GLOBAL CONNECTIONS A PUBLICATION OF THE AMERICAN UROLOGICAL ASSOCIATION
VOLUME 8
ERECTILE DYSFUNCTION THROUGH THE AGES
AUA2015 new orleans
Sharing Knowledge/Setting Standards
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CONTENTS 4
G LO BA L S T R I D E S
Up Close and Personal: AUA Secretary Gopal Badlani, MD
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FE AT U R E
Erectile Dysfunction Through the Ages
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AUA Residents Bowl Competition Expands Internationally Global Connections is published twice-yearly by the American Urological Association Education and Research, Inc. (AUA). The AUA believes that the information in this newsletter is as authoritative and accurate as is reasonably possible and that sources of information used in preparation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any kind are disclaimed. This newsletter is not intended as legal advice, nor is the AUA engaged in rendering legal or other professional services. For comments or questions email us at communications@AUAnet.org.
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FE AT U R E
Global Training in Urology
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BY T H E N U M B E R S
AUA International Education and Outreach Efforts
G LO B A L S T R I D E S
GOPAL BADLANI, MD, AUA SECRETARY
GLOBAL STRIDES AUA Secretary Gopal Badlani, MD, has been instrumental in expanding AUA’s international programs during his tenure. With his five-year term coming to a close in May 2015, Global Connections wanted to get his thoughts on the progress that has been made over the last several years in this area and what he sees for the future of AUA’s international programs.
Q
As incoming Secretary five years ago, what were your goals for the AUA’s international programs? Have these come to fruition?
A
My vision was to build a bridge of education with four to five countries. The fact that we are now connected with so many countries and regions around the globe has far exceeded my expectations.
Q A
What do you view as the AUA’s biggest strength internationally?
The strength of the AUA is its organizational ability and the experience of the staff, but nothing would have been possible without the visionary leadership of our international partner societies. I am humbled by their dedication and commitment to our collaborative initiatives.
SBU President, Dr. Aguinaldo Nardi, enjoys the support of Brazilian football from Dr. Gopal Badlani, AUA Secretary, during the SBU leadership’s visit to the AUA headquarters building.
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G LO B A L S T R I D E S
Dr. Badlani cheers “gambay” with colleagues in China while enjoying dinner during the Chinese Urological Association’s annual meeting.
Q A
How do AUA’s international programs benefit AUA members in general?
AUA membership today is over 20,000 strong due, in large part, to increased international membership over the last several years. The international flavor of our Annual Meeting allows all members of the AUA to benefit from sharing and exchanging knowledge with colleagues from around the world. AUA members have the opportunity to attend or serve as faculty at AUA courses in so many countries around the world, which is another benefit of AUA’s commitment to international programs. The larger the number of members, the stronger the organization is as a whole, top to bottom. When they say there is strength in numbers, it is certainly true of the AUA.
Q A
How has the practice of urology changed with globalization?
AUA guidelines influence patient care around the globe. A multidisciplinary approach to the care of cancer in urology and the use of the robot in urology are examples of trends started in the U.S. that are now global.
Q A
How does globalized urology benefit/advance patient care, research, etc.?
Evidenced-based guidelines improve patient care, and our new data/census initiative will benefit patient care around the world. In-person educational programs help improve knowledge for better care of the patient and increase peer-to-peer networking among international colleagues. Online education through the AUAUniversity can reach every AUA member around the globe.
JUA President Yukio Homma, MD, along with AUA leadership and International Society Presidents, hammer open sake barrels to celebrate the JUA’s 100th anniversary, in Yokohama, Japan.
Q A
Have there been any unexpected benefits from AUA’s global efforts?
Our partnerships with multinational organizations and the realization of training centers in sub-Saharan Africa were most gratifying. Initiated by Dr. Robert Flanigan, the Global Philanthropic Committee has brought multinational urology organizations closer and has greatly benefitted urologists in areas of need. CO N T I N U E D O N P G 6 ▼
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G LO B A L S T R I D E S
Leaders from the Urological Society of India and AUA continue to nurture their friendship and expand collaborations. ▼ CO N T I N U E D F R O M P G 5
Q A
Q A
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Q A
What has been the biggest challenge in implementing AUA’s international programs?
