP cases has been created. The aim of ongoing research projects in this field is to

Multicentre registries Thanks to the multidisciplinary nature of our group, we were able to develop multicentre registries, including of metastatic PCa patients, and to investigate the efficacy and side effects of novel therapies in the management of hormone-sensitive and castration-resistant disease. For example, we recently reported that the use of novel ARTAs is associated with a similar toxicity profile and efficacy as chemotherapy in the setting of metastatic patients with hormone-naïve disease. Impact COVID-19 Finally, as COVID-19 had a profound impact on everyday life of physicians involved in the management of PCa as well as patients affected by this disease, we established a multicentre collaboration aimed at evaluating the impact of the pandemic on surgical activity, waiting lists and risk of adverse outcomes. Remarkably, our analyses

Giorgio Gandaglia, Milan (IT), Chairman

Giancarlo Marra, Turin (IT), Member

Francesco Ceci, Milan (IT), Member

Peter Chiu, Hong Kong (HK), Member

Isabel Heidegger, Innsbruck (AT), Austria, Member

Veeru Kasivisvanathan, London (GB), Member

Claudia Kesch, Essen (DE), Member

Jonathan Olivier, Lille (FR), Member

Felix Preisser, Frankfurt (DE), Member

Fabio Zattoni, Padova (IT), Member

Constance Thibault, Paris (FR), Member

Massimo Valerio, Lausanne (CH), Member

Roderick Van Den Bergh, Nieuwegein (NL), Member

Derya Tilki, Hamburg (DE), Member

Igor Tsaur, Mainz (DE), Member

Christian Fankhauser, Lucern (CH), Associate Member

Ignacio Puche Sanz, Granada (ES), Associate Member

Pawel Rajwa, Vienna (AT), Associate Member

demonstrated that the COVID-19 outbreak resulted in a delay in the administration of curative-intent therapies in patients with localised PCa with a stage migration towards more aggressive disease features. Guidelines Office Apart from these projects, an active collaboration with the Prostate Cancer Guidelines Office has been established with the aim of joining efforts in writing systematic reviews to answer unmet needs in PCa management. We are also devoting our energy to developing an electronic prospective platform to collect date from all PCa treatment modalities, including surgery, radiotherapy and ablative energies. We are looking forward to receiving applications from talented young academic urologists who are willing to contribute their work, dedication, and enthusiasm. As we strongly believe that having multiple specialties is the backbone of our success, we encourage applications from all medical specialties dealing with PCa.

YAU meets at EMUC21 An interview with Dr. Juan Gómez Rivas EMUC21 was held in Athens on 25-28 November, and it featured a great deal of satellite meetings. One of these was held by the EAU’s Young Academic Urologists, an organised group of young up-andcoming urologists who are already making great strides in research, EAU activities and as urologists in their own right. Dr. Gómez Rivas (Madrid, ES) has been Chairman of the Young Academic Urologists (YAU) since May 2020 and he looked forward to the first face-to-face meeting under his leadership. At EMUC there was a series of reports from the different working groups. What are some particular highlights, in your opinion? The YAU autumn meeting was finally held after two years of us missing face-to-face meetings. The series of reports coming from the groups is needed as it is a way to find out how other groups work, their internal structure, potential intergroups collaborations and networking. Some highlights: despite COVID outbreak, a record of 62 applications were reviewed. As for publications, between all the groups they have published more than 70 indexed papers during 2021, most of them in high-impact journals. Others have started collecting multicentric databases and prospective trials which is a way of gathering higher evidence. Another highlight was the new collaborations between YAU and other EAU offices: we have started a close collaboration with the EAU Research Foundation. An example of this collaboration is the approval of the MARS study which is the first international, multicentre, observational study regarding priapism. We are also working closely with the Guidelines Office, offering courses on methodology for our members, and the new EAU Policy Office, among others.

Working group members

October/January 2022

know the outcomes of the procedure in more detail, to provide risk stratification tools and to investigate the anatomical distribution of recurrent disease in the prostate.

We are made up of 11 working panels, and many of them use European Urology Today and social media platforms to update readers on the ongoing projects. I wouldn’t want “spoil” their announcements so keep reading European Urology Today and the YAU’s social media for the latest information.

better with group tasks than strangers. This is what makes YAU different from other groups, we are more than people gathering to archive a goal, we are friends coming together for success. At your meeting there was a talk by Prof. Van Poppel about the new Policy Office, is this something that the YAU is interested in collaborating with, and how? Policy changes is the final action of what academics pursue: the benefits of patients. The YAU is looking forward to starting a collaboration with this newly created office. Change is a major part of our lives, whether it is a personal change, change in technologies or education, healthcare, and policies. For achieving change, human power is needed, setting out a path into patient advocacy, knowing the current framework, diffusion, etc. The young academics have a potential role in all this setting. In general, how do you look at the YAU’s role within the EAU? What are some accomplishments, what’s still ahead of you? The YAU is the seed of future key opinion leaders, stakeholders in their specific fields and moreover future leaders of urology globally. With the EAU’s mentorship, and with the motivation of our group, we try to create future leaders to help themselves and others to push forward. To set the right direction, build an inspiring vision, and create something new in a dynamic, exciting, and inspiring way. An example of this, are the numerous awards won in our group, from Veroniqué Phé as Crystal Matula winner in 2021, to the Hans Marberger winner Paolo Dell’Oglio. The YAU has always been a machine of scientific production, and ahead of us is finding the best place for our members after their period finishes. When they become more mature, experienced… where they will be heading? We need to give the same opportunities for a continuous career development programme to all of them, no matter gender, geographics, race; and we are working on it. Nowadays, we have increased our female representation in the board, accepted members from other continents, from underrepresented European areas…

Does the YAU have a specific way of approaching these urological topics as represented by the working groups? In other words, what sets the YAU apart from other working groups or offices within the EAU? Teamwork is a popular topic nowadays. We all want our working groups to be the best of the best. Yet, sometimes success is more likely and enjoyable when we are surrounded by friends. And sometimes, teaming up with someone else can be the start of a Dr. Gómez Rivas hands a Certificate of appreciation to his long friendship. There are scientific proofs coming predecessor, Prof. Selçuk Silay who was an "inspiration, whose from Psychology investigations that friends perform leadership took YAU to the next level." European Urology Today

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The right information at the right time can save lives EAU Patient Day’s Roundtable on prostate cancer results in thirteen calls to action Prof. Eamonn Rogers Chair, EAU Patient Office Galway (IE)

emacruairi@me.com

Prof. Hein Van Poppel Chair, EAU Policy Office University Hospital Leuven Leuven (BE) hendrik.vanpoppel@ kuleuven.be Every year, almost 450,000 men across Europe are diagnosed with prostate cancer, leading to 92,000 deaths. [1] Despite prostate cancer being the most common cancer in males throughout Europe, three quarters of the European men admitted that they have limited knowledge about the function of the prostate and its propensity to become diseased, particularly from prostate cancer. [2] Patient awareness of the risks of serious urological disease based on educated interpretation of clinical symptoms, signs, and laboratory tests, coupled with the availability of targeted health services, are leading factors in the early diagnosis of urological conditions. Most men are uncomfortable talking to peers about their urinary and sexual health. Many tend to suffer in silence, rather than discuss “taboo” diseases such as prostate cancer. Most deaths in male cancers occur because many men do not address their conditions in time, sadly continuing to ignore symptoms and delay seeing their doctors, and/or cannot access the appropriate supportive health service.

The roundtable discussion at EAU21, with Profs. Van Poppel and Rogers

principal stakeholders in a man’s prostate cancer journey participated in the “Roundtable: Prostate Cancer, The Road to Successful Intervention”, which was broadcast on EAU Patient Day, during the virtual Annual EAU Congress (EAU21), on Friday 9 July 2021. The Roundtable participants consisted of: • A spouse of a prostate cancer patient who presented with advanced prostate cancer at first diagnosis • A general practitioner • A healthy man • A prostate cancer patient on active surveillance • A prostate cancer patient on androgen deprivation therapy • Two urologists

“The doctor’s approach must focus on the timely detection of prostate cancer.”

A number of questions were formulated around: 1. Awareness, education, and communication 2. Early detection 3. Active surveillance 4. Treatment

Also, all doctors must be adequately educated and informed through continuous professional development so as not to squander the opportunity to inform and address relevant health concerns when a man presents with concerns about his prostate. The doctor’s approach must focus on the timely detection of prostate cancer.

“Patients need to fully disclose their medical history, any previous surgeries and use of medication.” The Roundtable resulted in the following calls to action:

Therefore, it is important to ask: Awareness, education and communication What roles do patients and healthcare providers share during visits concerning the diagnosis and treatment 1. Improve awareness and educate the public about of prostate cancer? prostate cancer communicating through (local) awareness and advertising campaigns, screening What are the responsibilities of the stakeholders at programmes, and information made available at each stage of a prostate cancer patient’s journey in the GPs office. terms of diagnosis delivery, patient information, 2. Develop an algorithm whereby HCPs can navigate shared decision making, and treatment? the steps of a prostate cancer patient’s health journey to ensure all the boxes in terms of Do healthcare professionals (HCPs) ask the right information provision have been ticked. questions and disclose that information necessary to 3. Partners are often more actively engaged in address the patients’ needs? seeking information about the disease and available treatments, as a coping strategy to Similarly, do patients voice the questions and disclose reduce fears and anxiety, but also to be able to the right information that allows the HCP to address care for and support the patient during the their needs? treatment decision-making process. HCPs should recognise this and encourage partner Understanding how patients and HCPs communicate participation, to incorporate the partner and what information they share at a given time is perspective and help couples navigate important for several reasons. educational materials and resources according to their information needs and preferences. [3] • It helps us determine if and where there is a lack 4. Patients need to fully disclose their medical of knowledge. history, any previous surgeries and use of • It also helps us determine who should share medication. They need make sure to bring all critical information and at what stage, with a relevant documentation to the consultation. targeted strategy to overcome issues related to 5. Individual, case-related interdisciplinary this as the end goal. coordination between GPs, cardiologists and • Finally, and most critically, published evidence urologists should be encouraged. shows that successful patient engagement leads to better treatment outcomes. Roundtable on prostate cancer To gain more knowledge and insight into the physician-patient communication, some of the 24

European Urology Today

“A uniform approach to prostate cancer screening is needed from European healthcare systems.”

Early detection 1. Provide internationally recognised, specific guidelines for GPs to eliminate the lack of consistency in the approach to prostate cancer timely detection. 2. A uniform approach to prostate cancer screening is needed from European healthcare systems. This challenges the EAU to engage with national societies and EU policymakers of healthcare policy, to implement internationally agreed methods of alerting patients to prostate cancer. While there may be regional differences in policy concerning prostate cancer screening, health services should at least educate patients and HCPs on the detection and treatment acknowledging the associated risks and benefits, so the patient can make an informed choice. 3. Inform men about the tests available for early detection of prostate cancer: PSA testing, digital rectal examination, and the availability of prostate cancer risk calculators. This was stated to facilitate engagement. 4. To reduce the potential financial burden caused by overdiagnosis and overtreatment, urologists should adopt an intelligent risk stratified screening method which consists of the use of risk calculators, testing for biomarkers, and the use of MRI in patients with an elevated PSA, instead of undergoing biopsy as the next step. Active surveillance 1. Prostate cancer patients who are recommended active surveillance as a treatment option should be well informed and educated about this type of treatment and offered psychological and peer to peer support to ensure adherence to the strict follow-up scheme.

“Patients with prostate cancer are very willing to participate in clinical trials if there is a relevance to their condition and if the risks and benefits of the trial are properly explained.” Treatment 1. Men should be better informed about prostate cancer treatment options and be actively involved in the treatment decision-making process. 2. Prostate cancer patients should be made aware of the cardiovascular risks when being offered androgen deprivation therapy and should be given the option of a cardiovascular health assessment prior to starting treatment. 3. Patients with prostate cancer are very willing to participate in clinical trials if there is a relevance to their condition and if the risks and benefits of the trial are properly explained. Conclusion The Roundtable shows there are lessons to be learned when it comes to effective communication between HCPs and patients. Both HCP and patient

awareness about prostate cancer, particularly its early detection, and treatment saves lives. It is therefore imperative that allied HCPs, GPs, urologists, oncologists, and cardiologists join forces and work alongside each other to adopt a patient-centred approach, to educate and help patients and partners during the treatment decision-making process, and to keep patients as healthy as possible during and after their cancer treatment.

