European Urology Today Vol. 35 No. 2 - April/May 2023

EAU23 report: Year-on-year progress

By Erika De Groot, Stephanie Fitts and Loek Keizer

The 38th Annual Congress of the European Association of Urology was a momentous occasion in Milan, Italy, earlier this year. An extensive and dynamic scientific programme shed light on ground-breaking research and novel technologies. Attracting over 9,800 delegates from 123 countries, more than 1,700 experts shared their knowledge and latest research findings during 300 sessions that included state-of-the-art lectures, debates, panel discussions and 47 courses (including Hands-on training) organised by the European School of Urology.

Over four days, there were eight plenary sessions, a full day of live surgery, multiple game-changing sessions, 28 thematic sessions, 15 Urology Beyond Europe lectures, poster presentations, prestigious awards, Patient Day, YUORDay and industry sessions. During this time, both the 7th International Congress on the History of Urology, and the annual meeting of European Association of Urology Nurses (EAUN23) took place as well.

This article provides a short summary of some highlights from EAU23, but for the most complete coverage of the congress, you can read the full news reports on www.eau23.org/news.

Day 1: GU cancers and supportive care

In his state-of-the-art lecture “Optimising supportive care for metastatic GU cancers”, Dr. Florian Scotté (FR) cited the findings of the National Cancer Database retrospective study “Considerations for palliative care in urologic oncology” by Bryn Launer, et al. The study showed supportive care is infrequent for patients with advanced urologic malignancies, and outlined the possible barriers, such as misconception about what palliative care is, limited access to the healthcare system and patients’ acceptance.

One of the solutions that Dr. Scotté discussed was derived from the paper “Integration of oncology and palliative care: A Lancet Oncology Commission” by Stein Kaasa, et al. wherein two approaches were combined: tumour-directed approach (focus on treating the disease) and host-directed approach (focus on the patient). He stated that this combination will result in a systematic assessment, improvement in patient-reported outcomes, and active patient involvement in the decisions. As a consequence, there will be better symptom control, improved physical and mental health, and better use of healthcare resources.

Kidney transplantation (KT)

Dr. Javier Sanchez Macias (ES) presented the lecture “Bladder function and Lower urinary tract symptoms (LUTS) after renal transplant”, whereby he provided information on post-operative lower urinary disorders including absence of bladder, low capacity bladder and neurogenetic bladder. “The implementation of new minimally-invasive technologies for the management of patients with LUTS will in the future oblige their daily use in transplant patients. New studies will be necessary to determine whether Rezūm, Aquablation or transurethral HIFU (high intensity focused ultrasound) techniques will replace endoscopic

enucleation and TURP (transurethral resection of the prostate)”, stated Dr. Sanchez Macias.

Lively debates followed between Dr. Oscar Rodriguez Faba (ES) and Dr. Romain Boissier (FR) on the topic of “Urological evaluation of the recipient before kidney transplant should be obligatory”. Dr. Rodriguez stressed that a proper urological evaluation of a KT patient is necessary. “Urological complications comprise the second most common adverse event after KT. Pretransplant targeted urological evaluation allows for optimisation of the urinary tract accepting the graft.”

“We are also doing some fascinating translational work comparing pre- and post- tissues to see what effect LuPSMA has on the tumour microenvironment. This work is ongoing and it may give us an idea of how to better select patients for this type of targeted treatment.”

Day 2: Bladder cancer (BCa) sessions

Incontinence and sexual dysfunction are of real concern especially in young women after neobladder surgery but it is a frequently overlooked topic. “Roughly 25% of new BCa patients each year are diagnosed in female patients” stated Dr. Manuela Tutolo (IT) in her lecture ‘Treatment of incontinence and sexual dysfunction after cystectomy’. “Our goal as urologists should be to guarantee optimal urological outcomes together with optimal functional outcomes in these patients. The surgeries are difficult with serious complications that have an impact on quality of life (QoL).”

Phase 3 ZIRCON study

Prof. Peter Mulders (NL) presented the latest results in a game changing session on the use of 89Zr-DFO-girentuximab for PET/CT imaging of clear cell renal cell carcinoma (ccRCC). According to Prof. Mulders, the ZIRCON study exceeded sensitivity and specificity targets, which also included small masses (cT1a <4cm), and had a favourable safety and tolerability profile. “These positive results suggest that 89Zr-DFOgirentuximab improves identification of primary ccRCC compared to cross-sectional imaging. It has the potential to improve management by aiding risk stratification and holds promise to improve staging in ccRCC, therapeutic target (radiopharmaceuticals) or to image other solid tumours.”

Latest OpeRa results

Prof. Marc-Oliver Grimm (DE) delivered an update on the OpeRa study, which compared robotic assisted partial nephrectomy (RAPN) and OPN (open partial nephrectomy) in intermediate/high complexity renal tumours. With RAPN, there was a numerically lower 30-day complication rate (primary endpoint), but with regard to oncologic (R1-rate, TRIFECTA) and functional outcomes (eGFR, ischemia time <25 minutes), there was no difference. There was less intense pain management required with RAPN, less pain reported and a better QoL scored (through POD30).

New robotic systems

One of the best-attended sessions at EAU23 was without doubt the live surgery session “Technology developments never end”. Running continuously from 10:30 to 19:00hrs, the programme featured more than 30 cases, with extra attention for the newest single-use scopes, and Thulium and Holmium laser enucleation of the prostate. The programme also featured less common cases, for instance two pre-recorded presentations on inflatable penile prostheses.

AI and PCa diagnosis

Dr. Maarten De Rooij (NL) presented the study design for 'Prostate Imaging: Cancer Artificial intelligence (PI-CAI Challenge)’, which aims to evaluate the performance of modern AI algorithms at patient-level diagnosis and lesion-level detection of csPCa (clinically significant PCa). “The preliminary results in the reader study arm show that bpMRI (biparametric) has similar csPCa detections to mpMRI (multiparametric) assessments. We have to look into experience, workflow, image quality and protocol familiarity to evaluate future work. We look forward to the next steps in which we will establish the primary endpoint, comparing AI with radiologists”.

Final results of LuTectomy study

Dr. Renu Eapen (AU) shared the concluding results for the prospective study of dosimetry, safety and potential benefit of upfront [177Lu] Lu-PSMA-617 radioligand therapy prior to radical prostatectomy in men with high-risk localised PCa. “We have seen that Lu-PSMA, followed by surgery is safe, it is well tolerated, and it is effective. Radiation dose delivery is high and targeted, but variable. We are seeing some encouraging responses from a biochemical, imaging and pathological point of view. Further research is worthwhile to see if this could be an effective treatment strategy in well selected patients.”

“Radical cystectomy with ONB (orthotopic neobladder) is an attractive treatment option, but it has high rates of voiding/sexual dysfunction. We should treat patients conservatively as much as possible.” In Dr. Tutolo’s opinion, it is important to optimise surgery to preserve sexual function, select patients upfront according to their risks of incontinence or other general complications, and properly inform patients to create realistic expectations. She believes there is a clear need for more prospective studies and a real multidisciplinary approach.

In the afternoon sub-session on robotic surgery, Asst. Prof. Nina Harke (DE) joined Auditorium 1 from Niguarda Hospital in Milan and performed a robotic partial nephrectomy with a highly distinguished panel of moderators: Profs. Alex Mottrie (BE), Henk Van Der Poel (NL) and Alessandro Antonelli (IT). Her demonstration was followed by a Retzius-sparing robotic prostatectomy by Dr. Antonio Galfano (IT), using the new Hugo system, also in Niguarda. The system was installed just three months prior, and the team had performed fewer than 20 cases so far. “We are still exploring the possibilities of the system,” said Dr. Galfano.

''Our goal as urologists should be to guarantee optimal urological outcomes together with optimal functional outcomes in these patients.''

Delegates on their way to their next sessions

New Editors-in-Chief European Urology and EU Oncology under new leadership

Outcomes Study Educational Visualisation Tool BPH

BPH Outcomes Study - Educational Visualisation Tool is intended for educational purposes and not for clinical use. The BPH tool is solely intended to inform healthcare professionals to help visualise and understand the results of the statistical modelling published by Gravas S et al 2022. The BPH Tool has not been validated for and is not intended for clinical use with individual patients. It is not intended to substitute for medical advice or intended to drive or inform to take decisions with diagnosis or therapeutic purposes of any condition for any individual patients.

References: 1. Gravas S, et al. EAU Guidelines on the Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO), 2021. Available at: http://uroweb.org/guideline/treatmentof-non-neurogenic-maleluts/ Accessed March 2023. 2. Avodart Italy SmPC Summary of Product Characteristics (SmPC) effective 22 October 2020. 3. Combodart Italy SmPC Summary of Product Characteristics (SmPC) effective 22 October 2020.

Abbreviations: BPH, benign prostatic hyperplasia; LUTS/BPH, lower urinary tract symptoms secondary to benign prostatic hyperplasia. In Italy the registered trade name for dutasteride is Avodart and for dutasteride-tamsulosin is Combodart.

Abbreviated Product Information – Avodart

Soft Capsules 0,5 mg

Prescription SSN

Class A*

Price € 11,78**

*Providing system: medicinal product subject to medical prescription (RR) ** Without prejudice to any reductions and/or modifications imposed authoritatively by the competent Health Authority.

Therapeutic Indications

Avodart is indicated for the treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH). Reduction of the risk of acute urinary retention and surgery with moderate to severe symptoms of benign prostatic hyperplasia

Posology and method of administration

Avodart can be administrated alone or in combination with the alpha blocker tamsulosin (0,4 mg). Adults (including the elderly): The recommended dose is one capsule (0.5 mg) taken orally per day. The capsules must be swallowed whole and must not be chewed or opened as contact with the contents of the capsule may cause irritation of the oropharyngeal mucosa. The capsules can be taken with or without food. Although early improvement can be seen, it may take up to 6 months before a response to treatment is achieved. No dose adjustment is required in the elderly. The most commonly observed adverse reactions include impotence, altered (decreased) libido, ejaculation disorder, breast disorder.

Full SmPC of AVODART (23 November 2017) for EU is available athttps://mri.cts-mrp.eu/portal/details?productnumber=SE/H/0304/001

Scan the QR code to access the Italian SmPC of Avodart

Abbreviated Product Information – Combodart

Hard capsules 0,5 mg

No prescription SSN

Class C*

Price € 36,00**

*Providing system: medicinal product subject to medical prescription (RR) ** Without prejudice to any reductions and/or modifications imposed authoritatively by the competent Health Authority.

Therapeutic Indications

Combodart is indicated for the treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH). Reduction of the risk of acute urinary retention and surgery with moderate to severe symptoms of benign prostatic hyperplasia

Posology and method of administration

The recommended dose of Combodart is one capsule (0.5 mg/0.4 mg) once a day.

When appropriate, Combodart can be used to replace dutasteride and tamsulosin hydrochloride used together in current dual therapy to simplify treatment.

When clinically appropriate, a direct switch from dutasteride or tamsulosin hydrochloride monotherapy to Combodart may be considered. The most commonly observed adverse reactions include dizziness, impotence, altered (decreased) libido, ejaculation disorder, breast disorder.

Full SmPC of COMBODART (23 November 2017) for EU is available athttps://mri.cts-mrp.eu/portal/details?productnumber=DE/H/2251/001

Scan the QR code to access the Italian SmPC of Combodart

For the use of registered medical practitioner or a Hospital or a Laboratory only. Avodart/Duodart is for use in men only. Avodart/Duodart trade marks are owned by or licensed to the GSK group of companies.

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ or search for MHRA Yellowcard in the Google Play or Apple App Store. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441.

The British ProtecT trial update was presented by Prof. Freddie Hamdy (GB): “Survival from clinicallylocalised prostate cancer (PCa) remains very high over a median of 15 years (96-97%), irrespective of treatment allocation. Men with metastases do not necessarily die from PCa and those who do, they have lethality features yet to be identifiable, and are not easily impacted by multimodality treatment approaches.”

Prof. Hamdy concluded that current riskstratification methods are unreliable and that new tools are needed. However, the indications for active monitoring or surveillance can be expanded safely to intermediate-risk disease. Treatment decisions need to balance “trade-offs” between the reduction of metastases, long-term hormones, and local progression with radical treatments against their short-, medium-, and long-term impacts on sexual, urinary, and bowel function.

On QoL, Prof. Jenny Donovan (GB) told the plenary session’s audience that based on the newlypublished patient-reported outcomes, “Men newly-diagnosed with localised PCa can now carefully assess the trade-offs between the benefits and harms of treatment options: in the short, medium, and long-term and using their own values and priorities to make prudent and well-informed treatment decisions.”

European Urology Today

Editor-in-Chief

Prof. J.O.R. Sønksen, Herlev (DK)

Section Editors

Prof. T.E. Bjerklund Johansen, Oslo (NO)

Dr. B.C. Bujoreanu, Cluj Napoca (RO)

Prof. O. Hakenberg, Rostock (DE)

Dr. P. Østergren, Copenhagen (DK)

Dr. G. Ploussard, Toulouse (FR)

Prof. J. Rassweiler, Heilbronn (DE)

Prof. O. Reich, Munich (DE)

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)

S. Fitts, Arnhem (NL)

L. Keizer, Arnhem (NL)

H. Lurvink, Arnhem (NL)

EUT Editorial Office

PO Box 30016

6803 AA Arnhem

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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

Challenges in urogenital infections

In his presentation, oncologist Prof. Andrea Alimonti (CH) stated that intra-tumoural microbiome plays a role in the development of prostate cancer (PCa).

“The microbial species that reside in the urinary tract might be initiators of chronic inflammation in the prostate, ultimately leading to PCa by causing the development of PIA (proliferative inflammatory atrophy). Several species of pro-inflammatory bacteria and/or known uropathogens are enriched in men with PCa. The prostate tumour microbiota is different from the one of normal tissues.”

During the state-of-the-art lecture “Pathophysiology and the role of the host in urosepsis”, Dr. Zafer Tandoğdu (GB) stated that sepsis is no longer considered as SIRS (systemic inflammatory response syndrome). “Sepsis is a dysregulated host response with both pro- and anti-inflammatory processes. It is important that we understand timely recognition before the transition to sepsis, and early warning scores can help detect that. We should be mindful that if there is an infection, there can be sepsis,” said Dr. Tandoğdu.

Day 4: UroEvidenceHub

Prof. James N’Dow (GB) presented details on the EAU’s Data Initiatives, with an overview of current and upcoming efforts by the EAU to host, manage and process real-world clinical data to fill evidence gaps in current urological knowledge.

In the setting up of the new UroEvidenceHub, the first pilot of which will deal with PCa, the EAU hopes to use real-world evidence to better individualise patient care. The new “data haven” project will build on established experience and (non-urological) expertise the EAU has with the PIONEER network and OPTIMA partnership.

Part of this session also addressed the highlytopical subject of Artificial Intelligence (AI) and how it might transform urology in the coming years. Dr. Michael Bussmann (DE) and Prof. Philippe Lambin (NL) explained the basic principles for successful use of AI and its expected applications within urology. The most likely tasks to be taken over by AI include image analysis, diagnosis, treatment planning, patient monitoring, administrative tasks, research and even aiding in a “hands-on” way on improving surgeons’ accuracy when operating robotically.

Urinary stones

In his lecture on new laser technologies, Prof. Olivier Traxer (FR) had three important take home messages. He shared the formula Energy x Frequency = Power, or J x Hz = Watts, emphasising the importance of energy and power, over frequency. Secondly, when evaluating the effectiveness of new laser technology, the real-life application should be leading as laboratory settings cannot always be reproduced bedside. Finally, Prof. Traxer presented a useful rule of thumb for the audience: for kidney stones, work from surface to centre and always use 20-25W or less. For ureteral stones, from centre to surface and using a lower frequency range of 12-15W.

Plenary Session: Men’s Health

Ass. Prof. Faysal Yafi (US) presented his lecture on “Wearables for erectile quality: Catchy gadget or valuable clinical instrument?”, with a summary of what is currently the market and what is planned for the market in the near future.

“Wearable (electronic) devices/gadgets are gaining popularity amongst consumers and investigators for sexual function tracking, erectile dysfunction (ED) and premature ejaculation (PE).

The prevalence of male sexual dysfunction increases with age, with over 50% of men aged 40 to 70 years reporting some degree of ED. Prevalence has also become increasingly common in young men as well, with 14.1% of males aged 18-31 reporting a diagnosis of ED and growing trends show reliance on PDE5i for erectile function in younger men.”

Best of EAU23 sessions

New to the scientific programme this year was the Special Session “Best of EAU23 Abstracts: An expert discussion” which showcased top-tier research on oncological and non-oncological topics, including three prize winning abstracts.

Under the oncology category, the top-prize winning abstract A1163: Proteomic profiling of muscleinvasive bladder cancer treated with neoadjuvant chemotherapy described four pre-NAC and two post-NAC proteomic clusters with distinct biology and survival outcomes, alongside novel prognostic biomarkers.

The second prize was given to A0890: The Stockholm3 prostate cancer screening trial (STHLM3): An interim analysis of mortality results after 6.5 years of follow-up which concluded that the results cautiously suggest a potential effect on reducing PCa mortality by a single intensive screening intervention using PSA and Stockholm3 in combination to the cost of increasing PCa incidence. Longer-term follow-up is needed and is underway.

Dr.

Tutolo (IT) presents the non-oncology

First prize-winning abstract 'Similar artefact susceptibility for water- and air-filled urodynamic systems' (A0693 )

Abstract A0693: Similar artefact susceptibility for water- and air-filled urodynamic systems: Results from a randomised controlled non-inferiority trial received the top prize of the non-oncology category. The research results demonstrated that AFS are non-inferior to WFS regarding overall quality of urodynamic traces. However, both measurement systems have particular pitfalls that need to be known for problem solving during urodynamic investigation (UDI) and require awareness for accurate interpretation of UDI.

The congress concluded with the Special Session “Best of EAU23: Take-home messages”, whereby a panel of experts shared the congress highlights on 10 topics, from liquid biopsy to early detection of PCa, paediatrics, BCa, functional urology, stones, benign prostatic hyperplasia, andrology, and imaging.

Access more EAU23 content

All webcasts, videos, posters and full-text abstracts are currently accessible via the EAU23 Resource Centre. Delegates have full access. If you did not attend EAU23, you can still register for on-demand access to explore all scientific content shared during the congress. Please note that accreditation is no longer valid. For more details, see www.eau23.org/rc

Prof. Andrea Alimonti (CH) gives the state-of-the-art lecture 'Microbiome has a role in the development of genitourinary cancers'

Manuela

Overview of prizes and awards

EAU Willy Gregoir Medal 2023

L. Martínez-Piñeiro, Madrid, Spain

- Handed out by C. Chapple

EAU Crystal Matula Award 2023

J. Gómez Rivas, Madrid, Spain

Supported by LABORIE

- From left to right: C. Chapple, J. Gómez Rivas, M. Fürstenberg (LABORIE)

EAU Frans Debruyne Lifetime Achievement Award 2023

J. Catto, Sheffield, United Kingdom

- From left to right: C. Chapple, F. Debruyne, J. Catto

Opening Ceremony

Friday, 10 March

EAU Hans Marberger Award 2023

R. Campi, Florence, Italy

Supported by KARL STORZ SE & CO.KG

- From left to right: C. Chapple, R. Campi, P. Cantu (KARL STORZ SE & CO.KG)

-

EAU Innovators in Urology Award 2023

P. Wiklund, Stockholm, Sweden

- Handed out by C. Chapple

EAU Prostate Cancer Research Award 2023

E. Ventimiglia, Milan, Italy

Supported by the FRITZ H. SCHRÖDER FOUNDATION

- From left to right: C. Chapple, E. Ventimiglia, M. Roobol (FRITZ H. SCHRODER FOUNDATION)

CAU Lecturer Recognition Award 2023

J. Sanchez Macias, Barcelona, Spain

- Handed out by A. Breda

SIU Lecturer recognition Award 2023

A. Ackerman, Los Angeles, United States of America

- Handed out by S. Silay

EAU Ernest Desnos Prize 2023

R. Vela Navarrete, Madrid, Spain

- From left to right: C. Chapple, R. Vela Navarrete, P. Van Kerrebroeck

EAU Patient Advocacy Medal of Excellence 2023

R. Giles, Duivendrecht, The Netherlands

- From left to right: C. Chapple, R. Giles, E. Rogers

SUO Lecturer Recognition Award 2023

P. Spiess, Tampa, United States of America

- Handed out by C. Mir

Plenary Sessions

AUA Lecturer recognition Award 2023

J. Denstedt, London, Canada

- From left to right: S. Ferretti, J. Denstedt, T. Knoll

New EAU Honorary Members 2023

M. Roobol, Rotterdam, The Netherlands

Handed out by C. Chapple

A. De La Taille, Créteil, France - Handed out by C. Chapple

H. Haas, Heppenheim, Germany - Handed out by C. Chapple

C. Evans, Sacramento, United States of America - Handed out by C. Chapple

A. Chiu, Taipei, Taiwan - Handed out by C. Chapple

A. Rodríguez, Winston Salem, United States of America - Handed out by C. Chapple

at the 38th Annual EAU Congress

Top-3 Best Patient Poster Award 2023 – 1st place prize

R. Giles, Duivendrecht, The Netherlands

- Handed out by M. Jewett

Patient Day

Friday, 10 March

Best paper published in 2023 by YAU

T. Piramide, Turin, Italy

- Handed out by J. Gómez Rivas

YAU Meeting

Friday, 10 March

Section Awards

Saturday, 11 March

Prize for the Best Paper published on Fundamental Research in the Urological Literature

L. Au, E. Hatipoglu, M. Robert De Massy, K. Litchfield, G. Beattie, A. Rowan, D. Schnidrig, R. Thompson, F. Byrne, S. Horswell, N. Fotiadis, S. Hazell, D. Nicol, S. Shepherd, A. Fendler, R. Mason, L. Del Rosario, K. Edmonds, K. Lingard, S. Sarker, M. Mangwende, E. Carlyle, J. Attig, K. Joshi, I. Uddin, P. Becker, M. Werner Sunderland, A. Akarca, I. Puccio, W. Yang, T. Lund, K. Dhillon, M. Vasquez, E. Ghorani, H. Xu, C. Spencer, J. López, A. Green, U. Mahadeva, E. Borg, M. Mitchison, D. Moore, I. Proctor, M. Falzon, L. Pickering, A. Furness, J. Reading, R. Salgado, T. Marafioti, M. Jamal-Hanjani, on behalf of the PEACE Consortium, G. Kassiotis, B. Chain,J. Larkin, C. Swanton, S. Quezada, S. Turajlic (London, Sutton, United Kingdom; Bizkaia, Spain; Melbourne, Australia; Antwerp, Belgium)

For the paper: “Determinants of anti-PD-1 response and resistance in clear cell renal cell carcinoma” Cancer Cell 39 (2021); https://doi.org/10.1016/j.ccell.2021.10.001

- Handed out by C. Chapple

First Prize for the Best Abstract (Oncology)

A. Contreras-Sanz, M. Reike, G. Negri, Z. Htoo, S. Spencer Miko, K. Nielsen, M. Roberts, J. Scurll, K. Ikeda, G. Wang, R. Seiler, G. Morin, P. Black (Vancouver, Canada)

For the abstract: “Proteomic profiling of muscle invasive bladder cancer treated with neoadjuvant chemotherapy”

- Accepted by M. Reike, handed out by A. Stenzl

First Prize for the Best Abstract (Non-Oncology)

M. Kasten, O. Gross, M. Wettstein, C. Anderson, V. Birkhäuser, J. Borer, M. Koschorke, S. Mccallin, U. Mehnert, H. Sadri, L. Stächele, T. Kessler, L. Leitner (Zürich, Switzerland)

For the abstract: “Similar artefact susceptibility for water- and airfilled urodynamic systems: Results from a randomized controlled non-inferiority trial”

Supported by the IBSA

- From left to right: A. Stenzl, M. Kasten, G. Villa (IBSA)

Top-3 Best Patient Poster Award 2023 – 2nd place prize

A. Filicevas, Brussels, Belgium

Top-3 Best Patient Poster Award 2023 – 3rd place prize

A. Lawler, London, United Kingdom

Best abstract published in 2023 by YAU

G. Gandaglia, Milan, Italy

Best reviewer published in 2023 by YAU

R. Bertolo, Rome, Italy

Prize for the Best Paper published on Clinical Research in the Urological Literature

G. Basile, M. Bandini, E. Gibb, J. Ross, D. Raggi, L. Marandino, T. Costa De Padua, E. Crupi, R. Colombo, M. Colecchia, R. Lucianò, L. Nocera, M. Moschini, A. Briganti, F. Montorsi, A. Necchi (Milan, Italy; Vancouver, Canada; Massachusetts, New York, United States of America)

For the paper: “Neoadjuvant Pembrolizumab and Radical Cystectomy in Patients with Muscle-Invasive Urothelial Bladder Cancer: 3-Year Median Follow-Up Update of PURE-01 Trial” Clin Cancer Res (2022); https://doi.org/10.1158/1078-0432.CCR-22-2158040

- Handed out by C. Chapple

Award Gallery

Saturday, 11 March

Second Prize for the Best Abstract (Oncology)

C. Micoli, A. Crippa, A. Discacciati, H. Vigneswaran, T. Palsdottir, M. Clements, M. Aly, J. Adolfsson, W. Fredrik, P. Wiklund, T. James, J. Lindberg, H. Grönberg, L. Egevad, T. Nordström, M. Eklund (Solna, Sweden)

For the abstract: “The Stockholm3 prostate cancer screening trial (STHLM3): An interim analysis of mortality results after 6.5 years of follow-up”

- Handed out by A. Stenzl

Best Scientific Paper Award 2023 published in European Urology

S. Siva, M. Bressel, S. Wood, M. Shaw, S. Loi, S. Sandhu, B. Tran, A. Azad, J. Lewin, K. Cuff, H. Liu, D. Moon, J. Goad, L-M. Wong, M. LimJoon, J. Mooi, S. Chander, D. Murphy, N. Lawrentschuk, D. Pryor (Melbourne, Brisbane, Australia)

For the paper: “Stereotactic Radiotherapy and Short-course Pembrolizumab for Oligometastatic Renal Cell Carcinoma— The RAPPORT Trial”

European Urology; Volume 81, Issue 4, P364-372, April 1, 2022

Supported by ELSEVIER

- From left to right: J. Catto, D. Murphy on behalf of S. Siva, B. Chen (ELSEVIER)

ESTU René Küss Prize 2023

V. Gomez Dos Santos, Madrid, Spain

- From left to right: E. Lledo Garcia, V. Gomez Dos Santos, M. Musquera Felip

ESUO Helmut Haas Award 2023

H. Heers, Marburg, Germany

- Handed out by H. Haas

Overview of prizes and awards

Best Paper Award 2023 published on Fundamental Research in European Urology

K. Welén, E. Rosendal, M. Gisslén, A. Lenman, E. Freyhult, O. Fonseca-Rodríguez, D. Bremell, J. Stranne, Å. Balkhed, K. Niward, J. Repo, D. Robinsson, A. Henningsson, J. Styrke, M. Angelin, E. Lindquist, A. Allard, M. Becker, S. Rudolfsson,R. Buckland, C. Carlsson, A. Bjartell, A. Nilsson, C. Ahlm, A-M. Connolly, A. Överby, A. Josefsson (Gothenburg, Umea, Uppsala, Lingkoping, Jonkoping, Malmo, Sweden)

For the paper: “A Phase 2 Trial of the Effect of Antiandrogen Therapy on COVID-19

Outcome: No Evidence of Benefit, Supported by Epidemiology and In Vitro Data”

European Urology; Volume 79, Issue 1, Pages 16-19

Supported by ELSEVIER

- From left to right: J. Catto, K. Welen, A. Josefsson. B. Chen (ELSEVIER)

First Prize Best Paper Award 2023 published on Robotic Surgery in European Urology

G. Marra, M. Agnello, A. Giordano, F. Soria, M. Oderda, C. Dariane, M. Timsit, J. Branchereau, O. Hedli, B. Mesnard, D. Tilki, J. Olsburgh, M. Kulkarni, V. Kasivisvanathan, A. Breda, L. Biancone, P. Gontero (Turin, Italy; Paris, Nantes, France; Hamburg, Germany; Istanbul Turkey; London, United Kingdom, Barcelona Spain)

For the paper: “Robotic Radical Prostatectomy for Prostate Cancer in Renal Transplant Recipients: Results from a Multicenter Series” European Urology, Volume 82, issue 6, Pages 639-645

Supported by the VATTIKUTI FOUNDATION

- From left to right: J. Catto, G. Marra, M. Bhandari (VATTIKUTI FOUNDATION)

Best Paper Award 2023 published on Clinical Research in European Urology

L. Harper, T. Blanc, M. Peycelon, J. Michel, M. Leclair, S. Garnier, V. Flaum, A. Arnaud, T. Merrot, E. Dobremez, A. Faure, L. Fourcade, M. Poli-Merol, Y. Chaussy, O. Dunand, F. Collin, L. Huiart, C. Ferdynus, F. Sauvat (Saint Denis De La Réunion, Bordeaux, Paris, Nantes, Montpellier, Rennes, Marseille, Limoges, Reims, Besançon, Saint-Pierre, France)

For the paper: “Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves:

Result of the CIRCUP Randomized Trial”

European Urology; Volume 81, Issue 1, P64-72

Supported by ELSEVIER

- From left to right: J. Catto, T. Loubersac on behalf of L. Harper, B. Chen (ELSEVIER)

Second Prize Best Paper Award 2023 published on Robotic Surgery in European Urology

H. De Barros, M. Van Oosterom, M. Donswijk, J. Hendrikx, A. Vis, T. Maurer, F. Van Leeuwen, H. Van Der Poel, P. Van Leeuwen (Amsterdam, Leiden, The Netherlands; Hamburg, Germany)

For the paper: “Robotic-assisted prostate-specific Membrane

Antigen-radioguided Salvage Surgery in Recurrent Prostate

Cancer Using a DROP – IN Gamma Probe: The First Prospective Feasibility Study”

European Urology, Volume 82, Issue 1, Pages 97-105, July 1, 2022

Supported by the VATTIKUTI FOUNDATION

- From left to right: J. Catto, A-C. Berrens on behalf of H. De Barros, Dr. M. Bhandari (VATTIKUTI FOUNDATION)

Resident’s Corner Awards - Awards for the two Best Scientific Papers published in European Urology by residents

K. Meghani, L. Cooley, B. Choy, M. Kocherginsky, S. Swaminathan, S. Munir, R. Svatek, T. Kuzel, J. Meeks (Chicago, San Antonio, United States of America)

