European Urology Today January/February 2017 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology Managing catheterassociated UTI

Evidence-based prevention schemes Dr. B. Köves

Vol. 29 No.1 - January/February 2017

EMUC16 Overview Report

Health illiteracy in urology patients

Multi-disciplinary issues in onco-urology

Challenges in patient education

12-13

Dr. M. Van Balken

EAU17 Preview: Prospects, trends and challenges A Scientific Programme that digs deep into innovations and core urology issues By Joel Vega With a little over a month to go, final preparations are in full swing for the 32nd EAU Annual Congress in London and a preview of the Scientific Programme hints of highly interactive discussions, in-depth presentations and practical recommendations from some of the world’s most renowned opinion leaders and experts in urology and related medical disciplines. “What makes the Annual EAU Congress in London special? For starters, there are new additions to the Scientific Programme which provides not only theoretical perspectives but also identifies best practices in clinical practice. We also emphasize evidence-based medicine and latest research outcomes,” said Prof. Arnulf Stenzl, Chair of the EAU Scientific Congress Committee.

Stenzl: “Take-home messages from Plenary Session 1 will certainly be a rich source of practical insights. We believe legal perspectives are not often discussed in congresses and this session will trigger insights in our practice and make doctors be more alert to potential crisis situations.” ‘Hot topics in andrology” will be the focus of Plenary Session 2 and lectures such as the pharmacological and surgical ways to fertility in young men (Majid Shabbir, GB) are among the highlights in a session that explores testosterone therapy in prostate cancer patients, scrotal pain, penile implants and male contraception, to name a few current issues.

Bladder cancer takes centre-stage in Plenary Session 3 (Redefining and optimising bladder cancer care) particularly in the state-of-the-art lecture by Jürgen Gschwend (DE) who will present the evidence for lymphadenectomy in transitional cell carcinoma (TCC). “The programme is a result of hundreds of hours of Asked to comment on the controversial issue of careful selection and close networking among lymphadenectomy, Gschwend said radical cystectomy committee members from various countries who have and pelvic lymph node dissection (PLND) is regarded worked with passion and commitment,” added Stenzl. the gold standard for muscle-invasive bladder cancer This year the main Plenary Sessions were expanded for decades. “However, the extent of PLND is still from four to seven to accommodate new formats such discussed and controversial. Many retrospective as the opening plenary session “Sleepless nights: studies have demonstrated an influence of the extent Would you do the same again?” which critically of PLND as well as the number of lymph nodes re-evaluates management decisions in kidney cancer resected during PLND,” said Gschwend, as he added cases through a lawyer’s perspective. that recent studies “provide further evidence that an extended PLND may be beneficial, even in patients with otherwise organ-confined bladder cancer.”

TOP FIVE

Thematic Sessions • Robotic Salvage Prostatectomy Debate, Expert Challenges Experts, Thematic Session 2, Sunday, 26 March 10.30-12.00 • Biomarkers for OAB, State-of-the-art lecture, Thematic Session 4, Sunday, 26 March 10.30-12.00 • How will immunotherapy change the treatment paradigm? State-of-the-art lecture, Thematic Session 6, Sunday, 26 March 10.30-12.00 • How can microbiome affect the urinary tract? State-of-the-art lecture, Thematic Session 16, Monday, 27 March 10.30-12.00 • Controversies in metastatic prostate cancer, Thematic Session 17, Monday, 27 March 10.30-12.00

“Similar to an actual court case, three urologists would be cross-examined by a lawyer on why and how they based their treatment strategies. How they defend their decisions will allow the audience to consider new perspectives and be more aware of the consequences,” said Stenzl. On the dock are urologists Axel Bex (NL), Charles Karim Bensalah (FR) and Vsevolod Matveev (RU) who will undergo cross-examination by lawyer Bertie Leigh (GB), senior partner of Hempsons and a specialist in medical law and healthcare litigation.

Cutting-edge Science at Europe’s largest Urology Congress For EAU members only: EAU17 abstracts available at eau17.org as of 24 February

and 18 Thematic Sessions scheduled from Days 2 to 5 (Saturday -Tuesday), participants are faced with a wide range of choices depending on topics, subspecialty and current interest. The opening day itself presents 12 joint sessions of the EAU with regional and international urological associations and four Special Sessions such as the 4th ESO Prostate Cancer Observatory, the Prostate Cancer Prevention Group, EAU Patient Information Project and the Meeting of the Young Academic Urologists (YAU).