The AUA is highly active in the global urologic community and would like to continue expanding our collaborations and activities to additional areas; however, costs remain a challenge. In addition to the support of our industry partners, the AUA Board is committed to this educational effort, as we believe in the benefits of these programs to all AUA members. What achievement, in terms of international programs, are you most proud of during your tenure as AUA Secretary?
A
I am most proud of the friends I made during my tenure. I am also very proud of the honorary memberships I’ve received from many urological organizations for representing the AUA. The resolve of the faculty to participate in courses despite the challenges of international travel made me proud of their dedication.
Q
What was the biggest surprise during your experience as the AUA’s international programs representative?
A
There was an unexpected and unscheduled landing in the old city airport of Amman, Jordan, during a sandstorm on my way to the Egyptian urology meeting shortly after the Arab Spring. I disembarked the plane and took a private taxi through the city to the international airport. It was an exciting adventure, and I did make my connection flight, though it made a few people mad at me!
VO L U M E 7 • G LO B A L CO N N EC T I O N S
What is your favorite memory from your international travels as the AUA Secretary?
There are so many—mostly, the kindness of the multitude of people who took care of me when traveling abroad. Others were big events, such as participating in the 100th anniversary of the Japanese Urological Association. India, of course, has a special meaning for me. The IVUmed missions, made possible in part by the AUA grant and the generosity of many others, have a special place in my heart as well. What do you see on the horizon for global urology?
The sun has just come out on this effort. I would love to see the multinational urological organizations collaborate further on educational efforts, just as we currently do with philanthropic efforts through the Global Philanthropic Committee. We have done quite a bit, but there is so much more to do! To sum it up, I can share one of my favorite quotes: “To give or share your knowledge is the best gift, as it costs so little and it makes the person richer!”
F E AT U R E
THROUGH THE AGES
by Dr. Ira Sharlip and Kelly-Lynne Russell Erectile dysfunction, previously called impotence, is a common sexual dysfunction characterized by the inability to achieve and/or maintain an erection of the penis sufficient for sexual satisfaction. Erectile dysfunction, or ED, is probably more common than most men realize. It is estimated nearly 100 million men in the world suffer from some form of ED. In general, it is estimated that 40 percent of men have difficulties at age 40, 50 percent at age 50, 60 percent at age 60 and 70 percent at age 70. From the beginning of civilization, the penis has been both a symbolic and a flesh-and-blood gauge of man’s place in society. In the ancient world, the erect penis was a symbol of maturity and power. Nearly every society and culture have used the penis as an icon of power and strength. CO N T I N U E D O N P G 8 ▼
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▼ CO N T I N U E D F R O M P G 7
PREVALENCE AROUND THE WORLD The breadth of knowledge about ED epidemiology has expanded significantly in the past 30 years. Several national and international studies have been performed using population samples, and have produced data on the prevalence and incidence of ED. Worldwide estimates of ED prevalence range from 2 percent in men younger than 40 years of age to more than 80 percent in men 80 years or older. Studies have also indicated ED is not only highly prevalent, but its incidence is strongly agerelated. Due to this correlation, and as a growing number of men age, the number of men with ED is expected to increase. Because Japan has a higher proportion of older citizens and a large aging population, researchers view the future of the rest of the world by studying what happens there. The Ministry of the Health and Welfare of Japan has projected the percentage of the population over 65 years of age will represent as much as 25 percent by 2020, and by 2060, will increase to nearly 40 percent. With the advancing age of the general population in Japan, treatment needs for erectile dysfunction (ED) and late-onset hypogonadism (LOH) are simultaneously increasing. Epidemiological studies using IIEF (International Index of Erectile Dysfunction) have actually demonstrated the high prevalence of ED in the general population. However, unlike U.S. and European countries, enthusiasm for ED treatment does not seem to be as high in the Japanese population,” said Kohi Shiraishi, MD, PhD, Associate Professor of Urology, Department of Urology, Yamaguchi University School of Medicine. The French, German and Swedish populations will have similar age distributions as Japan by the year 2020. In comparison, American and British populations are younger, and the number of citizens over the age of 65 is not expected to reach 20 percent until the year 2030.
“WHILE YOU’RE ALIVE I’M HOPEFUL RUSTIC GUARD / COME. BLESS ME, STIFF PRIAPUS: MAKE ME HARD.” This is a (poetically) translated prayer to Priapus, the Greek god of livestock, fruit trees and male genitalia, and is among the first and least terrifying erectile dysfunction cures we’ve seen throughout history.