For the paper: “First-in-human Intravesical Delivery of Pembrolizumab Identifies Immune Activation in Bladder Cancer Unresponsive to Bacillus Calmette-Guérin”

European Urology, Volume 82, Issue 6, P602-610, December 1, 2022 - no picture available

Award Gallery

Saturday, 11 March

D. Mucharski, Krakow, Poland

- From left to right: J. Vasquez, D. Mucharski, D. Carrión Monsalve

First Prize EAU Guidelines Cup 2023

K. Beyer, L. Moris, M. Lardas, M. Omar, J. Healey, S. Tripathee, G. Gandaglia, L. Venderbos, E. Vradi, T. Van Den Broeck, P-P. Willemse, T. Antunes-Lopes, L. Pacheco-Figueiredo, S. Monagas, F. Esperto, S. Flaherty, Z. Devecseri, T. Lam, P. Williamson, R. Heer, E. Smith, A. Asiimwe, J. Huber, M. Roobol, J. Zong, M. Mason, P. Cornford, N. Mottet, S. MacLennan, J. N’Dow, A. Briganti, S. MacLennan, M. Van Hemelrijck, on behalf of the PIONEER Consortium (London, Aberdeen, Liverpool, Newcastle-upon-Tyne, Cardiff, United Kingdom; Leuven, Belgium; Athens, Greece; Milan, Rome, Italy; Rotterdam, Utrecht, Arnhem, The Netherlands; Berlin, Dresden, Germany; Porto, Braga, Portugal; Leon, Spain; Paris, St. Etienne, France; Massachusetts, New Jersey, United States of America)

For the paper: “Updating and Integrating Core Outcome Sets for Localised, Locally Advanced, Metastatic, and Nonmetastatic Castration-resistant Prostate Cancer: An Update from the PIONEER Consortium”

European Urology, Volume 81, Issue 5, P503-514, May 1, 2022

- From left to right: J. Catto, K. Beyer, L. Moris

Second Prize EAU Guidelines Cup 2023

L. Albers, Rotterdam, The Netherlands

-

YUORDay23 Saturday, 11 March

L. Tzelves, Athens, Greece

- From left to right: J. Vasquez, L. Tzelves, D. Carrión Monsalve

Third Prize EAU Guidelines Cup 2023

Audience Prize EAU Guidelines Cup 2023

G. Margue, Bordeaux, France

- Handed out by J. Vasquez

EUSP Best Scholar Award 2023

Y. Abu Ghanem, Ramat Gan, Israel

- Handed out by A. Merseburger

Second Prize for the Best Abstract by a resident

N. Rahav, M. Udah, S. Cohen, B. Chertin, O. Shenfeld (Jerusalem, Israel)

For the abstract: ”Proximal urethrostomy (PU) versus urethroplasty (U) for complex urethral strictures (CUS)

- From left to right: J. Vasquez, N. Rahav, E. Checcucci, D. Carrión Monsalve

First Prize for the Best Abstract by a resident

A. Ng, F. Giganti, A. Asif, V. Chan, M. Rossiter, A. Nathan, P. Khetrapal, L. Dickinson, S. Punwani, C. Brew-Graves, A. Freeman, M. Emberton, C. Moore, C. Allen, V. Kasivisvanathan, Q. Prime (London, United Kingdom)

For the abstract: “Global variation in the quality of multiparametric magnetic resonance imaging of the prostate from the PRIMEtrial (the glimpse study)

- From left to right: E. Checcucci, A. Ng, D. Carrión Monsalve, J. Vasquez

Third Prize for the Best Abstract by a resident

F. Möller, M. Månsson, J. Wallström, M. Hellström, J. Hugusson, R. Arnsrud Godtman (Skövde, Gothenburg, Sweden)

For the abstract: “Prostate cancers detected in the PSA interval 1.8-3 ng/mL - results from the Göteborg 2 prostate cancer screening trial

- From left to right: E. Checcucci, F. Möller, D. Carrión Monsalve, J. Vasquez

From left to right: J. Vasquez, L. Albers, D. Carrión Monsalve

Saturday, 11 March

First Video Prize

S. Cho, J. Kim, B. Cheon, J. Han, D-S. Kwon, J. Lee (Seoul, South Korea)

For the video: “V40: Multi-center, prospective, single arm, pivotal study to evaluate the efficacy and safety of robotic-assisted surgery easyuretero-100 in patients in need of retrograde intrarenal surgery

- Handed out by F. Van Der Aa

Second Video Prize

C. Yee, P. Lam, Y. Hong, P. Lai, Y. Tam, T. Ng, S. Yuen, M. Tam, C. Chan, K. Lo, J. Teoh, P. Chiu, C. Ng (Hong Kong, China)

For the video: “V83: Robotic augmentation cystoplasty: 1-year outcome of the anterior and posterior approaches

- Accepted by C-F. Ng; handed out by F. Van Der Aa

The European Urology Platinum Awards 2023

Best Booth Award 2023

Ipsen Pharma

Video Session

Sunday, 12 March

Third Video Prize

A. Ta, J. Olphert, W. Tan, M. Alkhamees, G. Shaw, A. Sridhar, J. Kelly (London, United Kingdom)

For the video: “V16: Technique and outcomes from prostate capsule-sparing during robotic male cystectomy

- Accepted by J. Olphert; handed out by F. Van Der Aa

International Friendship Dinner

Sunday, 13 March

M. Albersen, Leuven, Belgium

- Handed out by J. Catto

J-N. Cornu, Rouen, France

- Handed out by J. Catto

First Prize for the Best Practice development-oriented Poster Presentation

C. Oliveira, S. Ross, C. Gkika, C. Molokwu (Bradford, United Kingdom)

For the poster: “Prediction of missed clinically significant prostate cancer after adoption of new prostate specific antigen (in mcg/L) referral guidelines”

Supported by HOLLISTER

- From left to right: R. Zonderland (HOLLISTER), A. Semedo, who received the prize on behalf of C. Oliveira, P. Allchorne

Second Prize for the Best Practice development-oriented Poster Presentation

R. Dalton, R. McConkey, T. Kelly, G. Rooney, M. Healy, L. Murphy, M. O'Loughlin, M. Dowling (Galway, Roscommon, Limerick, Ireland)

For the poster: "Establishing a journal and research club to support urology nursing research culture"

Supported by HOLLISTER

- From left to right: Paula Allchorne, R. Zonderland (HOLLISTER), T. Kelly, who received the prize on behalf of R. Dalton

International EAUN Meeting

Monday, 13 March

First Prize for the Best Science-oriented Poster Presentation

C. Cassells, C. Semple, S. Bingham (Dundonald, Jordanstown, Antrim, United Kingdom)

For the poster: "Maximising sexual wellbeing | cancer care

e-Learning resource: Healthcare professionals’ views on acceptability, utility and recommendations for implementation“

- From left to right: P. Allchorne, C. Cassells, J. Verkerk-Geelhoed

Prize for the Best EAUN Nursing Research Project Presentation

G. Villa, S. Trapani, S. Gnecchi, A. Poliani, D.F. Manara (Milan, Rome, Italy)

For the research project: “Female urge urinary incontinence in an Italian tertiary referral university and research hospital: A prevalence study”

- Handed out by P. Allchorne

A. Mottrie, Aalst, Belgium

- Handed out by J. Catto

G. Novara, Padova, Italy

- Handed out by J. Catto

T. Morgan, Ann Arbor, United States of America

A. Vickers, New York, United States of America

- From left to right: H. Clinton, C. Chapple, P. Cabri

EAU23 Patient Day shifts the focus to shared decision-making

Poster Sessions and roundtables on survivorship, cystitis and patient-physician communication

By Kevin McBride

This year patients took the spotlight at EAU23, with representation across the scientific programme, three roundtables, and the first EAU Patient Advocacy Medal of Excellence.

Roundtable discussion: Patient-physician communication

Dr. Rachel Giles from the International Kidney Cancer Coalition (IKCC), winner of the EAU Patient Advocacy Medal of Excellence, built on her momentum by opening the day’s first roundtable discussion “Patient-Physician Communication” by underlining how patient engagement interventions save lives.

There is a large body of RCT-based evidence that patient engagement interventions improve qualitative outcomes, including quality of life, anxiety, depression, compliance and fatigue. Data suggests a survival benefit for engaged patients, and early data is very promising, but the interdisciplinary consensus at the first roundtable of EAU23’s Patient Day agreed that the subject demands greater attention and additional research is required. It is crucial for both medical experts and patients to recognise that contemporary patient advocacy must take a comprehensive and holistic approach, encompassing not only direct support for patients, but also guidance for research initiatives and influence over the healthcare and regulatory policies that affect patients' lives.

To help understand where patient-physician communication breaks down, social psychologist Tamás Bereczky pointed to the hierarchical nature of healthcare and how that facilitates barriers to functional patient-physician communication. The healthcare system often places doctors on the top of a hierarchy, while patients are often “reduced to a number or a line on an Excel sheet.” This creates a system of epistemic injustice, as the patient’s experience can be invalidated on the basis of their hierarchical status.

The roundtable concluded with some best practices should include tackling paternalistic and hierarchical approaches, educating both physicians and patients, limiting jargon and using empathy. Patient experts recommended shifting from only considering “hard” outcomes, like time limits and financial constraints, to including soft

outcomes like a patient’s emotional state and understanding of their medical situation. It was agreed by all that this fundamental issue needs to be tackled early on in specialists’ medical journeys, potentially starting with training in medical school, and that the subject needs more research and specific, clear guidelines targeting patient education and communication.

Surviving urological cancer and chronic disability from urological disease

Survivorship was the focus of the day’s second roundtable, as the panel discussed the needs of patients suffering from chronic urological illness and addresses strategies that empower them to manage their disability in partnership with healthcare professionals.

Dr. Christian Schulz-Quach discussed the mental health consequences of survivorship and why urological patients are particularly vulnerable. “Now turn to your neighbour and discuss your genitals”

Dr. Schulz-Quach directed the audience to demonstrate the sociological element to protecting our genitals. Urological patients are particularly hesitant to actively engage, so physicians need to open the dialogue and understand the mental health issues their patients may be experiencing and additionally must give communication tools to help handle shame.

patients, particularly when their condition does not align with their gender.

Roundtable discussion: What is cystitis?

Ms. Jane Meijlink from the International Painful Bladder Foundation (IPBF) opened the discussion with a monologue on the convoluted, and often contradictory web of taxonomy and nomenclature of cystitis. The history of misunderstandings around cystitis led to an intricate and misleading vocabulary around cystitis, confusing for even experienced physicians, let alone patients.

The Patient Office further had representation across one plenary session: Controversies on EAU Guidelines II: Testicular and bladder cancer and stones, by Rob Cornes from ORCHID and two thematic sessions: Locally advanced BCa: Misconception of informed consent, by Lydia Makaroff from the WBCPC and EAU Guideline session: Non-neurogenic female LUTS, by Monica De Heide from BekkenBodum4All.

Further compounding breakdowns in communication are the taboos around discussing sexual dysfunction or conditions in gender nonconforming persons. Erik Briers emphasised the need to adequately inform patients about the risks to sexual health when treating male cancers. “Libido loss is not a side effect, but a consequence of ADT.”

Lydia Makaroff from the World Bladder Cancer Patient Coalition (WBCPC) discussed how these problems are amplified in gender nonconforming

Interstitial Cystitis has a wide array of debilitating symptoms that can be easily misdiagnosed due to their lack of uniformity as Anna De Santis from the European Reference Network (ERN), eUROGEN, discussed. Between the dizzying array of terminology and symptoms, patient engagement and physician awareness are crucial to improving patient outcomes.

Patient representation across the congress

The Patient Office participated in multiple sessions throughout the congress. The Patient Office hosted a sold out Clinical Leadership Development Workshop: Educating clinicians on the value and benefits of patient empowerment and engagement.

The Patient Lounge served as a homebase for patient advocates to network, and recharge for more sessions. Patient Day at EAU23 was a resounding success and the Patient Office is already hard at work ensuring more is to come.

Urological patients’ presentations

2022 Global Patient Survey: Reported experience of diagnosis, management, and burden of renal cell carcinomas in >2,200 patients from 39 countries

Rachel Giles

Best Patient Poster Presentation: First Prize

A comprehensive summary of patient and caregiver experiences with bladder cancer: Results of a survey from 49 countries

Alex Filicevas

• Best Patient Poster Presentation: Second Prize

How can we improve patient-clinician communication in men diagnosed with prostate cancer?

•Ailbhe Lawlor

Best Patient Poster Presentation: Third Prize

Commitment to collaboration in continence care

•Lynne Van Poelgeest-Pomfret

Importance of shared decision making in prostate cancer to ensure that patients and clinicians recognize and address patients’ treatment goals

•Ernst-Günther Carl

Collection of patient reported outcomes in daily clinical practice – experiences from a prostate cancer network

•Lionne Venderbos

“In today’s world it seems irresponsible and patientunfriendly to keep changing the name of a disease. Time for global consensus on the name and definition, and a truly patient-centric approach.”

Patient lounge in the EAU23 Exhibition

Impressions from Patient Day

Patient Advocacy Medal of Excellence – R. Giles

Prof. Oliver Hakenberg Section editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 74

This 70-year-old man underwent left radical nephrectomy with cavotomy and extraction of a long intracaval tumour thrombus extending into the atrium in April 2022. The operation was performed together with cardiac surgeons and went well.

The histology was clear cell renal carcinoma and some parts of the tumour thrombus had been adherent to the vena cava. Post-operative recovery was prolonged and complicated by a pulmonary embolism.

Now the patient presents with a follow-up CAT scan showing extensive recurrence of the intracaval tumour thrombus, again extending into the right atrium.

Discussion point:

What management is possible and advisable?

Surgery with or without neoadjuvant treatment

Comments by Prof. Axel Heidenreich Köln (DE)

Reflecting the medical data given and the 2 CT images presented, we have to consider the following issues with regard to the most appropriate second-line management

• the tumour thrombus was removed completely during the first surgery so recurrence could be due an infiltration of the wall of the inferior vena cava resulting in subsequent re-growth

• just interpreting the abdominal CT image, the left renal vein seems to be in place with a local recurrence, which is quite unique since the vein needs to be resected including the left caval orifice of the renal vein at time of thrombus surgery

• postoperative pulmonary embolism could have been due to tumour thrombus material or due to a classical apposition thrombus

• postoperative recovery was prolonged for reasons we do not know (blood loss, comorbidities, SIRS, etc.), but which have to be integrated in the decision-making process with regard to the next step of treatment

• postoperative adjuvant immune-oncological therapy with pembrolizumab was not delivered

The next step of treatment could be first line immune-oncological therapy, redo surgery or a combination of neoadjuvant immuno-oncological therapy followed by surgery.

What I need to know prior to the next step of therapy

• pre-existing comorbidities and physical fitness of the patient.

• presence, localisation and extent of the potential infiltration of the wall of the inferior vena cava. The thrombus looks like a floating thrombus in the right atrium, but I cannot identify the true extent of the intracaval thrombus. Therefore, MRI scan and an transoesophageal echocardiography should be performed since this information will dictate the primary treatment approach. Infiltration of the IVC above the diaphragm would be a severe contraindication for a surgical approach.

• presence of or absence of metastatic systemic disease

Case provided by Prof. Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany.

E-mail: oliver.hakenberg@med.uni-rostock.de

Treatment options

Surgery is an option if the patient is in good general health and if the thrombus is only partially infiltrating the IVC wall below the diaphragm. In this scenario, the IVC can be replaced by a venous prosthesis (Figure 1). Our own data on redo surgery of intracaval relapses of tumour thrombi are good with long-term cure in all patients. Surgery will effectively prevent future complications to local growth

such as blockage or infiltration of the right renal vein, blockage of the liver veins (Budd Chiari syndrome), repetitive haematuria, to name a few. However, surgery in this situation is complicated, extensive and needs the presence of a multidisciplinary team involved in a 2-cavitary approach with cavotomy and cardiopulmonary bypass surgery. A mere transperitoneal of thoraco-abdominal approach (which is our preference in first line surgery), will not be able to completely resect the thrombus. The perioperative mortality is in the range of 2-5% and 90 day mortality is in the range of about 15%. Due to the high risk of systemic relapse, adjuvant immuno-oncological treatment with pembrolizumab should be initiated postoperatively.

Neoadjuvant systemic therapy with the combination of ipilimumab/nivolumab or PD-L1 inhibitors plus multityrosine kinase inhibitors might be another option. However, response rates are low and the tumour thrombus shrinkage is reported in the range of about 10%, which usually does not result in significant reduction of the difficulties of surgery. Treatment-associated side effects have to be considered as the fact that any progression will result in the impossibility to completely resect the thrombus with the negative consequences reported above. If a partial response would be achieved after four cycles of treatment, surgery can be performed with a lesser rate of complications.

Stereotactic ablative radiation therapy might represent an individual and still experimental approach. However, the current series describe a response rate of 58% with a palliation of symptoms in all patients. Treatment associated side effects are low and only grade 1-2 side effects have been described. The median overall survival is 34 months which is not poorer as compared to surgery alone. Depending on the extent and size of the residual tumour thrombus, second line surgery can still be performed after radiation therapy.

In my view, redo surgery represents the treatment modality with the highest chance for cure, but also with the highest probability of severe, life-threating complications.

A surgical approach with assistance of both the liver transplantation and cardiothoracic teams

Comment by Prof. Kilian Walsh Galway (IE)

The original surgery was performed with the assistance of cardiothoracic surgery and I assume the patient was put on cardiopulmonary bypass for the procedure.

As you stated, technically the procedure went well and the patient has recovered from his pulmonary embolism. The present CAT scan shows caval recurrence, the options include a biotherapy regimen with a combination of oncological agents, but I would favour a surgical approach and utilise the assistance

of both the liver transplantation and cardiothoracic teams.

The liver transplant team usually have donor IVC from a previous retrieval, but if they do not, they can utilise a PTFE graft. After mobilisation of the liver they can resect the IVC and replace it with donor IVC tissue or a PTFE graft. When the IVC is clamped the tongue of tissue in the atrium can fall back into the IVC with a reduction of flow and a vascular clamp can be applied above the level of the thrombus. This will give a 30 to 40 minute window to resect and replace the IVC with graft and if necessary anastomose the left renal vein back into the graft. However, if

you are unable to get a clamp above the level of the thrombus, then the patient can be put on cardiopulmonary bypass so that the cardiothoracic team can open the atrium and milk the thrombus back into the IVC. This gives the liver transplant team more time for resection and anastomosis, and they will not have to work against the clock.

I know this is possible as we performed such a case when I was a Consultant Urologist at King's College Hospital in London and the case went well. Sadly, my present institution in University Hospital Galway does not have liver transplantation, so I would have to refer to a suitable centre, but I believe surgery is the best option for this patient.

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. 75

A 28-year-old man complained of dysuria 3 weeks after a ureteroscopy with fragmentation of a ureteric stone. A urethrogram showed a bulbar stricture and direct vision internal urethrotomy was performed. Due to an intraoperative false passage, the indwelling urethral catheter was left in situ for one week. Three months later, the patient still has a weak urinary stream. The current urethrogram is attached.

Discussion point:

• What treatment is advisable?

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

Case study No. 74 continued

The patient underwent surgery together with the cardiothoracic team. With cardiopulmonary bypass, the intracaval thrombus was removed; however, the intraatrial part of the thrombus was adherent to the wall of the atrium and had to be dissected after opening the atrium. Thus, the resection had to be considered incomplete at least on the microscopic level (R1).

Histology again showed renal cell carcinoma, partially necrotic. The patient recovered well from surgery and was discharged after 8 days. Adjuvant immunotherapy was recommended.

Fig. 1

Fig. 2

Fig. 1 Retrograde

Fig. 2 Antegrade

Fig. 1: Replacement of the subdiaphragmatic IVC and part of the left renal vein for relapsing intracaval thrombus

Key articles from international medical journals

RM (inter-patient variability) was closely related to adverse allograft outcomes, and hence, more attention must be given to pre-transplant PRA-positive patients.

Source: Combined impact of the inter and intra-patient variability of tacrolimus blood level on allograft outcomes in kidney transplantation.

Yohan Park, Hanbi Lee, Sang Hun Eum, Eun Jeong Ko, Ji Won Min, Se-Hee Yoon, Won-Min Hwang, Sung-Ro Yun, Chul Woo Yang, Jieun Shin, Byung Ha Chung.

Front Immunol 2022 Nov 16;13:1037566. doi: 10.3389/fimmu.2022.1037566. eCollection 2022.

No opioid strategy is feasible after major urologic surgery

Opioid analgesics have been correlated with an increased rate of death in the US. Such prescriptions after surgery remain a major contributor to the opioid misuse crisis, potentially leading to inadequate chronic use or overdose-related deaths.

High variability of tacrolimus trough levels impacts allograft outcomes

Tacrolimus (TAC) has been widely used as an immunosuppressant after kidney transplantation (KT). However, the combined effects of intra-patient variability (IPV) and inter-patient variability of TAC-trough level (C0) in blood remains controversial. This study aimed to determine the combined impact of TAC-IPV and TAC inter-patient variability on allograft outcomes of KT.

“Considerable tacrolimus serum level variations contribute to adverse allograft outcomes.”

In total, 1,080 immunologically low-risk patients who were not sensitised to donor human leukocyte antigen (HLA) were enrolled. TAC-IPV was calculated using the time-weighted co-efficient variation (TWCV) of TAC-C0, and values > 30% were classified as high IPV. Concentration-to-dose ratio (CDR) was used for calculating TAC interpatient variability, and CDR < 1.05 ng•mg/mL was classified as rapid metabolisers (RM). TWCV was calculated based on TAC-C0 up to 1 year after KT, and CDR was calculated based on TAC-C0 up to 3 months after KT. Patients were classified into four groups according to TWCV and CDR: low IPV/ non-rapid metaboliser (NRM), high IPV/NRM, low IPV/RM, and high IPV/RM. Subgroup analysis was performed for pre-transplant panel reactive antibody (PRA)-positive and negative patients (presence or absence of non-donor-specific HLA-antibodies). Allograft outcomes, including death-censored graft loss and biopsy-proven allograft rejection were compared.

The incidences of death-censored graft loss, allograft rejection and overall graft loss were the highest in the high-IPV/RM group. In addition, a high IPV/RM was identified as an independent risk factor for death-censored graft loss. The hazard ratio of high IPV/RM for death-censored graft loss and the incidence of active antibody-mediated rejection were considerably increased in the PRA-positive subgroup.

The authors conclude from their results that high intra-patient variability combined with

In this prospective study, the authors have designed an intervention protocol aiming at avoiding any opioid prescriptions at discharge after major urologic surgery (nephrectomy, cystectomy, radical prostatectomy). The primary outcome was the number of patients receiving any opioid prescription and the opioid dose prescribed per patient. Secondary outcome measures included the need for additional opioid prescriptions, patient-reported outcomes, unplanned health care utilisation (telephone calls, clinic or emergency department visit, re-admissions), and complication rates.

The control (preintervention) group included 202 patients, from May 2017 to December 2018, who were given opioid prescriptions (dose, duration) at the discretion of discharging health care professional. In the initial feasibility, patients were given a 1-page informational handout that explained the rationale for avoiding opioids and using nonopioid medications for post-operative pain control. The opioid prescriptions were at the discretion of the prescribers who were given instructions to try to limit opioid prescriptions to four days or fewer. For the intervention (ie, NOPIOIDS group with 384 patients), a standardised workflow included preferential use of nonopioid analgesics during hospital stay using electronic order sets, with instructions to prescribers (via email). Instructions were repeated when staff rotations changed. In addition, an instruction sheet with visual guidance for use at home was provided at discharge.

inadequate pain control were similar between the controls. No patients in any group required an unplanned visit to the clinic or emergency department due to pain. The overall 30-day complication rates were similar between groups, ranging from 16% to 21 (P = .69).

This study shows that an improved perioperative protocol may virtually eliminate opioid prescriptions after major abdominopelvic surgery. Preoperative patient engagement to set appropriate expectations and post-discharge analgesic instructional handout made this intervention readily acceptable by the prescribers and the patients. Some limitations may be highlighted such as the lack of patient-reported outcomes data for the control group and only from a small number in the lead-in group. However, this prospective, interventional study clearly demonstrates that a perioperative program involving both patients and caregivers, focusing on education and team engagement may drastically change the prescription of opioids after major abdominopelvic cancer surgery without adversely affecting pain control, complications, or recovery.

Source: Implementation and assessment of no opioid prescription strategy at discharge after major urologic cancer surgery. Mian BM, Singh Z, Carnes K, Lorenz L, Feustel P, Kaufman RP Jr, Avulova S, Bernstein A, Cangero T, Fisher HAG. JAMA Surg. 2023 Feb 8:e227652. doi: 10.1001/jamasurg.2022.7652. Epub ahead of print. PMID: 36753170; PMCID: PMC9909575.

Which laser is better for the endoscopic treatment of stone disease?

Technology in urological endoscopy continually evolves. Advances involve the use of new lasers for the fragmentation, dusting, and vaporisation of urinary stones.

Thulium Fibre Laser (TFL) has been recently introduced in the market as an effective alternative to the Holmium-YAG lasertripsy due to its high-absorption coefficient (four times higher than holmium), substantial versatility in terms of range of settings, and physical characteristics allowing for thinner fibres as small as 50 µm. TFL has been proposed as the ideal solution not only for the lasertripsy of urinary stones but also for other applications on soft tissue (e.g. prostate enucleation, ablation of upper tract urothelial tumours, etc).

A number of in-vitro and in-vivo publications have shown a superiority of TFL over standard Ho:YAG laser for lasertripsy of urinary stones, even though several biases have been identified. None of them included the latest generation of Ho:YAG embedded with the so-called Moses technology, consisting in high-powered pulse-modulated Ho:YAG laser.

calculated sample size consisted of 45 patients per arm with a statistical power set to 80% to detect a difference of 6 minutes or more of operative time. Whether or not this primary endpoint reflects a meaningful clinical issue is out the aims of the present report.

Secondary endpoints included laser firing time, total laser energy, ablation efficiency (defined as total laser energy/stone volume), stone-free rates (defined as either no visible at all or <3mm stone fragments on KUB X-ray at four to eight weeks after JJ stent removal), complication rate and quality of life scores at WISQOL (Wisconsin Stone Quality of Life) questionnaire.

Inclusion criteria involved ureteric and renal stones of maximum 20 mm per stone without restriction of overall number of stones. In both patient groups, a 200 µm core laser-fibre was used with an initial default setting of 0.8 J and 8 Hz for fragmentation and 0.3 J and 80 Hz for dusting. However, surgeons were free to customise the settings during the surgeries according the circumstances.

Overall, no differences for baseline characteristics regarding patients (age, gender, ASA [American Society of Anesthesiology] score, etc) and stones (number, size, sites, overall volume burden, etc) details were recorded.

The null hypothesis was accepted, as no difference in terms of ureteroscope length of time was detected between groups (21.4 vs 19.9 minutes for Moses and TFL groups, respectively). Furthermore, no differences were reported for most of the secondary endpoints, including stone-free rate, complication rate, and QoL scores.

Nevertheless, lower total energy and higher ablation efficiency was observed in favour of the Moses group. According to the authors impressions, less ablation efficiency for the TFL laser was observed anecdotally in cases of harder/denser calcium stones; however, the increased need of energy for the TFL not necessarily translates to a higher risk for harms to patients.

Furthermore, the TFL potentiality is still to be fully explored, so that at the end of the study there is no “winner” but rather the confirmation that both laser are excellent options for stones lasertripsy.

Source: Pulse-modulated Holmium:YAG laser vs the thulium fiber laser for renal and ureteral stones: A singlecentre prospective randomised clinical trial. Christopher R Haas, Margaret A Knoedler, Shuang Li, Daniel R Gralnek, Sara L Best, Kristina L Penniston, Stephen Y Nakada J Urol . 2023 Feb;209(2):374-383. doi: 10.1097/JU.0000000000003050. Epub 2023 Jan 9.

Of 686 patients, 202 (29.4%) were in the control group, 100 (14.6%) were in the lead-in group, and 384 (56%) were in the NOPIOIDS group. Thirty-nine patients (5.7%) were using opioids prior to surgery. No difference in baseline patient characteristics was noted including the use of robotic approach among the groups. Among 647 opioid-naive patients, the proportion of patients receiving any opioid prescription at discharge decreased significantly from 80.9% in the control group, to 57.9% in the lead-in group, and 2.2% in the NOPIOIDS group, mainly for kidney surgery (p<.001). None of the 229 patients undergoing radical cystectomy or prostatectomy required any opioid prescriptions at discharge in the NOPIOIDS group. The number of calls related to

Recently, a randomised trial of a single institution has been conducted to test the efficacy of the latest generation of the two lasers (i.e. the TFL and the advanced pulse-modulated Ho:YAG [Moses]) at the same range of settings and conditions.

QPM assay: A promising rapid, first-stage tool for infection and AMR diagnosis

Effective antibiotics should be administered within one hour after diagnosis of severe urinary tract infections and sepsis. However, current state-of-the-art infection and antimicrobial resistance (AMR) diagnostics are based on culture-based methods with a detection time of 48–96hrs. Therefore, it is essential to develop novel methods that can provide real-time diagnoses. In this paper investigators demonstrate that the complimentary use of label-free optical assay with whole-genome sequencing (WGS) can enable rapid diagnosis of infection and AMR.

The primary endpoint was the ureteroscope time, calculated from the insertion of the scope (either semi-rigid or flexible ones) in the ureteric orifice. Accordingly, the

The presented assay is based on microscopy methods exploiting label-free, highly sensitive quantitative phase microscopy (QPM) followed by deep convolutional neural

"An improved peri-operative protocol may virtually eliminate opioid prescriptions after major abdominopelvic surgery."

"A lower ablation efficiency for the TFL laser was observed anecdotally in cases of harder/denser calcium stone."

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com

Prof. Francesco Sanguedolce Section editor Barcelona (ES) fsangue@ hotmail.com

Dr. Peter Østergren Section editor Copenhagen (DK)

peter.busch. oestergren@ regionh.dk

networks-based classification. The workflow was benchmarked on 21 clinical isolates from four WHO priority pathogens that were antibiotic susceptibility tested, and their AMR profile was determined by WGS.

systemic treatment options for mHSPC across patient subgroups in a “living” systematic review and network meta-analysis. The method of a living review is unique and allows for continuous evidence updates in part through advanced computer programming and artificial intelligence.

The proposed optical assay was in good agreement with the WGS characterisation. Accurate classification based on the gram staining was 100% recall for gram-negative and 83.4% for gram-positive, species identification was 98.6%, and assessment of resistant/susceptible type was 96.4%. At the individual strain level there was 100% sensitivity in predicting 19 out of the 21 strains, with an overall accuracy of 95.45%.