“The Roundtable highlighted the need for an integrated approach to be taken by healthcare providers when informing men about prostate cancer as a disease, particularly its early detection, treatment strategies and their risks and benefits.” Persuading men to take their health seriously presents a serious challenge. They need to have a better understanding of the risk and symptoms of prostate cancer, and they should be encouraged to seek support from a medical professional if they suspect anything unusual. This challenges health service providers and professional bodies as well as individual stakeholders to improve communication using modern methods of information technology e.g. EAU Patient Information website. [4] Partners should actively participate in conversations with their male partners and their doctors. Data on the importance of peer-to-peer support from fellow prostate cancer sufferers in patient support groups was presented during the Patient Poster session at EAU21 and it showed that peer support is crucial for patients recently diagnosed or undergoing treatment. [5] The Roundtable highlighted the need for an integrated approach to be taken by healthcare providers when informing men about prostate cancer as a disease, particularly its early detection, treatment strategies and their risks and benefits. There is a particular need to provide professional services that address the unmet needs of patients, as was shown at EAU215. ___________________________________________________________________ This project was funded by Ferring Pharmaceuticals. Its content has been independently developed and approved by the EAU Patient Office. References 1. ECIS - European Cancer Information System. 2018. Incidence and Mortality Estimates. Available at: https:// ecis.jrc.ec.europa.eu/ 2. Urology Awareness Survey. EAU Press Release 2018 [Conducted July 2018] https://urologyweek.org/content/ uploads/EAU-press-release_urology-awareness.pdf 3. Aasthaa Bansai, et al. Information seeking and satisfaction with information sources among spouses of men with newly diagnosed local-stage cancer. J Cancer Educ. 2018 April ; 33(2): 325–331. doi:10.1007/s13187-0171179-6. 4. Patient Poster Session. EAU Virtual Congress 2021. https://bit.ly/3zJXXpB 5. EAU Patient Information website, patients.uroweb.org

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EUREP22 20th European Urology Residents Education Programme 2-7 September 2022, Prague, Czech Republic

www.eurep22.org A unique and exclusive training opportunity General information

Registration information

Participation and contribution This teaching programme has been developed and created exclusively for all European urological residents. The EUREP provides an almost complete update and overview of modern urological practice presented by a distinguished European faculty. The EUREP is an initiative of the European School of Urology (ESU) in collaboration with the European Board of Urology. The written part of the FEBU exam (Fellow of the European Board of Urology) will take place at a later date in different cities throughout Europe. Further information will be available on www.ebu.org. Format The format is a full six-day course comprising of five modules. Each day is made up of two sessions that last around seven hours. Morning sessions feature state-of-the-art lectures, while afternoon sessions offer interactive case discussions, video, and test-your-knowledge sessions. The hands-on-training sessions will take place around the modules. The training which is sponsored by Olympus helps the participants sharpen their skills and offers hands-on interaction with state-of-the-art equipment. Venue The EUREP will be organised in Prague, Czech Republic. The venue at the Clarion Congress Hotel provides excellent facilities and the four-star hotel has all the necessary facilities needed for both the scientific programme and social activities. Travel Arrival date: Thursday, 1 September Departure date: Wednesday, 7 September after the modules end at 12.30.

Important dates Online registration opened on 3 January 2022. The selection process will be made after registration closes on 1 May 2022. A total of 360 participants will be selected. Participants will be notified by email if they have been selected. If selected, the deadline for cancellation is 1 August 2022. After this time a cancellation fee of €500 will be charged. Selection criteria Registrations can only be submitted through the online registration system. The registration is considered complete if the registration is accompanied by a letter from the head of department indicating the date that the participants' training will end. Additional criteria 1. EAU membership. Priority is given to those who are or become a member before the registration deadline 2. Year of training. Priority is given to residents in their final year of training (i.e. training should be finished before September of the following year based on the information received from the proof of status) 3. It is required to obtain CME credits by completing European Urology multiple choice questions (MCQ’s). For further information please check www.eurep22.org 4. First-come, first-served basis 5. English skills 6. Geographic spread. The nationality stated during the online registration process is leading 7. It is only allowed to attend the EUREP course once 8. There are limited places available for non-European residents

Important information for applicants!

For further detailed information regarding the registration rules for the 20th EUREP course we strongly recommend that you visit www.eurep22.org

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

Registration non-European residents If you are a non-European resident that is interested in taking part in the 20th EUREP course please go to www.eurep22.org for the rules and regulations regarding participation.

Hands-on Training Courses Sharpening Your Skills: TUR, URS, and Laparoscopy Intensive hands-on training is offered as an essential part of EUREP. This year's programme consists of practical activities with state-of-the-art equipment in laparoscopy, ureteroscopy (URS) and transurethral resection (TUR) -all of which are sponsored by Olympus. The workshop provides the participants with a unique opportunity to learn the basic techniques using complex training models under expert supervision. Thanks to the intense tutoring scheme -with a personal tutor per training station- optimal learning is warranted. The courses in laparoscopy are specifically designed for individuals with minimal or no prior experience in laparoscopic suturing. Tutors will, of course, gladly adapt tasks for more experienced individuals. Basic techniques will be trained in a dedicated step-by-step programme including intracorporeal suturing depending on individual skill level. Scientific secretariat ESU Office October/January 2022

The training curriculum for the ureteroscopy workshop is designed by Prof. Olivier Traxer of Tenon Hospital, Paris. Residents will learn about the proper use of flexible ureteroscopes using a variety of stone disposables in order to remove kidney stones. The course in transurethral resection of the prostate gives residents the great opportunity to learn more about the basics of high-frequency surgery, the instruments needed, as well as, tips and tricks for daily surgery. Participants can only participate in one session optimal learning is warranted. For more information on the different training modules, please visit www.eurep22.org. The hands-on-training workshops are sponsored by an unrestricted educational grant from:

T +31 (0)26 389 0680

Preliminary programme 2022 Module 1 Urological cancer Testis & Penile cancer Treatment of localised and metastatic testicular cancer Treatment of localised and metastatic penile cancer Non-muscle invasive bladder cancer Diagnosis, staging and risk stratification Management of low, intermediate and high risk disease Upper urinary tract cancer Muscle invasive bladder cancer Surgical and non-surgical treatment options Neoadjuvant and adjuvant chemotherapy

F. Liedberg (SE), Chair

K. Bensalah (FR) A. Merseburger (DE)

M.C. Mir Maresma (ES)

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

Module 2 Prostate cancer and male voiding LUTS Prostate cancer Screening, early detection and staging Treatment for localised disease Active surveillance, surgical treatment, radiation, focal therapy Locally advanced and metastatic prostate cancer Treatment of castration resistant prostate cancer and new agents

T. Steuber (DE), Chair

S. Ahyai (DE)

N. Mottet (FR)

J. Walz (FR)

E.C. Serefoglu (TR)

A. Skolarikos (GR)

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

Module 3 Andrology, stones and upper tract endourology Andrology Physiopathology diagnosis and treatment of erectile dysfunction Penile curvature Priapism and metabolic syndrome Male infertility diagnosis and treatment Surgery for male infertility and vasectomy Male hypogonadism Stones Aetiology, management and prophylaxis of urolithiasis ESWL treatment of urolithiasis Percutaneous and open surgery

C. Scoffone (IT), Chair

S. Minhas (GB)

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

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

K. Sievert (DE), Chair

A. Giannantoni (IT) T. Greenwell (GB) G. Karsenty (FR)

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

Y.F. Rawashdeh (DK), Chair

B. Burgu (TR)

N. Lumen (BE)

Z. Tandogdu (GB)

Trauma Diagnosis and management of kidney, bladder and urethral trauma

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

eurep@uroweb.org European Urology Today

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ESUR21: An excellent platform to discuss urology research Delegates leave virtual meeting fully up to date on all relevant developments By Prof. Kerstin Junker (DE), chair of the EAU Section with the ESUR board created an online programme of Urological Research and Prof. Gabri Van Der that maximally facilitated discussions amongst the Pluijm (NL), president ESUR21 meeting delegates. What follows are some of the highlights of ESUR21. The 27th Meeting of the EAU Section of Urological Research (ESUR21) was held online on Friday 8 and “The audio-visual team together Saturday 9 October 2021 in collaboration with the EAU Section of Uropathology (ESUP). Outstanding with the ESUR board created an international experts delivered lectures on the online programme that maximally exciting latest results from multiple studies into urological diseases, and delegates left the meeting facilitated discussions amongst fully up to date on all relevant developments in the the delegates.” field of urological research. Day 1 Highlights of the first day included the expert presentations in three lively sessions, i.e. “Patientderived and Humanised Models for Translational Cancer Research” (Plenary Session 1), “Mechanisms of Tumour Progression and Therapy Resistance” (Plenary Prof. Gabri Van Der Pluijm (left) and Prof. Kerstin Junker chair a session at ESUR21 Session 2), and “Journal impact factor, h-index and other metrics: advantage or obstacle of high-quality research.” discussed the most used metrics for scientific output, EAU22 The online meeting was successful and sufficient. Of such as journal impact factors and the Hirsch Index. In Plenary Session 1, Dr. Ralph Gareus (The Jackson “The ESUR meeting has always course, we all hope that we will be able to meet in Laboratory, DE) provided a comprehensive overview person again in the future. At the 37th Annual EAU of the strengths and limitations of humanised mouse Day 2 been an excellent platform for Congress (EAU22), for example, which is taking place On day 2, Dr. Geert Van Leenders (Erasmus MC, NL) models for cancer research. Afterward, Dr. Dana PhD researchers, senior researchers, Mustafa (Erasmus MC, NL) discussed novel in Amsterdam from 18 to 21 March 2022. Here, the described novel ways of prostate cancer grading ESUR and ESUP will organise a joint meeting entitled during Plenary Session 3 “New Developments in possibilities in the digital and spatial profiling of preclinical scientists, and “Biomarkers in uro-oncology: From bench to Pathology.” cancer tissues with the NanoString platform. clinicians.” bedside”, which will be chaired by Prof. Junker and Prof. Maurizio Colecchia (IT). Stay tuned at www. Plenary Session 4 addressed the topic of novel In Plenary Session 2, Prof. Helmut Klocker (Medical The ESUR meeting has always been an excellent eau22.org for the latest information on this next University Innsbruck, AT) discussed the role of immunotherapeutic approaches and treatment platform for PhD researchers, senior researchers, meeting! oncometabolites in prostate cancer progression, combinations. Dr. Nadine van Montfoort (Leiden preclinical scientists, and clinicians to meet and University MC, NL) discussed new developments and in particular mitochondrial OXPHOS remodelling. discuss new developments in urology research. The Missed ESUR21? You can still access all sessions in strategies in immuno-oncology. This preclinical Prof. Hubert Hondermarck (University of Newcastle, strength of this comprehensive meeting is that there is AU) highlighted recent discoveries regarding presentation was followed by presentations from Prof. the ESUR21 Resource Centre at esur21.org. always enough room for discussion and networking Kerstin Junker (Saarland University, DE) and Prof. mechanisms contributing to nerve-cancer crosstalk due to the relatively small scale of the meeting. As a and the effects of nerve-cancer crosstalk on prostate Elfriede Nossner (Helmholtz Zentrum Munich, DE) result, participants are offered multiple opportunities cancer progression and dissemination. discussing combination therapies for renal carcinoma. to interact with other delegates, e.g. during poster At the end of Plenary Session 4, there was a very VIRTUAL sessions. Obviously, this works best in a face-to-face Finally, Prof. Michael Menger (DE), the dean of the lively panel discussion on the status quo in the field 8-9 October 2021 meeting format, but the audio-visual team together medical faculty of the Saarland University, critically and on future perspectives.

The ESUR board and abstract reviewers had decided to dedicate a substantial part of the scientific programme to short talks (15) and poster presentations (28) on selected abstracts. This was in particular decided for the young researchers among our delegates, who had started their PhD research project just prior to or during the Covid-19 pandemic. Furthermore, 12 expert speakers were invited to present their work.