VO L U M E 7 • G LO B A L CO N N EC T I O N S
In a 2013 study published in Translational Andrology and Urology, researchers took a critical look at epidemiology and statistics for sexual dysfunction in Asian men and compared them to men across the world. Breaking the globe into seven separate sections, they discovered that, although the prevalence of ED varied among countries, an analysis of age patterns and association with background disease and behavior were very similar among the various populations. The differences in prevalence of ED may reflect cultural differences in the perception of, attitudes toward, and willingness to report ED across cultural divides. According to some studies, treatment-seeking rates in France, Germany, Italy, Spain, the United Kingdom and the United States showed a peak during middle age. The most common reason for older patients to not seek treatment is the mistaken impression that ED is a natural part of aging.
F E AT U R E
PREVALENCE OF ERECTILE DYSFUNCTION GLOBALLY: Figure 1: Erectile Dysfunction over the age of 40
8% Northern Europe 8% Southern Europe 11% Non-European West 9% Central/South America 8% Middle East 15% East Asia 22% Southeast Asia 10% Entire Study
IMPACTS OF ERECTILE DYSFUNCTION The predicted worldwide increase in the prevalence of ED (associated with rapidly aging populations), combined with highly publicized medical treatments, is expected to raise challenging policy issues in nearly all countries. Already underfunded national health systems will be confronted with unanticipated resource requests and challenges to existing government funding priorities. Additionally, the economic impacts of ED are not limited to the cost of diagnosis and treatment, but also include the impact on the patient and society in various ways, such as loss of time at work and decreased productivity, decreased quality of life for the patient, and the effect on the partner, the family and co-workers. The projected trends represent a serious challenge for health care policymakers to develop and implement policies to prevent or alleviate ED. The largest projected increases for both economic and personal impacts were in developing countries located in Africa, Asia and South America.
ERECTILE DYSFUNCTION THERAPY: A GLOBAL EFFORT The earliest recognized impotence treatments date back to historic Egypt, Greece, China and Rome, where different elements of animals, believed to have aphrodisiac properties, were used for the treatment of impotence.
During the start of the 20th century, European doctors tried to treat ED by transplanting animal testicles, including those from goats, boars and deer, into humans. Though these treatments failed, they did succeed in energizing U.S.-based surgeon J.S. Wooten (1902) and U.S.-based professor G.F. Lydston (1908) to conduct the first penile surgeries by tying off blood vessels to cause penile engorgement. Then, in 1935, researchers from the Netherlands identified the male hormone testosterone, and the modern era of ED treatment began. The earliest penile implants were based on the observation that some animal species possess a penile bone, but attempts to implant bone or cartilage into the human penis failed, as the grafts were quickly absorbed. The heroes behind the modern penile prosthesis were F. Brantley Scott, MD, and his Houston, Texas, colleagues, who were able to successfully implant a device into the penis that could be pumped with saline to achieve erection. Shortly thereafter, U.S.based urologists Michael Small, MD, and Hernan Carrion, MD introduced an implantable, rigid rod as a prosthesis. While later designs utilized silver wire and hinges, these models were the prototypes of today’s penile prosthetics. In 1981, Ronald Virag, a French vascular surgeon who was interested in the treatment of ED, accidentally injected the drug papaverine, used to dilate blood vessels, into a patient’s penis. The injection caused an immediate erection, thus initiating the treatment of ED by intracavernosal injection therapy. But it was CO N T I N U E D O N P G 10 ▼
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F E AT U R E
▼ CO N T I N U E D F R O M P G 9
not until the 1983 AUA Annual Meeting, when British-born Dr. Giles Brindley gave his now-infamous crowd-scattering oratory about the direct and personal impact of papaverine injections, that papaverine made its impact on the U.S.-based urologic community. Then, in the late 1980s and early 1990s, a monumental discovery occurred. Researchers found sildenafil, a phosphodiesterase (PDE) type 5 inhibitor being studied to treat angina, also caused erections. In 1998, the U.S. Food and Drug Administration (FDA) approved sildenafil to treat impotence. This was quickly followed by FDA approval of additional PDE5 inhibitors tadalafil and vardenafil. Shortly after the drugs were approved in the United States, they were also approved for use in Europe, and just five years after oral ED drugs appeared, ED diagnoses increased by 250 percent. “Remarkably within just the past two decades, our approach to general sexual dysfunction and erectile dysfunction, in particular, has rapidly evolved and dramatically been altered,” says Dr.