The results from this proof-of-concept study demonstrate the potential of the QPM assay as a rapid and first-stage tool for species and strain-level classification, and for detecting the presence or absence of AMR, which WGS can follow-up for confirmation. Overall, a combined workflow with QPM and WGS complemented with deep learning data analyses could, in the future, be transformative for detecting and identifying pathogens and characterisation of the AMR profile and antibiotic susceptibility.

The present paper demonstrates that use of label-free optical assay with whole-genome sequencing complemented with deep learning data analyses is a method of bacterial identification that warrants further studies as it has minimum dependencies on the still time-consuming approach of bacterial culturing.

Source: Highly sensitive quantitative phase microscopy and deep learning aided with whole genome sequencing for rapid detection of infection and antimicrobial resistance. Ahmad A, Hettiarachchi R, Khezri A, Singh Ahluwalia B, Wadduwage DN and Ahmad R. Front. Microbiol. 2023;14:1154620. doi: 10.3389/ fmicb.2023.1154620

Which men with metastatic hormone-sensitive prostate cancer should be offered triple therapy?

The treatment recommendations for metastatic hormone-sensitive prostate cancer (mHSPC) have changed dramatically in the last decade. New treatment combinations have shown compelling overall survival (OS) benefits, leading to a treatment intensification at this stage of the disease.

Last year, the results from PEACE-1 and ARASENS were published and guideline recommendations were changed. It is now recommended in the EAU Guidelines to offer docetaxel in combination with androgen deprivation therapy (ADT) plus an androgen pathway inhibitor (API) to men with mHSPC fit for docetaxel.

PEACE-1 and ARASENS were randomised clinical trials that investigated the addition of an API, abiraterone plus prednisone (AAP) and darolutamide respectively, to a backbone of ADT + docetaxel. The addition of an API provided an OS benefit over placebo. While the addition of an API to ADT + docetaxel has been shown to improve OS, it has not formally been shown if the addition of docetaxel to ADT + API infers similar OS benefits.

Riaz et al. sought to compare the current

The authors had a particular interest in comparing triplet therapy with an API + ADT. In all, 10 randomised clinical trials comprising 11,043 patients across nine unique treatment options were assessed. The triple therapy regimens were ranked the potentially most efficacious treatments for mHSPC. The patients that seemed to benefit the most were those with synchronous and high-volume mHSPC. Interestingly, the triple therapies were associated with better OS when compared with ADT + docetaxel, but not when compared with an API + ADT, i.e. ADT + enzalutamide, ADT + apalutamide or ADT + AAP. At the same time, the triple therapies were associated with a higher risk of Grade 3 and above adverse events.

and practising optimal toilet posture. These trials reported that few children experienced complete resolution of nocturnal enuresis (5 to 33%).

tebj@medisin.uio.no

The authors conclude that triple therapy may be preferred for men with high-volume synchronous mHSPC while omitting docetaxel may be preferred for metachronous low volume mHSPC. For those with high-volume metachronous disease or low-volume synchronous mHSPC an individualised risk-based approach must be taken.

This study highlights the importance of carefully selecting the right patients for triple therapy and considering the benefits versus potential harms of adding docetaxel to an API doublet with ADT. The extend of metastatic disease and time of metastatic presentation are some of the variables that may guide treatment selection. However, further efforts to individualise treatment and better understand the heterogeneity of mHSPC are warranted.

Source: First-line Systemic Treatment Options for Metastatic CastrationSensitive Prostate Cancer: A Living Systematic Review and Network Metaanalysis. Riaz IB, Naqvi SAA, He H, et al. JAMA Oncol. 2023 Mar 2:e227762. doi: 10.1001/jamaoncol.2022.7762.

The efficacy of standard urotherapy in the treatment of nocturnal enuresis in children is not well-supported by the current evidence

Initial conservative management of primary nocturnal enuresis (PNE) is about information and demystification. PNE involves mainly informing the family about urinary tract dysfunction and spontaneous resolution; lifestyle, and dietary changes (fluid intake and diet for constipation); registration of symptoms and voiding habits; and support and encouragement in children. PNE is usually the initial preferred treatment modality for many physicians and also other health personnel as it is conservative approach. There may be inconveniencies to employ them properly as it requires some strict life style changes such as fluid intake restriction.

The study includes a systematic literature search to look at the impact of this standard approach. Out of 2,476 studies 22 randomised controlled trial (RCT) studies were included to the study. Most other studies scored poorly in terms of evidence quality as studies combined several urotherapy interventions and studied different study populations. Twenty-two RCTs reported 0 to 92% of children being dry after standard urotherapy treatment. Three RCTs with the highest quality scores individualise and optimise drinking, voiding during the day,

There is insufficient evidence for offering standard urotherapy to children with PNE as first-line treatment modality. Until better evidence becomes available, considering other treatment modalities such as medical treatment or alarm treatment, may save time for children who are suffering from nocturnal enuresis.

The available literature in the field of standard urotherapy concerning the treatment of children with PNE lacks high level of evidence due to heterogeneity of the study populations and interventions. The limited number of high-quality studies does not really support the use of standard urotherapy for PNE.

Due to the presence of insufficient evidence for recommending standard urotherapy to children with PNE as a first-line treatment modality, other treatment options such as medical treatment or alarm treatment should be considered earlier especially for the patient group who suffers significantly.

Source: The efficacy of standard urotherapy in the treatment of nocturnal enuresis in children: A systematic review. Cecilie Siggaard Jørgensen, Konstantinos Kamperis, Johan Vande Walle, Søren Rittig, Ann Raes, Lien Dossche.

Journal of Pediatric Urology, Volume 19, Issue 2, 2023, Pages 163-172

Oral tebipenem pivoxil hydrobromide in complicated urinary tract infection

There is a need for oral antibiotic agents that are effective against multidrug-resistant gram-negative uropathogens. Tebipenem pivoxil hydrobromide is an orally bioavailable carbapenem with activity against uropathogenic Enterobacterales, including extended-spectrum beta-lactamaseproducing and fluoroquinolone-resistant strains.

In this phase 3, international, double-blind, double-dummy trial, the investigators evaluated the efficacy and safety of orally administered tebipenem pivoxil hydrobromide as compared with intravenous ertapenem in patients with complicated urinary tract infection or acute pyelonephritis. Patients were randomly assigned, in a 1:1 ratio, to receive oral tebipenem pivoxil hydrobromide (at a dose of 600 mg every 8 hours) or intravenous ertapenem (at a dose of 1 g every 24 hrs) for 7- 10 days (or up to 14 days in patients with bacteraemia). The primary efficacy end point was overall response (a composite of clinical cure and favourable microbiologic response) at a test-of-cure visit

(on day 19, within a ±2-day window) in the microbiologic intention-to-treat population. The noninferiority margin was 12.5%.

"…oral tebipenem pivoxil hydrobromide was noninferior to intravenous ertapenem in the treatment of complicated urinary tract infection…"

A total of 1372 hospitalised adult patients were enrolled; 868 patients (63.3%) were included in the microbiologic intention-totreat population (50.8% of whom had complicated urinary tract infections and 49.2% of whom had pyelonephritis). An overall response was seen in 264 of 449 patients (58.8%) who received tebipenem pivoxil hydrobromide, as compared with 258 of 419 patients (61.6%) who received ertapenem (weighted difference, -3.3 percentage points; 95% confidence interval [CI], -9.7 to 3.2). Clinical cure at the test-ofcure visit was observed in 93.1% of the patients in the microbiologic intention-to-treat population who received tebipenem pivoxil hydrobromide and 93.6% of patients who received ertapenem (weighted difference, -0.6 percentage point; 95% CI, -4.0 to 2.8); the majority of patients with microbiologic response failures at the test-of-cure visit were asymptomatic patients with recurrent bacteriuria. Adverse events were observed in 25.7% of patients who received tebipenem pivoxil hydrobromide and in 25.6% of patients who received ertapenem; the most common adverse events were mild diarrhoea and headache.

The authors conclude that oral tebipenem pivoxil hydrobromide was noninferior to intravenous ertapenem in the treatment of complicated urinary tract infection and acute pyelonephritis and had a similar safety profile. (Funded by Spero Therapeutics and the Department of Health and Human Services; ADAPT-PO ClinicalTrials.gov number, NCT03788967).

Source: Oral Tebipenem Pivoxil Hydrobromide in Complicated Urinary Tract Infection. Eckburg PB, Muir L, Critchley IA, Walpole S, Kwak H, Phelan A-M, Moore G, Jain A, Keutzer T, Dane A, Melnick D, Talley AK. N Engl J Med 2022 7;386(14):1327-1338. doi: 10.1056/NEJMoa2105462

Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

"Accurate classification based on the gram staining was 100% recall for gramnegative and 83.4% for gram-positive, species identification was 98.6%, and assessment of resistant/ susceptible type was 96.4%."

"Triple therapies were associated with better OS when compared with ADT + docetaxel, but not when compared with an API + ADT."

"Until better evidence becomes available, considering other treatment modalities such as medical treatment or alarm treatment, may save time for children who are suffering from nocturnal enuresis."

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

Prof. Oliver Reich Section editor Munich (DE) oliver.reich@ klinikum-muenchen.de

Prof. Serdar Tekgül Section Editor Ankara (TR) serdartekgul@ gmail.com

The touch that transforms

We believe the success of our science is measured by the lives we touch. So we are always working— pushing the boundaries of what’s possible to transform lives today and tomorrow.

Testis cancer therapy and fertility

Three challenging cases in the outpatient and office urology setting

brenneis-dr@gmx.de

helabio@yahoo.gr

In the case of a newly diagnosed malignant tumour, the initial focus is on the therapy strategies and chances of cure. Most patients with urological cancers have already concluded their family plans. However patients with malignant testicular tumours have a low age of predilection (15-35 years) and thus they are just prior to or during their reproductive age. Therefore, in addition to inquiries of further diagnostics, therapy, and prognosis, the question of further life planning with regard to the desire for children and fertility preservation should also be addressed during the diagnosis.

Since the cure rate of testicular tumour is almost 100% in predominantly young patients, the question of fertility preservation after completion of therapy is becoming increasingly important. Studies in gynaecology show that 76% of men and women wish to have a child after completion of therapy, however, only 12% felt adequately informed by the treating physician prior to therapy [1,2]. Since the primary diagnosis is usually made in the office or at the outpatient urology clinic, this specialist group has a high responsibility in terms of counselling this group of patients.

This fact is also taken into account by the EAU Guidelines on Testicular Cancer [3], which points out that the patient should be informed about fertilitypreserving measures during the diagnostic process. In particular, a pre-therapeutic ejaculate analysis should be performed if necessary. Furthermore, a hormone status (testosterone, FSH, LH) should be determined. Pretherapeutic sperm quality is often reduced in affected patients. Leydig cell insufficiency is also frequently present. Treatment of testicular carcinoma can further damage the reproductive function. However, sperm quality often recovers within 1-4 years after surgery, radiation, or chemotherapy depending on the doses of radiation and the type of the administered chemotherapy.

Case 1 - L.S. *1990

On September 2022, patient L.S. (born in 1990) presented to the urology office with painless right testicular enlargement. In his medical history he reported a bilateral orchidopexy during his childhood. He was suffering from the sequelae of a COVID-19 infection in the sense of long-COVID syndrome. The clinical examination showed a hardened and enlarged right testis of about 8cm. The left testis was normal. Ultrasonographically the entire right testis was consumed by an inhomogeneous tumour. Only a narrow fringe of normal testicular parenchyma was found marginally (Figure 1). Testicular tumour markers were negative (ßHCG <0.1 IU/l; AFP 2.5ng/ml). His hormonal profile revealed decreased testosterone with normal pituitary hormones (testosterone 1.82ng/ml (3-9), FSH, LH, estradiol normal). The CT examination of the thorax and abdomen showed inconspicuous organs, with no enlarged lymph nodes. As the couple wished to have a child, a semen analysis was performed. The semen analysis showed only a few motile spermatozoa (on average 1 sperm WHO-A motile, 1-2 dead spermatozoa per field of view) in the context of OAT syndrome (oligoasthenoteratozoospermia).

Cryopreservation was not possible. The patient underwent right radical orchiectomy and the histological examination revealed an embryonal cell carcinoma of the right testis pT1cN0cM0R0. A surveillance strategy was recommended. The case was presented to the German Second Opinion Centre Testicular Carcinoma (eConsil) and the recommendation was confirmed. In January 2023, an inconspicuous follow-up examination was performed and a re-evaluation of the fertility status is planned after 1 year. The question of testosterone substitution has not yet been conclusively resolved, as it will also have a negative impact on sperm quality which may also be negatively affected by testicular carcinoma per se. In addition, it is unclear to what extent the long-COVID syndrome could influence his fertility potential.

and the remaining genitals were inconspicuous. The ultrasonographic examination showed two 5 and 10 mm inhomogeneous masses centrally in the left testis (Figure 2) and dilated venous vessels confirmed the presence of varicocele. Tumour markers (ßHCG, AFP) were within the normal range. Peripheral testosterone level was normal at 6.73ng/ ml (3-9ng/ml). Semen analysis revealed normal findings with normal sperm count. After discussion with the patient, a cryo-depot was created from 2 sperm donations. In July 2022, a radical orchiectomy on the left testis with contralateral testicular biopsy on the right testis was subsequently performed. Histologically, a seminoma with GCNIS in the surrounding testicular tissue was found. Right testicular biopsy showed no GCNIS. In seminoma stage 1 Lugano (pT2cN0cM0L0V1S0R0), a good prognosis, a surveillance strategy was proposed. This proposal was confirmed in the presentation at the German Second Opinion Centre Testicular Tumour (eKonsil). The follow-up was scheduled for January 2023 without any finding.

In accordance with the EAU Guidelines, all patients should be offered sperm cryopreservation (3). This should ideally be done before surgery, or at the latest, before chemotherapy. Since cryopreservation causes a 50% deterioration of sperm quality, a pretherapeutic ejaculate analysis is necessary to assess the existing fertility and to exclude higher grade fertility disorders. The goal is to preserve sufficient sperm for approximately 10 ICSI cycles. However, after recovery of spermiogenesis, the dissolution of the cryo-depot should be considered, also for cost reasons. This is also one of the tasks of outpatient follow-up urologists.

Case 2 - M.L. *1999

In July 2022, patient M.L. (born in 1999) presented with a slight pain in the left testicle. In addition, there was a fear of a testicular tumour following the press reporting 3 testicular tumour cases in players of the German "Bundesliga" (national soccer league). These reports led to many presentations in urological offices in Germany in 2022 to emphasise the need of the clinical and ultrasonographic examination of young men.

Clinical examination showed two hard lumps in the left testis and a varicocele grade I-II. The right testis

Approaches to cryopreservation of spermatogenetic stem cells in prepubertal patients with testicular tumours are currently still considered experimental [4, 5]. In particular, fertility preservation in the case of germ cell neoplasia in situ (GCNIS) of the contralateral testis should also be considered. Recommended radiotherapy of the residual testis can lead to irreversible damage to the germinal epithelium and subsequent infertility. In this case, a detailed explanation to the patient is necessary. In this rare situation, individual therapy planning is necessary, also in the sense of a risk-adapted watchful waiting strategy in case of an existing desire for parenthood. Bilateral synchronous and metachronous testicular tumours represent a further challenge. In this case, attention to the fertility situation is also urgently required.

Case 3 - M.H. *1992

In November 2011, patient M.H. (born in 1992) underwent radical orchiectomy for a mixed testicular tumour (70% seminoma, 30% teratoma). Clinically it was a stage 1, therefore a surveillance strategy was followed. In the regular follow-up, last 9-monthly, control examinations presented normal findings without change of tumour marker levels. On July 2022 an echo-reduced finding in the left residual testis near the vascular bundle was noticed (see figure 3). This finding was confirmed by the MRI. In the laboratory, ßHCG increased to 5.0ng/ml

(to 3.0ng/ml) with normal AFP and LDH. Peripheral testosterone levels were within normal range. There was an urgent suspicion of metachronous testicular carcinoma in the remaining testis on the left side after orchiectomy for testicular carcinoma right sided 10 years ago. The findings were discussed in detail with the patient, who had no children of his own yet. A normal semen analysis was performed and 2 cyrosperm deposits were created. The left testis was surgically exposed. Cryosection confirmed the finding of testicular carcinoma. Because of the anatomically very unfavourable position at the vascular pedicle, it was not possible to perform an organ-sparing resection and radical left orchiectomy was performed. The histological examination showed a classic seminoma without angio- and neural sheath infiltration with extensive GCNIS and reduction of spermiogenesis, Stage 1, pT1cNx M0 V0Pn0. The MRI revealed suspicious retroperitoneal lymph nodes but these had completely regressed on follow-up 3 months later. This was also followed by presentation to eConsil. Surveillance strategy was initiated. Follow up was unremarkable. Shortly after surgery, testosterone substitution with testosterone undecanoate depot (TUD) was initiated.

Thus, in addition to the diagnosis and treatment modalities of testicular carcinoma, the issue of fertility forms an important pretherapeutic aspect in young patients with a high chance of cure and long-term survival. These aspects should not be lost sight of, especially in office and outpatient urology when the diagnosis is mostly shocking for the patient, since mistakes in primary management can be hardly corrected later.

References

1. Liebenthron J, Baston-Büst DM, Bielfeld AP, Fehm TN, Kreuzer VK, Krüssel J-S. S2k guideline: fertility preserving measures in oncological diseases. Gynaecologist 2018; 51(11):926-36.

2. Schover LR, Rybicki LA, Martin BA, Bringelsen KA. Having children after cancer. Cancer 1999; 86(4):697-709.

3. M.P.Lagana et al: EAU Guidelines on testicular cancer 2015.

4. Picton HM, Wyns C, Anderson RA, Goossens E, Jahnukainen K, Kliesch S et al. A European perspective on testicular tissue cryopreservation for fertility preservation in prepubertal and adolescent boys. Hum Reprod 2015; 30(11):2463-75.

5. Kliesch S. Androprotect and perspectives on fertility therapy. Urologe 2016; 55(7):898-903.

"Since the cure rate of testicular tumour is almost 100% in predominantly young patients, the question of fertility preservation after completion of therapy is becoming increasingly important."

Dr. Horst Brenneis Urologie im MVZ Südwest Pirmasens (DE)

Ass. Prof. Fotios Dimitriadis 1st Urology Dept. Aristotle University of Thessaloniki (GR)

Figure 1: Ultrasound: right testis almost completely consumed by an inhomogeneous tumour

Figure 2: Ultrasound: 2 suspicious inhomogeneous echo-attenuated foci in the testis

Figure 3a and b (top and bottom): Ultrasound: inhomogeneous focus in the residual right testis after orchiectomy for mixed testicular cancer 10 years ago

USANZ Trainee Week 2022 impressions

An educational highlight of our residency

Andreas Christodoulides Nicosia General Hospital Strovolos (CY)

andreaschristodou-

Klara Smolić Fellow of Urology Clinical Hospital Centre Rijeka Faculty of Medicine, University of Rijeka Rijeka (HR)

klara.smolic@uniri.hr

The Urological Society of Australia and New Zealand (USANZ) Trainee Week 2022 was held from 20 to 24 November 2022 at the Pullman Melbourne Albert Park in Melbourne, Australia. The programme brought together urology trainees from across Australia and New Zealand, as well as 10 foreign delegates for a week of interactive and informative sessions on urology-related topics. The week included a mix of plenary sessions, interactive workshops, case discussions, and social events.

The USANZ Trainee Week is a premier education programme held annually and hosted by a different team of renowned urologists and their associates. The programme is designed specifically for Surgical Education and Training (SET) urology trainees and compulsory for trainees in SET1 to SET4. The programme objectives are to update, standardise, and maintain urological clinical practice to the fullest.

The USANZ Trainee Week experience was unique. Planned and impromptu discussions, expert guidance and enrichment of proficiencies were blended with enthusiasm, team spirit, and humour. The whole programme was professional, educational, and fun.

The formal atmosphere was lightened up with a fun urological quiz made to look like a Jeopardy Quiz and a laughter-packed competition called “Masters of the Uroverse” where every team had different costumes. In addition, our hosts from USANZ organised an enjoyable trip to the zoo for all international delegates, where we had a chance to learn about the extraordinary Australian flora and fauna.

Final impressions

Words cannot begin to describe our USANZ Trainee Week 2022 experience. It is not every day one gets the chance to travel across the globe for educational purposes.

Programme content

The USANZ Trainee Week 2022 started with written and oral in-service assessment exams for the trainees which are meant to prepare them for their final exam at the end of the residency. As international delegates, we were able to listen to the oral part of the exam which consists of four different categories.

The plenary sessions covered a range of urology topics, including urologic oncology, functional urology, and urological trauma as well as some non-medical topics such as communication skills and burnout syndrome in medical professionals. The speakers were experienced urologists and researchers who presented the latest research and advancements in their respective fields. The plenary sessions were well-attended and gave the trainees valuable insights and knowledge.

As a recap, the programme’s schedule were as follows:

• Day 1: Practice examinations

• Day 2: Focus on retroperitoneal and testicular oncology, female urology, and uro-radiology

• Day 3: Activities centred on prostate cancer and LUTS (lower urinary tract symptoms)

• Day 4: Focus on andrology, male infertility and sexual dysfunction, surgeons as people, and more

• Day 5: Concentrated on bladder cancer, uro-pathology, upper- and lower-tract trauma

Relations Office

The whole programme formed an optimal environment where young urologists convene for an intensive learning experience. All aspects of the programme were well organised from the get-go. Everything ran smoothly and no technical difficulties were encountered. We always received prompt responses to our emails concerning the schedule and no query remained unanswered. Complete guidance was offered as to arriving and departing from the country which we appreciated.

The lectures have met and exceeded our expectations. We were fortunate to gain vital insights from all the lecturers and enjoyed the interactive discussions, but most of all, the playful yet professional atmosphere. In addition, we have met and enjoyed the company of truly amazing people.

Attending programmes such as this is a great way for trainees to learn from experts, gain practical skills, and network with colleagues in their field.

"Without a doubt, USANZ and the EAU have made it possible to overcome the consequences of the pandemic, and return to face-to-face learning." We are honoured to have been given the opportunity to participate. We would do it again in a heartbeat! This experience is a highlight of education during our residency, and we encourage young urologists in training to attend educational programmes like these as often as possible.

This was a once-in-a-lifetime opportunity and we highly recommend it to residents and young urologists to seize the opportunity and attend!

“The whole programme formed an optimal environment where young urologists convene for an intensive learning experience.”

"Without a doubt, USANZ and the EAU have made it possible to overcome the consequences of the pandemic, and return to face-to-face learning."

Dr.

lides1986@gmail. com

Dr.

Super fun “Master of the Uroverse” activity

International delegates with Programme Chair Dr. Kathryn McLeod at the final dinner

Interactive session “The Surgeon as human - A whole human approach to navigating life as a surgeon”

Leading journals welcome new Editors-in-Chief

The visions of Profs. Briganti and Rouprêt in shaping the future of clinical research

By Erika De Groot

Authorities in their respective specialties and prize winners of various accolades, Prof. Alberto Briganti (IT) and Prof. Morgan Rouprêt (FR) have taken the mantle of editors-in-chief (EICs) of the prestigious journals European Urology (EU) and European Urology Oncology (EUO), respectively. These journals are part of a family of journals published by Elsevier which also include European Urology Focus and European Urology Open Science

Read on to get to know the EICs, their aspirations, and the challenges they anticipate in their new roles.

Prof. Briganti takes the lead

This June, Prof. Briganti will succeed Prof. James Catto (GB), who has led the EU journal and overseen its family of journals since 2013. Both will collaborate until the end of next year assuring a smooth and solid transition.

Prof. Briganti is a Full Professor of Urology at the Vita-Salute San Raffaele University in Milan, Italy.

Author of more than 1,200 scientific works published in international peer-reviewed journals, Prof. Briganti’s main research interests include prostate cancer and genitourinary (GU) malignancies. Since 2017, Prof. Briganti has been the EIC of EUO, a sister journal devoted to the study of GU malignancies. He is also a reviewer of numerous scientific journals in urology and oncology.

Coordinating the activities of all EAU journals

“The EU journal will maintain the lead in coordinating the activities among all four journals as excellently done by Prof. Catto. All EAU journals will work closely together to maintain a tight link and launch common initiatives to ensure that high quality science and contributions will stay within the EAU journals,” said Prof. Briganti.

Plans for the journal

“The main plans for the EU journal will include maintaining the highest possible level of scientific quality while improving dissemination beyond the boundaries of urology. These will be achieved through a series of novel initiatives aimed at improving the content dissemination within the entire scientific community; expanding access to contents; introducing new formats of online education; implementing publication formats; and fostering the importance of inclusion and diversity,” stated Prof. Briganti.

More features to the journal

Prof. Rouprêt proposed to add the following elements to EUO:

1. Additional special thematic issues not sponsored by the pharmaceutical industry

The Editorial Board will define two thematic issues (on top of the six regular issues) per year. These will comprise a mix of open-access original articles (obtained by an open call), and invited systematic reviews.

2. Virtual special issues (VSI)

VSI can be created by grouping together articles already published in other issues in a digital issue of the EUO on specific themes. This increases the visibility of the journal (i.e. downloads and citations) when some articles are highlighted and grouped.

3. Editorial enhancements

Additional features such as lay summaries, graphical abstracts, infographic creation and dissemination, and highlights will be included.

To ensure that the EUO continues to meet high standards and publishes the most relevant research, Prof. Rouprêt stated that the journal should attract data from pivotal research projects.

supports the pursuit of a multidisciplinary approach by delivering high quality science and research in GU malignancies.”

Journals on socials

Throughout his career, Prof. Briganti received numerous accolades such as the EAU Crystal Matula Award, which is a coveted prize given to young promising urologists who have the potential to be future leaders in academic urology.

“The designation as editor-in-chief of this prestigious journal provides me with a great sense of professional satisfaction. To accede to this function is a privilege; I aspire to further contribute to the urological scientific community,” stated Prof. Briganti.

Tasks and duties

Prof. Briganti’s core responsibilities as EIC will include:

• Ensuring that published papers in the journal reflect the full scope of urology practice and meet highest scientific standards covering the latest advances

Thanks to the precious works of all editors, the EU journal became one of the leading journals in the field of urology which covers the entire spectrum of all urological diseases. However, there is a continuous need to attract high quality research and maintain the high scientific profile of the journal. For these aims, the EU journal will focus on reinforcing collaborations with all major scientific societies and journals, key opinion leaders, scientific and patient groups to maintain stellar scientific quality content and reach all different stakeholders. Prof. Briganti said, “Journals should be more accessible not only to multidisciplinary professionals, but also to lay audiences who can reap the benefits from research especially in the field of urology.”

• Developing new initiatives to keep the journal at the forefront of urological research and technology

To broaden the journal’s readership, there will be a series of initiatives aimed at introducing new formats of papers; implementing new ways of science dissemination; collaborating with all sections and offices of the EAU; expanding editorial fellowship programmes and educational activities. All of these aims can be achieved by a structural change in the way journals are considered and perceived, which should then shift from a passive to an active practice changing tool.

He added that the journal will reinforce its collaboration not only with all EAU sections and offices but also with different scientific groups, journals and societies. These collaborations will create a new and successful platform aimed at increasing the journal’s impact on the urological and non-urological communities.

About the EU journal

Since its inception in 1975, the EU journal publishes peer-reviewed original articles, reviews, and opinion-piece editorials on a wide range of urological problems on a monthly basis. The EU has a current Impact Factor (IF) of 24.344 making it the leading journal in the field.

EUO welcomes Prof. Rouprêt

With an equally steadfast dedication to urology and a fellow EAU Crystal Matula Award recipient as well, Prof. Rouprêt will take on the EIC role for the EUO journal as successor to Prof. Briganti.

To date, the EUO is ranked 1st in GU cancer journals, 3rd in urology, 9/90 (Q1) in Urology & Nephrology (code ZA), and 42/246 (Q1) in Oncology (code DM). “We aim to further boost EUO’s content quality and scientific rigour, broaden the readership, and address the needs of our specialty. We will incorporate measures demonstrating the journal's reach also beyond the IF.” stated Prof. Rouprêt.

“Although the main results from a large phase III clinical trial may naturally go to journals such as the New England Journal of Medicine or Lancet Oncology, the EUO Editorial Board must be in permanent contact with key investigators and groups in clinical research in GU oncology. This is to draw in the results of the ancillary studies of large therapeutic trials in the field of GU cancer, or the publication of the post hoc analysis into the EUO.” said Prof. Rouprêt.

The EUO journal aspires to forge links and attract scientific data from all over the world. If the English language becomes a challenge, the journal aim to offer solutions so that the language barrier will not hinder submissions to the EUO.

Major challenges facing the field of urology today

Social media helps the journals become vehicles that provide dynamic, accessible, and reliable scientific information. Stay updated on their latest publications via their Twitter, Facebook, and LinkedIn accounts. For more information on the journals, please visit www.europeanurology.com/ and euoncology.europeanurology.com/

It runs in the family

Our family of journals—European Urology, European Urology Focus, European Urology Oncology and European Urology Open Science—share a passion for urology, an unending commitment to patients, a dedication to multi-disciplinary science, and a continuous focus on quality.

— Welcome to our family.

According to Prof. Rouprêt, clinical research is the heart of the EUO reactor. He stated that without research, there are no publications and no evolution of the EAU Guidelines as well. He said, “In practice, urologists are already investigators and implementors of clinical or fundamental research to varying degrees.”

Prof. Rouprêt stated that the first step is to further stimulate the EAU's onco-urological network, then boost the global onco-urological network beyond the borders of EAU. “The future of clinical research in oncology lies in the extension of EUO's collaboration with identified research networks. The EUO Editorial Board must network to solicit systematic reviews, position papers, or consensus papers.”

According to Prof. Rouprêt, the field of GU malignancies is extremely broad and cancer management requires complex, almost encyclopaedic know-how, and constantly evolving medical and surgical knowledge. He stated, “In recent years, we have seen a revolution in the management of GU cancers which involves diverse disciplines. None of the advances would have occurred without close collaboration between different specialists and health professionals. Nowadays, such collaboration represents one of the pillars of modern treatment of cancer patients and increasingly provides individualised pathways of care to improve patient survival and quality of life. It is in this spirit that the EUO

europeanurology.com

euoncology.europeanurology.com

Listed in PubMed

eu-openscience.europeanurology.com

eu-focus.europeanurology.com

Indexed

“The main plans for the EU journal will include maintaining the highest possible level of scientific quality while improving dissemination beyond the boundaries of urology.”