European Board of Urology welcomes new President Jeroen Van Moorselaar hails efforts to create virtual oral exam in 2021 By Loek Keizer While the EAU and the European Board of Urology (EBU) have to maintain a formal distance when it comes to accrediting events and education, there is also scope for the two bodies to collaborate, says the EBU’s new President, Prof. Jeroen Van Moorselaar (Amsterdam, NL). “Collaboration can come in small things,” says Prof. Van Moorselaar, “like supplying cases for use as exam questions, to representing the field of urology in certain international organisations, and, most broadly, the shared goal of raising the quality of urological care throughout Europe.” Prof. Van Moorselaar succeeded Prof. Arnaldo Figueiredo (Coimbra, PT) in May 2021. Van Moorselaar is currently the Chairman of the Amsterdam UMC Urology Department, having previously worked in Utrecht and Nijmegen, all in the Netherlands. Van Moorselaar is a Fellow of the EBU (FEBU) since May 2000.

countries, being held in place of national urology exams. The Certification Committee aims to standardize urological training at the highest possible level, reviewing applications of training programmes, performing site visits and constantly updating requirements for certification programmes. This certifies centres offering residency training or acting as an EUSP Host Centre. Van Moorselaar: “There is currently a big difference in levels of training across Europe, also depending on the amount of hands-on experience that residents get as part of their training. We think that by visiting and eventually certifying these centres, they improve their levels of training and reach a de-facto European standard.” Finally, the Accreditation Committee works to accredit educational events for Continuing Medical Education (CME) and Continuing Professional Development (CPD). In this capacity the EBU works on the recommendations and Learning Objectives in Urology of the European Union of Medical Specialists (UEMS) and the

Over the years, Prof. Van Moorselaar has had many positions related to the EAU and EBU. These include acting as National Coordination Office for the European Society of Residents in Urology (ESRU), Chairman of the EAU Video Committee (2004-2012) and being a faculty member of EUREP while also continuing to sit on the board of the European School of Urology. A mission The EBU is made up of three committees, for Examination, Certification and Accreditation. The first draws up high-quality exams that reflect European standards for the annual In-Service Assessment, and the Written and Oral parts of the EBU Exam. Those who successfully complete their exams can call themselves “Fellow of the European Board of Urology”. The exams also have an official certification status in some European Board of Urology

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European Urology Today

New EBU President Jeroen Van Moorselaar (Amsterdam, NL)

European Accreditation Council for CME (EACCME). Furthermore they work on the Training Requirements for the Specialty of Urology for trainers, trainees and training institutions as part of the European Standards of Postgraduate Medical Specialist Training. National urological societies delegate two urologists to form the EBU board at large, including the aforementioned three boards and also an executive board.

“We had the virtual exam in November, and are anticipating the results of this innovative new method. A lot of other organisations within the UEMS are watching our lead in this.” Putting the EBU on the map Prof. Van Moorselaar realizes that EAU members might not be intimately familiar with the EBU, but he stresses that there are areas of overlap and certainly several opportunities for EAU members to contribute to and benefit from the activities of the EBU.

The Virtual Oral Exam In times of the worldwide pandemic, the traditional oral component of the FEBU exam had to be postponed in 2020, creating a backlog of candidates. For 2021, the “It’s true, as a regulatory body we are less visible, EBU arranged for a virtual alternative to the onbut we are very busy behind the scenes,” says Van location exams. Moorselaar. “People who work in the EBU are extremely dedicated and some have been there for Van Moorselaar: “This was an incredible challenge for many years.” us, but I have to commend Prof. Serdar Tekgül (Ankara, TR), chair of the Examination Committee for his efforts. “One important way to increase visibility of the EBU We had to recreate examination conditions in a virtual and its works is to get people to use their FEBU title setting, with case presentations, limited times to where possible, like in e-mail signatures. The title answer, and recording and reviewing of all responses.” certainly has a status, also outside of Europe. When I recently applied to become a member of ASCO, “All questions/cases are the “FEBU” was one of the qualifications on the form pre-recorded in a that I could select, and I was most impressed!” candidate’s native language (one of ten “There’s only two representatives per country, but if this year). The readers are interested, they can always approach their candidate’s answers national society to see if one of the two positions will are recorded and then become available.” reviewed by two reviewers, with a third One collaborative project between the EBU and the one on hand if the EAU is using questions from ESU courses as EBU exam scores differ too much. questions. In 2021, there are 120 reviewers for 590 “Young Urologists have regularly prepared questions candidates, which for us. With so many exams, we always need more! means they review or We use the EAU Guidelines as the basis of all of our otherwise screen questions and always conform to the latest editions. around 10 each.” The answers always refer to specific Guideline entries to avoid any ambiguity. We’re also always looking for cases to serve as exam questions. Send them to us via your country’s representatives!”

October/January 2022


Virtual PCa21 delivers vital updates on PCa management On imaging, risk stratification, the role of genetics and more The 5th EAU Update on Prostate Cancer (PCa21) commenced online in the afternoon of 16 October 2021 and led by renowned experts and steering committee members Prof. Morgan Rouprêt (FR) and Prof. Arnulf Stenzl ( DE). This article provides an overview of PCa21 activities and some of the key messages from the sessions.

biopsy is the first choice. The current EAU Guidelines strongly recommend that performing prostate biopsy using this approach has lower risk of infectious complications.

The PCa21 scientific programme was divided into four sessions centred on the imaging of localised prostate cancer (PCa) and risk stratification; locally advanced and oligometastatic PCa; metastatic castrationresistant prostate cancer (mCRPC) and metastatic hormone-sensitive prostate cancer (mHSPC); and the role of genetics in the clinical management of PCa. Each session was a balanced blend of lectures, deliberations on patient cases, and interactions between faculty and participation through the Q&A feature of the virtual platform.

Locally advanced and oligometastatic PCa session During his lecture “The role of novel imaging in the work-up of biochemical recurrence after local treatment”, Asst. Prof. Jan Philipp Radtke (DE) stated that conventional imaging and Choline-PET are inferior in detecting biochemical recurrence (BCR) compared to 68Ga-PSMA PET. With regard to BCR, Prof. Radtke stated that PSMA-PET imaging is superior to all different PET-imaging strategies; and in terms of change treatment options in BCR, 68Ga is promising.

PCa imaging and risk stratification session In his lecture “How to do early detection in the era of mpMRI?”, Prof. Henrik Gronberg (SE) stated that the risk prediction model can reduce the number of MRIs, biopsies, and Gleason 6. However, it needs to be calibrated well, and assessed from a health and economy perspective.

Prof. Steven Joniau (BE) and Prof. Rouprêt spearheaded this session.

Dr. Raisa Sinaida Abrams-Pompe (DE) provided the pros and cons of prostate-specific membrane antigen (PSMA) therapy during her presentation “PSMA-PET for initial staging: The new standard for everybody?”. According to Dr. Abrams-Pompe, PSMA is more accurate than conventional imaging and has higher sensitivity and specificity. She stated that it can be a “one-stop shop” examination for whole-body staging. However, with PSMA there is lack of standardised reporting. It is not widely available and current (evidence-based) guidelines were established using conventional imaging. One of the key points that Prof. Nicolas Mottet (FR) provided during his lecture “Biopsy and imaging” was that in terms of biopsy approach, transperineal

Virtual meeting Saturday, 16 October 2021

The first PCa21 session was chaired by Prof. Rouprêt and Dr. Jochen Walz (FR).

mCRPC and MHSPC session In her lecture on the use of PARP inhibitors (PARPi) in PCa, Dr. Elena Castro (ES) shared “What is clear is that patients with gene alterations in BRCA1/2 are the ones that benefit the most. We know that the safety profile is well-characterized, as well as, the toxicity profile and how to manage them. However, what remains unclear is are the other non-BRCA HRR that may predict response to PARPi? What is the role of the

Dr. Castro discusses current scenario of iPARP

different types of alterations? What is the best sequence of treatments? Who are the patients that could benefit from PARPi in terms of combinations?”

needs to be of high sensitivity. He underscored that careful attention to potential false positive and false negative results is required.

Prof. Joaquim Bellmunt (ES) offered his expert insights during his presentation “Cross resistance between treatment: Where do we stand?”. He said that despite improvements in outcomes, patients still succumb to the disease due to the development of resistance. He added that there is a lack of a well-defined treatment sequence and potential for cross-resistance between therapies. He stated that the development and use of biomarkers indicating resistance will improve patient stratification for treatment.

During the presentation, “Germline mutations in prostate cancer: What to search and in whom?”, Dr. Joaquin Mateo (ES) shared that identification of patients with germline mutations leads to the identification of healthy individuals carrying mutations at the high risk of developing cancers (prostate and non-prostate). He added that there is a need to implement a clear framework for informed consent and access to testing.

Prof. Bellmunt co-chaired the third PCa21 session with Prof. Dr. Axel Merseburger (DE). Session on the role of genetics in PCa management The final PCa21 session commenced with the lecture "Somatic mutation assessment: When and for whom?" Prof. Philip Cornford (GB) wherein he stated ctDNA testing can also be considered for somatic mutations, but testing is not widely available and

Some of the esteemed PCa21 faculty deliberating

Prof. Stenzl and Prof. Alberto Briganti (IT) led this session. How to view all the sessions To (re)access all sessions while accumulating CME credits, please go to the virtual platform via https://virtual.uroweb.org/virtual/pca21 and log in with your MyEAU credentials. Once logged in, clicked on “On Demand”. The virtual platform will remain open until 16 January 2022 (17:15 CET).

Sergio Musitelli 1928-2021 Unmatched expert in Urological History and Inaugural Desnos Prize Winner

Prof. Sergio Musitelli, renowned expert on the history of urology and much-loved founding member of the EAU History Office passed away on 5 October, 2021. Sergio Musitelli was born in Milan in 1928. After Greco-Latin secondary school he studied Ancient Arts and Greco-Roman Philology at the University of Milan, and got his degree in 1951. He obtained a Philosophy degree in History in 1953, specialising in classical philology, glottology, oriental literatures and languages (Sanskrit, Prakrit, Hindi, Sindi, Hindustani), Egyptology and in Roman Philology. Since 1954, he devoted himself to the History of Ancient Science and in particular of Medicine (from its origins up to the 18th century). He was Visiting Professor of History of Urology, Sexology and Andrology at the University of Pavia. Since the start of the EAU History Office, Prof. Mustelli functioned as a professional history expert and he participated in all activities. Based on his position as an expert in history, Prof. Musitelli was one of the most active contributors to the work of the EAU History Office, not only with numerous articles and books but also in

October/January 2022

Inaugural Winner of the EAU Ernest Desnos Prize In 2018 the board of the EAU History Office decided unanimously to award the very first EAU Ernest Desnos prize to Prof. Musitelli for his enormous contributions to the history of medicine but more in particular his profound work in the field of the history of urology.

reviewing submitted articles for the annual De Historia Urologiae Europaeae volumes. Furthermore he was responsible for a detailed and reliable index of all published volumes of these series. With his perfect knowledge of Greek and Latin, and even Egyptian hieroglyphs he was very helpful and useful to all members of the History Office in translating old texts.

Hence he was responsible for a further professionalisation of historiography in the field of Urology, and the History Office benefitted greatly from his efforts.

But, above all, Sergio was a good and lovely friend for all members of the EAU History Office. He was always present to help and to translate and to motivate.

And perhaps most important he was a real Pater Familias! He loved his wife Irene and his six children Claudio, Laura, Floriana, Giorgio, Dario Notable publications for the History Office of the EAU and Giulio. His deepest sadness was the death of are: the complete translation and facsimile of Mariano his youngest son by a car accident several years ago. Sergio never recovered from this loss. Santo's Golden Booklet on the extraction of the Bladder stone by incision (1998); Lithotomy of the Prof. Musitelli’s own publications brought an original Bladder (2007) a facsimile and translation of book by We will miss his realistic remarks in our Fabricius Hildanus; Who was Who in European Urology Committee but above all we will miss him as a viewpoint, always based on extensive literature (2001), with all data of urologists and surgeonreal friend. search, but with a very critical interpretation of the available material. He taught us all that history, and urologists from the oldest times up till 1950; and two Dr. Johan Mattelaer and Prof. Dirk Schultheiss hence also history of urology is much more than volumes of Selected Passages spanning highlights telling an interesting story, but that it is also a science. from ancient history to modern day. Former chairmen of the EAU History Office

European Urology Today

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1. prostate-specific membrane antigen. 2. carbonic anhydrase 9. 3. large amino acid transporter 1.

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European Urology Today

October/January 2022

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© 2022 Telix Innovations SA. Rue de Hermée 255, 4040 Herstal, Belgium. The Telix Pharmaceuticals name and logo are trademarks of Telix Pharmaceuticals Limited and its affiliates. All rights reserved. TLX-2022-01-01. Date of Preparation: December 2021.


2021: A Breakthrough year for new robotic systems Dusseldorf and Gronau welcome world’s robotic experts for ERUS-DRUS21 By Loek Keizer

approach as a highlight for delegates. The same procedure is carried out by different surgeons, each using their personal technique. “On day one, we had eight radical prostatectomies, as performed by top-rated surgeons. The way they approach the prostate, the little differences, as surgeons we really learn by watching.”