Gerald Brock, Professor of Surgery at Western University, Canada, and Vice President of Education at the Canadian Urological Association. “The advent of PDE5i’s and the biological pathway in which they act to induce enhanced penile blood flow has been the nest of innovative research,” he continued. Since those early treatments, doctors, scientists and the pharmaceutical industry around the world have worked and continue to work to find new treatments for ED. Still, many patients don’t realize the breadth of treatments that are available to them. “It’s amazing to me. Because of many global studies, research and breakthroughs, doctors today have the ability to tailor a variety of strategies and treatment options for their patients,” remarks Dr. Irwin Goldstein, Director, San Diego Sexual Medicine and Editor-in-chief of the Journal of Sexual Medicine. “There are pills, shots, stem cell options and a variety of other strategies. We also have the penile implant—we have a strategy for as long as they own a penis; we can [help them achieve] a hard erection nine times out of 10,” he added.
CO N T I N U E D O N P G 12 ▼
HISTORY OF ERECTILE DYSFUNCTION 2000 BCE
50 CE
1902-1908
1948
The first recorded mention of impotence is written on Egyptian papyrus scrolls.
Pliny the Elder prescribes using leek or garlic pounded with fresh coriander into wine as an aphrodisiac.
First penile surgeries induce erection by tying off blood vessels to cause engorgement.
Alfred Kinsey’s “Sexual Behavior in the Human Male” shows ED to be more prevalent than had previously been thought.
1000 BCE 2000 BCE
0
Late 1880s Practitioners use imaginative means to induce erectile function.
1800
1850
1900
1000 CE
1912
320 BCE In ancient Greece and Rome, impotence sufferers used natural plant and animal byproducts to increase potency. According to Greek philosopher Theophrastus, the satyrion plant can enable a man to perform up to 70 times in a row.
Early 1800s French physician Dr. Vincent Marie Mondat invents the mechanical penis pump.
VO L U M E 7 • G LO B A L CO N N EC T I O N S
Sigmund Freud postulates that most cases of erectile dysfunction are caused by neuroses and repressed desires, not physical causes.
1930s-1940 Drs. Bogoras (1936) and R.T. Bergman (1948) insert rib cage grafts into penis for added rigidity.
1960s Masters and Johnson pioneer sexual dysfunction research, and determine that a great deal of ED is psychological.
F E AT U R E
ANECDOTE Erectile Dysfunction doesn’t just affect the patient. Ted is having the time of his life at 60. Now retired, Ted spends his days antiquing with his wife and occasionally playing golf with his now retired ex-coworkers. As Ted ages, he starts to notice he can’t lose weight as easily; he’s having trouble with back tension and his golf stroke; and, even more devastatingly, he is experiencing problems with achieving erection and with sexual intimacy. His wife is worried about Ted and tells him it’s time for a change. Ted books an appointment with his urologist, and anxiously awaits his conversation with his doctor about what he’s been experiencing.
“WE HAVE A STR ATEGY FOR AS LONG AS THEY OWN A PENIS; WE CAN [HELP THEM ACHIEVE] A HARD ERECTION NINE TIMES OUT OF 10” 1973 Dr. Brantley Scott develops first successful inflatable penile prosthesis.
1960
“Masters and Johnson said it best, ‘You can’t have a sexual problem that doesn’t influence your partner.’ If your partner is not happy sexually, you have a problem,” comments Dr. Goldstein. This is where most urologists meet erectile dysfunction face to face. These stories are all too familiar for men around the world and, surprisingly, often remain unheard by their urologists. Many men are hesitant to tell their doctors about their sexual dysfunction and loss of functionality related to sexual health. Despite being largely treatable, erectile dysfunction still goes unreported in most men, leaving a great population of men who suffer regularly with impotence. “Uncovering sexual issues in patients can be uncomfortable for physicians; and as a result, despite all of us knowing it’s the right thing to do … many of us choose not to do it,” Brock remarks. “The data is clear; patients want us to ask [about sexual problems]. In almost all cases, they are relieved when we open the door to talk about their problems.”
1982
Late 1980s
1998
Dr. Ronald Virag discovers the effects of papaverine.
Duplex ultrasound to test penile circulation pioneered by Dr. Tom Lue. Cavernosometry is introduced by Dr. Irwin Goldstein.