“The EUO journal aspires to forge links and attract scientific data from all over the world.”

New EIC of the EU journal, Prof. Briganti Prof. Rouprêt to lead the EUO journal

ESU Urology Boot Camp Lisbon 2022

Technical skills training to 1st-year residents

Prof. Ben Van Cleynenbreugel

Dept. of Urology University Hospitals

Leuven Leuven (BE)

Ben. Vancleynenbreugel@ uzleuven.be

Mr. Shekhar Biyani

Dept. of Urology

St. James’s University Hospital

Leeds (GB)

shekharbiyani@ hotmail.com

Dr. Tiago Oliveira

Depts of Urology

Armed Forces Hospital

Lisbon University Hospital Lisbon (PT)

tiagoribeirooliveira@ sapo.pt

In light of the limitations of traditional surgical training, over the past decades, simulation-based training has been extensively explored and used as an adjunct to traditional surgical training, namely for the development of technical skills via individual hands-on practice.

A comprehensive approach to surgical training in urology

In recent years, the European School of Urology (ESU) and the European Association of Urology (EAU) sections have been developing a series of structured and integrated training curricula in specific urological techniques. In view of the clear success of these activities, the ESU has created the Standardisation in Surgical Education (SISE) programme, which is a collaborative venture aiming to implement a comprehensive approach to all training activities within the EAU. SISE encompasses a series of structured, standardised and validated training curricula targeted at all trainee levels. The first step in the programme is the ESU Urology Boot Camp.

The ESU Urology Boot Camp project

Developed in Leeds by Mr. Shekhar Biyani (GB), the Urology Simulation Boot Camp, 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 the SISE programme.

One of the most important hallmarks of the ESU Urology Boot Camp is the 1:1:1 training model, where one trainee has a dedicated training station and an experienced trainer for the entire duration of each module, therefore maximising the learning experience. With a series of different low- and high-fidelity models and a considerable amount of state-of-the-art urological equipment, trainees are provided standardised hands-on training on laparoscopy, flexible and semi-rigid ureterorenoscopy, transurethral resection of the prostate and bladder tumours, flexible and rigid cystoscopy, bladder catheterisation, suprapubic catheter placement, scrotal examination and circumcision.

Following a very successful pilot course in Portugal in 2018, additional courses have been organised in Portugal, Belgium, Serbia, Lithuania, Austria, Greece and Poland. After 12 courses, organised in seven different countries, more than 160 European residents from 14 nationalities have attended the ESU Urology Boot Camp, more than 87% of which considering the course extremely useful for their near future.

ESU Urology Boot Camp Lisbon 2022

The fourth edition of the ESU Urology Boot Camp in Portugal was organised on 19 November, 2022 at Fortaleza de São Julião da Barra, which is a historical military fort developed for the coastal defence of the Port of Lisbon and currently the official residence of the Minister of Defence.

The course was organised by the ESU and the Lisbon Faculty of Medicine Centre for Postgraduate Training in Urology (CFU), in collaboration with the Armed Forces Hospital and the Lisbon University Hospital Centre, the scientific support of the Portuguese Association of Urology and the Portuguese College of Physicians’ Board of Urology, and the sponsorship of Karl Storz, Teprel, Janssen, Boston Scientific, Medtronic, and Mediplus.

The intensive course programme provided participants the opportunity to acquire and train several urological skills in eight hours of hands-on training. Each participant was assigned a dedicated model and individually guided by a trainer. This was a unique opportunity for first-year urology residents to learn a series of different technical skills that are of paramount importance in daily clinical practice. The quality of the models and equipment, the motivation and competence of the faculty, and the use of ESU’s validated training models warranted the clear success of the course amongst the participants.

clinical activities. The focused training can help improve clinical proficiency and self-confidence. In 2023, a first edition of the course is planned for Germany, Italy and Romania in addition to the new edition of the ESU Urology Boot Camp in Portugal, Belgium, Serbia, the Baltic countries, Austria, Greece and Poland.

The organisation of future ESU Urology Boot Camps will be initiated via the SISE programme platform.

The ESU Urology Boot Camp Working Group will analyse all new Boot Camp requests and provide a

step-by-step manual, a checklist, and a timeline for the implementation of every course to support and guide the organising committees throughout the entire process. The ESU Urology Boot Camp Working Group will also prepare a “Train the Trainer” course for all the faculty to ensure the highest quality of training. To guide and facilitate the implementation of the course, a previous visit as an external observer to another Boot Camp will be part of the process. For more information on the programme, please visit https://www.sise-urology.com/

1st Urology Boot Camp Poland

Programme to boost proficiency among residents

to process standardised knowledge to young urology adepts.

(PO)

marcin.jarzemski@ gmail.com

Notably a highlight of 2022, the first Polish Urology Boot Camp took place in Bydgoszcz just before the Meeting of the Endourology Section of the Polish Urological Association.

Twelve trainees together with 12 trainers convened at St. Lucas Hospital where the trainees learned basic and fundamental urological skills. After the short “Train the Trainer” briefing, trainers were ready

On 18 November, a full day was dedicated to urology training in laparoscopy, lower and upper tract endoscopy, urethrotomy, scrotal examination and circumcision.

Keeping in mind the total number of residents in a populous country such as Poland, with at least 50 residents finishing their residency programme each year, the response and demand for a course such as the Urology Boot Camp is undoubtedly great. Looking ahead in fulfilling the need for such a course, there is a plan to set a Urology Boot Camp in Poland for at least two times a year.

At the basis of the SISE programme, the ESU Urology Boot Camp is a standardised course for first-year residents which comprises a full day of intensive hands-on training and organised into four separate training modules. The aim of the programme is to provide high-quality technical skills training that enables every urology resident in Europe to acquire the necessary technical skills to perform the common procedures before they start working with patients.

Future perspectives

The aim of the ESU Urology Boot Camp Organising Committee (Prof. Ben Van Cleynenbreugel, Mr. Shekhar Biyani, and Dr. Tiago Oliveira), is to implement an ESU Urology Boot Camp for first-year urology residents on a national level and on an annual basis. The objective is to provide first-year urology residents a platform to acquire and train basic urological technical skills, based on a standardized curriculum, prior to starting urological

“The quality of the models and equipment, the motivation and competence of the faculty, and the use of ESU’s validated training models warranted the clear success of the course amongst the participants.”

Dr. Marcin Jarzemski Jan Biziel University Hospital Bydgoszcz

Faculty and participants of the boot camp in Lisbon, last November

Meet the Urology Boot Camp organisers, trainers, and trainees

Primary urethral carcinoma

Introducing the updated ESU course for the EAU Guidelines on Primary urethral carcinoma! Update your knowledge on the latest research, diagnostics and treatments for this complex disease. Enroll now and renew your skills!

Learning Objectives

• Review the most updated EAU Guidelines on Primary urethral carcinoma

• Learn how to make informed decisions in the treatment of patients

• Test your knowledge on the latest developments

At a glance

• Publication date: March 2019

• Most recent update: January 2023

• Available in English

• Contributors: Dr. Nikolaos Grivas, Prof. Georgios Gakis and Dr. Richard Meijer

• Earn 1 European CME credit (ECMEC)

• Duration: Approx. 60 – 90 minutes

Muscle-invasive and metastatic bladder cancer

Upgrade your knowledge on Muscle-invasive and metastatic bladder cancer with the updated ESU course for the EAU Guidelines. Learn the most current insights and best practices. Enroll now and enhance your knowledge!

Learning Objectives

• Review the most up-to-date EAU Guidelines on Muscle-invasive and metastatic bladder cancer

• Learn how to make informed decisions in the treatment of patients

• Test your knowledge on the latest developments

At a glance

• Publication date: June 2019

• Most recent update: January 2023

• Available in English

• Contributors: Prof. Henk van der Poel, Prof. Alfred Witjes and Dr. Richard Meijer

• Earn 1 European CME credit (ECMEC)

• Duration: Approx. 60 – 90 minutes

Joining urology’s young, promising urologists at UROBESTT

Finetuning skills during the Challengers and HOT sessions

Prof. Charles Van Praet Dept. of Urology Ghent University Hospital Ghent (BE)

charles.vanpraet@ uzgent.be

I had the opportunity to attend the recentlyconcluded URO Berlin Skills Teaching and Training (UROBESTT) programme. The European School of Urology (ESU) organised this year’s UROBESTT at the Karl Storz Berlin Visitor and Training Centre from 16-18 February, 2023. The programme is aimed at young urologists practising urologic endoscopy and/ or minimally-invasive surgery.

UROBESTT was well-attended not only by colleagues from Europe, but also from countries such as Iran, Mexico, Paraguay and Uzbekistan. The programme alternated from plenary sessions by experts, Challengers sessions by participants, smaller group sessions on tips and tricks in endourology, individual case presentations, and hands-on training (HOT).

The expert session highlights included techniques and indications for endopyelotomy by Prof. Olivier Traxer (FR), an overview of minimally invasive surgical techniques (MIST) for benign prostatic hyperplasia (BPH) by Prof. Bhaskar Somani (GB), management of uretero-intestinal stenosis by Prof. Joan Palou (ES), and the role of lymphadenectomy in prostate cancer by Prof. Henk Van Der Poel (NL).

Every participant was invited to send in several of their research topics for a 15-minute presentation

and was challenged by three experts in the Challengers sessions. First, I shared the Ghent University Hospital experience with Retzius-sparing radical prostatectomy (RS-RARP). Introduction of RS-RARP significantly improved our patients’ early (two weeks) and late (one year) urinary continence from 32% to 84% and from 76% to 99%, respectively. Although this came at the cost of an increased positive surgical margin rate, oncological outcome at two years was very similar. Longer oncological follow-up is warranted [1].

Second, I presented our in-house developed renal 3D models with perfusion zone algorithm for planning robot-assisted partial nephrectomy (RAPN). These models allow us to accurately plan and execute RAPN with selective arterial clamping in 92% of patients [2]. I was very honoured to receive the first prize for these presentations.

Furthermore, every participant was encouraged to present a four-minute clinical case to 10 to 15 colleagues and have a discussion. This was a unique opportunity to share personal experiences and get feedback from peers and experts.

One of the highlights was the HOT session, where we could practise endoscopy and laparoscopy on simulation models. The two-hour session enabled us to practise our skills and get valuable feedback from experienced urologists.

Being with a group of young urologists also means enjoying the evenings in the great city of Berlin. During the first night, a fire alarm at the hotel and subsequent evacuation started an unexpected midnight networking opportunity on the street. Fortunately, it proved to be a false alarm. The second evening, a networking dinner was organised at a Thai restaurant. The spicy Thai food turned dinner into yet another HOT session (pun intended). It was a

memorable evening, where I made friends from all over the world.

Attending this three-day course was an invaluable experience that provided me with a wealth of knowledge, skills, practical experience, and new friends. I would hereby like to thank the organising committee, as well as the other participants for this very interactive course. I highly recommend it to starting urologists with a passion for minimallyinvasive urology.

References

1. Lambert E, Allaeys C, Berquin C, et al. Is It Safe to Switch from a Standard Anterior to Retzius-Sparing Approach in Robot-Assisted Radical Prostatectomy? Current

Oncology 2023; 30(3), 3447-3460; DOI: https://doi. org/10.3390/curroncol30030261

2. De Backer P, Vermijs S, Van Praet C, et al. A Novel

Three-dimensional Planning Tool for Selective Clamping During Partial Nephrectomy: Validation of a Perfusion Zone Algorithm. European Urology 2023; e-pub before print; DOI: https://doi.org/10.1016/j.eururo.2023.01.003

Enhance your career with online education

UROBESTT delegates and faculty at the KARL STORZ Visitor and Training centre in Berlin

Interesting lecture from Prof. Athanasios Papatsoris on the role of PDD in urothelial tumours

Learning-by-doing at the LAP stations

The Greek Patient Office

A new initiative to bridge the gap

Who we are?

The Greek Patient Office currently consists of seven core urologists, but with a wide network of collaborative colleagues throughout Greece. It is a team of young scientists, with a high level of urological knowledge and scientific work, which is accompanied by a strong willingness to offer patient information and advocacy to ensure the best benefit to them. Of course, this is not a restricted and closed team, as all Greek urologists have been invited as potential collaborators and participants of the Greek Patient Office activities. The core members of the Office have scheduled meetings to discuss current issues and prospective actions.

Our aims and scope

position to be sited inside HUA, providing appropriate information for visiting patients.

Limitations

Unfortunately it is not always easy and comfortable to persuade a urological society for the need of a committee, such as the Patient Office. The idea of an active patient in shared decision-making and the importance of his advocacy is probably novel for the ears, not only of urologists, but for the entire doctor society. Moreover, financial organisations and companies are currently not so familiar with such activities and events, which can make resourcing quite difficult.

Follow the Greek paradigm

There is an organised plan for the Greek Patient Office, although we do encounter some difficulties in our effort to establish it in the conscience of Greek urologists, patients, organisations, and societies. The feeling is that despite the hard work, there is light at the end of the tunnel. Our paradigm consists of a selective group of scientists, open teamwork, open ears and eyes on patients and societies, and of course challenging activities, to communicate creatively with the only subject: The Patient.

The way to our goals may seem to be labyrinthine, but we are confident that we will beat Minotaur.

HUA

Steering Committee Member, Larissa (GR) mikesamih@ hotmail.com

A high level of doctor and patient communication is vital to achieve the appropriate treatment and management of illnesses. It is essential to build a trusting relationship between patients and doctors based on the doctor’s scientific competency and the patient’s personal needs and adhesion to treatment therapies. This can create shared decision-making, giving the patient an active role in their therapeutic options.

The European Association of Urology (EAU) has already introduced the Patient Information Office, highlighting the need for patient advocacy and encouraging urologists to have meaningful discussions with their patients. Following in their footprints, the Hellenic Urological Association (HUA) recently established the Greek Patient Office for the advocacy of local urological patients.

Best practice of information sharing between the patient and urologist is our essential target and was the main reason for HUA to establish its own patient office. The basic members of the Office have the responsibility to encourage Greek urologists to be more active in discussions with their patients and give them the appropriate advocacy. On the other hand, we are trying to contact and motivate patient communities and associations to join us for informative campaigns and events, not only as simple observers, but also as active participants. This will allow us to get closer to our patients, and be able to listen carefully to their actual needs as they can express their own point of view and potential advocacy. Urologists can help with this!

Current activities

Although the Greek Patient Office is in its neonatal stage, we are already quite active organising events in collaboration with social partners, organisations, and patient associations. We are also on the way to implementing other committees within HUA to contribute with their experience and material for specific topics, such as functional urology and urological cancer. There is a gradual increase in activity in our social media accounts, with an increased number of followers. Our website development was a priority and we are already in the

Where you can find us:

Facebook: HUA Patient Office | www.facebook.com/huapatientoffice

Instagram: @huapatientoffice | www.instagram.com/huapatientoffice/

LinkedIn: HUA Patient Office | www.linkedin.com/in/hua-patient-office-31a252253/

Twitter: @HUAPatient | twitter.com/HUAPatient

e-mail: patientsinfo@huanet.gr

Site: www.huanet.gr/γραφειο-ασθενων/

European Urological Scholarship Programme (EUSP)

Don't forget to submit your online application for a Short Visit, Clinical Visit, One-year Scholarship or Visiting Professor before 1 September.

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

Dr. Markos Karavitakis Board Member, EAU Patient Office

HUA Patient Office, Steering Committee Chairman Athens (GR) markoskaravitakis@ yahoo.gr

Dr. Michael Samarinas Urology Consultant, General Hospital of Larissa

Patient Office,

A 12-month update on the PRIME Trial 'PRostate Imaging using MRI ± contrast Enhancement' study well on its way

Assoc. Prof. Veeru Kasivisvanathan University College

London and UCLH

PRIME Chief Investigator

London (GB)

@veerukasi

Dr. Aqua Asif University College

London

PRIME Research Assistant London (GB)

@AquaAsif

Dr. Alexander Ng University College

London

PRIME Research Assistant

London (GB)

@AlexBCDNg

Ms. Marimo Rossiter University College

London

PRIME Research Assistant London (GB)

@MarimoRossiter

Study design: PRIME (NCT04571840) is a prospective, international, within-patient, multicentre, level 1–evidence clinical trial evaluating whether biparametric MRI (bpMRI) is noninferior to mpMRI in the detection of clinically significant prostate cancer (csPCa). Men with clinical suspicion of PCa undergo mpMRI as per standard of care. The dynamic contrast-enhanced imaging (DCE) sequence is then blinded from the radiologists to report the bpMRI. The DCE sequence will then be unblinded to the radiologist to report the full mpMRI. All MRI scans are reported using Likert and PI-RADS v2.1 scores. Patients with non-suspicious MRI (scores 1 or 2) on bpMRI and mpMRI and low risk of PCa will be recommended to undergo PSA surveillance. Patients with suspicious MRI (scores 3,4 or 5) on either bpMRI or mpMRI will undergo MRI-targeted biopsy.

Suspicious areas will be labelled with their location and whether they were suspicious on either bpMRI or mpMRI.

Targeted biopsy cores will be stored separately from areas that were uniquely suspicious on DCE so that conclusions can be made on whether the pathology was from suspicious areas on the bpMRI or mpMRI or both. Systematic biopsies will also be taken. The simplified study schema is shown below in Figure 1

Primary outcome:

The proportion of men with csPCa detected (Gleason Grade ≥ 3+4) / Gleason grade group 2 or greater).

Key secondary outcomes:

1. Agreement between bpMRI and mpMRI in score of suspicion

2. Proportion of men with clinically insignificant cancer detected (Gleason grade 3+3 / Gleason grade group 1) and;

3. Agreement between bpMRI and mpMRI on treatment decision eligibility

Implications of PRIME

If bpMRI is non-inferior to mpMRI, then bpMRI will become the new standard of care for PCa detection in men with suspected PCa, allowing for a greater capacity to deliver MRI scans to meet the demand.

First Prize for Best Abstract

Our team has been recognised by the European Association of Urology (EAU) 2023 with a prestigious prize during its Annual Congress, which took place in Milan, Italy. First author, Dr. Alexander Ng, received the First Prize for Best Abstract by a Resident in Urology, for their research into prostate MRI quality. This year, there were just under 5,000 abstract submissions, and of course, this is regarded as one of the biggest international urology meetings.

The GLIMPSE study, which analysed the MRI quality control phase from the ongoing international multi-centre PRIME study, evaluated whether biparametric MRI is non-inferior to multiparametric MRI in the detection of significant PCa. We carried out the first global overview into the variation of prostate MR image quality. Initial MRI quality was fair, with room for improvement, particularly with DCE imaging. With very basic changes in line with PI-RADS recommendations, global MRI quality can be easily improved.

Commenting on the award, Dr. Ng said: “I’m extremely honoured and privileged to receive the first prize for best abstract by resident in urology. I would like to say thank you to my colleagues, supervisors, mentors, and family, as we aim to ensure that all men who require an MRI can get access.”

Chief Investigator, Assoc. Prof. Veeru Kasivisvanathan (GB) said: “This represents the hard work and dedication of the PRIME team and our international collaborators. This achievement showcases the bright future of academic urology and the power of collaboration in advancing medical research.”

Dr. Asif added, "I am truly grateful for the unwavering support and dedication of our international collaborators, mentors, peers, and loved ones, who have all played a crucial role in our success. Our collective efforts are helping break down barriers to accessing MRI, ultimately improving the lives of countless men around the world. I am proud to be part of this incredible team, and I firmly believe that together, we can continue to make a positive impact."

PRIME Investigators’ Meeting at EAU23

The PRIME team recently held a hybrid-style PRIME Investigator’s Meeting at EAU23 in Milan, Italy. It was wonderful to see so many brilliant international minds come together, as our investigators joined us both in person and online. During the meeting, we provided a study update, built on last year's ideas, and explored future study ideas, all while fostering a collaborative and inspiring atmosphere.

Recent Progress of PRIME

Since opening to recruitment in April 2022, the PRIME trial is recruiting ahead of schedule! We are pleased to announce that we have now surpassed the 300-patient mark for recruitment, with 18 sites opened to recruitment from 9 countries (UK, Spain, Germany, Italy, Brazil, Argentina, Australia, Canada and USA).

We would like to congratulate and celebrate our international centres, without whom none of this would be possible.

https://www.ucl.ac.uk/surgery/research/ department-targeted-intervention/urology/ prime-trial-information

Follow us on Twitter @PrimeMRI!

Sites that have met the target recruitment number of 30 patients:

Country Site

Italy Sapienza University of Rome

University Hospital of Udine

Germany The Martini-Klinik

Spain University Hospital Reina Sofia

Principal Investigator(s)

PI: Valeria Panebianco

PI: Rossano Girometti

PI: Lars Budaeus

Co-PI: Enrique Gómez Gómez

Co-PI: Daniel José López Ruiz

UK Addenbrooke’s Hospital Co-PI: Tristan Barrett Co-PI: Christof Kastner

Sites that are currently recruiting:

Argentina Centro de Urologia CDU

Co-PI: Marcelo Borghi Co-PI: Hernando Rios Pita

Australia Alfred Health, Monash University Co-PI: Jeremy Grummet Co-PI: Richard O'Sullivan

Brazil Hospital Sírio Libanês Co-PI: Publio Cesar Cavalcante Viana Co-PI: Adriano Basso Dias

Canada Princess Margaret Cancer Centre PI: Sangeet Ghai

Germany University Hospital Essen Co-PI: Claudia Kesch Co-PI: Boris Hadaschik

Heinrich Heine University Düsseldorf Co-PI: Jan Philipp Radtke Co-PI: Lars Schimmöller

Italy San Raffaele Hospital

PI: Alberto Briganti

Spain University Hospital La Moraleja Co-PI: Miguel Angel Rodríguez Cabello

Co-PI: Carolina Aulló Gonzanlez

UK University College London Hospital Co-PI: Veeru Kasivisvanathan

Co-PI: Caroline Moore

Royal Free Hospital PI: Paras Singh

USA Mayo Clinic, Rochester PI: Lance A. Mynderse

Icahn School of Medicine, Mount Sinai PI: Ash Tewari

Weill Cornell Medical Centre

Country Site

Co-PI: Daniel Margolis

Co-PI: Jim Hu

Principal Investigator(s)

Australia Peter MacCallum Cancer Centre PI: Declan Murphy

Belgium Ghent University Hospital PI: Pieter De Fisschere

Denmark Herlev Gentofte University Hospital PI: Lars Boesen

France Sorbonne Université PI: Raphaele Renard-Penna

Centre Hospitalier Universitaire de Bordeaux PI: Gregoire Robert

Centre Hospitalier Universitaire de Lille PI: Philippe Puech

Germany University Hospital Frankfurt Co-PI: Mike Wenzel Co-PI: Felix Chun

Italy San Giovanni Battista Hospital Co-PI: Giancarlo Marra Co-PI: Marco Gatti

Netherlands Radboud University Medical Centre Co-PI: Maarten De Rooij

Co-PI: Bas Israël

Singapore Tan Tock Seng Hospital PI: Jeffrey J. Leow

USA NYU Langone PI: Samir S. Taneja

MD Anderson PI: Tharak Bathala

UK Lister Hospital PI: Nikhil Vasdev

Dr. A. Ng received the prestigious First Prize

Milan, with Dr. A. Asif and Assoc. Prof. V. Kasivisvanathan

PRIME Investigators’ Meeting 2023. Attendees In-Person: A. Bjartell, J. Piper, M.A. Rodríguez Cabello, A. Rannikko, L. Boesen, C. Kesch, L. Budäus, A. Villers, B. Hadaschik, A. Asif, L. Klotz, V. Kasivisvanathan, F. Giganti, G. Giannarini, A. Ng, J.P. Radtke, C. Caris, W. Witjes, G. Brembilla, N. Vasdev, G. Robert, A. Stabile, A. Dehghanpour, A. Borrelli.

Table 1: List of sites opened for recruitment

Table 2: List of sites undergoing next steps

The touch that transforms

We believe the success of our science is measured by the lives we touch. So we are always working— pushing the boundaries of what’s possible to transform lives today and tomorrow.

Reconstructive options in penile cancer surgery

Surgical possibilities according to the new EAU-ASCO Collaborative Guidelines on penile cancer

Dr. Saskia Morgenstern Dept. of Urology Agaplesion Markus Krankenhaus Frankfurt (DE)

saskia.morgenstern@ agaplesion.de

“Besides its role in sexual functioning and urination, a fully functional penis is central to a patient’s sense of wholeness, desirability and masculinity. Hence, the aims of the treatment of the primary tumour are complete tumour removal with as much organ preservation as possible, without compromising oncological control.”

This quote from the newly published EAU-ASCO (American Society of Clinical Oncology) Collaborative Guidelines on penile cancer summarises the importance of reconstructive considerations when it comes to the treatment of men suffering from this often particularly burdensome cancer.

The following article provides an overview of the fascinating surgical options to preserve or restore esthetical and functional aspects in penile cancer, which can be of great importance to the affected man. For each TNM stage based on the UICC/AJCC 8th edition, intra- and postoperative pictures from our centre illustrate the current guideline recommendations for surgical treatment.

Nevertheless, there might be non-surgical or non-organ-sparing options better suited for some patients, thus a detailed discussion of the various treatment options taking into consideration the various individual factors of the patient should be performed with the patient prior to any treatment.

Biopsies and surgical margins

Biopsies (preferably as excision biopsies, Figure 1) are indicated if the nature of the lesion is uncertain, if non-surgical treatment is intended, and for surgical staging in selected cases. Despite low evidence, the current literature justifies keeping surgical margins as minimal as >1-10 mm, especially in low grade and smaller tumours.

Variation glans resurfacing plus penoscrotal web removal in order to avoid additional donor-side morbidity. Excess of scrotal skin can be used as a graft. 1st row: preand intraoperative findings, 2nd row: 6 month post op, 3rd row: harvesting the full thickness skin from the penoscrotal web, 4th row: placing the graft after maximal defatting and removal of hair follicles.

Fig. 6: Penectomy with perineostomy in a patient with tumour invasion to rectum and bladder. 1st row: preoperative findings, 2nd row: partial penectomy (which later was converted to a total penectomy in the same operation), signs of stool in the urine after passing a transurethral catheter, 3rd row: flap for perineostomy, mobilising ventral bulbar urethra, 4th row: opened urethra and final aspects.

Partial and total penectomy

Key points

a

To protect full voiding accuracy, the shape of the meatus was restored. The green dotted line shows the 5 mm macroscopic margin.

Organ-sparing options with simultaneous reconstruction

According to the present evidence, organ-sparing options are recommended in localised tumours (PeIN, penile intraepithelial neoplasia), Ta, T1-T2, (see Figures 2-4), but it requires more extensive followups and leads to a higher risk of recurrence, especially in more aggressive lesions.

Partial penectomy is indicated in tumours invading the corpora cavernosa (T3, Figure 5), if organ-saving procedures or strict follow-ups are not desired/ possible. Total penectomy (Figure 6) with perineal urethrostomy is reserved for large invasive tumours not amenable to partial amputation and in large local recurrences with the involvement of the corpora cavernosa.

Staged penile reconstruction

Staged penis reconstruction in specialised centres can be offered, once no further oncological treatment is required. If surgical treatment of the primary cancer was performed without reconstruction, then in some cases operations similar to the buried penis can be sufficient to regain voiding and sexual function (Figure 7). In cases of total penectomy, a full phalloplasty with free flaps (e.g. RAP), pedicle flaps (e.g. ALT) or localised flaps can be performed (Figure 8).

Penis-sparing surgery with simultaneous reconstruction or staged reconstruction can lead to strong positive effects in multiple areas of the patient’s life and should be offered to suitable penile cancer patients, especially if cosmesis and sexuality are of ongoing importance to them. It is recommended to have a very clear and open discussion with the patient (and partner if applicable) to find the best individual treatment option. The patient needs to be informed that a less radical treatment despite its broad benefits has a higher risk of recurrence and requires a stricter follow-up regime. Especially if a less- organ saving approach is chosen, it could be very relieving for the patient to be informed about the possibilities of future reconstructive options in specialised centres.

References

EAU-ASCO Penile Cancer Guidelines. Edn. presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6

All pictures and surgeries by Dr. Saskia C. Morgenstern, Dept. of Urology, Agaplesion Markus Krankenhaus Frankfurt (DE)

Phalloplasty by Prof. Jens Rothenberger, Dept. Plastic surgery, Agaplesion Markus Krankenhaus Frankfurt (DE)

“Have a very clear and open discussion with the patient (and partner if applicable) to find the best individual treatment option.”

Fig. 1: Shows a biopsy taken in

curative manner.

Fig. 2: Glans resurfacing - 1st row: dividing the glans epithelium in 4 quadrants and dissection, 2nd row: partially and fully de-epithelialized glans, and grafting with split skin graft from the thigh.

Fig. 5: Partial penectomy - 1st row: view on open cavernous bodies and urethra, surrounded by spongiosum body and (3rd image) closed cavernous bodies, 2nd row: mobilisation and centralisation of urethra and grafting with split skin graft from the thigh.

Fig. 7: Penile reconstruction by resection of lymphoedema, penile anchoring and grafting - 1st row: preoperative findings, 2nd row: 1 week post op, 3rd row: placing the anchor sutures, 4th row: shaft anchoring and grafting with split skin graft from left thigh.

Fig. 8: Full penile reconstruction from top left: harvesting and tubularising the free flap for the radial forearm phalloplasty, schematic drawing of an inflatable penile implant in the phalloplasty and a 1 week post op after the glans sculpturing procedure.

Fig. 3:

Fig. 4: Local excision/partial glansectomy with reconstruction - 1st row: preoperative findings, 2nd and 3rd row: mobilising and closing remaining glans tissue, 4th row: postop findings, 5th row: 6 month postop findings.

“If surgical treatment of the primary cancer was performed without reconstruction, then in some cases operations similar to the buried penis can be sufficient to regain voiding and sexual function.”

Patients with bladder pain syndrome/interstitial cystitis

Long-term use of intratrigonal onabotulinum toxin A

ruipinto@mac.com

was 50.7 (±14.5) years, the mean baseline VAS score on a scale of 1-10 was 5.7 (±1.7), and the mean follow-up was 8.8 (± 4.2) years. The global treatment maintenance ratio was 53%, meaning that approximately half of the patients accepted the necessity of a long-term treatment programme with the toxin.

Results

may further contribute to an increase in the intervals between retreatments. This data may indicate that OnabotA, combined with simple conservative measures and eventually oral medication should be used by patients at their own discretion.