Having already been postponed from 2020 to 2021, Dr. Jörn Witt (Gronau, DE) was relieved to have hosted a successful combined Section meeting for robotic urologists in Germany on 11-13 November. The EAU Robotic Urology Section (ERUS) and the German Society of Robotic Urology (DRUS) joined forces for this meeting, attracting both an international audience and “Another interesting session was when Dr. Ketan Badani performed a very difficult partial nephrectomy. a strong local presence of German urologists, nurses This was a clinical T2 case, and we saw that it is not and patients. only feasible but sometimes well indicated to perform partial nephrectomy in T2 settings. We also saw Nearly 550 people attended ERUS-DRUS21 over those cystectomies, and Prof. Minervini performing a three days. An online option was also offered for Florence diversion. From him we learned how we people who couldn’t make the trip, but it was the could perform an alternative reconstruction of the promise of the first face-to-face event in almost two years that led to relief and joy among the participating bladder.” faculty and delegates. On the final day, Prof. Henk Van Der Poel performed an ePLND ICG fluorescence including PSMA tracer-guided “We can look back on a very good meeting from a scientific point of view, but also concerning the clinical robot-assisted surgery. Breda: “This is something we’ve been talking about for a few years now, with cases,” said Dr. Witt as the meeting drew to a close. “I’m very proud of the team in Gronau, in particular Dr. encouraging results. There was also a superlative case from Prof. Stöckle, a redo anastomosis after radical Wagner and Dr. Liakos, and everyone involved in prostatectomy. These are tips and tricks that people organising the meeting in Dusseldorf, as well as my need to know.” tireless personal secretary.” “We’d already dealt with postponing the meeting from 2020 to 2021, and this year I was very keen to have a ‘regular’ face-to-face meeting. We followed all of the local health and safety guidelines and were lucky to hold the meeting while possible.”

“People are afraid of a learning curve with the new systems, but with the experience we have so far, for experienced surgeons it only takes a few cases to adapt to the new machines. As emerging systems are comparable in terms of functionality, it also becomes a question of economy.” Highlights ERUS-DRUS21 offered delegates a three-day scientific programme filled with eight live surgery sessions, state-of-the-art lectures and many case discussions. Several satellite meetings were offered, such as the Junior ERUS-YAU meeting, which focused on the needs of young urologists, the ERUS-EAUN collaborative meeting with the European Association of Urology Nurses, and a number of German-language meetings for nurses, students and patients. Four courses by the European School of Urology were also available. Dr. Witt’s highlights from the scientific programme came in surgery: “We saw some complex kidney cases done to a very high level by experienced surgeons. It’s becoming a challenge to see how much you can extend limits in surgical oncology with organ preservation. We also learned some new robotic applications, such as artificial urinary sphincter implantation in females.” “It’s amazing to see how much robotic surgery has evolved over the past 20 years. Some of this year’s presentations offered some reflection. Robotics has changed urology completely in a relatively short timeframe, in the face of quite a bit of resistance in the beginning. But a good tool cannot be avoided over time.” ERUS Chairman Dr. Alberto Breda (Barcelona, ES) pointed to the so-called “different ways to skin the cat”

Dr. Breda was also particularly enthusiastic about the comparison between two ways to perform an intraoperative pathological analysis, be it with a frozen section (NeuroSAFE) or confocal endomicroscopy (VivaScope). Audiences saw Prof. Rocco communicating live with his pathologist (in a “double remote” setting for those watching in Dusseldorf) as a digital reconstruction filled the screen. “These new techniques will help us select some high-risk patients who could undergo a nerve-sparing procedure even though this is currently not an indication in such a population.” New robots enter the market For many years, the theme at ERUS meetings was the development of robotic urology, and in particular the promise of new manufacturers and systems reaching maturity and acceptance in hospitals. It seems 2021 is a breakthrough year, with a huge variety of systems being on-site or demonstrated in (as-)live surgical sessions. Many participants of ERUS-DRUS21 agreed that we find ourselves in a pivotal time for robotic urology, including Prof. Christian Thomas (Dresden, DE), co-moderator of the 5th live surgery session: “More and more robotic systems are entering the market and we’re seeing that it’s feasible to do procedures like radical prostatectomies or partial nephrectomies to more or less the same standard as the systems we are familiar with.” “It’s very promising. People are afraid of a learning curve with the new systems, but with the experience we have so far, for experienced surgeons it only takes a few cases to adapt to the new machines. As emerging systems are comparable in terms of functionality, it also becomes a question of economy.”

It’s a bit like a car. There are a lot of developments but the basic principles stay the same.” First meeting as chair ERUS-DRUS21 was also memorable as the first ERUS meeting under the chairmanship of Dr. Breda, who succeeded founding chairman Prof. Mottrie in 2020 (see box). “Yes, it was a new, big responsibility but I felt well-protected by the EAU’s congress office,” said Breda. “We were in constant contact. The decision to go on-site was only made in September, so we didn’t have a lot of time to pull it off. We did our best, the entire team. There is nobody who didn’t do their job. In the end it paid off. The team from Gronau were excellent in selecting cases. Our audiovisual partner, MediAVentures is a fantastic company. They worked flawlessly and are so professional, you can tell they’ve done this so many times.” In 2022, it will be Dr. Breda’s turn to host the ERUS

meeting in Barcelona. ERUS22 – Barcelona Robotika is set to take place on 5-7 October, with more details to be announced soon. Significantly, Dr. Breda is keen to have the meeting take place on weekdays, hoping for higher attendance figures right until the end of the meeting. “An improved pandemic situation might also allow for more social events, an important component for a meeting of the ERUS family.” The German Society of Robotic Urology will have its own meeting in Tübingen on 25-26 November, 2022 chaired by Prof. Arnulf Stenzl. In terms of scientific programme, Dr. Breda thinks live surgery and semi-live cases should be the focus of the ERUS meeting, supplemented with ESU courses where delegates can learn from experts in a more intimate setting. “These courses always throw up a lot of interesting discussions and science. It’s a chance to sit down with expert, and have direct interaction. And that’s just one benefit of having a face-to-face meeting again!”

Prof. Alex Mottrie wins Wickham Award at ERUS-DRUS21 At the Dusseldorf meeting, founding chairman of the EAU Robotic Urology Section Prof. Alex Mottrie was presented with the John Wickham Lifetime Achievement Award for his contributions to robotic urology. Prof. Peter Wiklund presented the award, citing Prof. Mottrie’s role in training numerous colleagues from all across the world in the field of robotic surgery and his tireless efforts to establish and improve training. Wiklund called him “a true pioneer”. In addition to his presidency/chairmanship of ERUS, Prof. Mottrie is founder and CEO of the ORSI Academy, training a whole new generation of surgeons.

As robotic systems diversify, what does this mean for training curricula that might be geared to specific companies? Prof. Thomas: “That’s certainly an important factor. Some systems do not yet offer a dual console and I think that’s mandatory for education to become a robotic surgeon.”

Prof. Mottrie’s successor as ERUS Chairman, Dr. Alberto Breda called the award “completely deserved. Alex is an exceptionally good person and a ‘talented brain’, no doubt about it. Most of all, he’s extremely passionate. He dedicated his life to education, and he built this community of not only extremely talented surgeons, but also good humans. He founded a good family to work with, a real combination for success.”

Dr. Witt also noted the significance of 2021 as a breakthrough year. “Speaking from both the perspective of ERUS and the German society: we have been waiting for this time to happen for at least 5 years. We hoped that new systems wouldn’t only be in development but finally in clinical use. “We saw the first live cases in Chile and Japan this year. This is a turning point.”

“When he accepted the award, you could see he was very emotional, he made us cry. You don’t see that often. In the course of our careers, we’ve all received prizes from time to time, but you don’t often see a man so overcome with emotion. He is truly a passionate man who dedicated his life to science. To me he is the founder, the honorary and forever member of the ERUS community.”

Dr. Breda opens ERUS-DRUS21, the first ERUS Section Meeting under his chairmanship

October/January 2022

ERUS-DRUS21 featured eight live surgery sessions, with three simultaneously moderated procedures

On the potential for a price war, Dr. Witt cautioned that differences might not come in purchase price but in maintenance or the limited-use components. “It’s difficult for a new company to come up with something completely different that’s also better than what we have.

John Wickham Award Prof. Mottrie joins Prof. Walter Artibani (2019) and Prof. Claude Abbou (2018) as winners of the award. The award is given on an annual basis, honouring surgeons who have made a significant contribution to robotic surgery. The prize consists of a medal featuring an engraving of John Wickham’s likeness. No winner was announced in 2020 due to the virtual nature of ERUS20. The award is named after John Wickham (1927-2017), a true pioneer of robotic surgery. Together with Prof. Brian Davies of Imperial College, Wickham developed and engineered the first robotic device in urological surgery named the PROBOT. Wickham used the PROBOT to perform the very first robotic procedure on the prostate in London in April of 1991. He coined the phrase “minimally-invasive surgery” to describe the future of the field. Mr. Wickham passed away in late 2017, at the age of 89.

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11-13 November 2021 Dusseldorf, Germany European Urology Today

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EMUC21: Multidisciplinary updates from diverse fields Congress delivers on its credo of working together to improve patient care By Erika De Groot and Juul Seesing With 925 registrants from 49 countries, delegates and 95 faculty members convened from 25 to 28 November 2021 in Athens, Greece for the 13th European Multidisciplinary Congress on Urological Cancers (EMUC21). Through the collaborative efforts of the European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), and the European SocieTy Radiation Oncology (ESTRO), the face-to-face format of the congress enabled and encouraged intensive interaction, which is essential for a truly multidisciplinary congress such as EMUC21, to achieve its goals. On 25 November, the 9th Meeting of the EAU Section of Urological Imaging (ESUI21) took place in conjunction with EMUC21. The ESUI21 and EMUC21 scientific programmes comprised lectures interspersed with Hands-On Training courses courtesy of the European School of Urology (ESU), the meeting of the Young Academic Urologists (YAU), the Radioligand therapy session, the EMUC Symposium on Genitourinary Pathology (ESUP), and the Uropathology training workshop.

more prevalent are artificial intelligence and digital pathology.”

Pathology Prof. Colecchia’s first take-home message came from Dr. Gladell Paner’s (US) presentation on the new WHO classification of renal tumours. “This classification includes morphologically-defined and molecularlydefined entities,” Prof. Colecchia said. Later, Prof. Colecchia referred to Prof. Paolo Gontero’s (IT) presentation in Plenary Session 3 for his pathologic takeaways regarding non-muscle-invasive bladder cancer (NMIBC): “Promising urinary markers for surveillance challenge urine cytology and will likely replace it in clinical practice. No prognostic marker can currently be recommended in clinical practice. Molecular classifications are promising but are not yet ready for routine application.” Prof. Colecchia ended his summary with his vision for the future: “I have great expectations for the coming years. In particular, the molecular characterisation of uro-metastatic patients and the use of liquid biopsy in the routinary management of these patients will be the gold standard. Other useful tools that will become

Having the congress onsite again enriches the overall experience

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European Urology Today

ESUI21

25 November 2021 Athens, Greece

Radiation oncology Prof. Pinkawa gave the conclusions on radiation oncology, “There is a lack of data on the treatment outcome of the use of PSMA PET in prostate cancer patients. PSMA PET has clinical importance, which will be further defined in studies over the next years.” He cited Dr. Stefano Fanti’s (IT) lecture, who had said in Plenary Session 1, “The 2022 EAU Guidelines on Prostate Cancer will recommend using PSMA PET or a whole-body MRI in high-risk patients to increase the sensitivity. The guidelines will emphasise the very important limit of the lack of outcome data on subsequent treatment changes.”

On radio-immunotherapy for bladder preservation, Prof. Pinkawa said, “There are studies taking place on bladder preservation with the combination of radiotherapy and immunotherapy. Specifically in the UK, bladder preservation using radiotherapy is considered as a standard method that is more frequently used than a cystectomy, especially now in these times of COVID-19. But currently we don’t have EMUC21 and ESUI21 were for some delegates the first convincing data considering this combination. We in-person events they attended after two years. The have some data that showed increasing toxicity that is atmosphere was electric and the audience’s not tolerable, and we don’t have convincing results enthusiasm, palpable. Even online, EMUC21 generated yet that really show an improved disease-specific buzz with an impressive 3.6 million impressions on survival.” Twitter alone. Urology Esteemed members of the Steering Committee, Prof. Prof. Merseburger offered trial updates of “Extended Arnulf Stenzl (DE) of the EAU, Prof. Aristotelis Bamias vs limited Pelvic Lymph node dissection in prostate (GR) of ESMO, and Prof. Michael Pinkawa (DE) on cancer”, which was presented by Dr. Jean Lestingi behalf of Prof. Peter Hoskin (GB) of ESTRO, brought (BR). “In a subgroup analysis, intermediate- and the congress to a conclusion. high-risk patients in particular benefitted from extended lymph node dissection (EPLND). EPLND This report collates some take-home messages, remains the gold standard for lymph node staging. Its information on awards and the recipients, how to oncological role still needs to be defined," stated Prof. access the sessions, and where the next EMUC and Merseburger. ESUI editions will take place. Take-home messages Being an event with a multidisciplinary nature, the take-home messages were categorised according to diverse fields. Prof. Maurizio Colecchia (IT) delivered the summary on pathology, Prof. Pinkawa on radiation oncology, Prof. Axel Merseburger (DE) on urology, Prof. Raymond Oyen (BE) on radiology, and Prof. Jan Oldenburg (NO) on medical oncology.