"With seven exciting Plenary

Insights from opinion leaders on key issues are valuable in triggering dynamic discussions, said Sessions and 18 top-notch Stenzl. He picked out several thematic issues that aim Thematic Sessions scheduled from to provide fresh insights such as Thematic Session 2 with a debate on robotic salvage prostatectomy, days 2 to 5 (Saturday -Tuesday), pitting Declan Murphy (AU) against Axel Heidenreich participants are faced with a broad (DE), a state-of-the-art lecture on overactive bladder (OAB) biomarkers in Thematic Session 4 by Katia range of choices" Monastyrskaya (CH), and Robert Jones (GB) discussing the impact of immunotherapy on urothelial cancer Also on the opening day is the first line-up of poster treatment during Thematic Session 6. abstract and video sessions, which reflects the high “Thematic Session 6 on immunotherapy will provide a abstract submissions (approximately 5,000) this year. “Submissions came from 84 countries worldwide. view of upcoming vaccines in bladder and renal cell This year the abstract reviewers and the EAU Scientific cancers that will reduce doctor’s standard use of Committee members did a wonderful job by putting chemotherapy as a first-line option,” Stenzl said. extra effort on the review process,” noted Stenzl (See Another ‘not-to-miss’ event is Plenary Session 5 with Related Story on Page 4-5, ‘A forward looking programme in London’). three debates alternating with three state-of-the-art lectures on prostate cancer management. A highlight debate on prostate cancer screening will feature Jonas Approaching its fifth decade, the Annual EAU Congress has evolved into what can be considered as Hugosson (SE) and Gerald Andriole (US) taking opposing views on the harms and benefits of prostate a signpost event in international urology and highly cancer screening. A head-to-head debate, Stenzl said both participants and the audience will re-visit a controversial subject that has thrown Europe and North America to opposing perspectives. “If the audience expects the European side to win the debate hands down, they could be in for a surprise since the issue is certainly not a “done deal”. The current data favours the European (ESRPC) arguments for prostate screening, but there are also key points to consider from the American’s viewpoint”, Stenzl said. “So let’s stay alert to what this interesting debate will yield since it promises to be a tough discussion.” In what could be among the major topics to emerge from the five-day meeting, Stenzl noted participants may closely follow the presentations on the PROMIS trial results by Hashim Ahmed (GB) (Plenary Session 5), the ProtecT trial lecture by Freddie Hamdy (GB) (Plenary Session 5) and the Special Session of the Prostate Cancer Prevention Group which will examine active surveillance and follow-up protocols. With seven plenary sessions the first three days of which feature two simultaneous plenary sessions,

January/February 2017

www.eau17.org

esteemed for its comprehensive and scientific discussion of urology. “Staging this complex event requires near accurate coordination, creativity and commitment. The work behind the scenes is often not visible or apparent to the public, but it is there, holding all the minute but crucial details in place. Thanks to the superb team, the EAU Central Office and the support from Congress Consultants, we are able to deliver what is not only expected but also beyond, and that is ensuring knowledge-sharing that leads to more optimal healthcare,” said Stenzl.

Bookmark this • Prostate Cancer Prevention Group, Special Session, Friday, 24 March, 10.00-16.00 hrs. • Sleepless Nights, Plenary Session 1, Saturday, 25 March, 8.30-10.00 hrs. • Hot Topics in Andrology, Plenary Session 2, Saturday, 25 March, 8.30-10.00 hrs. • Prostate Cancer Screening Debate, Plenary Session 5, Monday, 27 March, 7.30-11.00 hrs.

EAU Opening Ceremony & Networking Reception On Friday 24 March the EAU launches the 32nd Annual Congress with an official Opening Ceremony. During the 1,5 hrs programme, EAU Secretary General Chris Chapple will welcome everybody to London and give a general update on what to expect during the congress. Also prestigious EAU Awards will be handed out: the EAU Willy Gregoir Medal, EAU Frans Debruyne Award, EAU Hans Marberger Award, EAU Crystal Matula Award, EAU Innovators Award and the Prostate Cancer Research Award.

After the Opening Ceremony you will have the chance to catch up with your colleagues from all over the world and make new contacts and appointments during the EAU Networking Reception. Join us at the eURO Auditorium to celebrate the start of EAU17!