References

1. Engeler D, Baranowski AP, Berghmans B, Borovicka J, Cottrell AM, Dinis-Oliveira P, et al., EAU guidelines on chronic pelvic pain 2022. Eur Urol. 2022

cruzfjmr@med.up.pt

Bladder pain syndrome /interstitial cystitis (BPS/IC) remains a difficult condition to manage, and has no curative treatment so far. Thus, a key part of BPS/IC management is on symptom control, with a particular focus on pain.

The first line of treatment involves patient education and stress control [1]. The second line involves oral analgesic therapies and pharmacological agents, intended to replenish the glycosaminoglycan layer. In the later line of treatment, surgical therapies may be introduced, including intratrigonal injection of onabotulinum toxin type A (OnaBotA) [1]. Once the OnaBotA is inward, the neurons cleave proteins that are essential for the docking of the neuronal vesicles to the membrane [2]. In sensory neurons, the release of neuro peptides, ATP and the trafficking of pain receptors from neuronal vesicles to the membrane is impaired [2].

The application of OnabotA in the trigone was previously justified by the fact that this bladder region has the highest density of nociceptors [3]. Since 2004, multiple studies showed that 100 units of OnaBotA are effective and safe in pain control, decreasing LUTS and improving life quality, in BPS/IC patients.

OnabotA action rarely extends for more than 12 months, after which symptoms recur and patients request new injections. Previous prospective studies were mainly short- or medium-term with only a few injection cycles [4, 5]. Information regarding long-term efficacy and safety in real-life conditions were lacking, until 2022 [6].

Real-life study

In the retrospective study of our cohort of BPS/IC patients treated with intratrigonal OnaBotA, the duration of treatment cycles was analysed and possible predictors of response and persistence on therapy were investigated. Patient characteristics were compared: age, the initial pain intensity, the overall treatment duration, and the duration of the first treatment cycle. For this purpose, three groups of patients were defined. The responders group comprised of 25 patients currently in treatment (patients with disease control achieved after an injection and patients that requested a reinjection). The group of non-responders to OnaBotA included 17 patients. The third group included 5 patients lost to follow-up due to non-therapeutic causes.

A total of 193 procedures were performed. Treatment per patient varied between 1 (10 patients) and 14 treatments (1 patient). Approximately 50% of patients received 4 or more treatments. The mean age of the patients at the time of the first injection

The intervals between treatment requests were surprisingly long. The median time between the 1st injection and the request for the 2nd injection was the shortest, with a median duration of 390 days (P25: 287; P75: 590). Afterwards, the duration of the effect of each treatment increased and remained very stable (see Fig. 1 above). The median intervals for requesting another treatment ranged between 414 and 669 days. The overall median interval between one injection and the following patient's request for reinjection was of 500.5 days (P25: 350; P75: 581).

Age, time to request the reinjection and pain intensity before the first intervention was not different between responders and non-responders. The majority of patients had a short response to the first trigonal injection, with 9 patients being responders (7 patients), while only 2 patients abandoned the OnabotA programme because of lack of efficacy. This suggests that the duration of the effect after the first injection should not be used as a predictor of long-term treatment efficacy.

Concerning safety, and urinary tract infection (UTI), straining to void and acute urinary retention with the need to initiate clean intermittent catheterisation (CIC) were reported. Of the 193 procedures carried out 71 procedures had no information about adverse events. In the remaining 122 procedures, 58 had no adverse events, simple UTIs were recorded in 36 cases, and straining was reported in 13 patients. The need for CIC occurred in only one procedure.

The comparison of the baseline characteristics of patients considered responders and non-responders did not identify predictive parameters for success or failure. Interestingly, the lack of response after the first injection should not be a reason to negate a second injection to BPS/IC patients starting an OnaBotA treatment. In fact, 7 out of 9 patients in this situation had excellent results in posterior treatments.

It should be stressed that more than half of the patients in our cohort remained in treatment, a proportion that compares positively with that observed in overactive bladder cohorts [7].

A limitation of this real-life study is the confoundable effect caused by the possible use of other drugs during each treatment cycle with OnabotA. As already mentioned patients had free access, at their discretion, to non-opioid analgesic drugs, amitriptyline, leukotriene receptor antagonists and antihistaminics to better control the symptomatology. The additional medication would probably be taken more often when the OnaBotA effect started to decline. However, in a real-life setting, BPS/IC patients rarely achieve symptom control with monotherapy, in particular, the patients represented in this cohort were refractory to oral and intravesical instillation treatments. Combination therapy to control systemic pain and to control urological symptoms is often necessary to increase the quality of life of BPS/IC patients.

Send

The most interesting finding from the analysis of our cohort was the long interval between the patient request for retreatment. The duration of effect of each treatment, exceeding one year on average, was longer than the duration reported in clinical trials, in which only OnabotA was allowed. The on-demand use of non-opioid analgesic drugs, amitriptyline, leukotriene receptor antagonists and antihistaminics were allowed in the cohort and may have substantially reduced the necessity of toxin reinjections. The long efficacy is a relevant finding for clinical practice as it decreases the burden that repeated injections cause to patients and health facilities.

As the treatment for BPS/IC is tailored to each patient, and flares and remissions occur at various times and frequencies, these factors may increase the time between patients requests for a reinjection.

In addition, the invasiveness and potential complications associated with OnabotA injections

Submission deadlines:

2. Cruz F., Targets for botulinum toxin in the lower urinary tract. Neurourol Urodyn [Internet]. 2014 Jan 1;33(1):31–8. Available from: www.doi. org/10.1002/nau.22445

3. Pinto R, Lopes T, Frias B, Silva A, Silva JA, Silva CM, et al. Trigonal injection of botulinum toxin A in patients with refractory bladder pain syndrome/ interstitial cystitis. Eur Urol. 2010;58(3):360–5

4. Giannantoni A, Di Stasi SM, Nardicchi V, Zucchi A, Macchioni L, Bini V, et al. Botulinum-A toxin injections into the detrusor muscle decrease nerve growth factor bladder tissue levels in patients with neurogenic detrusor overactivity. J Urol. 2006 Jun;175(6):2341–4

5. Pinto RA, Costa D, Morgado A, Pereira P, Charrua A, Silva J, et al. Intratrigonal onabotulinumtoxinA improves bladder symptoms and quality of life in patients with bladder pain syndrome/interstitial cystitis: A pilot, single centre, randomised, double-blind, placebo controlled trial. J Urol [Internet]. 2018;199(4):998–1003. Available from: www.doi.org/10.1016/j.juro.2017.10.018

6. Abreu-Mendes P, Ferrão-Mendes A, Botelho F, Cruz F, Pinto R., Effect of intratrigonal botulinum toxin in patients with bladder pain syndrome/interstitial cystitis: A long-term, single-centre study in real-life conditions. Toxins (Basel). 2022;14(11).

7. Marcelissen TAT, Rahnama’i MS, Snijkers A, Schurch B, De Vries P., Long-term follow-up of intravesical botulinum toxin-A injections in women with idiopathic overactive bladder symptoms. World J Urol [Internet]. 2017 Feb 7;35(2):307–11. Available from: www.link.springer.com/10.1007/ s00345-016-1862-y

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

Dr. Pedro AbreuMendes Dept. of Urology, Centro Hospitalar Universitário de São João and Faculty of Medicine of Porto (PT) pedromendes.uc@ gmail.com

Assoc. Prof. Rui Almeida Pinto Dept. of Urology, Centro Hospitalar Universitário de São João and Faculty of Medicine of Porto (PT)

Prof. Francisco Cruz Dept. of Urology, Centro Hospitalar Universitário de São Joãoand Faculty of Medicine of Porto (PT)

"The long efficacy is a relevant finding for clinical practice as it decreases the burden that repeated injections cause to patients and health facilities."

Fig. 1: The median duration of effect between injections (y-axis in days of effect duration counting the time between an injection and the patient request for a new treatment).

Multiple successes for urological rare disease network

ERN eUROGEN: EC funding will continue activities for 2023-2027

Ms. Jennifer Tidman ERN eUROGEN Business Support Manager Nijmegen (NL)

jen.tidman@ radboudumc.nl

ERN eUROGEN (www.eurogen-ern.eu) is the European Reference Network (ERN) for rare urogenital diseases and complex conditions. Its establishment and launch were supported by the EAU which remains an extremely valued supporting partner of the network. Below is an update on the ERN's ongoing activities and recent successes.

Referral of patients to ERN eUROGEN

We would like to remind EAU members that any clinician in the EU/EEA can refer patients with a rare urogenital disease or a complex condition that falls within the scope of the ERN. Our multidisciplinary team of experts can give secure virtual consultations using the Clinical Patient Management System (CPMS) to diagnose, suggest treatment or surgery, and then provide post-operative and transitional support. See more: www.eurogen-ern.eu/ what-we-do/virtual-consultations-cpms

A new, improved, and even easier-to-use CPMS is being developed by IBM and is expected to launch by the end of 2023, with a final version in Summer 2024. ERN eUROGEN is providing input and recommendations in this process.

Call for EC funding under EU4Health programme

The European Commission (EC) has invited ERNs to submit proposals for grants to support their coordination, management and operational activities from September 2023-2027 under the EU4Health work programme. The total budget available to the 24 ERNs is €77,400,000 (i.e., €3,225,000 per ERN) which may even be increased by a maximum of 20%. The ERN eUROGEN coordination team is working hard to submit the proposal and the evaluation results are expected at the end of July/start of August 2023.

Under this grant, ERN eUROGEN plans to intensify collaboration with the EAU Patient Office, the EAU Guidelines Office, and the European School of Urology, with further exciting initiatives being co-developed.

First five-year evaluation of ERN ERN eUROGEN has successfully submitted its information for the first five-year evaluation of the ERNs in accordance with EC regulations, which mandate that all networks are evaluated at least five years after approval.

This includes self-evaluations from all the network’s healthcare provider (HCP) members and the network itself, interviews, documentation review, and onsite and virtual audits. This is all evaluated by an Independent Evaluation Body (IEB) to compare activities and progress against original objectives, check outcomes and performance, and the contribution of each member.

developments”, followed by a presentation by Mr. Rob Cornes (GB) on behalf of the ERN eUROGEN ERN Patient Advocacy Group (ePAG) on “The importance of communication in rare diseases and complex conditions: The patient perspective.” Patient empowerment will be a prominent feature of the next grant and the network already has several exciting activities underway relating to patient awareness and information.

This was followed by a presentation relating to each of the ERN’s three workstreams. Dr. Ramon Gorter (NL) and his colleagues gave the Workstream 1 (rare congenital uro-recto-genital anomalies) presentation on “Urogenital problems in rare and complex forms of anorectal malformation: Paediatric surgical, urological, & gynaecological perspectives.” All presenters emphasised the importance of both a multidisciplinary team approach and transition from paediatric to adult services – an important issue, recognised by ERN eUROGEN’s newly formed working group on ‘Transition’.

For Workstream 2 (functional urogenital conditions requiring highly specialised surgery), Mariangela Mancini (IT) spoke on “Interstitial cystitis: Current evidence, personal perspectives, ideas for the future”, and stated the diagnosis pathway she feels should be in every urology textbook: history, physical exam, lab tests, abdominal ultrasound, cystoscopy with hydrodistension and biopsy, and urodynamics.

Finally, Dr. Arnout Alberts (NL), Dr. Yue Che (DE), and Dr. Peter-Paul Willemse (NL) gave presentations about “Testicular cancer: Collaborative projects” relating to Workstream 3 (rare urogenital tumours), which emphasised the value of expert networks such as ERN eUROGEN.

Involvement in EAU Guidelines

ERN eUROGEN clinical experts and ePAG representatives have been involved in a multidisciplinary panel, coordinated by the EAU and the American Society of Clinical Oncology (ASCO), which has just released new international collaborative guidelines on the management of penile cancer. We are very proud of their contribution to this important work.

ERN eUROGEN and ERN ITHACA (Intellectual disability, TeleHealth, Autism and Congenital Anomalies) are currently working with the EAU Paediatric Guidelines Panel on guidelines for the management of neurogenic bladder in spinal dysraphism. ERN eUROGEN will also be working with the EAU Female LUTS Guidelines Panel on guidelines for vesicovaginal fistulae.

Other ERN eUROGEN successes

ERN eUROGEN aims to share and spread information, knowledge, and best practice, and foster developments that improve care within and outside the network.

One way of achieving this has been through the EC’s ERN Exchange Programme, which closed on 31 January 2023. At the evaluation meeting, ERN eUROGEN discovered that despite being one of the smaller ERNs, with 33 five-day packages initially allocated, it had performed best out of all 24 networks, delivering 82 packages. Positive evaluations have been received from everyone who took part. ERN eUROGEN would like to thank all its visitors and hosts for their enthusiasm and dedication. We have launched a new, self-run and self-funded exchange programme, which is open to our network members, and we will continue this under the next grant.

The worsening humanitarian needs in Ukraine are escalating the plight of special children with special needs, so OMNI-Net recently launched the “Help us help them” initiative to raise funds for these children and provide a glimmer of hope. Proceeds will help children who need catheters and cerebral shunts. See www.gofundme.com/f/help-ukrainian-childrenwith-disabilities to learn more.

ERN eUROGEN will also be supporting visits by Ukrainian doctors to its HCPs under its above mentioned exchange programme and is petitioning the EC to open up the CPMS to Ukraine, even though it is outside the EU/EEA.

The EC expects the evaluation to take approximately one year. The IEB is now preparing the draft evaluation reports for each member, which will include the summary and detailed results, as well as comments and recommendations. The final results will be published on the EC’s website for public health.

EAU23 Congress: Thematic Session

ERN eUROGEN held a very successful and wellattended Thematic Session on rare and complex urology at EAU23 in Milan, on 13 March 2023.

Ms. Michelle Battye (GB), ERN eUROGEN programme manager, delivered an “Update on ERN eUROGEN

ERN eUROGEN is producing a book “Rare and complex urology”, published by Elsevier, with overview chapters on network development and activities such as collaboration, guidelines, and our patient registry, followed by clinical chapters on each expertise area we cover. Each clinical chapter will be authored by experts from at least three HCPs within Europe to ensure quality and consensus. Work is progressing well, and the book will be published in early 2024.

Support for Ukraine

ERN eUROGEN is collaborating with the International Federation for Spina Bifida and Hydrocephalus (IFSBH) and has signed a Memorandum of Understanding with ONMI-Net Ukraine (a network of over 20 children’s hospitals in Ukraine) to help children with rare disorders and their families.

"Patient empowerment will be a prominent feature of the next grant and the network already has several exciting activities underway relating to patient awareness and information."

Ms. Michelle Battye, Mr. Rob Cornes, Dr. Ramon Gorter and Dr. Mariangela Mancini (clockwise) presenting in the Thematic Session on rare and complex urology at EAU23

New DEEP-URO study builds on GPIU success

It’s time to find a solution for antimicrobial-resistant bacteria

international offices, and pharmaceutical companies. Our goal was to design and develop a dynamic Pan-European scientific platform, capable of connecting and operating many independent, integrative modules. We aimed to create a global network for infectious disease research and patient care, with UTI serving as the pilot specialty of the platform (Figure 3a, 3b, and 4).

(GB), Prof. Tommaso Cai (IT), Prof. Florian Wagenlehner (DE), Dr. Béla Köves (HU), Prof. Kurt Naber (DE)

Over the past 20 years we have been conducting the Global Prevalence Study of Infections in Urology (GPIU), which has allowed us to identify the increasing threat of antimicrobial-resistant (AMR) bacteria. This has been a collective effort with the support of the urology community. We are proud to have established a unique position to demonstrate the problem of AMR in urology, and we have been successful in raising awareness of the issue through our research and publications.

However, we know that this is not enough. With the increasing threat of AMR, we need to take action to find a solution. That's why we are embarking on a new journey with the DEEP-URO study, where we aim to evaluate the effectiveness of de-escalation of antibiotic prophylaxis in reducing the incidence of infectious complications and antibiotic resistance while maintaining patient safety. We are confident that with our established collective altruistic approach, we can contribute to tackling AMR in urology, and our efforts will contribute worldwide (Figure 1).

Nonetheless, we persevered, and the first annual registration was conducted in 2003. It was christened the Pan European Prevalence study (PEP-study). The registration process proved to be a resounding success, and the study was repeated the following year as the Pan Euro-Asian Prevalence study (PEAP-study).

The success of the study continued, and it evolved into GPIU, the Global Prevalence study on Infections in Urology. By 2015, the study was operational in 73 countries, and over the years, more than 30,000 hospitalised urological patients have been screened for hospital-acquired infections. [1]

retrospective data analyses published and to influence guidelines recommendations. We were criticised for a continuous retrospective approach and for random inclusion of study centres over the years. Not even the best mathematical modelling could compensate for that. We could also not provide evidence that local investigators had been trained to fill in report forms. Although the study always had a central ethical approval, hospitals in some countries questioned the need for approval by local and regional ethical committees.

After careful consideration, we realised that we were at a crossroads. The success of our SENTRII project had put us in a favourable position to secure funding for several years. However, we were faced with a crucial decision: should we continue with a more educational and developmental project, or shift our focus to a more urology-centric research project that would address the pressing challenges of antibiotic resistance? After much discussion, we decided to pursue a new concept called DEEP-URO (DEEscalation of antibiotic Prophylaxis in UROlogical procedures for prevention/tackling of antibiotic resistance). By leveraging our experience with GPIU, the shortcomings we had encountered, and the new ideas we had developed for SENTRII, we believed that we could make a meaningful contribution to the field of urology and tackle one of the most pressing public health challenges of our time.

In 2021, a dedicated research group was formed with a vision to provide evidence-based answers to all relevant knowledge gaps in the field of genitourinary tract infections that have real-life impact on patients. The group adopted a very focused, management oriented working structure to effectively identify, design, organise and implement multiple research projects. We realised that antibiotic prophylaxis was a field where lack of evidence hinders our ability to provide the best practice to our patients in urology.

DEEP-URO study

The PEP, PEAP and GPIU studies

It all began with Dr. Paul Madsen (DK), who journeyed to Wisconsin with his German spouse in pursuit of their American aspirations. As a result of his contributions to medicine, he was bestowed an honorary degree by the Danish Queen. Dr. Madsen initiated a program of one-year fellowships in urology for talented and driven young urologists. Among the Danes in this group was a German man named Prof. Naber, who was introduced to the study of urinary tract infections. At the EAU congress in Paris in 1996, Prof. Kurt Naber assembled a group of experts from around the world to discuss the pressing issues surrounding UTIs and antibiotic treatment in urology. Invitees included luminaries like Dr. Joan Palou Redorta (ES), Prof. Bernard Lobel (FR), Prof. Henry Botto (FR), Prof. Michael Bishop (UK), Prof. Péter Tenke (HU), Prof. Hakki Mete Cek (TR), and Prof. Bjerklund Johansen. At that time, many of us were unfamiliar with terms such as pharmacokinetics, pharmacodynamics and nosocomial. In 2000, we founded the European Society for Infections in Urology and produced the inaugural edition of the EAU guidelines on UTI. The society later became a full section of the EAU.

Background

It was clear to us that infective complications could pose a significant threat to the success of surgeries. One of the most prevalent diseases we encountered was urinary tract infection (UTI). It became evident that reducing infective complications could serve as a vital tool in improving the quality of care we provided. However, the rate of infective complications in urology, the causative agents, and risk factors were not well understood.

We proposed establishing a prevalence registry through an electronic network like the recently established virtual Institute of Urology in Norway. Prof. Bishop voiced his scepticism, stating that this was not possible on an international level.

Funding and technology

From the beginning, the ESIU and its UTI guidelines panel have faced challenges in finding sponsors due to our unique stance of trying to reduce overconsumption of antibiotics. Nevertheless, we have had the full support of the EAU, EAU Research Foundation, and its secretary generals. Urologists drafted the CRFs and IT structure, and IT engineers at the EAU developed the applications. The study platform relocated to the Technische Hochschule in Mittelhessen (THM) in Giessen, Germany, with more IT support available as the study expanded. Annual grants from the Swiss Merian Iselin Clinic and the invaluable contributions of Prof. Gernot Bonkat (CH) facilitated this relocation.

Outcomes

The PEP and PEAP studies provided crucial insights into hospital acquired infections in urology, including microorganisms causing these infections and their resistance rates to commonly used antibiotics. Over the years, the annual studies have yielded an abundance of data, which has been instrumental in enhancing our understanding of UTI. With these data, we have developed a new clinical classification of UTI, defined contamination categories, identified risk factors, established antibiotic stewardship measures, and informed guidelines on treatment and prophylaxis. Furthermore, several side studies have been performed, including infective complications after prostate biopsies [2] and the SERPENS study on urosepsis which provided valuable data from nearly 1000 patients. The GPIU project has produced numerous lectures, abstracts, articles and doctoral theses, culminating in the ICUD book and the Living textbook, both serving as living monuments of our efforts [3,4]. Most recently, GPIU data was utilised to develop an optimal empirical treatment model for UTI through Bayesian mathematics [5].

The transition

As medical journals and guideline developers came to pay increasing attention to study design and level of evidence, it became more difficult to get our

Meanwhile, nosocomial infections and antimicrobial resistance was increasing and there were few, if any new antibiotics in the pipelines of pharmaceutical companies. The trends we had been studying, the needs we had identified and the measures we had called for were named by others as “antimicrobial stewardship” [6]. A comprehensive evaluation performed on assignment by the UK government told us that our topic was at the heart of an imminent crisis (The O`Neil report). We realised that our experience was valuable but also that we needed to re-define our goals and our way of working. Several meetings were held in the core study group (Figure 2).

With great enthusiasm and determination, we embarked on a months-long journey to develop an application for the EU cost project, SENTRII. This project was nothing short of ambitious, with the support of numerous esteemed researchers, research institutions, scientific organisations,

In the world of medicine, overuse of antibiotics in surgical prophylaxis is a serious issue that contributes to the growing problem of antimicrobial resistance. This can lead to difficulty in treating even the most basic infections after surgery. That's why the DEEP-URO study is so important. It aims to increase our understanding of rates and risk factors for infectious complications in urology and to determine the actual need for antibiotic prophylaxis in urological procedures.

The traditional study designs used in medicine may not be the most efficient way to generate the necessary evidence due to the many technical variations in surgical procedures, patient factors, available antibiotics, and spatiotemporal variation of antimicrobial resistance. That's why the DEEP-URO study has a novel design to generate high-level evidence for appropriate use of antibiotic prophylaxis in urology.

By evaluating the effectiveness and necessity of antibiotic prophylaxis de-escalation for select urological interventions, the DEEP-URO study offers a new approach to solving this critical problem. The study design is summarised in Figure 5.

DEEP-URO will use an innovative study platform that has the potential to improve the use of antibiotics

Fig. 1: New leaders: Prof. Wagenlehner and Dr. Köves are replaced by Dr. Tandoğdu and Prof. Tommaso Cai as chair and co-chair of ESIU

Co-authors: Dr. Zafer Tandoğdu

“We are confident that with our established collective altruistic approach, we can contribute to tackling AMR in urology, and our efforts will contribute worldwide.”

Prof. Truls Erik Bjerklund Johansen Dept. of Urology Oslo University Hospital (NO)

Fig. 2: Development meeting of DEEP-URO study. From left: Dr. Bela Köves, Dr. Tandoğdu, Prof. Bjerklund Johansen, Prof. Naber and Prof. Wagenlehner in Giessen, Germany

Fig. 3a and b: Dr. Tandoğdu and Dr. Köves discussing the transition from GPIU to DEEP-URO

related to urological interventions, thereby leading to better patient outcomes and reduced risk of antibiotic resistance. The platform provides a master protocol with inbuilt study control mechanisms for governance, ethics, common outcome measures and generic confounders.

Study strategy and objectives

DEEP-URO will initially focus on five index procedures, including radical prostatectomy, radical cystectomy, radical nephrectomy, transurethral resection of bladder tumours (TURBT), and transurethral resection of prostate (TURP). Study outcomes will be used to model personalised antibiotic prophylaxis protocols.

The primary objective of DEEP-URO is to identify the limits of antibiotic prophylaxis de-escalation by comparing 30-day infection rates (deep tissue, skin, urinary tract, and sepsis) relative to contemporary intensive antibiotic prophylaxis protocols. Secondary objectives are to measure the need for additional surgical interventions to resolve an infection in 30 days, measure HRQoL (health-related quality of life) outcomes, and establish a separate cohort of microbiological samples of perineal swabs, rectal swabs, and urine for antimicrobial resistome research.

specific variables. The process of cycles to integrate a surveillance driven RCT approach is illustrated in Figure 6.

Randomised trial. Run as a step-wedge design, the time a cluster switches from conventional extensive antibiotic prophylaxis arms to the limited antibiotic protocol will be randomised. Each cluster will focus on a specific urological intervention and will be conducted using a stepwise randomisation approach. The study will evaluate the effectiveness of de-escalation of antibiotic prophylaxis in reducing the incidence of infectious complications and antibiotic resistance while maintaining patient safety.

Study sites and time plan

DEEP-URO will be conducted at select hospitals with a well-established track record of successfully recruiting participants in previous portfolio studies, including GPIU and SERPENS. To ensure maximum recruitment, the national representatives should also identify centres in their respective countries that have experience and are skilled at leading capable participant recruitment.

Based on our projections, we estimate that the first cycle of DEEP-URO will take approximately 30 months to complete. However, we anticipate that subsequent cycles will require less time to complete as the knowledge and expertise gained from each cycle accumulates. This will enable us to conduct future cycles more efficiently, potentially reducing the duration of each cycle and accelerating the overall progress of the study.

Organisation

The Deep-URO study is organised with principal investigators, a scientific working group and national lead investigators as shown in Textbox 1.

Principal investigators: Dr. Zafer Tandoğdu (GB), Prof. Florian Wagenlehner (DE), Prof. Truls Erik Bjerklund Johansen (NO)

Study cycles. To achieve study objectives, DEEP-URO will consist of cycles which include a cohort to establish baseline event rates (including AMR rates) followed by a randomised study testing efficacy of de-escalation as compared to standard of care. By following this cyclic structure, the study can be conducted in a rigorous and systematic way, with each cycle building upon the previous one to enhance the effectiveness of antibiotic prophylaxis de-escalation in the context of urological interventions.

Cohort study. The aim is to identify the local incidence of surgical site infections, healthcare associated UTIs and sepsis, as well as antibiotic resistance rates. This information will inform the power calculations of the subsequent cluster randomised trial, which will evaluate the efficacy and safety of antibiotic prophylaxis de-escalation for a select intervention.

Study clusters. Clusters will be created according to local antimicrobial resistance prevalence. The study platform will provide an information governance framework, data collection interface and data storage accessible for all sub-studies within DEEP-URO. A generic case report form (CRF) will be developed with subsections for the index procedure-

Scientific working group: Dr. Lailla Schneidewind (DE), Dr. Jose Medina Polo (ES), Ms. Ana-Maria Tapia (ES), Dr. Jennifer Kranz (DE), Dr. Tommaso Cai (IT), Dr. Béla Köves (HU)

National chief investigators:

• Dr. Jose Medina Polo (ES)

• Prof. Bhaskar Somani (GB)

• Dr. Razvan Petca (RO)

• Dr. Carlos Ferreira, and Dr. Tiago Oliveira (PT)

• Dr. Ulanbek Zhanbyrbekuly (KZ)

• Dr. Akis Afoko (UG)

• Prof. Laila Schneidewind (DE)

• Dr. Maxime Valee (FR)

• Prof. Mathew Roberts (AU)

• Prof. Jørgen Bjerggaard Jensen (DK)

Database administrator: Dr. Adamos Hadjivasiliou (GB)

Research fellow: Dr. Eva Falkensammer (AT)

Textbox 1. Organisation of the DEEP-URO study

DEEP-URO was set in motion at EAU23 in Milan, where study protocols and objectives were discussed. Our scientific working group is committed to identifying the initial index procedures and developing electronic clinical record forms, building on previous work and leveraging IT solutions from the GPIU platform.

We've already conducted a review of infection rates after urological procedures and are currently performing a systematic review of infective complications after robotic-assisted radical prostatectomy. We've scheduled regular video meetings under the leadership of Dr. Köves to ensure everyone is aligned and progressing towards our goals.

Invitation

We invite you to join us on this new journey. Our team values the contributions of all investigators, and we prioritise recognition through co-authorship and

acknowledgements. Together, we can make a historical change and find a solution to this growing problem. The DEEP-URO study will soon be open, and we need dedicated investigators and partners from strong urology centres who can commit themselves to perform complete DEEP-URO study cycles for a given procedure and help provide high-level evidence to support publication in high impact journals and inform urological guidelines.

We need investigators who understand the trifecta of antimicrobial stewardship in urology, which can be summarised as "no infections, no resistance, and as little use of antibiotics as possible." Join us in this effort to tackle AMR in urology and make a real difference for patients around the world!

References

1. Wagenlehner F, Tandogdu Z, Bartoletti R et al. The Global Prevalence of Infections in Urology Study: A long term, worldwide surveillance study on urological infections. Pathogens 2016, 19;5(1), 10, doi:10.3390. PMID: 26797640

2. Naber KG, Scaeffer AJ, Heyns CF et al. Urogenital infections (Textbook 1182pp). International Consultation on Urological Diseases (ICUD) and European Association of Urology ISBN: 978-90-79754-41-0, Arnhem: 2010

3. Bjerklund Johansen TE, Wagenlehner FME, Matsumoto T, et al eds. Urogenital infections and inflammations. Berlin: GMS; 2017-.DOI: 10.5680/lhuii000032

4. F.M.E. Wagenlehner, E. van Oostrum, P. Tenke et al. Infective complications after prostate biopsy: Outcome of the Global Prevalence of Infections in Urology (GPIU) prostate biopsy study 2010 and 2011 – A prospective, multinational, multicentre prostate biopsy study. European Urology 2013; 63: 521-527.

5. Zafer Tandoğdu. Healthcare associated urinary tract infections in urology departments. Faculty of Medicine, University of Oslo. 2020. ISBN 978-82-8377-595-2

6. Tommaso Cai. Aspects of antimicrobial stewardship in urinary tract infections. Faculty of Medicine, University of Oslo. ISBN 978-82-8377-941-7

“The traditional study designs used in medicine may not be the most efficient way to generate the necessary evidence due to the many technical variations in surgical procedures, patient factors, available antibiotics, and spatiotemporal variation of antimicrobial resistance.”