25-28 November 2021 Athens, Greece

“The 2022 EAU Guidelines on Prostate Cancer will recommend using PSMA PET or a whole-body MRI in high-risk patients to increase the sensitivity.” He reiterated one of the key points of the Trial of Imaging and Surveillance in Seminoma Testis (TRISST) presented by oncologist Dr. Stefanie Fischer (CH) during a multidisciplinary case discussion on active surveillance: MRI is non-inferior to computer tomography, avoids irradiation, and should be recommended. Radiology Radiologist Prof. Oyen discussed the ESUI21 lecture "The new mpMRI: Biparametric MRI: fast and accurate" by radiologist Dr. Giorgio Brembilla (IT) in Plenary Session 1: The MRI Corner: Faster and cheaper. Prof. Oyen underscored that biparametric MRI (bpMRI) lacks dynamic contrast-enhanced sequence (DCE-MRI) and may lead to greater uncertainty in lesion detection and scoring. Prof. Oyen also provided the key messages based on the deliberations during Plenary Session 4: Kidney cancer: Multidisciplinary case discussions. He stated, "When finding an incidental renal mass, a tailored approach for elderly and frail patients or patients with comorbidities is most suitable. It is very important that the patients and their relatives are well-informed on what the place of additional imaging is in diagnosis and staging; when and how biopsies are performed; therapeutic options and potential risks; when the follow-up is, and if there are shortcomings of the follow-up." Oncology The last presentation of EMUC21 came from Prof. Oldenburg, who took to the stage and provided conclusions from oncology-centric presentations. He stated PSMA PET findings are predictive for decreased biochemical recurrence (BCR) and treatment-free survival. This was one of the key messages from the debate "Should PSMA PET impact on treatment in newly diagnosed PCa (debate yes vs no)?", wherein Prof. Tobias Maurer (DE) represented “Yes.” In addition, Prof. Oldenburg cited the lecture “Circulating tumour DNA for decision making in high risk and metastatic bladder cancer” by Prof. Lars

Prof. A. Choudhury shares insights in radio-immunotherapy for bladder preservation

During the ESU/ESUI HOT course in prostate MRI reading

Prof. Grange donates prize money to YAU

Deliberations during the multidisciplinary case discussions

Dyrskjøt (DK) and said, “Circulating tumour DNA (ctDNA) comes from cancer cells. If you can measure ctDNA, then you’ll know there could be a tumour somewhere. DNA fragments can be analysed from blood and urine. The likelihood of detecting ctDNA increases by the stage and the size of the tumours.”

“PSMA PET/CT will not replace mpMRI for primary diagnosis and staging. There’s no reason to,” Dr. Van Leeuwen said; however, he underlined that there are occasions a PSMA PET should be performed for primary staging: “In those patients who cannot have an mpMRI, who have a high-risk disease for metastatic screening, and in PIRADS 1-3 patients who are considered for observation rather than biopsy.”

ESUI21 highlights One of the aims of ESUI21 was to examine current and emerging imaging technologies. In the aforementioned “The MRI Corner: Faster and cheaper” session, Dr. Brembilla described the current concerns surrounding MRI. An increased demand for prostate MRI and a limited availability of MRI scanners and dedicated radiologists and radiographers cause long waiting times while MRI contrast media can bring about side effects, Dr. Brembilla explained. On top of this, MRIs are costly, too. Non-contrast MRI, better known as bpMRI, not only avoids contrast media but is also cheaper and faster with only a minor implication for PI-RADS scoring. Thus, Dr. Brembilla asked himself and the audience, “Is bpMRI THE solution?” The answer, of course, is not that black and white. bpMRI lacks dynamic contrast-enhanced MRI (DCE-MRI). “The absence of DCE could have an effect on the identification of the lesion, especially when the reader of the MRI is less experienced,” Dr. Brembilla said. In the same session, Prof. Jelle Barentsz (NL) outlined the strategies for approaching lower PIRADS-III lesions, lesions in which the presence of clinically significant prostate cancer is unclear. He set out six strategies. The MRI should be of a good quality and should be read by an expert, Prof. Barentsz emphasised. Furthermore, he laid out that the use of a contrast MRI is advised while the use of prostate-specific antigen density (PSAD) may help, too. A double read and the use of artificial intelligence completes the approach, with one possible addition. “PSMA PET/CT, but this is a work in progress,” Prof. Barentsz said. Dr. Pim Van Leeuwen (NL) expanded on PSMA PET in Plenary Session 6: The PSMA PET corner. He tried to answer the question whether PSMA PET/CT is going to replace multi-parametric magnetic resonance imaging (mpMRI) for primary prostate cancer diagnosis and staging in the future.

“Also, PSMA PET/CT is better than mpMRI for the primary staging of the pelvic lymph nodes.” Award winners At EMUC21, six Best Poster Awards were bestowed on professionals from diverse fields. Dr. Ekaterina Laukhtina (AT) achieved the remarkable feat of winning an award for Best Poster in two different categories: “Renal Cell Cancer, Testicular Cancer, and Penile Cancer” and “Urothelial Cancer.” Dr. Anke Richters (NL) also won a Best Poster Award in the category of urothelial cancer while Dr. Simon Spohn (DE), Dr. Constantinos Zamboglou (DE), and Prof. Stenzl each received a Best Poster Award for their and their team’s work in prostate cancer research. A special shout-out to Prof. Philippe Grange (DE), who won the second prize in the Best ESUI Abstract Awards for his abstract “Virtual arterial clamp: A 3D step towards personalised medicine?” He donated the prize money to the Young Academic Urologists (YAU), who will use it for a new platform to collect data for future research. Explore the Resource Centres Relive the congress experience, watch/review all the sessions, (award-winning) abstracts, and (e-)posters in full in the Resource Centres of EMUC21 (www.urosource.org/resource-centre/EMUC21) and ESUI21 (www.urosource.org/resource-centre/ESUI21). Look back on conversations on Twitter by using the hashtags #EMUC21 and #ESUI21. Check out the photo impressions on Facebook (www.facebook.com/ EAUpage). Feel free to retweet and/or share! See you in Budapest! We look forward to welcoming you at the 14th European Multidisciplinary Congress on Urological Cancers (EMUC22), which will take place from 10 to 13 November 2022 in Budapest, Hungary, with ESUI22 happening on 10 November. Save the dates and see you there! October/January 2022


Urology Week 2021: International effort against incontinence taboo National Societies from across the world supported the campaign Europe observed Urology Week from 20 to 24 September 2021. This year’s theme focused on incontinence and the taboo surrounding this condition. Supported by Medtronic, the EAU conducted an international survey on the issue of incontinence and people’s awareness of its prevalence and treatment options. The survey’s results showed that 10-20% of the people in Europe deal with urinary incontinence. Of the countries interviewed (UK, France, Germany, Italy, and The Netherlands), nationals of the UK had the highest incidence of unawareness of treatment options. The complete review of the survey results can be found in the official press release at www.urologyweek.org/ forpress.

International effort and collaboration From the survey it was revealed that 30% percent of people with Urinary Incontinence (UI) is not comfortable talking about it. Many expect that the condition will cure itself. To help break the taboo about UI, Urology Week 2021 focused on the various groups and daily activities affected by urinary incontinence. By talking about it with their healthcare professional and becoming more aware of available treatment options, patients can get back to doing the things the love most in life. The EAU encouraged national societies, medical practices and colleagues to come up with new and exciting ways to help promote this cause. Many events in honour of Urology Week were hosted not only in Europe, but also in Asia and the Middle East. The countries that participated include Australia,

Germany, Greece, India, Poland, Russia, Serbia, Spain, digital and print media, urologist appearances on The Netherlands, Turkey, and Ukraine. health TV shows, an open clinic, and a presentation of promotional materials in public spaces of health To help other organisations, clinics, and national institutions. Medical students were also involved in societies with highlighting incontinence and the campaign in order to raise awareness of promoting their events, new campaign posters were incontinence and the importance of a timely treatment created and translated into several languages besides by a doctor. English: Albanian, Basque, Catalan, Dutch, French, German, Greek, Italian, Mexican Spanish, Portuguese, The main event was a two-day International Russian, Spanish, Turkish, and Uzbek. Symposium called "Challenges of Modern Female Urology", which was held in the Hall of National Theatre in Leskovac, with 150 registered participants. A total of 12 lecturers made up a high-quality scientific programme on the anatomical, histological, functional, diagnostic, and therapeutic aspects of the modern concept of incontinence. The Symposium was enriched by its meaningful social and cultural programme. It was held according to all mandatory preventive measures against Covid-19.

Also the staff of the EAU Central Office in The Netherlands participated actively. They hosted a Challenge Week, where colleagues were asked to participate in various physical challenges to see how long they could ‘hold it’. The successful Challenge Week garnered much positive attention on social media, thereby increasing awareness among the public.

EAU staff engage in the Urology Week Challenge: how long can you hold the plank

Group photo of the delegates at the Symposium in Leskovac, Serbia

Serbia as a leading example in the international campaign A special thank you goes out to the Urological Section of the Serbian Medical Association, who supported Urology Week with a series of promotional activities aimed at shining the spotlight on incontinence. These activities included a campaign on the website, in

Prof. Dr. Dragoslav Bašic President Urological Section of the Serbian Medical Association

Rounding off the international collaboration for Urology Week, Prof. Christopher Chapple (GB) contributed an article entitled “Despite high prevalence, urinary continence still a taboo” to the UK’s Health Awareness campaign, which was also published in The Guardian. Join us for Urology Week 2022 Urology Week is a yearly initiative of the EAU, encouraging doctors and members of the public to talk more about urological conditions. Keep an eye on the official website www.urologyweek.org for the dates and theme for Urology Week 2022, where you can join us again to help spread the word about the importance of early diagnosis and available treatments.

Fellowship Programme

BALTIC22

European Association of Urology Nurses

7th Baltic Meeting in conjunction with the EAU 27-28 May 2022, Vilnius, Lithuania www.baltic22.org

Call for abstracts: deadline 1 April 2022

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 31 January 2022 • 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. An application has been made to the EACCME® for CME accreditation of this event