Opening Ceremony & Networking Reception Friday 24 March 2017 18.00 – 21.00 eURO Auditorium (Level 0) & Foyer Boulevard (Level 1)

You are invited!

European Urology Today

TRoMbone study to start accrual in Feb. 2017 UK feasibility trial of surgery in synchronous oligo-metastatic prostate cancer Dr. Prasanna Sooriakumaran TRoMbone Chief Investigator University College London Hospital London (GB) sooriakumaran@ gmail.com The European Cancer Observatory reports that metastatic prostate cancer kills nearly 100,000 men each year in Europe, making it the most significant disease that we manage1.

lymphadenectomy (modality-agnostic). Men who are stage M1b with 1-3 skeletal metastases, age <75, ECOG PS 0-1, and with locally-resectable disease will be eligible. The choice of staging modality will be as per standard clinical care, with more sophisticated imaging such as PSMA- or choline- PET being allowed but not needed for eligibility assessment. A grant application for an imaging sub-study on TRoMbone patients comparing imaging modalities is being constructed. Three centres will run TRoMbone: Oxford (PI Freddie Hamdy), the Royal Surrey County Hospital (PI Christopher Eden), and the unit I work in at University College London Hospital. The study will be managed by the Surgical Intervention Trials Unit (SITU) at the University of Oxford (Operational Lead Surjeet Singh).

resource to interrogate the biology of the disease. Funding applications to bio-bank these tissues and deliver a translational work-stream are in progress, in collaboration with Drs. Prabhakar Rajan and Gerhardt Attard from London. TRoMbone has been accepted onto the National Institute of Health Research Portfolio and thus has access to Clinical Research Network support. It has Ethical and other regulatory approvals, and is due to start accrual in February 2017, with a recruitment period of 12 months. TRoMbone is funded by awards from the Prostate Cancer Foundation and The Urology Foundation, and we are grateful to these organisations for supporting this important trial. References

At the current time, the AJCC TNM staging system groups all skeletal-metastatic prostate cancer as M1b2. This implication that all such disease is similar in prognosis may be mistaken, and recent evidence would support the premise that the volume of metastatic disease affects outcome. The UK-based STAMPEDE study (CRUK 06/019) demonstrated the benefit of docetaxel in men with hormone-sensitive advanced prostate cancer, but did not stratify metastatic cases based on volume3. The landmark CHAARTED study however showed that differences in chemo-responsiveness varied by metastatic load4. The low-volume metastatic group, defined as patients with less than four metastases and none in the viscera, had a median survival far in excess of the high-volume metastatic patients. Hence, it appears that the biology of oligo-metastatic (low-volume) disease may be different to that of poly-metastatic (high-volume) prostate cancer, with the oligo-metastatic state being transitory between locally-advanced and poly-metastatic disease.

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

In order to optimise randomisation, the study will embed a QuniteT recruitment investigation (QRI), as developed successfully in the ProtecT trial (ISRCTN 20141297). This will be run by Caroline Wilson from the University of Bristol to understand the recruitment process and how it will operate in each of the three centres, so that sources of recruitment difficulties can be identified and suggestions made to change aspects of design, conduct, organisation or training that could then lead on to improvements in recruitment. Should successful randomisation be demonstrated in TRoMbone, this would rationalise a larger, clinical trial focused on oncologic outcomes, albeit oncologic endpoints, safety/complications, and quality-of-life data will be captured in the feasibility trial also so these patient data are not ‘lost’ in the larger study. TRoMbone will also provide access to matched RP tissue, blood, urine (and even bone marrow in some cases) for men with newly-presenting oligometastatic disease, which is a novel and unique

1. http://eco.iarc.fr/eucan/CancerOne. aspx?Cancer=29&Gender=1#block-table-f 2. https://cancerstaging.org/references-tools/ quickreferences/documents/prostatesmall.Pdf 3. James ND, Sydes MR, Clarke NW, et al.: Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial. Lancet. 2016 Mar 19;387(10024):1163-77. 4. Sweeney CJ, Chen Y, Carducci M, et al.: Chemohormonal Therapy in Metastatic Hormone-Sensitive Prostate Cancer. N Engl J Med 2015;373:737-46. 5. Fossati N, Trinh QD, Sammon J, et al.: Identifying optimal candidates for local treatment of the primary tumor among patients diagnosed with metastatic prostate cancer: a SEER-based study. Eur Urol. 2015 Jan;67(1):3-6. 6. Sooriakumaran P, Karnes J, Stief C, et al.: A multiinstitutional Analysis of Perioperative Outcomes in 106 Men Who Underwent Radical Prostatectomy for Distant Metastatic Prostate Cancer at Presentation. Eur Urol. 2016 May;69(5):788-94.