Fig. 5: DEEP-URO study design

Fig. 6: Study platform with cycles of infective complications incidence connected to discrete trials to de-escalate antibiotic prophylaxis per procedure

Introducing the JUPITER project

A promising step towards evidence-based focal therapy for PCa

Dr. Eric Barret Institut Mutualiste Montsouris Paris (FR)

in patients with clinically localised PCa. Due to the lack of high-quality evidence, the JUPITER study has been developed.

eric.barret@imm.fr

JUPITER is a new prospective multicentre (and not randomised) European registry for patients undergoing FT for localised prostate cancer. It has been developed under the umbrella of the EAU Research Foundation who will set up the database using the Castor study management system. The principal investigators and directors of the research are Dr. Eric Barret (FR) and Prof. Juan MartinezSalamanca (ES).

jims09@me.com

In recent years the earlier diagnosis of prostate cancer (PCa) and the increased detection of small and clinically insignificant PCa has highlighted the need to reduce possible overtreatment and preserve a patient’s quality of life (QoL). In this context, focal therapy (FT) represents an ideal therapeutic option to achieve these objectives in selected patients and is a hot research topic in this field. Already in 2018, FT was considered as a possible and significant option for PCa care [1]. The most recent systematic review concluded that “more high-quality evidence is required before FT can become a standard treatment” [2]. The current EAU guidelines [2] recommend that FT can be applied “within a clinical trial setting or well-designed prospective cohort study” and states that “sufficient data are available to form the basis of some initial judgements” for FT

At least 1,000 patients will be recruited for 2 years in European centres already experienced in FT. Inclusion criteria are related to: patients characteristics (age ≥ 18 years, WHO performance status 0 or 1, no prior treatment for PCa and diagnosis of intermediate-risk PCa according to D’Amico’s 2003 risk group categories), mpMRI findings (detection of single lesion suspected PCa lesion on mpMRI < T3, with PI-RADS ≥ 3 and tumour localisation according to the segmentation model used in PI-RADS v2), biopsy modalities (with a systematic biopsy US-MRI fusion technique performed with a number of cores ≥ 3 per target), and pathological analysis (ISUP 2 or 3 within the target, with ISUP 1 outside the target acceptable if low volume).

The primary endpoint of JUPITER is the oncological efficacy of FT for localised PCa at 12 months follow

up, using several energy sources currently available. The secondary end points include the outcomes by energy, based on MRI, PSA changes and control biopsy, up to 60 months following the treatment.

Finally, in case of failure, the salvage treatments and their complications will be analysed.

If the study proves FT to be oncologically safe, and reduces the impact on patients’ urinary and sexual functions, it could become a valuable evidence-based therapeutic tool for both patients and urologists.

ADVERTORIAL

Reference

1. van der Poel HG, van den Bergh RCN, Briers E, et al. Focal therapy in primary localised prostate cancer: The European Association of Urology position in 2018. Eur Urol. 2018;74(1):84-91. doi:10.1016/j.eururo.2018.01.001

2. Hopstaken JS, Bomers JGR, Sedelaar MJP, Valerio M, Fütterer JJ, Rovers MM. An updated systematic review on focal therapy in localised prostate cancer: What has changed over the past 5 Years? Eur Urol. 2022;81(1):533. doi:10.1016/j.eururo.2021.08.005

3. EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam 2022. ISBN 978-94-92671-16-5

Circulating tumour DNA-guided treatment for high-risk, post-cystectomy muscle-invasive bladder cancer

Adjuvant atezolizumab for muscle-invasive bladder cancer using a minimally invasive biomarker approach

an unselected label in the United States but requires tumour cell PD-L1 expression ≥1% in Europe.[2,3]

While progress has been made against bladder cancer as a whole, there are still large subsets of patients with high unmet needs and a lack of clear guidance on how to treat them. For example, some patients with muscle-invasive bladder cancer (MIBC) who are at high risk for disease recurrence following cystectomy (pT3/T4 or N+), including those unable to receive neoadjuvant cisplatin-based chemotherapy, may benefit from adjuvant treatment. However, no data demonstrating overall survival (OS) benefit exist to guide patient selection and treatment.

To address this ongoing dilemma, biomarker-based personalised approaches have been pursued in urothelial carcinoma since the adoption of immune checkpoint inhibitors and other targeted agents.

PD-L1 is one consideration in selecting patients who may derive benefit from checkpoint inhibitors in some treatment settings; however, challenges exist in its applicability, including diagnostic assay choice, and are reflected by differences in recommendations between global health authorities.[1] For example, in the adjuvant setting, the checkpoint inhibitor nivolumab is approved with

The use of blood levels of circulating tumour DNA (ctDNA) as a biomarker for disease detection and recurrence has been demonstrated in multiple cancer types.[4] ctDNA is highly prognostic in MIBC[5] and may aid in risk stratification to inform post-surgical disease management, including determining which patients with ctDNA-negative status may be spared adjuvant therapy. It also represents a less invasive alternative to follow-up tissue biopsies, allowing for earlier detection of recurrence and potentially removing barriers to frequent testing of mutation status. An exploratory analysis from the phase III IMvigor010 study used ctDNA positivity as a surrogate for molecular residual disease to enrich for patients who may derive disease-free survival (DFS) or OS benefit with the checkpoint inhibitor atezolizumab compared with observation as well as to identify patients who could be spared adjuvant treatment [6,7]. These hypothesis-generating data provided rationale for further investigation of the role of ctDNA in MIBC management in the ongoing phase III IMvigor011 study.

IMvigor011 (Figure 1) is enrolling patients with high-risk MIBC to undergo serial ctDNA surveillance after cystectomy; patients with ctDNA(+) status, as determined using a personalised panel (tumour-informed) assay (Natera Signatera) will be randomised to adjuvant atezolizumab vs placebo (2:1). Patients who are ctDNA(–) will undergo surveillance for ctDNA relapse. Serial ctDNA surveillance after

cystectomy allows an intervention window before radiographic recurrence occurs. The primary endpoint is investigator-assessed DFS in patients who are ctDNA(+) within 24 weeks of cystectomy. Key secondary endpoints include OS in this population, investigator-assessed DFS in all randomised patients, and centrally reviewed DFS. Notwithstanding the importance of selecting the appropriate patient subset for adjuvant therapy, preventing overtreatment of patients who may not relapse is another key piece. Given the promise of ctDNA, we are excited to enrol patients in the IMvigor011 study evaluating adjuvant immunotherapy in patients with MIBC to prospectively test ctDNA as a biomarker, while we await results from other ongoing studies evaluating serial ctDNA testing for relapse detection (e.g., TOMBOLA, a phase II adjuvant atezolizumab study).[8]

Reference

1. Powles T. Adjuvant immuno-oncological treatment (next steps in immunotherapy for GU malignancies session). EAU 2023. Milan, Italy. 12 March 2023.

2. Opdivo (nivolumab). Prescribing information. Bristol Myers Squibb; 2023.

3. Opdivo (nivolumab). Summary of product characteristics. Bristol Myers Squibb; 2023.

4. Stadler JC, et al. Cancer Res 2022;82:349-358.

5. Szabados B, et al. Eur Urol. 2022;82:212-222.

6. Gschwend JE, et al. Overall survival by circulating tumor DNA status in patients with post-operative muscleinvasive urothelial carcinoma treated with atezolizumab: update from IMvigor010 (session GS5). EAU 2022. Amsterdam, the Netherlands. 4 July 2022.

7. Powles T, et al. Nature. 2021;595:432-437.

8. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/ NCT04138628. Accessed 29 March 2023.

Prof. Thomas Powles Barts Cancer Institute Queen Mary University of London ECMC Barts Health London (GB)

Prof. Juan MartinezSalamanca Hospital University Puerta de HierroMajadahonda and Lyx Institute of Urology Madrid (ES)

“JUPITER could become the means to obtain the evidence on focal therapy that many clinicians and surgeons involved in the care of prostate cancer are waiting for!”

Eric Barret and Juan Martinez-Salamanca (principal investigators of JUPITER)

Fig. 1: The IMvigor011 study (principal investigator: Thomas Powles) is enrolling patients with MIBC at 194 sites internationally. NAC, neoadjuvant chemotherapy; SOC, standard of care; WES, whole-exome sequencing.

Prophylactic radical prostatectomy in BRCA2 carriers?

How to assess men with familial prostate cancer

Prof. Chris Bangma Erasmus MC Dept. of Urology Rotterdam (NL)

c.h.bangma@ erasmusmc.nl

Prof. Peter Albers Universitätsklinikum Düsseldorf (DE)

complex, and no universal method for offering this information is available. In many European countries facilities have been created for genetic counselling, however, waiting lists are long. A molecular tumour board needs to shape the molecular results into an advice that is palatable for client as well as health professional. That is why in urology often a compact assessment of familial cancer incidence is performed, and based on that, a preliminary risk assessment is made to serve further decision making.

consuming [8], while genetic tests on the many existing BRCA2 mutations are not standardised. Implementation of genetic evaluation and consultation might be made feasible through remote counselling.

References

1. Castro E, Goh C, Leongamornlert D, Saunders E, Tymrakiewicz M, Dadaev T, et al. Effect of BRCA Mutations on Metastatic Relapse and Cause-specific Survival After Radical Treatment for Localised Prostate Cancer. Eur Urol. 2015;68(2):186-93.

p.albers@dkfzheidelberg.de

The increased public awareness on the genetic susceptibility of diseases is leading to an increased consumption of genetic screening tests worldwide. It has been estimated that over 30 million people actively underwent some form of germline testing, and it is expected that with decreasing consumer costs this might intensify rapidly. With the growing knowledge on the familial incidence of some cancers, our urologic patients will be stimulated to ask for genetic testing facing the development of a malignancy at older age, or to be informed on genetic risks considering their offspring. For prostate cancer it is perceived that a malignancy can run in families, but the observation is often used more as an explanation in retrospect than as a tool to modulate the diagnostic or therapeutic care path. Is it needed, and what impact does it have?

In the recent EAU23 session on familial prostate cancer, the work-up for the evaluation of men with a positive family history on prostate, ovarian, and breast cancer was discussed. The in-depth evaluation of the family is the terrain of clinical genetics. The consultation takes time, as a proper understanding of the impact of testing results is needed, as is a proper consent. The text might be

A ‘positive family history’ might lead to genetic testing, and reveal the presence of a gene mutation within the BRCA2 gene that is considered pathologic, and may lead to cancer. A malfunctioning BRCA2 gene does not sufficiently correct DNA-mistakes in the process of cell renewal. Not always will this result in a cancer in the prostate, and in case of a BRCA2 presence, it is estimated that during a life time the risk is ca 60%, leading to a worse survival compared to non-carriers [1]. Which is considerably more compared to the 11% chance on relevant PCa in the general population.

In the absence of genetic testing, there is no scientific argument to alter the normal work-up with a strong familial cancer tendency, however it might raise awareness and induce extra testing, e.g. by MRI in young patients.

However, the interpretation of MRI in young patients is not easy. Dr. Schlemmer (DE) explained on the variation in nodules seen on MRI of men participating in the PROBASE study, and emphasised that it needs special expertise to report on men aged 50 or younger [2]. A case presentation by Dr. Linares (ES) concerned a 55-year old BRCA2 carrier with a PSA of 2.12 ng/ml and a negative MRI, who by consensus of the discussion panel continued to be screened by PSA and DRE only, and MRI on indication. By illustrating the NCCN 2023 guidelines [3], Prof. Morgans (US) showed that based on the limited data available it should be considered to advise BRCA2 testing in men diagnosed with high-risk or metastatic PCa, and in men with a positive family history [4, 5]. As risk on other cancers is increased in BRCA2 carriers [6], in many countries male breast selfexamination is promoted [7]. But the genetic counselling, if available, can be tedious and time

In BRCA2 carriers with ISUP1 (Gleason 3+3) low risk tumours (case by Dr. Cogelnik from Gradec), Prof. Radtke (DE) showed the increased risk of early progression and worse outcome [9], but that there are no biomarkers other than MRI that play a role in estimating that risk. Overconsumption of diagnostics is high in this group, according to Prof. Boesen (DK), and MRI-only is not yet sufficiently mature to independently indicate biopsies in active surveillance. There is no evidence that a positive family history for PCa urges a more intense follow-up [10]. Nevertheless, Prof. Coelho (BR) made a strong plea for radical surgery in this patient group, in which the outcome is worse compared to men without germline mutations. The parallel of ‘prophylactic’ radical prostatectomy with BRCA2 positive women at risk for breast cancer is easy to suggest, and a randomised trial in BRCA2-positive men with low risk cancers for observation versus surgery has been initiated in Canada [11].

At a time in which the impact of a BRCA2 carrier status on younger men for the rest of their life is high, but the health professionals still do not have sufficient evidence to decide what to do, it might be best to focus on how to bring sufficient observations from around the world together to create fast and more relevant information. More than 30 million people have used consumer genetic tests, and they might at some time knock on our clinic door. In Germany, the German Cancer Aid has recently funded the organisation of a Prostate Cancer Prevention Clinic (ProFam-Risk*) for men with familial history. These kind of consultations are in place in other parts of Europe and the US as well. But the expert panel at EAU23 made a plea to gather data of these prevention clinics in order to get a more scientific view on the risks and also the magnitude of anxiety of men who ask for consultation. A lot is still to do in order not to overdiagnose and overtreat men with familial prostate cancer.

*abstract Anna Henrike Rabe, EAU23:Trials in progress

2. Krilaviciute A, Albers P, Lakes J, Radtke JP, Herkommer K, Gschwend J, et al. Adherence to a risk-adapted screening strategy for prostate cancer: First results of the PROBASE trial. Int J Cancer. 2023;152(5):854-64.

3. Schaeffer EM, Srinivas S, Adra N, An Y, Barocas D, Bitting R, et al. NCCN Guidelines(R) Insights: Prostate Cancer, Version 1.2023. J Natl Compr Canc Netw. 2022;20(12):1288-98.

4. Seibert TM, Garraway IP, Plym A, Mahal BA, Giri V, Jacobs MF, et al. Genetic Risk Prediction for Prostate Cancer: Implications for Early Detection and Prevention. Eur Urol. 2023;83(3):241-8.

5. Bancroft EK, Page EC, Brook MN, Thomas S, Taylor N, Pope J, et al. A prospective prostate cancer screening programme for men with pathogenic variants in mismatch repair genes (IMPACT): initial results from an international prospective study. Lancet Oncol. 2021;22(11):1618-31.

6. Lee DJ, Hausler R, Le AN, Kelly G, Powers J, Ding J, et al. Association of Inherited Mutations in DNA Repair Genes with Localized Prostate Cancer. Eur Urol. 2022;81(6):55967.

7. Segal N, Ber Y, Benjaminov O, Tamir S, Yakimov M, Kedar I, et al. Imaging-based prostate cancer screening among BRCA mutation carriers-results from the first round of screening. Ann Oncol. 2020;31(11):1545-52.

8. Paller CJ, Antonarakis ES, Beer TM, Borno HT, Carlo MI, George DJ, et al. Germline Genetic Testing in Advanced Prostate Cancer; Practices and Barriers: Survey Results from the Germline Genetics Working Group of the Prostate Cancer Clinical Trials Consortium. Clin Genitourin Cancer. 2019;17(4):275-82 e1.

9. Carter HB, Helfand B, Mamawala M, Wu Y, Landis P, Yu H, et al. Germline Mutations in ATM and BRCA1/2 Are Associated with Grade Reclassification in Men on Active Surveillance for Prostate Cancer. Eur Urol. 2019;75(5):743-9.

10. Telang JM, Lane BR, Cher ML, Miller DC, Dupree JM. Prostate cancer family history and eligibility for active surveillance: a systematic review of the literature. BJU Int. 2017;120(4):464-7.

11. Clark R, McAlpine K, Fleshner N. A Clinical Trial of Prophylactic Prostatectomy for BRCA2 Mutation Carriers: Is Now the Time? Eur Urol Focus. 2021;7(3):506-7.

PRAISE-U launches encouraging early detection of PCa

EU-wide project aims to reduce prostate cancer mortality through smart early detection

By Kevin McBride

The EU4Health programme has approved PRAISE-U (PRostate cancer Awareness and Initiative for Screening in the European Union), an ambitious three-year project involving 25 institutions from 12 countries. PRAISE-U’s mission is to design a nationally-tailored cost-effective early detection algorithm for prostate cancer screening in the EU to reduce morbidity and mortality caused by prostate cancer while avoiding overdiagnosis and overtreatment.

Prostate cancer is the number 1 and 2 cancer killing men in Northern and Western Europe respectively. It is the most frequent male cancer in Europe with important consequences for healthcare systems. Every year, around 450,000 European men are diagnosed with prostate cancer. Delayed diagnosis can lead to higher rates of metastasised disease, which is a disease state that coincides with a high mortality rate and a prolonged negative impact on the quality of life. It has been shown that organised repeated screening results in early detection that can reduce suffering and dying from prostate cancer.

[1] Modern tools and strategies can streamline the process to detect cancer when it poses a threat to the patient.

In direct partnership with a network of consortium members, PRAISE-U works to encourage early detection and diagnosis of prostate cancer in EU Member States through smart early detection and stimulate the implementation of early detection programmes in Member States. By aligning protocols and guidelines across Member States

and enabling the collection and analysis of relevant data, the project aims to reduce prostate cancer morbidity and mortality rates in Europe with customised and risk-based screening programmes.

Prof. Hein Van Poppel, chair of the EAU Policy Office: “The diagnostic pathway for prostate cancer has improved tremendously over the past decades [2]. PRAISE-U marks a new era in early detection of prostate cancer. Through this project, we want to provide clear guidelines and quality assurance tools that can be used by pilot sites to demonstrate that risk based approaches are effective, feasible, acceptable and cost effective. In our consortium, we have a strong partnership with the right mix of international academic experts, healthcare professionals, social scientists, economists, patients and health system pilot sites to make this a success.”

European Association of Urology National Cancer Institute, Lithuania

Erasmus University Medical Center, Cancer Institute, Rotterdam Ghent University

European Randomized Study of Screening for Prostate Cancer Health Service Executive, Ireland

Estonian Urological Society

University Research Clinic for Cancer Screening, Randers Regional Hospital, Central Denmark Region

Institute of Health Information and Statistics of the Czech Republic University College Dublin, National University of Ireland, Dublin University Medical Center Utrecht World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians

European Cancer Organisation Movember Foundation

Lower Silesian Oncology, Pulmonology and Hematology Center

National Institute of Public Health, National Institute of HygieneNational Research Institute, Poland

To achieve PRAISE-U’s goals a multi-disciplinary consortium centred around Europe’s leading clinicians and researchers in prostate cancer has been established. The consortium includes experts in prostate cancer and decision making, and a network of hospitals, medical societies, patient advocates and national authorities.

Guenther Carl-Ernst, Chairman of Europa Uomo: “We are delighted to support the implementation of PRAISE-U and we are so glad prostate cancer

International Agency for Research on Cancer

European Society of Urogenital Radiology

Department of Health of Galicia, Consellería de Sanidade de Galicia Europa Uomo

Althaia Xarxa Assistencial Universitaria The Czech Urological Society

Region Västra Götaland Sweden Region Stockholm, Sweden

Region Skåne, Sweden

Table. 1 The participants of the PRAISE-U consortium

is finally getting the attention it deserves as the EU’s most common male cancer. For us, every man whose cancer is detected too late, is one man too many.”

The PRAISE-U project is broken down into six work packages. The four core WPs are designed to gather knowledge, develop protocols for screening programs, pilot test the developed protocols, and evaluate the results. The two overarching WPs provide a framework for the entire project and include coordinating the project and disseminating the results. Each WP builds on the work of the previous one, and together they

contribute to the ultimate goal of developing a strategy that will reduce prostate cancer morbidity and mortality while minimizing overdiagnosis.

On 25-26 April, more than 50 members of PRAISE-U participated in the kick-off event for a new Pan-European prostate cancer screening initiative in Brussels.

For more info please visit www.praise-u.eu/

References:

1. Hugosson, J., Roobol, M. J., Månsson, M., Tammela, T. L., Zappa, M., Nelen, V., ... & Auvinen, A. (2019). A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. European urology, 76(1), 43-51. https://doi.org/10.1016/j.eururo.2019.02.009.

2. Van Poppel, H., Albreht, T., Basu, P., Hogenhout, R., Collen, S., & Roobol, M. (2022). Serum PSA-based early detection of prostate cancer in Europe and globally: past, present and future. Nature reviews. Urology, 19(9), 562–572. https://doi.org/10.1038/s41585-022-00638-6

3. Van Poppel H. et al. Prostate-specific Antigen Testing as Part of a Risk-Adapted Ealy Detection Strategy for Prostate Cancer: European Association of Eurology Position and Recommendations for 2021. Eur Urol (2021), Https://doi.org/10.1016/j.eururo.2021.07.024.

“For us, every man whose cancer is detected too late, is one man too many.”

Table 1: The participants of the PRAISE-U consortium

Updates from ESRU and YUORDay23

The residents' programme during EAU23

Dr. Frederikke Sørensen Member, Working Group ESRU Regional Hospital West Jutland (DK)

fec1411@gmail.com

The European Society of Residents in Urology (ESRU) is the residents’ voice in the EAU. Each member country of the EAU can participate with two National Chief Officers (NCO). The ESRU meets twice a year: during the annual EAU congress and during EUREP in Prague. There were 25 urology residents from 15 different countries at the recent meeting in Milan.

During the meeting we had an update on the BURST projects. The British research group has a close collaboration with the ESRU for recruiting investigators for their research projects. The new chair Dr. Enrico Checcucci (IT), accounted for the status of the EBU surveys ESRU participated in. Dr. Tiago Ribeiro De Olivera (PT) presented the progress of the Urology Boot Camp which has the goal to be an offer for all first-year residents in the EAU member countries. Until now 12 courses have been held in 7 countries. More than 160 residents have participated in the course. The boot camp is outlined as a one-day course with 3 hours theory and 8 hours of 1:1 hands-on training on models in: laparoscopy, upper urinary tract endoscopy, transurethral resection and lower urinary tract endoscopy.

The chairman of the Young Urologists Office (YUO)

Dr. Juan Vásquez, presented a new offer to young urologists under the age of 45: The EAU Talent Incubator. A 2,5-day course with a focus on soft skills such as decision-making for individuals and groups, negotiating and influencing, assertiveness in the workplace, presenting yourself well in a range of work situations and how to get the best out of your team. If you would like more information, you can visit www.uroweb.org/incubator

Two other new projects were presented, which included: the compliance of ESRU to recommendations of the EAU guidelines for NMIBC/ MIBC; and the residents perspective on kidney transplantation.

In the more formal part of the meeting, we had to say goodbye to the outgoing Chair Dr. Francesco Esperto (IT), and Dr. Diego Carrión Monsalve (ES) is now the new past Chair. Thank you, Chairs, for the good work in ESRU. Dr. Enrico Checcucci is new chair and Dr. Luca Afferi (CH) was voted as the new Chair Elect. Congratulations.

YUORDay23

The most visible contribution from the ESRU at the EAU Congress was YUORDay23, which comprises of

a whole day with sessions and presentations dedicated to residents in Urology. YUORDay always has a session about the European Urological Scholarship Programme (EUSP), and a research and academic session. If you are interested in taking a scholarship or how to study smarter, then these were the sessions for you. There was good attendance at the clinical session on surgery tips and tricks and I hope everybody who joined in got some useful tricks to use later on.

As something new this year, YUORDay had a session on nightmare cases, presented by a resident and discussed with an invited expert. Very intriguing cases, including robotic surgical repair of urinary leak after renal trauma not responding to conservative treatment, and delayed bleeding after PCNL resulting in both open repair and coiling were discussed. The last case involved the open repair of ureteral lesions, which was also very interesting. The topic of how to continue to have good competences in open surgery when more and more surgery is minimally invasive was briefly discussed.

In the “Urology for dummies” session, the presenters had the very hard task to make difficult topics easily understood for residents. Topics this year included: infertility workup, the metabolic evaluation of stone patients, the management of castration resistant prostate cancer, and how to make good use of urodynamics.

The last academic session of the day was “Challenging the guidelines”. The role of PSMA in initial staging of prostate cancer and the best treatment options for young men under the age of 50 years with LUTS was discussed. The day ended with the EAU Guidelines Cup, which was won by the Polish team. It was a very interactive session where both the finalists and the audience could answer. If you missed some of the presentations or want to re-watch them, several of the sessions from YUORDay23 can be found as webcasts on the EAU23 website.

Recognising the valued contributions Dr. Esperto (l) has made to the ESRU, with Dr. Monsalve (r)

Dr. Dominik Mucharski (PL) wins the 2023 EAU Guidelines Cup

An ESRU team effort at EAU23

The ESRU Board and National Chief Officers collaborating in Milan

Self-injection for penile enlargement Guidelines for residents to avoid serious complications

Dr. Stefan Tiganu Medlife Genesys Dept. of Urology Oradea (RO)

tiganustefan@

gmail.com

Dr. Madalina Sava Medlife Genesys Dept. of Dermatology Oradea (RO)

madalina.sava0508@

gmail.com

From ancient times, the size of the male genitals had a separate place in the definition of masculinity. Among the ancient Greeks, the small size of the genitals was considered a sign of beauty and intelligence, whilst a large penis was considered hideous and unattractive. [1] Other cultures like Arabic, Chinese, Japanese and Norsemen in their early times depicted men having larger penises than normal and this was considered a sign of masculinity. [2]

Contemporary men under the influence of culture, society and the media tend to underestimate their size, therefore, they want to increase it. Unfortunately for various reasons they end up resorting to dubious self-treatments and injections with allogeneic substances such as petroleum jelly, kanamycin and other mineral oils.

The practice of self-induced penile enlargement with allogeneic non-resorbable substances involves injecting foreign substances between the corpora cavernosa and penile skin to increase its girth and length. The idea behind this practice is that the injected substance will cause the penis to expand and create a larger size. However, this practice is extremely dangerous.

Injecting non-resorbable substances into the penis can cause serious complications, such as infection with subsequent sepsis, scarring, phimosis, deformities, acute urinary retention, substance migration, trophic ulcers [3] and even death.

Moreover, the injected substances may also cause allergies, inflammation, and irreversible tissue damage, leading to pain, discomfort and erectile dysfunction.

Self-induced penile enlargement with non-resorbable allogeneic substances is not only physically harmful but also mentally distressing. Men who engage in this practice may experience feelings of shame, guilt and anxiety due to insecurity about their size. However, it is important to note that penis size does not determine a man's sexual ability or satisfaction.

slit that was performed 2 months prior presentation due to acute urinary retention. At this time he accepted removal only of the bulge that on ultrasound appeared to be an abscess. The mass was removed and the skin defect closed without grafting. Intense fibrous process under the skin was revealed.

Fig. 1: Preoperative aspect after dorsal slit

Fig. 2: Immediate postoperative aspect

Fig. 3: Healing process 10 days after surgery

Case number II

• Local examination can find either a palpable mobile mass or a thickening of the skin with atrophic or ulcerated lesion on it, a penile deformity, oedema or a phimosis, sometimes urinary retention is the cause of ED presentation.

• If there is doubt in diagnosis, an ultrasound and an MRI may be of help. [4]

• If there is any sign of infection, a broad spectrum antibiotic should be initiated. If the patient has a fever, admission to a ward should be discussed, or if he is unstable, intensive care would be needed.

• All patients should be informed of further complications and the necessity of surgical intervention in the future.

Conclusion Self-induced penile enlargement with permanent fillers is dangerous, with possible severe complications in the long term- migration, granulation and infection. This potentially harmful practice should be avoided at all costs.

These male patients usually come to the emergency department (ED) with complications such as urinary infection and infected ulcers, urinary retention or considerable oedema. In most of the cases the patients can be managed conservatively but unfortunately they may need surgical therapy later in life to remove affected skin and in some cases a graft will be used. Even if the procedure goes perfectly, the cosmetic outcome may be unsatisfying. [3]

Below are two patient cases that presented at our outpatient clinic, and after further management, needed surgery.

Case number I

A 35-year-old male patient had his first presentation in our outpatient clinic with a narrow phimosis, a big bulge in his front foreskin and complaining of erectile disfunction, all after penile injection of petroleum jelly 10 years ago. His second visit was 6 months later, when he came with the same bulge but with a dorsal

A 28-year-old male had injected Kanamycin 2 years before presentation. All the injected mass migrated in the front part of his foreskin, inducing a very tight phimosis, with an inability to achieve orgasm. After counselling the patient and explaining possible complications, he agreed to have a circumcision performed.

Fig. 4: Preoperative image

Fig. 5: Immediate postoperative image

Follow-up results for both patients included a quality of life (QoL) evaluation, and surgery satisfaction was further assessed at control examination. For a young urologist managing such cases, it can be very challenging because of the lack of information and the rarity of cases, so we have provided some guidelines to follow.

Some guidelines

• History is of utmost importance, usually patients know the type of fillers, when it was done and the order of symptoms onset.

Setting a new course for ESUI: A manifesto

New Chair shares aspirations for the Section

Prof. Francesco Sanguedolce Fundació Puigvert Dept. of Urology Barcelona (ES)

fsanguedol@ fundacio-puigvert.es

The EAU Section in Urological Imaging (ESUI) is among the most challenging Sections of the EAU. From one side, urological imaging is a field in rapid expansion; on the other, imaging is at a crossroads of different medical and technological specialisations whose interaction might require special balance and extra effort. In fact, urological imaging involves radiological and nuclear medicine expertise, as well as software innovation for augmented/virtual reality, artificial intelligence, and deep learning.

The role of urologists is evolving in a way to better interact with imaging specialists and optimise the use of technology for the best clinical applications and outcomes. Urological imaging does not merely

EAU Section of Urological Imaging (ESUI)

mean “to see something”, it also means information (real or predicted) and it is up to us as clinicians and surgeons to make proper use of this information. How this will be realised is the current challenge.

Words from the previous and new Chairs

When Prof. Georg Salomon (DE) named me as his successor to leading the ESUI, I felt honoured and thrilled about my new role. I would like to express my gratitude to him, as well as to the ESUI Board members who have provided support and approved my candidature. Although this new role brings challenges, the inherent structure of the section is the perfect platform to undertake new and ambitious initiatives.

thank the board members for their continuous support and what would the sections and the EAU be without the hardworking and dedicated staff such as Mrs. Claudia Van Ijzendoorn, Mrs. Angela Terberg, Mrs. Sabrina Van Scherpenseel and Mrs. Soňa Lukačovičová, to name a few. Imaging in urology has changed significantly in recent years, both from a diagnostic and therapeutic point of view, and will change immensely in the near future. Throughout these changes, I’m sure ESUI will continue to be a reliable platform and channel of vital updates on imaging under the leadership of Francesco.”

Among the new initiatives, there will be the need to strengthen the collaboration with the natural “specialist partners” such as the urological working groups of the European associations of imaging (e.g. EAU Section of Urological Research, European Association of Nuclear Medicine, etc.). These strategic alliances will help identify those aspects of urological imaging worth of public debate and interaction, both in research and clinical practice.