October/January 2022

T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

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Management of post-prostatectomy incontinence Growing evidence about anti-incontinence device implantation Growing evidence The level of evidence regarding the use of antiincontinence device implantation in men has been historically poor, based on mostly retrospective cohort studies performed at the end of the last century. [9] Artificial sphincter has always been considered as the gold standard based on these old data and gigantic clinical experience by urologists worldwide. In the last 20 years, more stringent requirements have been set Jean-Nicolas.Cornu@ up for introducing new implantable devices, in line chu-rouen.fr with stronger market regulations, diffusion of evidence-based medicine, and strengthening of A specific context guidelines processes. For these reasons, newly Stress urinary incontinence (SUI) after prostatic released minimally invasive options (mostly male surgery (post-prostatectomy incontinence (PPI)) is slings and Pro-ACT™) have been studied through a daily challenge for urologists. Most cases of PPI more rigorous clinical protocols, including prospective are transient, as many patients fully regain their design, comparative trials, and clearer efficacy continence after one year. [1] Persistent symptoms endpoints. However, up to 2020, only level 2 evidence after 12 months may require specific management, has been published, with the field lacking a depending on symptoms severity, associated bother, large-scale randomised controlled trial to increase the and global clinical picture. While PPI is mostly a degree of evidence. [10] consequence of radical prostatectomy (around 10% of cases), SUI can also happen after benign prostatic MASTER trial obstruction relief surgery. [2] Despite several The MASTER trial is a multicentre, randomised possible explanations, the pathophysiology of PPI controlled trial (RCT) evaluating the efficacy of is rather seen as a confluence of several factors and transobturator male sling compared to standard remains poorly elucidated. The main hypothesis is a AMS800™ device for PPI management (after radical deficiency of the striated sphincter. prostatectomy or benign prostatic obstruction surgery). [11] In this non-inferiority trial, 380 men Patients seeking care for persistent PPI are in a very with PPI were randomised in 27 UK recruiting centres. specific situation. First, their symptoms are iatrogenic The main outcome criterion was incontinence (by definition). Gathering details about index prostatic symptoms 12 months after randomisation, and surgery, and taking a complete medical history non-inferiority was proven. However, the rather strict (including co-morbidities, pelvic radiation history, definition of incontinence (‘any self-reported and oncologic outcomes) is the first step of adequate symptom of incontinence at 12 months’) led to and personalised management. [3] The second step is somewhat surprising results, with 87% incontinent to assess the symptoms as precisely as possible, as men in the male sling group versus 84.2% in the SUI can be isolated or associated with other lower artificial sphincter group. Secondary analysis has urinary tract symptoms, such as overactive bladder or shown that men with > 250 g leakage at baseline did voiding difficulties. Severity of incontinence is a better after an AUS, especially regarding satisfaction. crucial point. Today there is no consensus about the Few severe adverse events were reported (6 after definition of mild, moderate or severe SUI, but the sling and 11 after AUS implantation). most widely used tool is 24-hr pad test, with a cut-off around 250 ml. [4] Unsolved issues Although it brings major information, and level 1 Beyond clinical evaluation, additional work-up may evidence supporting the use of transobturator male be proposed. Endoscopy can rule out urethral stenosis slings as well as the use of AUS, some issues remain or anastomotic stricture, or concomitant bladder unsolved. disease. Urodynamic studies are useful to assess any associated detrusor dysfunction, especially in case of First, the efficacy of transobturator male sling in the mixed incontinence. long term remains largely unknown. In case of failure, a subsequent AUS implantation can however be Principle of clinical management proposed. Furthermore, all slings are not equal, and Patients with PPI usually use collecting devices such mixing all transobturator tapes in the same trial could as pads, and less frequently penile sheaths or penile appear as confusing. A number of cohort studies have clamps. While the two latter are possible palliative shown that the complication rate after adjustable options and can offer some advantages over standard slings appears higher than after the retrourethral pads [5], they require specific information, male sling. [12] However, no head-to-head explanation and prescription. The first contact with comparison is available. the patient is the best occasion to deliver adequate information of availability of these products. Second, patient selection is an important issue. While the MASTER trial identifies a trend towards a The next discussion is about treatment options. While superiority of AUS in more severe cases, results do the solution may be surgical in most cases (see not reach statistical significance. However, this is in below), possible medical options include bladder line with previous reports suggesting that severe training, physiotherapy and duloxetine. [1] Bladder incontinence > 250 grams per day, pelvic radiation training and dietary measures (e.g. adequate fluid history, prior anti-incontinence surgery and previous intake) can always be an option since they are not urethral surgery are important factors to consider for harmful, but their efficacy remains elusive. patient selection for a male sling. [13] Physiotherapy, including pelvic floor muscle training, has been widely proposed but very often patients Third, patient preference is a really important issue. already do this within the early post-operative period. Since non-inferiority is established between AUS and The role of electrical stimulation and biofeedback slings, patients would rather opt for the less invasive remains unclear. Among drugs, duloxetine has been option, as previous papers have already shown. The studied for PPI management with encouraging results role of the surgeon is to provide complete, but in smaller studies to date. [6] The optimum independent, expert and adequate counselling in this dosage remains unknown. The patient has to be field. warned about off-label use in this indication, and about potential adverse events specific to this drug. New level of evidence Drug treatment (mainly antimuscarinics and Recent advances in the field of PPI have set a new beta-3-adrenergics) can be options for treating an level of evidence, possibly impacting the guidelines associated storage component of symptoms. [7] and recommendations. More than before even, transobturator slings and artificial sphincter are the In case of failure of conservative measures, surgical leading surgical options among the surgical treatment is required. Many surgical options are today armamentarium (see figure 1). Patient selection is the available since the introduction of the AMS800™ major challenge when choosing the way to treat PPI. artificial urinary sphincter marketed in 1972 and in its current shape since the early 80’s (see figure). [8] References Alternatives are peri-urethral injections, male slings 1. Rahnama'i MS, Marcelissen T, Geavlete B, Tutolo M, Hüsch (either autologous, synthetic bone-anchored (not T. Current Management of Post-radical Prostatectomy anymore used), synthetic fixed placed by Urinary Incontinence. Front Surg. 2021 Apr 9;8:647656 transobturator route (popular today), or adjustable, 2. Sabbagh P, Dupuis H, Cornu JN. State of the art on stress peri-urethral balloons (Pro-ACT™ device), and incontinence management after benign prostatic innovative sphincters. [9] obstruction surgery. Curr Opin Urol. 2021 Sep 1;31(5):473Prof. Jean-Nicolas Cornu Dept of Urology Charles Nicolle University Hospital Rouen (FR)

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478 3. Clark CB, Kucherov V, Klonieck E, Shenot PJ, Das AK. Management of urinary incontinence following treatment

Fig. 1: Surgical therapeutic approach for post-prostatectomy incontinence management

of prostate disease. Can J Urol. 2021 Aug;28(S2):38-43 4. Constable L, Cotterill N, Cooper D, et al. Male synthetic sling versus artificial urinary sphincter trial for men with urodynamic stress incontinence after prostate surgery (MASTER): study protocol for a randomised controlled trial. Trials. 2018 Feb 21;19(1):131 5. Macaulay M, Broadbridge J, Gage H, et al. A trial of devices for urinary incontinence after treatment for prostate cancer. BJU Int. 2015 Sep;116(3):432-42 6. Kotecha P, Sahai A, Malde S. Use of Duloxetine for Postprostatectomy Stress Urinary Incontinence: A Systematic Review. Eur Urol Focus. 2021 May;7(3):618-628 7. Andersson KE. The use of pharmacotherapy for male patients with urgency and stress incontinence. Curr Opin Urol. 2014 Nov;24(6):571-7 8. Van der Aa F, Drake MJ, Kasyan GR, Petrolekas A, Cornu JN; Young Academic Urologists Functional Urology Group. 9. The artificial urinary sphincter after a quarter of a century: a critical systematic review of its use in male non-

neurogenic incontinence. Eur Urol. 2013 Apr;63(4):681-9 10. Choinière R, Violette PD, Morin M, et al. Evaluation of Benefits and Harms of Surgical Treatments for Post-radical Prostatectomy Urinary Incontinence: A Systematic Review and Meta-analysis. Eur Urol Focus. 2021 Sep 22:S24054569(21)00236-4 11. Abrams P, Constable LD, Cooper D, et al. Outcomes of a Noninferiority Randomised Controlled Trial of Surgery for Men with Urodynamic Stress Incontinence After Prostate Surgery (MASTER). Eur Urol. 2021 Jun;79(6):812-823 12. Bole R, Hebert KJ, Gottlich HC, Bearrick E, Kohler TS, Viers BR. Narrative review of male urethral sling for postprostatectomy stress incontinence: sling type, patient selection, and clinical applications. Transl Androl Urol. 2021 Jun;10(6):2682-2694 13. Grabbert M, Bauer RM, Hüsch T, et al. Patient Selection in Surgical Centers of Expertise in the Treatment of Patients with Moderate to Severe Male Urinary Stress Incontinence. Urol Int. 2020;104(11-12):902-907

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October/January 2022


ESOU22: Principal topics, expectations and COVID-19 An exclusive interview with ESOU Chair Prof. Rouprêt The new year will launch with the commencement of the hybrid 19th Meeting of the EAU Section of Oncological Urology (ESOU22). Spearheaded by the esteemed ESOU Chairman Prof. Morgan Rouprêt (FR), the much-awaited meeting will take place from 21 to 23 January 2022 in picturesque Madrid, Spain.

COVID-19 pandemic. After a long period of isolation in practising our expertise and connecting with colleagues via virtual meetings and scientific exchanges, ESOU22 symbolises a milestone not only in the field of onco-urology and the way forward, but also healing after a traumatic period for our societies.

In 2020, the 17th edition was the EAU’s final in-person meeting before the emergence of the COVID-19 pandemic. Understandably, the meeting’s 18th edition was redesigned into a virtual event in 2021 and was still well-received by enthusiastic and undeterred participants. It received praise for the quality of presentations, the level of interaction, accessibility of the virtual platform, and most importantly, for providing the participants the possibility to update what they know during challenging times.

To be honest, my expectations for the meeting go beyond a solid event. I want to connect, discuss, exchange and have fantastic social interactions from a large urological family and have that normal “postCOVID life” feeling.

Now that ESOU22 will take place in Madrid and will be livestreamed, what can be expected? In this exclusive interview, Prof. Rouprêt (FR) shares what to look forward to at the meeting: the highlights, the impact of COVID-19 on disease treatment and management, and more. In addition, this article will also provide a quick programme overview, as well as, how to benefit from reduced registration rates. What are your expectations for ESOU22? Prof. Rouprêt: Back in January 2020, ESOU20 took place in Dublin. It was one of the last physical onco-urological events and EAU meetings before the

What are the principal topics that ESOU22 will cover and why do you think so? Prof. Rouprêt: The hot topics in onco-urology are the new drugs (systemic and intravesical) in the management of non-muscle-invasive bladder cancer; the revolution of immunotherapy as first- and second-line standard treatment of metastatic renal cell carcinoma; and the contribution of PET molecular imaging in the therapeutic strategies of advanced prostate cancer. In the ESOU22 scientific programme, what are some of the topic highlights per genito-urinary cancer? Prof. Rouprêt: In my personal selection, I would like to emphasise liquid biopsy in prostate cancer; 3Daugmented reality in partial nephrectomy surgical planning; management of indeterminate testicular masses; and how to improve the regimen if surveillance is opted for with regard to non-muscle-invasive bladder cancer.

Register now! Deadline: 23 January 2022

Prof. Roupret

Urologists took into account the pandemic’s impact on their patients and adapted treatments and strategies accordingly. What have we learned from dealing with the pandemic? Prof. Rouprêt: The pandemic has two faces. The first period, which I’ll refer to as the “dark side”, was the

onset of COVID-19 when we were stunned, uncertain, and fearful of this yet-to-be known virus. It is also the period when focus on other medical diseases took a back seat. The second period, which I’ll refer to as the “bright side”, was when we’ve learned to deal with this chronic situation and kept moving forward with the treatment of our patients. We designed cancer paths for our fragile patients COVID-free and shared our tips and tricks to overcome this new situation in our COVID-free units.

For the complete Scientific Programme visit www.esou22.org More about the programme The ESOU22 scientific programme will comprise of plenary sessions, a hands-on training courtesy of the European School of Urology (ESU) and an educational session by ESU, ESOU and the EAU Robotic Urology Section (ERUS). Each genitourinary cancer – from prostate to rare cancers – will have two or more plenary sessions dedicated to it for a comprehensive coverage of

updates, treatments, strategies, and expert insights. Expect lively debates and eye-opening case presentations in every plenary session. The ESU hands-on training (HOT) will take place on day two of ESOU22 and will focus on prostate magnetic resonance imaging (MRI) for urologists. The HOT is designed to give participants a chance to interpret MRI images and receive individual real-time feedback. The ESU-ESOU-ERUS educational session will include topics such as indication and results of robotic partial nephrectomy for T1/T2 tumours, robotic transperitoneal and retroperitoneal approach, and more. To view the full ESOU22 scientific programme, please go to www.esou22.org/scientific-programme Register for ESOU22 Join us at ESOU22, whether on-site in Madrid or as a virtual participant! Sign up for ESOU22 via www.esou22.org/registrations. Please note that you can still register onsite.

ESOU22 19th Meeting of the EAU Section of Oncological Urology 21-23 January 2022 Madrid, Spain

www.esou22.org

Introducing UROtech22: A new meeting for 2022 Collaborative meeting of the Urolithiasis and Uro-Technology Sections The EAU Sections of Uro-Technology and Urolithiasis (ESUT and EULIS) are holding a combined section meeting in 2022, under the banner of UROtech22. The meeting will take place in Istanbul on 26-28 May and feature live surgery, challenging case videos and scientific sessions with experts from both Sections. Topics to be covered range from BPH and stone disease, to prostate, renal and urothelial cancer. The meeting will examine all the different approaches that the urologist has at his or her disposal – including new robotic platforms. Hands-on-training by the European School of Urology will also be available on 25 May, requiring additional registration. We spoke to EULIS Chairman Prof. Christian Seitz (Vienna, AT) about his expectations for UROtech22. Prof. Seitz succeeded Prof. Sarica (Istanbul, TR) as EULIS chairman in the summer of 2021. Prof. Sarica is also involved in UROtech22, as Chairman of the local organising committee. Prof. Ali Gözen (Heilbronn, DE) is representing the ESUT contributions to the meeting as its chairman.

Abstract submission now open! Deadline: 14 February 2022 “UROtech22 is a new meeting format, as it brings together the EAU Sections of Urolithiasis and Uro-Technology,” says Prof. Seitz. “Both have already successfully worked together for years in the context of the Annual EAU Congress and other projects so it is a logical pairing.” “Both sections intersect at a core competence within urology: endourology. Many urologists in the world share their interest not only with transurethral or laparoscopic/robotic endourology but also with stone surgery, a main area of urology.” October/January 2022

“With this joint approach we expect to attract more urologists interested in the latest stone related developments, research and surgical skills from all parts of the world.” Synergy For a large part, the EULIS and ESUT programmes will run in parallel at UROtech22, allowing delegates to choose which sessions to attend. Live surgery will be a third “pillar” of the meeting. Prof. Seitz nevertheless expects a certain synergy between the two sections and their traditional audiences: “Beyond the sessions, I think we can expect a synergy on several levels. This translates into benefits for the audience. A joint meeting like this will combine organisational forces to reduce costs, resulting in reduced entrance fees. This is an aspect important to us to allow as many participants as possible to profit from the distinguished programme and faculty. “In addition, a world-class faculty, experienced in a variety of surgical procedures and with excellent presentation skills can serve for both sections at the same place and time which is advantageous in today’s traveling challenges.”

urothelial cancer and many new developments including upcoming robotic platforms.”