Sildenafil citrate, an oral medication for producing erections, is introduced to the market.
1970
1990
2000
2004 The Journal of Sexual Medicine is first published.
2010
1980
1973 Urologists Drs. Michael Small and Herman Carrion introduce first implant (the gelfilled Small-Carrion) semi- rigid rod as a penile prosthesis.
1983 British physiologist Dr. Giles Brindley introduces self-injectable phenoxybenzamine at an AUA Annual Meeting by injecting himself with the drug and then removing his pants during the presentation to demonstrate the results.
2013 1997 Medicated Urethral System for Erection (MUSE) introduced.
2003 Tadalafil and vardenafil, also oral medications, are introduced to the market.
Avanafil, which is marketed as a faster acting PDE5 inhibitor, is introduced.
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2020
F E AT U R E
LANDMARK ED STUDIES Ronald Virag’s Discovery of Papaverine Injections for ED
▼ CO N T I N U E D F R O M P G 10
EDUCATION FOR HEALTH CARE PROVIDERS The AUA Annual Meeting was host to many lectures and papers on sexual dysfunction, including, among others, papers on risk factors for ED; methods of reducing the risk of ED in prostate cancer patients; the relationship between prostate cancer and sexual dysfunction; and the impact of hypogonadism on sexual function. In addition, doctors can download tools at UrologyHealth.com to share with their patients who have questions about ED.
RESOURCES Lewis, R.: A critical look at descriptive epidemiology of sexual dysfunction in Asia compared to the rest of the world -– a call for evidence-based data. Online Translational Andrology And Urology, 2: 54-60, 2013. Available from http://www.amepc.org. Accessed Nov. 3, 2014 Small, Michael P., Carrion, Hernan M., Gordon, Julian A.: Small-Carrion penile prosthesis. Online Urology, 5: 479-486, 1975. Available from GoldJournal.net. Accessed Nov. 3, 2014 Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol.: 151: 54-61, 1994. Available from Journal of Urology. Accessed Nov. 3, 2014 Virag, R.: Editorial comment. The Lancet, 320: 8304, 1982 Mulcahy, John: Male Sexual Function: A Guide to Clinical Management. In: Current Clinical Urology, 2nd ed. Edited by J. Mulcahy. New York , NY: Humana Press, 2006.
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In 1982, the noted French vascular surgeon, Dr. Ronald Virag published a research article in The Lancet. His work suggested that intracavernous injection of papaverine could induce penile erection by relaxing smooth muscles in the penis. Studying the effects of papaverine injection in 25 subjects suffering from erectile dysfunction, Virag had shown that papaverine could initiate penile erection within 10 minutes to two hours after administration. His results were supported by a second study, in which Virag administered papaverine into the penis using an infusion pump. These findings were the first in a long line of work investigating treatments for erectile dysfunction.
1973 Publications – Penile Prostheses In 1973, Drs. Michael Small and Herman Carrion demonstrated the first intracavernous penile prosthesis—the “Small-Carrion penile prosthesis.” The device worked using a perineal surgical approach with revolutionary paired sponge-filled silicone prosthesis. The new prosthesis was inserted directly into the previously dilated corpora cavernosa of the patient. Of the initial 31 patients, excellent results were obtained in 27 and a good result in one. Additionally, of the three patients with initial serious complications, adequate functional results were attained in two. In the same year, Dr. Brantley Scott introduced his inflatable penile prosthesis with equally good results.
Massachusetts Male Aging Study Data from the Massachusetts Male Aging Study (MMAS) showed 34.8 percent of men aged 40 to 70 years had moderate to complete erectile dysfunction, which was strongly related to age, health status and emotional function. Data were taken from 1987 to 1989 in cities and towns near Boston, Massachusetts.
Rajan Veeratterapillay, MBBS, FRCS (Urol), of the United Kingdom (far right), celebrates victory as an international member of the New England Section Residents Bowl Team, winners of the 2014 AUA Residents Bowl.