Management of these patients may be quite intricated due to the lack of information in the literature and the inconsistency of patients being lost during treatment or follow-up for different reasons such as: shame, financial restrictions, unbalanced psycho-emotional environment, or dissatisfaction with cosmetical or functional results. Therefore, young urologists should be aware of the implications of such practices and manage the patients in a psychological supportive manner for the best compliance with minimal complications and optimal results.

References

1. Sergent B. Homosexuality in Greek myth. Continuum International Publishing Group; 1987.

2. Kim W. 2: History and cultural perspective. In: Park N, Cheol, Moon D, Geon, Kim S, editors. Penile augmentation. Berlin and Heidelberg. Germany: Springer-Verlag; 2016. p. 11–26.

3. Kadouch JA, van Rozelaar L, Kanhai RJC, Sawor JH, Karim RB. Complications of penis or scrotum enlargement due to injections with permanent filling substances. Dermatol Surg [Internet] 2012;38(7):1244–50. Available from: www.dx.doi. org/10.1111/j.1524-4725.2012.02479.x

4. Ahmed U, Freeman A, Kirkham A, Ralph DJ, Minhas S, Muneer A. Self injection of foreign materials into the penis. Ann R Coll Surg Engl [Internet] 2017;99(2):e78–82. Available from: www.dx.doi.org/10.1308/ rcsann.2016.0346

guidance); with the EAU Section of Uro-Technology (e.g. imaging simulation for focal therapy); and/or with the EAU Robotic Urology Section (e.g. augmented reality for surgical guidance during robotic surgery). ESUI will be committed to strengthening these collaborations such as promoting Joint Sessions in the relevant meetings, for example.

ESUI is already actively working with the European School of Urology and sharing the challenging task of taking to a new (upper) level the courses involving urological imaging. This new approach will allow the trainee to go through a standardised stepwise process to achieve proficiency in undertaking a complex intervention by using different sources of urological imaging.

Prof. Georg Salomon shared the following parting words: “It was my pleasure to contribute as Chair of the ESUI. I am pleased to hand the office over to Prof. Francesco Sanguedolce and I am sure that the activities of the ESUI will be expanded further under his leadership. I would like to take this opportunity to

As part of the Sections Office, ESUI will promote transversal collaborations. Nowadays most of innovation in urological imaging is applied in uro-oncology, clearly making the EAU Section of Oncological Urology a strategic partner, but other fields of interest will be shared with the EAU Section of Urolithiasis (e.g. new imaging modalities for stone characterisation, or augmented reality for PCNL

We will also welcome new and fresh forces, from the Young Academic Urologists working groups as well as any other enthusiastic youngsters who share the aims and the vision of our Section. We strongly believe that our Section is the perfect podium for those talented people who desire to emerge from the crowd.

Join the Section

Interested in contributing your knowledge and skills to ESUI? You are highly encouraged to apply. Please send an email to Mrs. Terberg (a.terberg@uroweb. org). We look forward to welcoming you.

Prof. Georg Salomon, outgoing ESUI Chair

"Injecting non-resorbable substances into the penis can cause serious complications, such as infection with subsequent sepsis, scarring, phimosis, deformities, acute urinary retention, substance migration, trophic ulcers and even death."

What’s on the agenda at UROonco23?

Get all your PCa, BCa, RCC and rare tumour updates in Gothenburg

By Stephanie Fitts

There is much excitement around the inaugural UROonco23 meeting, which is the new and improved EAU Section of Oncological Urology (ESOU) meeting combined with the educational ONCO Updates on prostate cancer, bladder cancer and renal cell carcinoma. Taking place in Gothenburg, Sweden, from 30 June to 2 July, the three day scientific programme has been designed by experts to share a broad range of the latest updates and advancements in onco-urology.

The integration of these meetings enables delegates to get the most recent findings in genitourinary cancers (GU) at a single location, as opposed to attending numerous meetings throughout the year. This ‘all-in-one’ comprehensive structure is expected to not only save time, but also foster collaboration among different onco-urology groups and facilitate the sharing of knowledge and expertise.

The meeting will be introduced by Prof Morgan Rouprêt (FR), chairman of ESOU and member of the UROonco23 steering committee. The format will be different from the former ESOU meeting, with an auditorium for the main scientific programme, and dedicated rooms for the more personalised sessions, such as: clinical case discussions, Real World Onco-Urology, and the STEPS programme.

externed pelvic lymph node dissection during radical cystectomy). These results are eagerly awaited. We had a German trial that presented negative results a few years back and we are looking forward to hearing what will happen with PLND during radical cystectomy (very interesting for urologists); Other trial updates will include CheckMate 274 about adjuvant nivolumab after RC, which Dr. Fred Witjes (NL) will present with long-term follow-up.”

sizes, there are three different session times to choose from. Time allowing, all three sessions will include the same clinical cases.

During UROonco23 there will also be an award presentation for the best article published in the European Urology Oncology over the year, with the winning author sharing the article highlights.

Early summer 2023

Morgan Roupret, Chair, UROonco23

The UROonco23 meeting provides European-based urologists with the opportunity to get a global perspective on GU cancer updates, with the scientific programme covering the latest research findings from other urological gatherings around the world, such as ASCO GU, AUA2023 and ASCO 2023. For more information or to sign up to attend, you can visit www.UROonco23.org

The late registration discount ends on 15 June 2023 (23:59 CEST).

According to Dr. Mir Maresma, there is much interest around future research results that will include the use of antibody drug conjugates at earlier stages of MIBC disease and next-generation therapies for NMIBC, mostly with intravesical delivery.

UROonco23

Steered by the EAU Section of Oncological Urology (ESOU)

30 June - 2 July 2023, Gothenburg, Sweden

www.uroonco23.org

Dr. Gianluca Giannarini (IT)

Expert insights

With four plenary sessions dedicated to prostate cancer, ESOU board member Dr. Gianluca Giannarini (IT), shares some details on the hot topics that will be discussed: “Prostate cancer sessions will cover the whole spectrum of the disease, with a special focus on novel image-based strategies for early detection, and management of locally advanced and oligometastatic disease in the era of PET imaging. Novel strategies of intensification and combination treatments in the overt metastatic setting will also be deliberated on.”

“Of particular interest, study investigators will give updates on several ongoing clinical trials (e.g. PEACE-1 and RADICALS-HD), and there will be thought-provoking debates on some EAU Guidelines, including challengers, defenders and a final verdict.”

“2023 is proving to be an exciting year for advances in the care of patients with prostate cancer. Important data was released earlier this year on the efficacy and safety of combination treatments for men with advanced disease, both in the hormonesensitive (ARASENS), and in the castration-resistant (MAGNITUDE, PROpel and TALAPRO-2) stage. At the recently concluded EAU23, the long-term results of the ProtecT trial were reported, showing low mortality in men with localised disease irrespective of treatment allocation to monitoring, surgery or radiation therapy. Prostate cancer research is in great ferment with continuous flourishing’s of clinical trials, e.g., the potentiality of molecular imaging for diagnosis and treatment, and the efficacy of novel paradigms integrating loco-regional and systemic therapies, with the aim to offer individualised pathways of care for what is among the most common malignancies.”

Dr. Maria Carmen Mir Maresma (ES)

Six trial updates for BCa

Dr. Maria Carmen Mir Maresma (ES), also part of the ESOU board, is co-chairing several plenary sessions on bladder cancer, and shares some of her programme highlights: “We will have six trial updates, five in bladder cancer and one on upper tract urothelial carcinoma (UTUC). The trial on UTUC will present interim analysis on the use of neoadjuvant chemo + IO for high-risk UTUC prior to radical nephroureterectomy.”

“Importantly, Prof. Seth Lerner (US) will present the primary results of SWOG 1011 (standard vs

Dr. Christian Fankhauser (CH)

New ASCO-EAU penile cancer guidelines

Dr. Christian Fankhauser (CH) is co-chairing two plenary sessions on rare tumours, with a focus on how to best manage men with penile cancer and palpable inguinal nodes, as well as the management of men with testis cancer and enlarged retroperitoneal lymph nodes. “Of particular interest, there will be points debated from the recently released (new) ASCO-EAU collaborated penile cancer guidelines. These new guidelines address every aspect of care from diagnosis to treatment and follow-up, with a patient-centred approach. They incorporate the many disciplines involved in the care of a patient with penile cancer, including urology, medical oncology, radiation oncology, pathology, and surgery.”

A case presentation and rebuttal on the topic of systemic therapy for cN2 penile cancer, concluding with deliberations from a panel of discussants is also a programme highlight, according to Dr. Fankhauser.

The second plenary session on rare tumours encompasses the evolving landscape in the treatment of stage II testicular seminoma and non-seminoma, in particular, primary retroperitoneal lymph node dissection (RPLND).

RCC: future goals and targets

There are two plenary sessions on renal cancer covering a range of topics including a lecture on genetic screening by Prof. Marston Linehan (US), OpeRa trial updates from Prof. Marc-Oliver Grimm (DE), and a panel discussion on the management of VHL-related and other hereditary kidney cancers. A lively debate will take place on the adjuvant treatment for advanced kidney cancer, and Dr. Friederike Schlürmann (FR) will review the future goals and targets in the management of advanced kidney cancer. There will also be an in-depth panel discussion on the treatment of oligometastatic RCC, including the role of cytoreductive nephrectomy (CN).

Interactive roundtable sessions

New developments and technologies in GU cancers will be deliberated on via interactive roundtable discussions, with up to nine urooncology clinical cases (a maximum of three on each topic – prostate cancer, bladder cancer and renal cancer) being presented in these unique sessions developed by the YAU. There will be lively discussions between key opinion leaders and delegates. To ensure small and dynamic group

“We will have six trial updates, five in bladder cancer and one on upper tract urothelial carcinoma (UTUC)”

“A special focus on novel image-based strategies for early detection, and management of locally advanced and oligometastatic disease in the era of PET imaging”

Prof.

What have urologists and the EAU achieved in 50 years?

EAU’s 50th Anniversary comes to an end with History Congress at EAU23

By Loek Keizer

On its first day, EAU23 in Milan was joined by another congress operating in its slipstream: the EAU History Office hosted the 7th International Congress on the History of Urology. The congress boasted the participation of three (former) EAU Secretary Generals, moderating and giving presentations of their own.

Notably in the morning session, Prof. Pat Walsh (Baltimore, USA) told the assembled audience the story of his and Prof. Donker’s discovery of nerve bundles around the prostate that led to the development of the nerve-sparing radical prostatectomy.

Prof. Walsh hailed the serendipity of his initial meeting with Prof. Donker, as he invited the latter, a lonesome stranger, to join him and his wife for dinner when Donker was visiting the United States in 1977. Four years later, Prof. Donker invited Prof. Walsh to visit a windmill museum in Leiden, the Netherlands, but they instead decided to go to Prof. Donker’s lab where he was researching the anatomy of stillborn males. Within hours they had identified the nerve

hesitance to adopt technological breakthroughs even as basic as the written word can offer a perspective. All in all, the History Congress served not just to open up a window to the recent past, but to offer perspective for discussion on very current issues. Experienced urologists reflected on what had been, or still remains to be achieved within their subspecialties. Young urologists showed the way forward with new avenues in treatment and research, building on their predecessors.

Webcasts are available of the presentations given at the History Congress. Visit www.eau23.org and browse the scientific programme or the EAU23 Resource Centre. Access is free if you attended EAU23, or can be purchased separately.

The History Office at EAU23

Milan-based inventor of the eponymous basket.

bundles that preserved potency and the surgical technique was developed in the following year.

Prof. Tony Mundy brought a prop to illustrate his colourful talk about the history of the treatment of urethral strictures, much of which he experienced or contributed to first-hand. Beyond the day-long international congress, the History Office had a variety of activities and milestones in Milan. Partly due to the virtual nature of EAU20 and EAU21, the History Office could present three new publications in Milan.

Prof. Walsh’s reputation ensured a very well-attended session on the history of oncological urology that also featured experts like Profs. Ribal, De La Rosette and former Secretary General Prof. Per-Anders Abrahamsson.

Using

the past to look at the future

In the afternoon, an eye-catching topic presented by Prof. Piet Hoebeke (Ghent, BE) was titled “#metoo” but covered (a history of) a wide range of genderand sexuality-related topics that urologists and their patients might deal with. Patients may have different priorities or health concerns based on their gender identity or sexual preferences.

EAU History Office Chairman Prof. Philip Van Kerrebroeck (Antwerp, BE) summed up the day with a wide-ranging philosophical talk that touched on the role of history, and indeed its importance, even at events like EAU23 that focus on the latest breakthroughs and technology. In looking at new developments in healthcare like artificial intelligence, big data or chip implants, previous generations’

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The commemorative EAU:50 marked the end of the EAU’s anniversary celebrations that started at EAU22 in Amsterdam. The 30th volume of De Historia Urologiae Europaeae was an anniversary in itself. Uniquely for Milan, this year’s congress gift Cache-Sexe: Covered, uncovered, discovered was written by Prof. Van Kerrebroeck.

As every year, the History Office prepared an exhibition across from the EAU Booth. This year it was tied to Prof. Van Kerrebroeck’s book and featured many of the unique and colourful genital coverings that are also featured in its pages. The exhibition also contained some notable artefacts from the EAU’s own past, tying in with the anniversary, and also celebrated Prof. Enrico Dormia, the

The exhibition also celebrated the 2023 winner of the EAU’s Desnos Prize for contributions to the History of Urology: Prof. Remigio Vela Navarrete (Madrid, ES). Prof. Vela Navarrete was selected by the History Office for his continued involvement in the field, authoring books on a wide range of historical topics, curating exhibitions and helping to set up the Spanish Urological Association’s own History Office.

Prof. Walsh takes the audience back to his and Prof. Donker’s discovery, over forty years prior. This part of the congress was chaired by Profs. Van Kerrebroeck and Dirk Schultheiss and former EAU Secretary Generals Prof. Debruyne and Abrahamsson.

Prof. Remigio Vela Navarrete accepts the 2023 Ernest Desnos Prize for his contributions to the history of urology.

Building on two decades of robotic expertise

20th Meeting of the EAU Robotic Urology Section to come to Florence

The EAU Robotic Urology Section will be hosting its 20th annual meeting in Florence on 13-15 September 2023. ERUS23 is Europe’s biggest event dedicated to robotic urology, a highly dynamic surgical meeting. Its scientific programme will focus on practical instructions on robotic surgery through live surgery sessions, case discussions and state-of-the-art lectures by key opinion leaders. There will also be opportunities for industry sessions, ESU Courses and a Technology Forum and, naturally, a unique opportunity to meet colleagues in robotic urology from across the world.

The ERUS meeting is also known for its special attention to the needs of younger urologists with a special Junior ERUS-YAU programme. This year will also feature a day-long EAUN programme for urology nurses, including specialised hands-on training.

Continuing the new direction of ERUS22 in Barcelona, ERUS23 will have even more of a focus on (live) surgery than past ERUS events. It is set to feature both oncological as well as nononcological urological surgery since the latter has taken an important position in the robotic urology field.

Prof. Andrea Minervini (Florence, IT) of Florence’s Careggi University Hospital spoke to us about hosting this year’s ‘anniversary’ event.

Submit your abstract now!

Deadline: 14 June 2023

“It’s a true honour and privilege to host next ERUS meeting in Florence for its 20th edition. The ERUS meeting is part of the annual ‘to do list’ among the many international congresses. I attended many previous editions, as organised by Profs. Mottrie and Breda, the ERUS Board and, of course, all of the many host centres. Obviously, we hope not to be outdone.

In this regard, the aforementioned anniversary comes just at the right time, since robotic surgery is experiencing an unprecedented revolution.”

“After almost two decades, there are now new contenders in the field for the leadership in robotic surgery, with new platforms coming to the market and aiming to overcome the historic monopoly. As such, we are witnessing the introduction of new solutions and new technical devices in the various robotic platforms, meaningfully disrupting the established robotic surgery landscape. At ERUS23 we will have the possibility to see in action and evaluate how different platforms perform in numerous urological procedures. It is definitely an event not to be missed for all robotic surgeons.”

Register now for the early fee!

Deadline: 14 June 2023

Hot topics at ERUS23

“Of course, we will not only talk about oncological surgery. Benign pathology, reconstructive surgery and kidney transplants will have a prominent place as well. Head to head comparison sessions about several hot topics in robotic surgery are also planned. Finally let's not forget that the training is also an important feature when talking about robotic surgery. In this regard, we will also talk about how to tailor and improve surgical training in our robotic centres.”

compare different robotic platforms working simultaneously.”

For the preliminary Scientific Programme visit www.erus23.org

Live Surgery in Florence

“Ours is the highest volume centre in Italy for all types of robotic surgery and also most of the benign pathology. As such, our staff is highly professional and quite used to hosting live surgery events. Obviously, a large-scale congress such as ERUS represents a major event and I am sure that everyone in my department will do their best to offer the best experience to both hosted surgeons and those attending the meeting. Of course, it should be considered that the specialisation and the commitment of the staff both rise as the number of different robotic platforms available on the market increases.

ERUS23

We are preparing to offer the best work experience possible.”

“I think Florence as a host location needs no introduction. It really is the cradle of the Renaissance. Hosting this congress in September in Tuscany offers all the premises to provide an unforgettable all-round experience, also outside of congress hours. But I don't want to give spoilers. Come to ERUS23 and see it with your own eyes!”

20th Meeting of the EAU Robotic Urology Section

13-15 September 2023, Florence, Italy

15th

“Surely the event will be further enhanced by the possibility of being able to see different robotic platforms in action in the same surgical procedure. Attendees will be offered many surgery sessions in which, thanks to the parallel screen set-up, it will be possible to directly

www.erus23.org

Interested in imaging?

The meeting of the EAU Section on Urological Imaging (ESUI) takes place on the first day of EMUC23!

Join the ESUI meeting on Thursday 2 November. Only interested in ESUI? Register for a single day registration!

In conjunction with

• 11th Meeting of the EAU Section on Urological Imaging (ESUI)

• European School of Urology (ESU)

• EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP)

• Young Academic Urologists Meeting (YAU)

"Robotic surgery is experiencing an unprecedented revolution."

Prof. Andrea Minervini, ERUS23 Local Organiser

New prostheses and live surgery in classical surroundings

Joint ESGURS-ESAU Section meeting is coming to Florence

By Loek Keizer

For 2023, the EAU Section Office is organising a Joint Meeting of the EAU Sections of Genito-Urinary Reconstructive Surgeons and Andrological Urology, ESGURS-ESAU23. Delegates can look forward to two days of andrological and live reconstructive surgery in Florence, Italy on 23-24 November 2023. Several hot topics will be covered in an inspiring setting that combines the history of Florence with its top-notch hospital facilities.

The two sections’ programmes will run in parallel on both days, and delegates can attend either meeting freely. We spoke to ESGURS board member Dr. Andrea Cocci (Florence, IT) who is chairing the meeting’s Local Organising Committee and looking forward to welcoming Europe’s urological surgeons to his hometown.

The ESGURS23 scientific programme will feature a three-screen set-up that allows for delegates to see the same disease treated with three different techniques simultaneously. Robotic surgery will also be receiving more attention at the meeting.

Submit your abstract now!

Deadline: 24 August 2023

Hot topics

“From my point of view, reconstructive surgery, like robotic urology, is constantly evolving, both as a surgical technique and as a result of the technology that is involved. As an example: during our upcoming meeting, new models of malleable and inflatable penile prosthesis will be presented, both for men and, interestingly, for patients with a neophallus, gender reassignment patients. The market had become dominated by two large companies in the past two decades and now there’s a new player.”

“These new prostheses will be compared to those currently on the market. Thanks to our three-screen

set-up, we will be seeing three kinds of prosthesis being implanted at the same time, which should make for a very interesting comparison. ESGURSESAU23 will also be the occasion at which we will see the presentation of new drugs for Peyronie’s disease.”

surgery. Right now, the field of penile surgery, genital surgery, is for urological surgeons, it’s a change of mindset.”

Robotics

“A major change we wanted in our meeting this year is the involvement of robotic reconstructive surgery in the programme. We believe that robotics has become an integral part of our profession and many urologists are interested in it.”

Register now for the early fee!

Deadline: 24 August 2023

From plastic surgery to urology

The presentation of these new prostheses and the involvement of robotic surgery represents a shift that reconstructive urology has been undergoing in recent years.

“I think within urology and the scientific committees that determine the contents of our meetings, there is increased attention for reconstructive surgery. Historically, the reconstructive branch represented most within urology was urethral reconstruction. At ESGURS-ESAU23 you will see that topics like phalloplasty or vaginoplasty, will also receive a lot of attention.”

“Our Section Chair Prof. David Ralph and the ESGURS board gave us a lot of space for sex-change patients at this meeting. This is also a reflection of increasing interest at medical schools and from residents in this type of surgery. In a way, it is also a social change. There is more attention for the procedure, but it has also increasingly become performed by urologists.”

“Historically, this type of surgery was performed by plastic surgeons but at the moment that’s shifting to urologists. I’m not sure why this shift is taking place. Mr. John Pryor the father of andrology and reconstructive urology, had a background in plastic

“The ESGURS meeting is by nature a pure, live surgery congress. This is what our audience and what the ESGURS board wants. We are aiming to include 19 procedures in two days. As it stands now, we will be welcoming surgeons from Spain, Italy, Belgium, the Netherlands, Germany, Turkey and the UK to operate in Florence. We will see top surgeons at work in prosthetic surgery, incontinence surgery, urethral stricture, bladder reconstruction, and robotic surgery for ureteral reconstruction. The scientific programme will be two days of three theaters, starting at 8:00, finishing at 19:00, with pure surgery and expert moderation.”

Young surgeons

“Another major change we decided on is to feature a younger generation of surgeons. Most of those performing the procedures are under 40, and most are female. This is an important message that the EAU wants to give. The present belongs to this generation, where we don’t have gender differences in our hospitals. The surgical schools, medicine in general, universities, are all roughly equally represented by male and female students and residents.”

“With our meeting, we didn’t just want female representation in panels of moderators, but crucially also in the theatres. I’m very proud to host an event like that. We’re not talking about some vague point in the future, we want to showcase how diverse our field is already at present.”

“Every urology meeting is an opportunity to talk, to develop new ideas, socialise and create connections. Florence will also be hosting the ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie’s disease on 22-23 November. In the masterclass we will cover Peyronie’s disease and treatment options for erectile dysfunction. This is aimed at younger colleagues, but we hope they stay for the rest of ESGURS-ESAU23.”

More details about the ESAU23 scientific programme will be announced on the meeting website shortly.

Florence

“All of the live surgery will be performed in Florence’s Careggi University Hospital! This is my chief, Prof. Andrea Minervini’s department. He used to be a fellow of current ESGURS chair David Ralph. We are very honored to continue this historical tradition, and to host this kind of event.”

“Florence has a great urological history, it’s one of the main Italian centres for robotic and reconstructive surgery. From our university, came several huge names in reconstructive urology like Dr. Barbagli, for instance. We have five ORs dedicated to urology and all five will be used to create a seamless three-screen programme for the attendees.

“Florence is a city full of beauty, good food, and history. When the congress is finished for the day, all participants will be able to enjoy the city. It will be hard work for our department in the coming months work but we’re happy and honoured to host.”

For the preliminary Scientific Programme visit www.esgurs-esau23.org

ESGURS-ESAU 23

Joint Meeting of the EAU Section of Genito-Urinary Reconstructive Surgeons & the EAU Section of Andrological Urology

IN CONJUNCTION WITH THE ESU-ESAU-ESGURS MASTERCLASS ON ERECTILE RESTORATION AND PEYRONIE’S DISEASE

23-24 November 2023, Florence, Italy

www.esgurs-esau23.org

“A major change we wanted in our meeting this year is the involvement of robotic reconstructive surgery in the programme."

Dr. Andrea Cocci, chair of the meeting’s Local Organising Committee

The best of EAUN23: A recap and key takeaways

Milan meeting elevates urological and supportive care

By Mrs. Jeannette Verkerk-Geelhoed, Mr. Mattia Boarin and Dr. Stefano Terzoni

Around 250 enthusiastic delegates from 30 countries all over the world convened at the 23rd International EAUN Meeting (EAUN23) from 11 to 13 March 2023 in Milan, Italy. Over 70 renowned experts, who comprised the meeting faculty, presented novel urological nursing research and technologies through 3 Plenary Sessions, 12 Thematic Sessions, 3 Poster Sessions, 2 Specialty Sessions, 2 ESU courses, and 10 State-of-the-art lectures. This report encapsulates some of the key takeaways from EAUN23.

Meeting the needs of the elderly population

EAUN23 kickstarted with Plenary Session 1: Increasing urological care in an aging population where Prof. Chris Chapple (GB) and Mr. Kevin Ancog (AU), Chair of ANZUNS (Australia and New Zealand Urological Nurses Society) presented vital viewpoints on the topic.

During Prof. Chapple’s lecture “Influence of an aging population on the urological care”, he discussed that the elderly population is increasing and along with this rise are more problems with bladder control and sexual function. As a consequence, this increase will influence the number of people seeking urological care. By 2050, about 30% of people in Europe will be older than 60 years of age; and access to healthcare will even be a bigger challenge.

Regarding functional urology, the lower urinary tract symptoms (LUTS) presenting in overactive bladder (OAB) was addressed. This can be caused by a change in bladder function when getting older; there is a change in the Pontine metrician centre.

Furthermore, incidences of urinary incontinence (UI) increases with age in women as in men. Often due to OAB symptoms, frail older people in particular have worse outcomes when it comes to surgery. One must take into account of the patient as a whole and not only his problem; for example, one could look into behavioural strategies such as frequency volume chart and lifestyle measures.

According to Prof. Chapple, UI is a common condition in older people that is usually multifactorial and a burden to the patient. Devices, aids, and technical solutions can have the potential to improve quality of care.

availability of a specific healthcare is matched according to a nurse’s area of responsibility and expertise. An example of this is upskilling the competencies of nurses to adapt the process of healthcare such as prostate biopsies in prostate cancer patients.

Mr. Ancog concluded that nurses have a critical role in responding to the health needs of elderly urological patients. He stated, “Since there is no ideal way of preparing services for the increase of elderly patients, we have to redesign our services, including upskilling of nurses to perform procedures that were traditionally done by doctors.”

Care for patients with a urostomy

Thematic Session 2: Supportive care and use of technology for patients with a urostomy provided updates and important insights on self-care strategies, the use of technology, and the role of the psycho-oncologist in patients with an ostomy.

The clinical nurse specialist is vital in the educational and emotional support for patients. When patients receive sufficient information, it can help reduce their emotional stress, as well as increase communication skills.

Mrs. Danila Maculotti (IT), presented a telemedicine implementation experience in ostomy patients. The digital health revolution in recent years has huge potential benefits but has increased risks concerning personal sensitive data and privacy. The Smart Ostomy Support (SOS) represents an innovative model to offer remote assistance to ostomy and incontinent patients, based on a telemedicine app.

There was much interest to see the research of peers

Another aspect to consider in aging is brain health (i.e. getting older healthy). The expression “use it or lose it” points to the direction of lowering the risk of dementia through engagement in intellectual, social, and physical activities. In addition, social isolation and loneliness are factors to consider as well. Pet therapy can help against loneliness and can help in survival.

In the lecture “How to prepare to an increase of urological elderly patients”, Mr. Ancog underscored that being prepared is crucial. He stated, “Are we prepared to the changes in healthcare now and in the near future? The elderly population is increasing faster every year. Moreover, helping the elderly patients prepare for appointments or hospital stays can be challenging. This is something we need to take into account as nurses.”

According to Mr. Ancog, healthcare is not only about getting better, but also about maintaining the maximum functional capacity of patients which can improve overall health and well-being. “As nurses, we should be prepared because of the increase of urological conditions such as haematuria, UTI (urinary tract infections), LUTS, penile disorders, and sexual activity in > 60 years. Research shows, 90% of elderly people are sexually active.

Mr. Ancog also covered service mapping in his lecture. Service mapping is a method wherein the

"...we

have to redesign our services, including upskilling of nurses to perform procedures that were traditionally done by doctors.”

The adaptation process to the new condition that requires different lifestyle and development of self-care skills, involves a great challenge on physical, psychological, and social levels. In her lecture “Self-care in ostomy patients - the experience of having a urostomy”, Dr. Giulia Villa (IT) presented the latest literature on ostomy nursing care, which also included support for both patients and their families with a focus on the results of expert group opinion on urostomy care.

Self-care is considered essential in the maintenance of psychological stability and quality of life among patients with urostomy. Promoting effective self-care is extremely important for an optimal adjustment. It is influenced by some factors such as cognitive and functional abilities; social support; access to care; experience and ability; motivation; cultural beliefs and values; confidence in abilities and habits.

Healthcare professionals have a key role in supporting adaptation by encouraging patients to be directly involved in stoma care, and creating the best conditions to promote an effective selfmanagement. Dr. Villa presented a study that investigated the most important factors in predisposing high level of self-care: female gender, high educational level, high levels of information received, autonomy in stoma management, and high self-efficacy.

Qualitative literature showed that the first challenge seems to be the decision-making about urinary diversion. During her presentation, Dr. Villa spoke about the patients’ experience after radical cystectomy with urostomy. The literature results showed that a urostomy brings important changes in all possible personal aspects, resulting in the need for a relational support system. The literature also stated that characteristics of self-care levels and the experience were similar to intestinal ostomy patients. Therefore, it is fundamental to support patients particularly in shared decision-making and selfmanagement of their urinary diversion.

To find support and help, patients would generally rely on internet searches and use non-secure tools that may fail to protect privacy and uphold confidentiality. The main goal of the SOS project is discourage potentially dangerous self-treatment and increase a safe ostomy management. The SOS project could decrease the environmental impact by helping patients with reduced mobility to receive a nursing or medical consultation without leaving the house. This technological support can reduce costs for the healthcare system, and prevent inappropriate emergency departments admissions.

The final lecture of the Thematic Session was by Dr. Alex King (GB), who discussed the psychooncologist’s support and role, ranging from the diversion's choice of urinary diversion to ostomy post-discharge daily management.

Therapeutic relationship between nurses and patients

On behalf of Italian National Association of Urology

Nurses (AIURO), State-of-the-art Lecture 1 AIURO keynote lecture: Italian research on measurable outcomes of the nurse-patient therapeutic relationship covered the clinical and human value of spending time in a therapeutic relationship during pelvic floor rehabilitation.