Register now for the early fee! Deadline: 1 April 2022 UROtech22 is also a chance for new research to be presented. Abstract submission for endourological topics is currently open for inclusion in the scientific Programme. Hands-on training and examinations will take place on Wednesday the 25th, before the regular programme begins. A

detailed scientific programme is being prepared by ESUT, EULIS and the local organisers and will be published in the coming weeks on the UROtech22 meeting website. Important dates: • Abstract submission is open until 14 February 2022. • R egistration is open! The discounted early fee is available until 1 April 2022. All in all, this is one of the biggest urology events of 2022 and we hope to see you there!

UROtech22 A joint meeting of the EAU Section of Uro-Technology and the EAU Section of Urolithiasis 26-28 May 2022, Istanbul, Turkey

Hot topics UROtech22 will naturally showcase the latest in uro-technology, from medical instruments to imaging technology and the latest robotic systems. Prof. Seitz highlights the strong focus on surgery: “At this meeting we are particularly focusing on surgery, offering live surgery and semi-live cases. These cases and procedures will cover virtually all aspects of stone disease. Plenary and thematic sessions will deal with deeper insights in selected topics.” “In addition to stone disease, we plan to cover topics related to prostatic diseases, renal and

www.UROtech22.org European Urology Today

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Profiles

“We have fought for an independent nursing framework" Mrs. Rita Willener wins Ronny Pieters Award for dedication and innovation in urology nursing For a long period, she was the only urology nurse practising at an advanced level in Switzerland. A long-time advocate for Evidence-Based Nursing (EBN), she improved urology nursing in her home country and went on to do the very same thing at a European level as a foundation member of the EAUN, all the while following her core belief that what is at the core of working in the medical field are the patients and their needs. Given her long history as a urology nurse of the highest standards, it comes as no surprise that the EAUN Board unanimously decided to award Mrs. Rita Willener (CH) the prestigious Ronny Pieters Award 2020, bestowed at EAUN21 in September 2021, to recognise and celebrate her dedication to and innovation in urology nursing research and practice. Mrs. Willener earned her Health and Nursing Care diploma in 1978. After 42 years of nursing, 21 years of which as a clinical nurse specialist in the Department of Urology at the University Hospital Bern, she retired in 2021. We spoke with her about winning the Ronny Pieters Award, an award named after Ronny Pieters (BE) to honour his pioneering achievements and contributions to urology nursing and the constitution and development of the EAUN. What does winning the EAUN Ronny Pieters Award mean to you? Mrs. Willener: “Ronny Pieters is an innovator. He has made our voices heard in the EAU Board. He never gives up. It is great that the award is named after him, and it is a great honour for me to receive it.” What has been your journey to winning this award? “I have been working in urology for almost my entire career. It is a fascinating field. I was the first Swiss clinical nurse specialist in urology with a

master’s degree. I helped organise the first EAUN Congress in Geneva (CH) back in 2001. In that same year, I initiated the Swiss association of urology nurses and started organising congresses, which I have been doing to this day. I have also built up my own mobile home care service for clean intermittent catheterisation (CIC).”

discussion and convince others of our opinions. We have fought for an independent nursing framework in favour of the patients. It was very exhausting, but I think we have done something great.” How has urology nursing changed over the length of your career? “In health care systems around the world, the diagnostic and technical possibilities have changed dramatically. Many examinations and operations are now carried out in an outpatient setting, and patients stay hospitalised for a short amount of time only. This has consequences for the whole system. Inpatients are increasingly geriatric. We have to think and act more comprehensively and interprofessionally. We cannot limit nursing to the hospital stay, but we also have to consider the home situation of the patients, so that therapies can be implemented effectively.”

“During all these past years, I had the opportunity to speak at many EAUN congresses and to lead the nursing care at the University Hospital Bern. In the last few years, I became more interested in palliative care, because we got more and more patients who lived with an incurable disease. At EAU21, I had the opportunity to present our model of palliative care.”

“Always keep the patient and her or his family in focus.”

What has been the most valuable experience for you as part of the EAUN? when things don’t work out right away. So I have never “Being a member of the EAUN and especially being a board member always motivated me. In the board, I been afraid to ask for advice from other experienced was very committed to contribute my part. I have had nurses. These international colleagues have always so many enriching exchanges and great opportunities motivated me. I appreciate their advice and to learn at congresses. Furthermore, urology nurses consideration.” are finally perceived as specialists.”

Who has influenced you the most on this journey? “My medical inspiration was Prof. Urs E. Studer (CH), who developed the neobladder. As the first Swiss nurse specialist in urology, I was very alone when I started out. I always had to fight for small progress. Prof. Studer supported me and the national and international development of a network for urology nurses. I was very happy with that. Fortunately, I have met many motivated colleagues along the way; colleagues who always helped take up my ideas for new projects. Without them, I wouldn’t have had the chance to develop anything.”

“When EBN came along, I was thrilled. Finally, we could really participate in the discussion.”

“I’ve always been inspired by nurses from abroad, and I have had the chance to experience various meetings with them. Both in the EAUN Board and in the scientific committee of the EAUN, I got to know highly esteemed colleagues who were more advanced in their roles than I was. From all of them, I have learned a lot. I am a fighter and have stamina. I don’t give up quickly; instead, I look for other ways to reach the goal

What is the importance of EBN in urology? “When I studied nursing in the seventies, EBN was not well known. At the time, we worked on behalf of the doctor, whose orders we carried out. We were hardly allowed to express our thoughts and observations during a doctor’s visit. When EBN came along, I was thrilled. Finally, we could put forward our own arguments. Finally, we could really participate in the

What is your dream for the future of urology nursing? “I have a dream on political level: I wish that we will have enough well-educated nurses who can do their jobs under good conditions and earn proper money. This is the only way we can guarantee safe and competent care.” What piece of advice would you give to a urology nurse starting out now? “Stay motivated, think outside the box, network, connect with good colleagues, do further training, stay in clinical practice, and always keep the patient and her or his family in focus.”

Stefan August Loening 1939 – 2021 Modest and universally respected trainer of a new generation of urologists

Stefan Loening shaped a modern department system and directed his consistent efforts to establish new regimens of treatment in urology. Especially through the introduction of minimally invasive surgical techniques, including robotassisted procedures with the Da Vinci robotic system for renal cancer, urinary bladder cancer, and prostate cancer as well as renal living donation, his department acquired a great reputation internationally.

The European Association of Urology mourns the death of its member Prof. Dr. Stefan August Loening. He died on 8 October 2021 at his home in Iowa City (US). Prof. Loening held the Chair of urology at the Charité – University Medicine Berlin (DE), from 1992 to 2007. Until 2021, he was Chairman of the Foundation of Urological Research instituted at his initiative in 1999. He was Fellow of the American College of Surgeons as well as member of a number of national and international associations, among which the German Society of Urology, the European Association of Urology and the American Urological Association. Stefan Loening was born in Lingen in northern Germany near the Dutch border. After completing the Gymnasium Carolinum, a renowned high school in Germany, he studied medicine at universities in Germany (Freiburg), Switzerland (Basel), and Austria (Innsbruck and Vienna). In 1968 he received an invitation from the Ventnor Foundation to come to the US and work as a medical intern. This became a much longer stay: in 1970 he married Vera Baucke, a fellow physician who had come to the US on the same fellowship programme. Both of them did their residency at Dartmouth Medical Centre in Hanover, New Hampshire. At the Cleveland Clinic in Ohio, Stefan Loening was a fellow in renal transplantation. In 1975, the family moved to Iowa City with their three sons. Stefan

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He focussed on training a new generation of urologists, using his international connections to foster and encourage young physicians to complete research periods outside of Germany as well. More than 400 research publications testify of his scientific work over his lifetime. He edited seven books and was member of several editorial boards. Loening worked at the department of urology at the University of Iowa Hospitals and Clinics and advanced to the rank of professor. His special fields of research were urological oncology and extracorporeal shock wave therapy, renal transplantation and prostate cancer. The fall of the border separating East and West Germany (and Berlin) in 1989 and their reunification a year later led him to spend a sabbatical at the prestigious Charité Hospital (University Medicine of Berlin, at that time the medical faculty of the Humboldt University), located in East Berlin. He became Chair of the department of urology and renal transplantation in 1994, after a provisional period as

Director of the department. His exemplary efforts for patients, students, staff and colleagues, combined with his unpretentious manner and his characteristic compelling sense of humour made him universally respected and very popular. Consequential to the political changes in Germany, all social, economical and educational processes were going through a time of upheaval, which also had its bearings on the medical system. Being equally familiar with the American and German mentality, he took a fair position without preconceptions in helping to consolidate and merge the university departments of urology in the eastern and western parts of Berlin.

For the outstanding services he rendered to the field of medicine, Professor Loening was honoured with the Order of Merit of the Federal Republic of Germany in 2007. The German Association of Urology awarded the Ritter von Frisch Prize to him in 2015. The Foundation of Urological Research, which he had called into being as an institution to support young scientists and physicians in urology in their scientific career, remained at the centre of his efforts after his retirement. The Foundation is his legacy, for the benefit of future generations in urological and related research.

October/January 2022


Prostate cancer care and exercise Exercise as a supportive care strategy in men with prostate cancer Dr. Brigitta R. Villumsen Dept. of Urology Gødstrup Hospital Herning (DK)

brigvill@rm.dk

that prostate cancer patients with a performance status higher than 0-1 are able to carry out beneficial exercises. Topic for future research Studies in localised prostate cancer suggest that exercise may reduce disease progression, however, strong evidence for this is still lacking and more intervention studies are needed. A relevant topic for future research is to investigate the optimum exercise modality, duration and dose, as this is not yet clearly verified. And, as mentioned above, even low-intensity physical activity after prostate cancer diagnosis has shown to be beneficial.

Regardless of disease state, exercise is (still) a cornerstone of prostate cancer care. And the amount of literature proving it is growing. 150 minutes' aerobic exercise per week combined with at least two In prostate cancer patients at any treatment stage sessions of resistance exercise and daily stretching (including post-treatment), low-volume resistance exercises for major muscle groups is recommended. exercise undertaken at a moderate-to-high intensity has found to be beneficial with regard to fatigue Positive effect and quality of life. Furthermore, it has the ability to However, the prevalence of physically active prostate mitigate depression and anxiety symptoms. cancer patients is not growing at a similar pace. Scientists are investigating how barriers to exercise can "Exercise training and testing be eliminated. They are also investigating how exercise programmes can be promoted, since the evidence of is generally safe for cancer the positive effect of exercise is delivered in numerous survivors." studies. Studies investigating the association between exercise and prostate cancer-specific mortality even show lower risk of prostate cancer-specific mortality in activities such as walking and biking. This means

Androgen deprivation therapy Exercise studies are mostly performed on and described in patients undergoing androgen deprivation therapy (ADT), and exercise has been stated as the most effective intervention in reducing side effects to ADT. In the EAU guideline for prostate cancer, there is strong evidence for

recommending 12 weeks of supervised combined aerobic and resistance exercise in patients undergoing ADT. A concern in this patient group is safety, due to the prevalence of bone metastases. This issue has recently been addressed in studies by giving specific recommendations regarding which exercises to avoid and which to perform based on the location of metastases. In 2019, the American College of Sports Medicine International Multidisciplinary Roundtable on Exercise and Cancer was published with specific recommendations regarding bone metastases. Recommendations In this patient group too, a standard exercise prescription is difficult to formulate. However, it is recommended to: • Avoid contraindicated movements that place an excessively high load on fragile skeletal sites. This means avoiding hyperflexion or hyperextension of the trunk, flexion or extension of the trunk with added resistance, dynamic twisting motion and high-impact loads; • Preventing falls must also be a goal of therapy, since falls play an important role in fracture aetiology; • Be aware of signs and symptoms of bone metastases. The 2018 American College of Sports Medicine's guideline on exercise in cancer survivors concludes that exercise training and testing is generally safe for cancer survivors and that every survivor should avoid inactivity.