This is, indeed, well-accepted in many other tumour types, and ‘old-school’ thinking that all systemic Table 1: RCTs in synchronous metastatic prostate cancer examining the role of local treatment disease, regardless of volume, is fatal and cannot beControl Arm Experimental Arm Acronyms Sponsor Control Experimental Control Acronyms Arm Sponsor Experimental Arm Control Arm Acronyms Experimental SponsorArm cured is Arm being challenged. A subgroup analysisArm of the ADT + Prostate RT STAMPEDE Arm H MRC SEER-Medicare dataset analysis suggested that the ADT ADT ADT + Prostate RT ADT STAMPEDE Arm H ADT MRC + Prostate RT Arm ADT H + MRC Prostate RT +ADT Prostate RT +/-ADT PEACESTAMPEDE 1 Unicancer greatest oncologic benefit for radical therapy in M1 ADT +/- abiraterone ADT +/abiraterone ADT + Prostate RT +/ADT PEACE +/abiraterone 1 Unicancer ADT +/abiraterone ADT + Prostate RT +/ADT + Prostate RT +/PEACE 1 Unicancer abiraterone prostate cancer was likely in those with the lowest (strat docetaxel) (strat docetaxel) (strat docetaxel) (strat docetaxel) abiraterone burden of metastatic disease, abiraterone further supporting the (strat abiraterone docetaxel) (strat docetaxel) (stratfor docetaxel) (strat docetaxel) concept of locally-directed therapy low-volume Best systemic therapy BST + RP or RT MDACC 5 metastatic cancer . Best systemic therapy BST + RP or RT Best systemic therapy MDACC BST + RP or RT Best systemic therapy BST + RP MDACC or RT

(Fox Chase/UCSF) ADT ADT + Prostate RT HORRAD Given the above evidence, it is surprising that ADT ADT + ProstateinRT ADT HORRAD Netherlands ADT + Prostate ADT RT HORRAD oligo-metastatic prostate cancer investigation the Treatment as usual TAU+ local Rx TRoMbone world-wide community has focused on oligoTreatment as usual TAU+ local Rx Treatment TRoMbone as usual (some UK TAU+ local asTRoMbone usual limited to Rx Treatment RAMPP recurrent disease in which sites of oligo-metastasis (some limited to RAMPP German (some limited to RAMPP oligometastases only) occur after primary therapy, with trials examining oligometastases only) GETUG oligometastases (planned) only) primary-directed treatment options in synchronous SWOG (planned) disease being few (see Table). STAMPEDE and the EORTC (planned) Belgian HORRAD (ISRCTN 06890529) trials are testing

(Fox Chase/UCSF) (Fox Chase/UCSF) Netherlands ADT + Netherlands Prostate RT UK TAU+ local UK Rx German (some German limited to GETUG (planned) oligometastases GETUG (planned) SWOG (planned)only) (planned) EORTCSWOG (planned) EORTC (planned)

Hence, there is a need for interrogation of surgery to the prostate (and regional lymph nodes) in men with newly-diagnosed oligo-metastatic prostate cancer. We have previously shown surgery to be technically feasible and safe in nodal- and skeletal-metastatic prostate cancer, using a multi-institutional cohort from Europe and the USA6. A German study, RAMPP, that I named and co-designed with Markus Graefen is examining the role of surgery in this space, and is steadily recruiting (though slower than expected) (NCT02454543). However, it was realised at the time of study inception back in 2013 that a national study was never likely to recruit enough patients to provide the power needed to detect differences in survival between control and intervention groups; hence, RAMPP has now opened in Austria (PI Shahrokh Shariat) and Sweden (PI Peter Wiklund). The UK research community however felt that, due to previous prostate cancer surgical trials failing to recruit, a similar protocolled study in the UK would require supporting pilot data first. And thus TRoMbone was born, with a mandate to test the ability to randomise men with synchronous oligo-metastatic prostate cancer to disparate treatments. TRoMbone, “Testing Radical prostatectomy in men with prostate cancer and oligoMetastases to the bone: a randomised controlled feasibility trial”, will randomise 50 men to standard-of-care (ADT with/ without docetaxel) versus standard-of-care plus radical prostatectomy with extended pelvic