At present, there are more patients who suffer from UI and access rehabilitation services compared to more than a decade ago. Rehabilitation is not a linear process and similar to stock market performance, there are improvement, relapse, and plateau. Success depends half on the rehabilitation personnel and half on the patient. Is there a way to assess the contribution of the therapeutic nursing relationship to the achievement of therapeutic objectives?

The characteristics of the nurse-patient therapeutic relationship was investigated from the point of view of adults living with UI during a conservative rehabilitation pathway. A monocentric, descriptive, mixed-method study was conducted in the nurse-led continence clinic of a teaching hospital in Milan on a sample of consecutive patients of both genders with non-neurogenic UI. Birthmothers and neurogenic LUTS were excluded, as the clinic does manage these types of patients.

A semi-structured interview, the Short Form 12 questionnaire, and a modified Mishel Uncertainty in Illness Scale(MUIS) questionnaire were administered. The rehabilitation programme was led by a nurse specialist using pelvic floor muscle training (PFMT), Functional Electric Stimulation, and Transcutaneous Tibial Nerve Stimulation according to EAU Guidelines and ICS (International Continence Society)

indications [1-3]. The interview was conducted as part of standard practice. Thematic and phenomenological analysis was conducted (interview guide available upon request) [4]. Regarding uncertainty, the theoretical framework was maintained and adapted the inventory based on Mishel's theory created for oncologic patients. The result is the MUIS-Pelvic Floor questionnaire, which we validated.

Ninety-one interviews and 91 SF-12 questionnaires were obtained (54M, 37F). The mean age was 67±4 years, and medial initial leakage was 245 grams/day, IQR[90;370], with 79% of the patients gaining continence after a median of 12 weeks. The patients had stress (n=63, 69.23%), urge (n=18, 19.78%) and mixed UI (n=10, 10.09%), similarly distributed in both genders (p=0.13). Eighteen persons (10M, 8F) required electric stimulation other than PFMT. The results were the following:

• The physical scores showed everyday activities requiring moderate effort (p<0.001), working ability (p=0.002) and limitation in everyday life (p<0.001).

• Psychological scores demonstrated emotional situation generated by UI (p=0.015), ability to concentrate (p=0.0145), perception of serenity (p=0.003), feeling of discouragement (p<0.001) and interference of UI with social activities (p<0.001).

• The psychological scores were higher at six weeks among patients explicitly reporting effective support from nurses (p=0.03).

• The MUIS-PF proved reliable (alpha=0.93) and valid (loadings range [0.62-0.95], KMO=0.937, Bartlett p<0.001).

Four domains emerged from the questionnaires and the interviews: ambiguity, incongruence, complexity, and unpredictability.

The supportive relationship (SR) aims to develop and foster the person's ability to understand the meaning of their situation and form a cognitive-behavioural scheme. The study was the first on rehabilitation nurses to have investigated in-depth the contribution of nurses' SR to adherence and patients' well-being. Therapeutic success requires dedication, education, and spending time understanding the challenges faced by patients. As the Italian code of nursing ethics says, "The time spent in therapeutic relationship is caring time.”

References

1. Harding CK, Lapitan MC, Arlandis S, Bo K, CobussenBoekhorst H, Costantini E et al. EAU guidelines on management of non-neurogenic female LUTS 2023. Retriewed from www.uroweb.org on Feb 23, 2023.

2. Cornu JN, Gacci M, Hashim H, Herrmann TRW, Malde S, Netsch C. EAU guidelines on management of male LUTS 2023. Retriewed from www.uroweb.org on Feb 23, 2023.

3. Abrams,P, Cardozo, L, Wagg, A, Wein, A. (Eds) Incontinence 6th Edition (2017). ICI-ICS. International Continence Society, Bristol UK, ISBN: 978-0956960733.

4. Priest H. An approach to the phenomenological analysis of data. Nurse Res. 2002;10(2):50-63. PMID: 12518666.

Access EAUN23 content

Webcasts are available of the presentations given at EAUN23. View the presentations in full, as well as abstracts, poster and video presentations. Visit www.eaun23.org and browse the scientific programme or the EAUN23 Resource Centre. Access is free if you attended EAUN23, or can be purchased separately. (https://resource-centre.uroweb.org/resourcecentre/eaun23).

We look forward to seeing you in Paris for EAUN24!

Meeting colleagues at the EAUN booth or at the stands of the exhibitors next to the booth was an important part of the experience

Dr. Stefano Terzoni represented the Italian nurses with a study on the nurse-patient therapeutic relationship

Educational Framework for Urological Nursing

Update April 2023: Where are we and where are we going

Jerome Marley EFUN Co-Lead Lecturer in Nursing Ulster University Belfast (GB)

jt.marley@ ulster.ac.uk

From the outset, the EAUN determined to always keep you, the members, updated on the development of the Educational Framework for Urological Nursing (EFUN). During the recent 23rd International EAUN Meeting in Milan, an EAUN presentation and discussion session was held wherein EFUN information and plans were shared. This article largely summarises the key issues presented.

Recent actions

In the latter portion of 2022, seven sub-groups gathered to consider the seven draft areas of EFUN which have been previously reported. These groups were composed of core members of the three associations EAUN, ANZUNS and BAUN, as well as invited expert partners.

The seven groups were tasked with devising outlining of the “learning outcomes” for the seven draft areas. These learning outcomes could loosely be described as the things that the subgroups thought that urology nurses should know, be, and do in each area. Once refined and agreed, the learning outcomes would then direct the educational offering within each area allowing national societies, educational institutions and others to understanding precisely the educational direction intended by EFUN.

When the work of the seven groups was received and analysed, it quickly became clear that only six sections were actually required as the original

seventh area, Nursing Responses to Patient-Centred Urological Health Needs, could be found throughout the remaining six areas. The six remaining areas are as follows:

1. Communication in Urology Care

2. Challenges in Leading and Managing Urology Care

3. Understanding and Applying Evidence and Research in Urology Nursing

4. Foundational Anatomy, Physiology and Pathophysiology in Urological Disease and Disorders

5. Fundamental issues in Benign Urology

6. Fundamental Issues in Urological Oncology

The learning outcomes received from the subgroups were sent, largely unaltered, to the boards of the three associations. The reason for this was simple and reflects the fact that EFUN is essentially an initiative of each board. It is they who must not only agree on the final EFUN, but it is the associations who will drive EFUN into the future through their education provision.

Current position

With an end date of the 31 January 2023, each board was required to discuss the EFUN learning outcomes and provide feedback to the steering group. This feedback would kickstart an intensive phase of learning outcome revision so that a second version of EFUN could be written. This version will be ready in early summer of 2023 and will be shared formally with the members of the three associations, the wider global urology nursing community, and other collaborators. At the end of this short consultation period, a definitive version of EFUN will be launched formally.

The board members of the three associations were asked to discuss the proposal that the original version of EFUN, which became known as EFUN Core, would essentially be the benchmark which all urology nurses should aim for no matter their location. In addition, the learning outcomes should

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be demonstrated by all urology nurses. It was further proposed that as the learning outcomes for Advanced Practice in urology nursing are an extension of the EFUN Core, the work on Advanced Practice should be undertaken after EFUN Core is complete. In principle, both of these proposals have been agreed.

Future plans

It has long been recognised that the creation of a set of learning outcomes is the easy part of this process. The more difficult challenge lies in supporting nurses with educational input that is targeted, available, and accessible to all. More difficulties also lie ahead, and the EFUN co-leads, myself and Julia Taylor, have already started to draw together some proposals that will be discussed with the EAUN, BAUN and ANZUNS looking at a range of issues that are essential to making EFUN a real live force in urology nursing. In particular, recognising that within EAUN, much work has already been done on important matters such as accreditation. EFUN will also need to walk step-bystep with this work and that is the intention.

EFUN seeks to allow urology nurses to attain and demonstrate their knowledge and competence in urology nursing care, and to be recognised for their

achievement through a system that is understood by all and accepted by all. Naturally for this to occur, issues such as formal educational programmes, ongoing professional development, accreditation, and potentially the creation of a system of registration of attainment are all being discussed. Any developments along these lines will be agreed with the three associations so that actions have the greatest impact across the world.

As part of its outreach, the EAUN Chair, Paula Allchorne, has been in close contact with urology nursing associations throughout the world to ensure that the EFUN process is understood by them and to continue the process of consolidating urology nursing in a very challenging post-pandemic period. This important work sits alongside the aspirations of the EFUN Project Team to ensure that eventually, EFUN is the accepted process for developing our practice in the years ahead.

EAUN will continue to ensure that you, the members, are fully updated as plans unfold.

EAUN 23 awards

Best EAUN Nursing Research Project Plan Presentation

G. Villa, S. Trapani, S. Gnecchi, A. Poliani, D.F. Manara, Milan, Italy

With the research project plan: “Female urge urinary incontinence in an Italian tertiary referral university and research hospital: A prevalence study”

Best Science-oriented Poster Presentation

First prize

C. Cassells, C. Semple, S. Bingham, Dundonald, Jordanstown, Antrim, United Kingdom

With the poster: “Maximising sexual wellbeing | cancer care e-Learning resource: Healthcare professionals’ views on acceptability, utility and recommendations for implementation”

Best Practice developmentoriented Poster Presentation

First prize

C. Oliveira, S. Ross, C. Gkika, C. Molokwu, Bradford, United Kingdom

With the poster: “Prediction of missed clinically significant prostate cancer after adoption of new prostate specific antigen (in mcg/L) referral guidelines”

Sponsored by HOLLISTER

Second prize

R. Dalton, R. McConkey, T. Kelly, G. Rooney, M. Healy, L. Murphy, M. O’Loughlin, M. Dowling, Galway, Roscommon, Limerick, Ireland

With the poster: “Establishing a journal and research club to support urology nursing research culture”

Sponsored by HOLLISTER

For photos please visit the EAUN Award Gallery or Resource Centre

Some members of the EFUN Project Team. From left: Jerome Marley (EAUN), Sarah Hillery (BAUN), Paula Allchorne (EAUN), Kevin Ancog (ANZUNS), Julia Taylor (BAUN)

The EAUN is listening to you!

Educational needs and opportunities in the spotlight in Milan

I opened the 23rd International EAUN Meeting (EAUN23) in Milan this year with a strong message to all our EAUN members, “The EAUN is listening to you”. Of course, not everybody is fortunate enough to attend the meeting in person so I thought I should follow-up my presentation with a written update. Nurses are often asked to take part in reflective practice. Organisations or board members of an organisation should do the same. From your much appreciated feedback we have reflected on the needs of our EAUN members. As a result of that the board has gone through a restructure so we can improve our delivery to you as members on what you want from us as an organisation, and to ensure we implement our long term strategy. (See www.nurses. uroweb.org/nurses/about-eaun/the-aims-andstrategy/.)

Nine different national societies met last year at the annual EAUN meeting in Amsterdam to discuss what the EAUN could do for everyone. A key theme everyone wanted was ‘educational support’. The restructure of the EAUN has allowed us to achieve this, by focusing on the ‘Special Interest Groups (SIGs). The SIGs (prostate cancer, bladder cancer, continence and endourology) have all increased their membership and are now delivering regular webinars, taking turns to run yearly ESUN (European School of Urology Nursing) courses and have started to review guidelines that are related to their areas of interest. This year’s National Societies Meeting was represented by 11 different countries. Based on the feedback from last year’s National Societies Meeting, we discussed three key areas to help with future collaboration.

1. Accreditation

• We have launched our collaboration with the EU-ACME/ACNE accreditation of CME/CNE programme in urology. This means educators can apply for accreditation on an educational course if it meets the required standards. If your country runs a webinar, activity or event that is educational, you can gain accreditation which allows individuals who attend the session to gain credits, add them to an individual’s educational profile to demonstrate continued professional development, and track all

further educational events they attend and any credits gained.

• Individuals get their own account/portfolio showing all the courses they have attended.

• The EAUN want to support other countries to accredit their local courses. This allows for courses to be internationally recognised, demonstrates a high standard and is more attractive to a wider audience.

2. Special Interest Groups (SIGs)

• We now have four special interest groups (prostate cancer, bladder cancer, continence and endourology). The aim of these groups is to gain representation from around the world and to encourage networking and provide a forum/think tank for allied professionals to exchange best practice and improve patient care. It is important we have representation globally, as it’s the only way we can standardise care and understand what new practices are going on globally. So please join the SIGs in your area of interest as we value everyone’s expertise and viewpoint.

3. Educational Framework for Urological Nursing (EFUN)

EFUN aims to standardise urology education by providing a framework with core urology learning outcomes for people to achieve.

• Version 1 of EFUN has been devised, indicating six learning outcomes, and each area will have specified educational content related to the learning outcomes. This version was reviewed by the panel and associations (EAUN, BAUN, ANZUNs), and version 2 is being drafted, once this has been agreed, and re-discussed with the associations, urology nurses and collaborators, version 3 will be published shortly after.

• We had a questionnaire response from 26 countries. 24 countries are interested in EFUN and particularly how EFUN could assist them better to serve their members through a potential accreditation system.

• A paper on how EFUN could be implemented has been drafted and will shortly be presented to the associations for further feedback. We are aware not all countries have heard of EFUN and we need to disseminate throughout the nursing community.

In summary, the EAUN is asking their (member) national societies three key questions:

1. Does your country need accreditation for any conferences, courses, educational events, activities, or local hospital course’s? Please follow this website: www.mycme.eu-acme.org/

2. Do allied members in your country want to join one of the SIG’s – to represent their country in a urological disease?

3. Will EFUN be useful in your country, by providing a urological educational framework that assists you better to serve your members through potential accreditation?

If you have any queries or responses to these three questions, please email me: p.allchorne@eaun.org. Our collaboration with other national societies and members across the globe is important to us, we cannot achieve our aims and long term strategy if we do not work in partnership together. We continue to have international links across the globe, e.g., recently I attended the 2023 Advanced Urologic Conference organised by SUNA (Society of Urologic Nurses and Associates) in America. Urology nurses in America often have similar challenges to us, but in a different health system. They have developed constructive solutions to address them, so we can all learn from each other. The EAUN is aware that many of us have the same struggles, hence, global collaboration is important to improve our continuing education and our work life balance, so we can give our patients the best care possible, given the resources available.

Mrs. Paula Allchorne Chair, EAUN London (GB)

The SIG Chairs met in Milan to discuss upcoming activities

Virtual support and the ADT programme

Educational tools for cancer patients

The changing needs on the healthcare environment in 2020 facilitated an evolution in the way we support our cancer patients. Below I will discuss two initiatives which have been very successful in providing supportive care for patients to this very day, that were also discussed in Thematic Session 3 at EAUN23 in Milan.

Virtual support group

The virtual support group and information series was developed in response to the covid pandemic. Working with Cancer Care West, the west of Ireland charity, we needed to look at a new method to reach our patients during this difficult and lonesome time.

The virtual support group and information series was developed to provide men and their families with information and support specific to their cancer, its treatment and potential side effects. Each group meeting is delivered over zoom and facilitated by the advanced nurse practitioner and a clinical

psychologist. An expert speaker is invited to attend each meeting and present on their specialist topic. Following the presentation, a safe space for questions is facilitated. The support and information series is advertised across social media platforms with links to register available within. An evaluation form is completed by patients following each session. This evaluation allows the facilitators to develop a theme for the next support and information series evening. Feedback from the sessions have been largely positive, with patients voicing knowledge of speakers and session format as key highlights. Poor engagement by the audience and session duration were areas noted for improvement. The support and information series is facilitated four times a year.

“The virtual support group and information series was developed to provide men and their families with information and support specific to their cancer, its treatment and potential side effects.”

Online ADT education programme

The second programme facilitated to assist patients on their prostate cancer trajectory is the androgen deprivation therapy (ADT) education programme.

EAUN23: Travel grant reports

This programme was developed by Mr. Richard Wassersurg an academic, scientist, and prostate cancer patient, as well as two clinical psychologists. Training for this programme & programme facilitation is kindly provided by the EAU. The aim of this programme was to provide men with more information on coping strategies and side effect management whilst on ADT. To do this, men are invited to register to attend an online class delivered by an advanced nurse practitioner. This interactive class equips patients with comprehensive information and behavioural change techniques to support them on their treatment journey. Each

Key takeaways, impressions, and anticipation for next year’s meeting

operating theatre and the remaining two groups visited two urological care departments. “Seeing urological units in different countries is useful. I could see similarities and differences with my own department in Sweden,” shared Mrs. Danielsson.

A focus on sarcopenia

theresa.junker@

Ms. Junker recently started working more in the bladder cancer (BCa) team at her institution. She attended the EAUN23 lecture by Mrs. Marian Rombouts (NL) on the physiotherapist's role regarding preparation and rehabilitation. This lecture highlighted that sarcopenia reduces the overall survival rate, increases rates of postoperative complications, lengthens the hospital stay, and decreases adherence to adjuvant therapies among BCa patients.

gun.danielsson@

The 23rd International EAUN Meeting (EAUN23) experience in Milan was a fusion of immersive activities and eye-opening lectures. As travel grant recipients, we enjoyed enriching our knowledge and skills, as well as meeting peers from around the world. In this report, we share our individual impressions and valuable take-home messages from EAUN23.

Watch and learn

Mrs. Gun Danielsson (SE) kickstarted her EAUN23 participation with the visit to the IRCCS San Raffaele Hospital. According to Mrs. Danielsson, the hospital visit was well organised. She and the rest of the participants received information about the hospital, the university, and areas of research the hospital undertakes. Then the participants were divided into three groups for a guided tour: One group visited the

“Knowing how crucial sarcopenia is for recovery in the population of BCa patients, knowledge from the lecture is something I will bring home from the meeting. Many of our patients who end up having a cystectomy have been in contact with our department for extended periods,” stated Ms. Junker. She added that the lecture made her think about how nurses should keep prehabilitation in mind earlier than what is currently done. She contacted a physiotherapist to teach more about sarcopenia and what to offer their patients at the outpatient clinic. Ms. Junker also enjoyed the outlining of tools used to assist the shared decision-making presented by Mrs. Deepa Leelamany (GB).

Frailty in BCa patients

During Thematic Session 7: Bladder Cancer Special Interest Group session: Frailty in bladder cancer – an underestimated marker in clinical practice?, Ms. Junker also found the lecture by Dr. Katharina Skovhus Prior (DK) interesting. It centred on how to counteract frailty and what is the current evidence. “I look forward to following her PhD project on Comprehensive Geriatric Assessment for perioperative optimisation in radical cystectomy (COMPETENCE). A project that hopefully will benefit many of our patients,” said Ms. Junker, who also met up with the EAUN Special Interest Group for Bladder Cancer.

Mrs. Danielsson shared that she, too, found the lectures of the session interesting. She said, “How do we really know which of our patients are fragile? We can see that some are old and fragile, but in some cases, it is not visible based on a patient’s appearance alone.” Mrs. Danielsson cited the

definition by Clegg et al which was published in Lancet 2013: “ Frailty is a multidimensional and dynamic age-related condition characterised by declining function across multiple physiological and psycho-social factors, accompanied by an elevated vulnerability to stressors.”

The session presented a review of various measuring instruments used as aids in identifying the fragile patients. There are more than 60 frailty assessment tools. Although none of the instruments are perfect nor universal, the screening tools are recommended for cancer patients aged 70 years and above. Some of the instruments presented during the session included the G8 Questionnaire, Comprehensive Geriatric Assessment (CGA), Clinical Frailty Scale (CFS), Edmonton Frailty scale (EFS), Electronic Frailty Index (eFl) and Modified Frailty Index (mFl). The most effective/efficient tool in urological patients appears to be the Modified Frailty Index (MFi5)/ CFS. Throughout the session, “think frailty” was underscored.

patient receives ‘a life on ADT’ book which provides patients with additional information and resources. Along with this, the ADT website offers patients additional support in the form of patient testimonials and educational video clips. Patient feedback has been largely positive with many people noting the comfort of having the book as a resource to refer back to and others valuing greatly the comments and discussions facilitated within the group session.

“Where I work, we currently have no routine nor measuring instrument to find the fragile patients. After listening to the lectures, I realise that this is something we should have. I will spread this newfound-knowledge to my colleagues so that we can implement this. As a start, we must investigate whether any of the measuring instruments that were presented have been translated into Swedish,” stated Mrs. Danielsson.

Expanding one’s world

According to Mrs. Danielsson, attending the lectures was rewarding; going to EAUN23 offered more than lectures and various poster presentations. She added, “It is exciting to visit the exhibition, see novel technologies, and familiarising with new literature. I want to say a big ‘thank you’ to the industry and the sponsors as well. They help develop healthcare and make opportunities to meet possible.”

“Aside from the exciting lectures and meeting familiar and new colleagues, I truly enjoyed having the time to connect with nurses and doctors from my institution. We had a lot of lively and interesting discussions on the different lectures we attended. In addition to talking about how to implement new perspectives in our institution, we also exchanged ideas about new projects, which hopefully will benefit our patients back home. Doing interdisciplinary research is the way to go if we what to make a difference for our patients. I want to thank EAUN for the opportunity to attend the meeting. I look forward to seeing peers and connecting with new friends in Paris at EAUN24!” Ms. Junker concluded.

About the travel grant

The Annual EAUN Travel Grant allows EAUN members who are working in the field of urology and based in Europe to participate in the EAUN Meeting. Non-members can apply for the grant providing they have submitted a paid EAUN membership application. For membership details, please go to http://nurses.uroweb.org/nurses/membership. Those who have applied for the grant but were not selected can re-apply.

“Attending the lectures was rewarding; going to EAUN23 offered more than lectures and various poster presentations.”

Ms. Rachael Dalton Galway University Hospital Galway (IE)

Rachael.dalton@ hse.ie

Ms. Theresa Junker Odense University Hospital

Dept. of Urology Odense (DK)

rsyd.dk

Mrs. Gun Danielsson Karolinska University Hospital

Dept. of Urology Stockholm (SE)

regionstockholm.se

Mr. R. McConkey chairing Thematic Session 3 on The development of nurse led virtual clinics for prostate cancer

Follow the leader: Groups were divided for the hospital tours

A peak into the facilities at the IRCCS San Raffaele Hospital

Dr. Giulia Villa (IT) shares her expert insights during the intro lecture at the hospital

My EAUN fellowship at UV Leuven

An eye-opening learning experience

Ms. Nethravathy Seenappa Nu Hospitals Dept. of Urology Bengaluru (IN)

nethravathy@ nuhospitals.com

My name is Nethravathy Seenappa and I am a registered nurse from India.

After obtaining my diploma in nursing in 2004, I started working at a dedicated nephro-urology hospital, the NU Hospitals in Bangalore, India. In 2016, I completed my bachelor’s degree in nursing followed by a master’s degree (MSN - urology).

The level of work was vastly different from my training as a nursing student. Our Chairman, Dr. Venkatesh Krishnamoorthy, an eminent urologist, opened my eyes to the need to grow further in the field of urology nursing. I have been in the urology operating room for the last 18 years. The motivation for an enhanced work profile comes from the institution I work at and the constant encouragement from urology consultants. As an operating room nurse, I participate in teaching urology residents about instrumentation and operative procedures

NU Hospitals has five branches. Four of them are located in different parts of India, and one in the Maldives. Today, I oversee functioning of operating rooms in all these branches.

I chose UZ Leuven as it is one of the largest university hospitals in Belgium. Its surgical department has 46 operating rooms (ORs) with dedicated urology and robotic units. Around 1,600 surgeries per year are performed at the hospital.

On 7 July 2022, which was my first day, I was welcomed and introduced to the OR complex by Ms. Julie Veryser. I was amazed by the welcoming environment and friendly staff. They took pains to make me feel like a part of their very competent team. Every day the procedures commenced at 7:30 AM. This meant that the nurses started their day on the dot at 7:00 AM The punctuality and time management were commendable.

On the second day, I was posted in the urology OR. In the first half of the day, I observed the open and endoscopic procedures.

surgery. Similarly, consumables were scanned once given to the scrub nurse. This scanning system also helped automatically send bills to patients and identify the expiry date of the consumables. Using technology to minimise human errors was amazing.

Ms. Kele Hoogeveen and Ms. Veryser, who are dedicated robotic urology nurses, helped me to understand critical processes in the OR. While I am familiar with our CMR robotic system, the introduction to the Da Vinci was very interesting.

On day five, I was at a nurse-led prostate clinic. The experience opened my eyes to the possibility of nurses taking up similar responsibilities in India. I was with Ms. Veryser at the prostate clinic. Patients diagnosed with prostate cancer report to the clinic and she counsels the patients pre-operatively. She visits them during their admission and follows them up after discharge at defined intervals.

Ms. Veryser was very patient and professional during her counselling. I was very inspired by the nurse-led clinic. Such nurse-led clinics are still in their infancy in India. This fellowship helped me realise the potential role that nurses could play in augmenting health care delivery in our resource-constrained environment.

On day six, I was in the urology outpatient department. All urology outpatient procedures were performed. It was great learning to see a single nurse competently handling sterile procedures.

I also had the opportunity to witness videourodynamics done by a nurse. While I was familiar with urodynamics, I had not witnessed videourodynamics earlier. The unit nurses were very professional and helpful, and went out of their way to explain and share their knowledge on every step of the procedure.

During the 7th day, the focus was on robotic urology procedures. I observed the robotic ureteric reimplantation performed by Prof. Frank Van Der Aa, head of the urology department.

The unit has the Da Vinci Xi Robot system which translates the surgeon’s hand movements to the console in real-time. The highly-magnified, 3D high-definition cameras provided extremely clear images of the surgical area. Compared to the CMR surgical robot (the one which I have trained in India), the Da Vinci has a single bedside unit with four arms and extra-long instruments.

On 20 July, the focus was on OR process and maintaining OR standards. I met Ms. Anneleen Jeanquart, the assistant head nurse who explained the process in the operating room in detail. This included planning for the nurses' duties, shift allotment, preparation of the theatre, inventory management, nurses training and privileges, and documentation followed in the OR.

Overall, the nursing communication skills were commendable and definitely contributed to the effective and speedy manner in which they perform their tasks. It has been a great pleasure to meet nurses who work with great pride in their profession and are also dedicated to their patients. I hope I can replicate the effective communication and enthusiasm that I observed among the surgical team members in my own setup.

The whole experience has given me a tremendous impetus to enhance my knowledge. It also helped me to improve my performance as a specialty nurse and a team player.

In weekends, I explored Brussels, Liege and Antwerp, and it was wonderful to see the historical places in Belgium.

I understand that in Belgium, the basic nursing training focuses more on clinical posting, and because of dedicated operating room nursing training, they are aware of the basic OR process which makes the on-the-job training easier. This is lacking in India, and it takes tremendous time and effort for us to train the general nurses for specialty care.

I thank each and every colleague I met at UV Leuven for their patience in mentoring and sharing their knowledge. My thanks to the EAUN for providing me with a great opportunity. A special thanks goes to Ms. Hanneke Lurvink and Ms. Marie Rose Aangeveld for coordinating my fellowship. I would like to express my appreciation to our management Dr. Venkatesh Krishnamoorthy, Dr. Prasanna Venkatesh and Dr. Maneesh Sinha for their constant support and guidance.

New EAUN Board Member:

Marcin Popiński

Nurses were posted in two shifts. In each shift, there were two nurses and they were completely responsible for the respective OR. Ownership on their responsibilities from transferring the patient from pre-op till shifting the patient to the recovery room. After each case, the OR was quickly cleaned/ disinfected and kept ready for the next patient.

When a patient was wheeled inside the OR, their barcode was scanned to confirm the patient's identity and to ensure that it was the right patient for the right

I felt privileged when Prof. Van Der Aa explained the surgery steps patiently.

The next two days, I observed complex robotic surgeries such as partial nephrectomy, cystectomy with ileal conduit, and total abdominal hysterectomy with colporrhaphy and mesh.

On 18 July, I visited to the Central Sterile Supply Department (CSSD) to observe the process and practice. I was accompanied by Mr. Wouter Meert, who is in charge of CSSD. The entire CSSD was automated for cleaning, disinfection and drying. ISO 13485 standard was followed in CSSD.Mr. Meert was very professional and through with the processes of the CSSD as per ISO 13485.

Next day, I met with the infection control team where I acquainted myself with Ms. Nele Stroobants and the team to know about the infection control practices followed in the OR complex. We had a very interactive meeting to understand the processes followed during and after the infectious cases (especially air-born transmission).

My name is Marcin Popiński. I am a new board member of the European Association of Urology Nurses (EAUN). I am 30 years old. I graduated with a bachelor’s degree in English Studies in 2014. I work at the Dr. Jan Biziel's University Hospital No. 2 in Bydgoszcz, Poland. I have almost eight years of experience as a nurse, and I am currently a nurse specialist in the field of surgical nursing. I earned my master’s degree for my thesis “Quality of live and mental health of patients with urinary incontinence” at Collegium Medicum in Bydgoszcz of the Nicolas Copernicus University in Toruń, Poland in 2017.

The main procedures performed at the urology clinic are: laparoscopic prostatectomy, endoscopy surgeries, and surgical treatment of urinary incontinence.

Since 2018, I have worked in Clinical Research Centre In-Vivo, first as a Clinical Research

Coordinator, currently as a Clinical Research Nurse. In the Centre, research in the field of urology, paediatrics, diabetology and others is performed.

I am a mentor for practical and internships of students from Collegium Medicum in Bydgoszcz of the Nicolaus Copernicus University in Toruń, Poland since 2019.

Since 2018 I have graduated many specialist courses in the field: cardiopulmonary resuscitation of adults, prescribing drugs and nurses and midwives’ prescribing, performing and interpreting electrocardiographic records in adults for nurses and midwives, training course for internship mentors, vaccinations, endoscopy, cardiopulmonary resuscitation of children, and diabetes educator.

I hope that my participation in EAUN Board will help to represent nurses from Eastern Europe. In my opinion, the biggest challenges for representation of nurses from that region are communication and training. Nowadays, But fortunately, English is getting more common in these countries now. I hope it will help to promote EAUN. Another challenge is that there are different educational pathways in Poland and Eastern European countries: urology nursing specialisation does not exist. In my opinion, cooperation with nurses from other countries can help them gain new experiences, as well as the motivation to focus on new ways to improve urology nursing in Eastern and Western Europe.

“This fellowship helped me realise the potential role that nurses could play in augmenting health care delivery in our resource-constrained environment.”

With Prof. Van Der Aa

“Overall, the nursing communication skills were commendable and definitely contributed to the effective and speedy manner in which they perform their tasks.”

Marcin Popiński, Nurse Specialist Dr. Jan Biziel's University Hospital No. 2, Urology Clinic Bydgoszcz (PL) m.popinski@ eaun.org

With the Urology Outpatient nursing team

Joining Ms. Hoogeveen and Ms. Veryser