AUA RESIDENTS BOWL COMPETITION EXPANDS INTERNATIONALLY For the first time in the three-year history of the event, the 2014 AUA Residents Bowl competition included participants from eleven different countries, including Australia, Brazil, Canada, China, Egypt, Germany, India, Japan, Mexico, the United Kingdom and the United States. Eight teams made up of residents from each of the AUA’s regional Sections (Mid-Atlantic, New England, New York, North Central, Northeastern, South Central, Southeastern and Western) participate in this event, and in 2014, international residents were assigned to each of the eight teams. Developed by AUA Secretary Gopal H. Badlani, MD, and the AUA Residents Committee, the Bowl is designed to increase sectional pride, present a social event with resident involvement and encourage camaraderie among residents from different programs. Involving international residents reinforces AUA’s goal to strengthen resident programming at the Annual Meeting and build bridges with the international community. The Residents Bowl takes place each year at the AUA’s Annual Meeting, with the teams competing against each other in the format of a single-elimination tournament. The teams answer urology-themed quiz questions and are awarded ten points for each correct answer. The team with the most points at the end of each game advances to a Semi-Final Round and ultimately the Final Round. Rajan Veeratterapillay, MBBS, FRCS (Urol), of Newcastle Upon Tyne, United Kingdom, joined the New England Section team and helped contribute to their championship journey. Veeratterapillay stated, “It was a pleasure for me to come to my first AUA Residents Bowl; I had a fantastic time. We actually won the competition, which was excellent.”
Veeratterapillay and all the international participants were selected by their national societies to attend the AUA’s Annual Meeting and participate in this event, while taking in everything the Annual Meeting has to offer. “The AUA Annual Meeting this year has been fantastic,” Dr. Veeratterapillay said. “There have been a lot of opportunities to make new friends, and visit with colleagues. It’s been excellent for networking.” The AUA would like to thank all the international residents who participated in the 2014 Residents Bowl: • Ahmed A. Aboumohamed, MD (Cairo, Egypt) • Ahmed M. Mansour, MD (Mansoura, Egypt) • Rajan Veeratterapillay, MBBS, FRCS (Urol), (Newcastle Upon Tyne, United Kingdom) • Arvind Kumar, MCh trainee (Lucknow, India) • Sachin Nataraj, MS (Lucknow, India) • Katsura Ishioka, MD (Tokyo, Japan) • Satoru Taguchi, MD (Tokyo, Japan) • Haibo Shen, MD, PhD (Shanghai, China) • Matthias Heck, MD (Munich, Germany) • Rafael Ribeiro Mori, MD, (São Paulo, Brazil) • Simon van Rij, MD (Melbourne, Australia). The next Residents Bowl will take place at the 2015 AUA Annual Meeting in New Orleans, Louisiana, and all Annual Meeting attendees are invited to come to the meeting, enjoy the fun and cheer on the teams! To read additional information about the Residents Bowl and the participants, visit AUA2014.org. If you are interested in learning about AUA membership for residents, please contact AUA Member Services at membership@AUAnet.org, visit AUAnet.org/ Join or call +1 (410) 689-3933.
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“The future of any profession depends almost entirely on the capability and vision of its youngest members. In case of urology, it is the residents who will determine the shape of this dynamic field well into this new century and beyond. It is imperative, therefore, to not only ensure that the best and the brightest choose to join our fold but also to train them well so that our medical system can keep pace with the changing urological scenario.” – Gagan Gautam, MD Department of Urology and Renal Transplant, Fortis Flt. Lt. Rajan Dhall Hospital, India – Guest Physician Author: Victor W. Nitti, MD
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F E AT U R E
In 2006, the World Health Organization (WHO) estimated the health service provider workforce (including physicians, nurses, associates and other community providers) at more than 39.4 million. While no exact number exists for the number of urologists among this group, what is certain is that urologists around the world train in a variety of residency programs while maintaining a central focus: to provide quality care to their patients. To train urologists well, residency programs must be designed to prepare physicians for everchanging urology scenarios. For some programs, goals vary from keeping pace with others, setting a new standard or continuing to innovate. Globally, some programs have differences in their approach to urologic training while other programs also have similarities.
TRAINING THE WORLD’S UROLOGISTS Standardized training for medical students was developed in the United States in the early 1900s following the publication of the now infamous Flexner Report. Other countries and regions (e.g., Europe) followed suit in standardizing requirements to practice. There is not, however, a single global standard for training across all international programs, and distinct differences can be seen along the path to becoming a urologist.