References and suggested reading • Ramalingam S et al. What should we tell patients about physical activity after a prostate cancer diagnosis? Oncology (Willston Park). 2015. Sep; 29(9): 680-5, 687, 694. • Campbell K.L. et al. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019. 51 (11): 2375-2390. • Lopez et al. What is the minimal dose for resistance exercise effectiveness in prostate cancer patients? Systematic review and meta-analysis on patient-reported outcomes. Prostate Cancer Prostatic Dis. 2021 Jun;24(2):465-481. • Mottet N. et al. EAU Guidelines on Prostate Cancer 2020. www.uroweb.org/guidelines/

EAUN Board Chair Past chair Board member Board member Board member Board member Board member Board member

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

www.eaun.uroweb.org

Sexocorporel: Clinical sexology in urological context Nurse practitioner counselling and therapy at the University Hospital of Bern Chiara Marti Clinical Sexologist Nurse Practitioner Dept. of Urology University Hospital Bern, Berne (CH) chiara.marti@ insel.ch The Department of Urology of the University Hospital of Bern uses an approach based on the model ‘Sexocorporel’ for nurse practitioner (NP) counselling in sexual health. The present article describes this counselling approach and how it integrates into traditional NP counselling approaches. Its potentials and limitations are discussed. In brief, the approach of Sexocorporel supports patients in the process of change and adaptation, so that they have a mindful self-perception and are aware of the situation and future challenges with a focus on body state. The article introduces a ‘real’ patient to describe the concept of Sexocorporel in more detail. Patient example Mr. T, aged 68 years old, has no more spontaneous erections 6 months after radical prostatectomy for prostate carcinoma. The tumour was completely removed; no biochemical recurrence was noticed. When he masturbates or has sex with his partner, he is able to increase the physical arousal to a climax and he experiences sexual arousal. Tumescence and rigidity are so impaired that usual penetration practice is not possible anymore. Mr. T‘s wishes to have his sexual functioning back as it was before the surgery. Importantly, he says he does not feel as masculine anymore. His perception is that his penis is ‘broken’ and he does not have any feeling in his penis. Because he is afraid he has to ‘perform’ sexually, he can no longer stand any tenderness from his partner. The idea of not being able to fulfil anyone’s expectations proves to be an unmanageable barrier. The social withdrawal is perceived as burden for Mr. T and his partner. Coaching Traditional NP counselling includes a coaching process which works on relationship topics, with the

October/January 2022

goal of accepting and coping with the situation. The aim of NP counselling is to familiarise the patient with his transition phase. This means the direct passage from one stage of life, circumstance or status to the next. It is indicative of change processes in the context of health and illness. In clinical practice, the need for change or transition becomes visible by formulated concerns or care problems. As part of clinical decision-making, a cognitive evaluation of the personal situation of affected patients is important to assess the perceived mental and physical burdens. The questions that often come up, related to urology, reveal a knowledge deficit around diagnosis and treatment, dealing with mortality salience, pelvic and genital rehabilitation after cancer treatment, as well as dealing with sexual dysfunction and the experience of manhood. Therefore, expertise in sexological knowledge and body therapy is needed in addition to specific knowledge in oncology nursing. Sexocorporel approach The approach of Sexocorporel greatly extends the traditional counselling approach as follows. Firstly, a clinical assessment of the arousal function aims for a better understanding of how Mr. T was able to feel his genitals prior to surgery and how he created a sense of masculinity before. A deeper exploration of the usual body behaviour of Mr. T results in a holistic picture of how his concerns are interconnected with his burdens. Secondly, this knowledge translates into specific regular exercises to experience how body states (muscle tension, breath, movement rhythm) correlate with certain emotions. Awareness exercises lead to perception exploration, consciousness training and perception modification. Thirdly, this body experience - or extended ability to create self-efficacy - is transferred to the actual concern. For Mr. T this could be, for example, the relief in the learning process that his personal feeling of power and manhood can be fuelled by increasing pelvis mobility and a deeper abdominal respiration during arousal regulation. Being a man who can be aroused and experience pleasure is a priority whereas ‘just’ functioning sexually is no longer a goal from Mr. T. Focus on arousal In clinical practice, we observe that men with successful focus on arousal instead of an absent erection, show a more reliable erection function and PDE-5 inhibitors are more effective. The most important premise is that sex and arousal can be learned.

Advantages of this approach compared to traditional NP counselling are broader and more holistic assessments of patient burdens by including body states. Men provide positive feedback and often state: “I have no mental problems, my body changed”. Therefore, it seems logical to work with the body first and to experience how cognitive and perceived changes (i.e. the assessment of burdens) are affected in parallel to body-related learning.

clinic offers an important opportunity for men to strengthen their health literacy. Gender-sensitive health research shows that humans socialised as males tend to respond poorly to traditional prevention programmes. There is a tendency for men to see health as the absence of disease: healthy is someone who is functioning. If something is not functioning, it is broken. When male sexuality is affected, it seems less threatening to them to see a urologist than a sexual therapist.

Interdisciplinary consulting The Department of Urology at the University Hospital Bern therefore has an important role in helping humans socialised as men to adequately triage their health issues with interdisciplinary consulting and with patient-oriented health care. In our clinical practice, we observed that the integration of knowledge from Clinical Sexology into patients‘ treatment plans successfully managed transitions. Sexual health in primary care Sexual counselling is not a paid service in Switzerland The effectiveness of Clinical Sexology consultation is and is not covered by health insurances. In the context currently investigated in research projects, carried out together with the Department of Health of a serious illness such as cancer, the need for Psychology and Behavioural Medicine at the support for relationship issues or sexuality is socially accepted. For health issues, access through a urology University of Bern. On the other hand, this NP counselling approach requires specific expertise and demand together with a master degree in nursing science combined with a specialised education in body therapy, sexology or the Sexocorporel approach. Furthermore, this counselling approach is not paid by insurance companies and needs future research developments.

A deeper exploration of the usual body behaviour of Mr. T results in a holistic picture of how his concerns are interconnected with his burdens.

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Post-EAUN21 webinar Well-attended event organised by Oncowijs in collaboration with V&VN Urology Nurses Jeannette VerkerkGeelhoed, PhD Student, MSc, NP EAUN Board member Nieuwegein (NL)

j.verkerk@eaun.org

On 28 September, the online webinar post-EAUN was held. This webinar was organised by Oncowijs in collaboration with V&VN Urology Nurses (Dutch national society for urology nurses). In the past, Oncowijs has organised post-EAUN meetings. The last 4 years the post-EAUN-meeting could not take place due to organisational issues and later Corona. This year the meeting was organised virtually in the form of a 1,5 hour webinar. Selection of topics Thanks to this collaboration we organised a beautiful webinar, in which we looked back at the virtual EAUN congress on 3 and 4 September, with a selection of topics. The webinar was attended by 230 nurses, nurse practitioners and other healthcare professionals. The questionnaire at the end of the webinar was completed by 174 people and showed an overall rate of 7.6 out of 10. During the webinar, various topics were presented which had also been presented at the EAUN congress. Presentations The presentations were given by I. Koeter, urologist, T. Van Der Hulle, internist-oncologist, N. Klok, uro-oncology nurse and J. Verkerk, nurse specialist andrology-urology. First, the management of LUTS from the patient's perspective on complaints and treatment options

was discussed. Questions such as ‘which tools are available for support’ and ‘how do I guide patients with regard to lifestyle’ were answered. Kidney function Then the topic of kidney function was highlighted, as it was during the EAUN congress. This is a subject that cannot be answered from the urology viewpoint alone and therefore we invited T. Van Der Hulle. During this part of the webinar, the various causes of kidney malfunction were highlighted. They can be pre-renal, renal or post-renal. If the problem is post-renal, the urologist is usually involved since it often has to do with an obstruction in the urinary tract. Questions about interpretation of creatinine and eGFR were answered. The influence of medicines and nutrition were considered and so was renal cancer. When should a nurse refer to a doctor in case of poor kidney function? Prostate cancer The next topic on prostate cancer was presented by N. Klok and T. Van Der Hulle. During this webinar, hormone-sensitive metastatic prostate cancer was reviewed. What does treatment with androgen deprivation therapy mean for a man and his partner? What is the influence of the treatment on physical, psychological and emotional aspects? What are the side effects of the different medications and radiotherapy? Sexuality in prostate cancer treatment was also discussed, as well as the different treatment options for erectile dysfunction. Indwelling catheters Catheter problems with indwelling catheters were discussed based upon the expert meeting, which was held to inform the panel that updates the guideline for indwelling catheters. It turns out that there is little hard evidence for the best solution to catheter problems and that patient-oriented treatment is always needed in shared decision between patient and nurse. This part is presented by N. Klok and J. Verkerk.

Chair Erik Van Muilekom discusses kidney cancer and prostate cancer care with Nicole Klok (r) and Ingrid Koeter (l) during the Post-EAUN in the Netherlands

Peyronie’s disease Finally, the topic of Peyronie’s disease was presented. An ESU course was held on this subject during the EAUN congress. At that time, treatment options counselling in the early phase of the condition and the operative treatment options and guidance in the chronic phase were discussed. During the webinar a summary of this course was given by J. Verkerk and I. Koeter. They explained the ins and outs of Peyronie’s disease and how

counselling is done in daily practice. An explanation of the surgical treatment options was also given. With this online webinar the tradition of a Dutch post-EAUN meeting has been given follow-up. It is organised in a close cooperation between Oncowijs, which organises educational meetings on oncological subjects, including uro-oncological subjects, and V&VN urology nurses. We intend follow-up on this initiative again after the next EAUN congress in March next year.

Join an EAUN Special Interest Group

www.eaun.org/about-eaun

EAUN22: A perfect time for learning and reflection Get current evidence-based and practical updates in urological nursing From 19 to 21 March 2022, the 22nd Meeting of the European Association of Urology Nurses (EAUN) will take place in Amsterdam, the Netherlands. We look forward to welcoming you back in person and we hope that the programme will offer all urology nurses up-to-date news on current evidence-based practice, education, and useful practical updates. Learning as catalyst There has been some essential learning for all nurses during the COVID-19 pandemic. EAUN22 will help provide a professional platform for clinical reflection: What have you learnt about your practice and yourself? What changes have you made and why? How can we apply what we have all learnt and can we apply them?

Register now for the early fee! Deadline: 19 January 2022

The meeting will give you time to meet with colleagues, as well as, discuss and debate new ideas and key topics for learning. Above all, one thing we have learnt in the last year is the need to be kind to ourselves. It is now time to pause and reflect, come to Amsterdam, and listen and learn again at EAUN22. What’s new? EAUN22 will cover a variety of topics. With so many urology sub-specialities, we are pleased to offer 11 themed sessions, which will give unique insight into current treatments, urological cancers, long-term urological conditions, and the impact of these on quality of life (QoL). The prostate and continence SIGs (Special Interest Groups) will also bring some focus on coping with cancer and living with long-term urological disease that will highlight the need for careful planning and management. 36

European Urology Today

Naturally, communication is an important part of individualised nursing care, and we are delighted to provide insight into communication strategies, and how these can be adopted to improve and help overcome potential obstacles in our day-to-day practice. Alongside this, we also take time to discuss the impact of frailty on our clinical care and decisionmaking processes. Our aim is to provide a holistic ‘whole person’ conference approach to the many aspects of urological nursing.

initiatives with the latest in research from within our European community.

For the complete Scientific Programme visit www.eaun22.org

Please come along and support your colleagues and hear about their research first-hand. It is the perfect opportunity to ask questions! Throughout the State-of-the-art, Plenary Sessions and more programme, the Plenary Sessions will provide useful There are 10 state-of-the-art sessions, which will provide key learning opportunities. These sessions are insights into the lessons we have learnt from the designed and developed by nurses (for nurses) who are currently leading and developing initiatives in many areas of urology, old and new: nurse-led clinics, new integrated models of care, paediatric urology, bone-health in prostate cancer, male infertility/testosterone deficiency, recurrent urinary tract infections, rare case presentations, and the role of genomic screening.

pandemic, the latest in cancer prevention initiatives, as well as, an update during the session “Educational Framework for Urological Nursing – where are we now?”. Join us at EAUN22 We would be pleased to have you at EAUN22! Connect with peers from around the world. Meet and discuss with key opinion leaders. Enrich your daily clinical practice with contemporary relevant updates on urological nursing. Register before 19 January 2022 (23:59 CET) to benefit from reduced rates of the early fee and secure your place at the meeting. Visit www. eaun22.org/registration/ for more information.

AMSTERDAM

19-21 March 2022

In collaboration with the European School of Urology (ESU), EAUN22 will also offer two EAUN-ESU courses. ESU Course 1 “Incontinence in children - Urodynamics in children will provide insights on the potential and limitations in the investigation and treatment of children with incontinence. The course will also cover topics such as urodynamics, the role of a voiding diary, pharmacologic treatment, and more. Upon attending ESU Course 2 “Diagnostics and different treatment options of Renal Cell Carcinoma, counselling of the patient during treatment”, participants will know more about the diagnostic options and treatment options for renal cell carcinoma, how to counsel the patient during treatment in side effects of treatment, and how the multidisciplinary team is composed and how they work together. The poster sessions allow nurses the opportunity to present their work, which combines practice-led

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22nd International EAUN Meeting

www.eaun22.org October/January 2022