MEDICAL SCHOOL While some countries may not allow students to apply for medical school until after their education level reaches the university level, some countries take a different approach. Israel and Italy require a prerequisite high school program. In Israel, students must complete a six-year program, along with examinations, to apply to medical school. In Italy, students must complete a five-year program in an institution that is classical, scientific or technical to achieve the high school license necessary to enter medical school. To be licensed to prescribe and practice in France,
according to Dr. Emmanuel Chartier-Kastler, “You need to fulfill 10 years of medical school. After six years you reach a level of ‘master’ but you then start residency (four or five years upon specialty). The six years are made up of pure medical school, and students will have to visit a lot of specialties to learn.”
RESIDENCY Many residency programs are similar in structure. For instance, Turkey, Egypt and Taiwan are all on a four-to five-year plan, with each training year having a specific structure and focus. Turkish medical residents must enter a five-year program and complete a certifying examination that consists of uropathology, uroradiology and clinical urology. Egyptian residents enter a four-year program: one year of clinical rotations in a university hospital, three years of theoretical and clinical training in urology, and the completion of an exam and thesis. In Taiwan, residents must enter a four-year program consisting of three years in general surgery, clinical urology or other clinical disciplines relevant to urology, and one year as chief resident in urology. Another key difference among programs can be found in their incorporation of general surgery training as a part of residency training. Not all programs require dedicated general surgery study; in countries such as CO N T I N U E D O N P G 16 ▼
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F E AT U R E ▼ CO N T I N U E D F R O M P G 15
RESIDENCY PROGRAMS IN EUROPE
Italy, Ukraine and Estonia, general surgery training is incorporated into the urologic residency. India, however, requires residents to complete three years of general surgery training followed by three years of supervised urology training.
DEGREES AND LICENSING
Germany 25
Perhaps the most definitive universal requirement to completing urologist training globally is the need to achieve degrees and licensing to practice. Countries like the United States, Egypt and Israel require bachelor and medical doctor (MD) degrees to practice, while countries like France and Turkey have six-year medical programs that train and provide a medical degree upon completion of the program. After completion of the medical programs in France and Turkey, urologists are fully licensed to practice medicine and prescribe medications.
Austria 7 Poland 7 Spain 5 Turkey 5 Switzerland 4 Belgium 3
FACTORS IMPACTING UROLOGY TRAINING
Czech Republic 3 Greece 2 Other: Croatia 1 Estonia 1 Finland 1
Hungary 1 Italy 1 Malta 1 Norway 1
Portugal 1 Sweden 1 The Netherlands 1
In Europe alone, there are 71 basic urology training programs certified by the European Board of Urology (EBU). In the United States, there were 123 accredited non-military urology residency programs in 2014.
In recent decades, new advances in medicine have dramatically changed urologic practice, and around the globe, training must keep pace with these breakthroughs. Some urologists believe that over the past 10 years the impact of robotic surgery is a dramatic change that has revolutionized training programs. The robot has become a “great equalizer” that gives the attributes of open surgery. Robot training has become a large part of many residency training programs, and many residents in Westernized countries leave their training program with experience in robotics. Another key factor is subspecialization. In his 2008 article in the Indian Journal of Urology, Dr. Gagan Gautam highlighted the growing need for a core competency in training for the management of common diseases in urology. “The advent and growth of new subspecialties has resulted in a rapid explosion of urological knowledge and skills,” he wrote. “This has led to a trend whereby urologists tend to become trained experts in a particular subspecialty. While this may be beneficial in selected institutions, most urologists in peripheral centers who cater to the majority of the Indian population need to be well-versed in general urological skills covering a wide array of these new specialties.”
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F E AT U R E
In the United States, another major issue facing urology training is the need for increased graduate medical education (GME) funding. In the United States, GME funding limitations are a contributing factor to the growing physician shortage. The AUA and physician leadership have been very involved in the effort to advocate for this need and keeping members informed of how they can advocate to improve GME funding; but it is worth noting that
the United States is not the only country facing a health care workforce shortage. In its 2013 report, “A Universal Truth: No Health Without a Workforce,” the World Health Organization (WHO) reported an international health care workers shortage of 7.2 million. The WHO estimates this number will balloon to 12.9 million by 2035 if steps are not taken to address the issue.
TRAINING AROUND THE GLOBE COUNTRY
GENERAL TRAINING
UROLOGY TRAINING
DEGREES TO PRACTICE
United Kingdom
Pre-registration House Officer 6 months medicine, 6 months surgery, 3 years surgical common trunk Senior House Officer rotation; 1-2 years of research
5 years urology
Medical degree, Membership of the Royal Colleges of Surgeons (MRCS) examination, Certificate of Completion of Training, FRCS examination
United States
1-2 years general surgery
4-5 years urology, followed by fellowship training, if desired
Bachelor’s and medical degree; state licensing exam
Greece
6 years medical school; 1 year of community health service or military service
5 years (1 general surgery, 3 urology, 1 in two rotations [gynecology, plastic surgery and/or pediatric urology])
Australia/New Zealand
1 intern year, 2 years general surgery
4 years
FRACS Examination
Germany
At least 60 months of practical medical training
4 year minimum
Oral examination
Russia
6 years of medical school
2-year internship in surgery, 3 years in urology
State Certification Exam
Taiwan
4-5 years with one year as chief resident
Sources: Accreditation Council of Graduate Medical Education, European Society of Residents in Urology
REFERENCES Freilich, D., Nguyen, H., & Phillips, J. (2011). Factors Influencing Residents’ Pursuit of Urology Fellowships. Urology, 78(5), 986-992. Gautam, G. (1927, December 5). THE UROLOGICAL REVOLUTION. National Center for Biotechnology Information. Retrieved September 11, 2014, from http://www.ncbi.nlm. nih.gov/pmc/articles/PMC2684367/
IOM Graduate Medical Education Report: Better Aligning GME Funding With Health Workforce Needs. (n.d.). Health Affairs Blog IOM Graduate Medical Education Report Better Aligning GME Funding With Health Workforce Needs Comments. Retrieved September 11, 2014, from http://healthaffairs.org/ blog/2014/07/31/iom-graduate-medical-education-report-better-aligning-gme-funding-with-health-workforce-needs/
Robots and urology training - Dr Runz. Op Report Ep. 7. (n.d.). YouTube. Retrieved September 11, 2014, from https://www.youtube. com/watch?v=l8sV1yp9gHc Surgery trainee readiness for practice - Dr Barone. Op Report Ep. 8. (n.d.). YouTube. Retrieved September 11, 2014, from https:// www.youtube.com/watch?v=I4brlQRrGiY
G LO B A L CO N N EC T I O N S • VO L U M E 7
BY T H E N U M B E R S
AUA INTERNATIONAL EDUCATION AND OUTREACH EFFORTS
BY THE NUMBERS “FRIENDSHIP IS THE ONLY CEMENT THAT WILL EVER HOLD THE WORLD TOGETHER.” —Woodrow T. Wilson
In medicine, friendship, as well as the sharing of knowledge and experience, is the glue that holds us together. It is through friendship and collaboration that great discoveries and advancements in the treatment of urologic disease can be achieved. The AUA has long recognized the value of involvement in the international urological community and has taken a lead role in international exchange. In this issue of Global Connections, Over 35 International Society Presidents and Representatives participate in AUA’s Presidents Reception in Orlando we explore some of the key statistics of AUA’s international education and outreach efforts. The AUA would like to thank our international colleagues and partners for their friendship and collaboration to standardize urology training and increase the quality of urologic care around the globe. For more information on AUA’s international programs or to find a program near you, please visit the AUA International Academy at www.AUAnet.org/Academy.
112 years of history and collaboration in the global urologic community
Globally engaged organization with over
20,000
members, one-quarter of
who practice in nearly 120 countries, representing the world’s largest collection of expertise and insight into the treatment of urologic disease
VO L U M E 7 • G LO B A L CO N N EC T I O N S
BY T H E N U M B E R S
2014: ANNUAL MEETING The AUA Annual Meeting continues to be the largest urologic meeting in the world — nearly 16,000 total attendees with urologic health professionals from 116 countries
2014 GLOBAL PROGRAMS OUTSIDE NORTH AMERICA 18 AUA Joint Symposiums
5 Best of AUA Annual
56% of attendees from outside the U.S.
Meeting programs
13.8 MILLION media impressions 20
TH
anniversary of AUA/CAU Spanish Urology Program
18 international society meetings
23 official AUA lecturers 5 Lessons in Urology courses for residents 8 International In-Service Examinations
24 specialty society meetings
>100
41 podium and 83 poster sessions 103 IC/PG Courses
academic exchange and visiting scholar participants since 2009
2,200 abstracts in all fields of urology 11 countries participated in the 2014 AUA Residents Bowl
11,677 Facebook fans
5,947 Twitter followers
692 YouTube subscribers
G LO B A L CO N N EC T I O N S • VO L U M E 7
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