European Urology Today

STAMPED PEACE 1

HORRAD

TRoMbon RAMPP

radiation in synchronous metastatic disease but ADT= androgen deprivation therapy; RT= radiotherapy; RP= radical prostatectomy irrespective of systemicdeprivation disease burden, and a US ADT= androgen therapy; RT= radiotherapy; RP= radical prostatectomy ADT= androgen deprivation therapy; RT= radiotherapy; RP= ADT= androgen deprivation therapy; RT= radiotherapy; RP= radical prostatectomy (courtesy of Christopher Sweeney, Boston, USA) study led by MD Anderson Cancer Center (NCT01751438) does have a surgical arm but is again not focused on oligo-metastatic disease. Box 1: TRoMbone eligibility criteria Inclusion Criteria Willing and able to give informed consent Male aged 18-74 years Synchronous oligo-metastatic prostate cancer (1-3 skeletal lesions on standard imaging) Locally-resectable disease ECOG PS 0-1

Exclusion Criteria Contraindications to radical prostatectomy and extended pelvic lymphadenectomy Visceral metastases Prior radiotherapy to the abdomen/pelvis or to skeletal metastases Any systemic therapy for prostate cancer for 3 or more months Participation in another prostate cancer clinical trial

Suitable for radical prostatectomy and extended pelvic lymphadenectomy within 3 months of starting standard care

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

Acronyms

European Urological Scholarship Programme (EUSP) Do not forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme, before the next deadline of 1 May 2017! For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website http://www.uroweb.org/education/scholarship/ January/February 2017

Update from the Guidelines Office EAU17 London March will see the publication of the full text and pocket versions of the 2017 European Association of Urology Guidelines. As always, the Guidelines will be available to collect - free for EAU full members - from the Congress Booth at EAU17, London. They can also be ordered by email at guidelines@uroweb.org. In this case postage costs will apply. Guidelines ESU Courses The Guidelines Office (GO) is pleased to announce that it will facilitate two European School of Urology courses at EAU17. The first course “What’s new in the 2017 EAU non-oncology Guidelines”, Sunday 26 March, 12.00-14.00 hrs., will focus on the major changes in the recommendation and text of the EAU Guidelines of Incontinence, Male LUTS and Infections. The second course “What’s new in the 2017 EAU Renal, Bladder and Prostate Cancer Guidelines”, Monday 27 March, 08.30-11.30 hrs., will focus on the major changes in the recommendations and text of the EAU Guidelines of these three foremost oncology topics. A bird’s eye overview of changes and their relevance for clinical practice will be the main focus of both courses giving attendees a quick insight into how the different fields are progressing. EAU17 exhibition In addition to the two exciting ESU courses the GO, will also have a presence at the EAU17 exhibition. We would encourage everybody to please stop by the Guidelines Office booth and meet our dedicated staff, who will be more than happy to answer any questions you may have regarding the many activities of the GO. The Guidelines Associates programme: Constructing Evidence-based Urological Clinical Practice Guidelines Evidence-based Clinical Practice Guidelines (CPGs) enable clinicians to translate the best scientific evidence into clinical practice. If utilised correctly, CPGs can potentially promote the most effective and highest quality healthcare. Evidence-based CPGs are defined Guidelines Office

as statements that include recommendations intended to optimise patient care. The development of evidencebased recommendations represents a complex process involving multiple stakeholders.

Lorenzo Marconi, MD, FEBU, Lead Senior Associate

Virginia Hernandez, MD, FEBU, Lead Senior Associate

The primary aim of the EAU Guidelines Office (GO) is to improve the care of urological patients in Europe. In order to deliver on this commitment the GO has been working towards the production of evidencebased CPGs, which ensure that high quality systematic reviews underpin key recommendations. To achieve this ambitious goal the GO established the EAU GO Associates Programme chaired by Prof. Thomas Knoll. With the support of the GO Methods Committee, this programme identifies and trains young European urologists in evidence synthesis, following robust Cochrane systematic review methodology. The programme has led to the development of multiple systematic reviews across all 20 EAU Guidelines Panels, providing a transparent link between the scientific evidence and guideline recommendations. We have been involved in this project since its inception in 2012. At its outset the programme consisted of a small group of young urologists, academically oriented, with expertise in systematic reviews. This group was fully trained in evidence synthesis methods and worked in close collaboration with the various Guidelines panels. The systematic reviews produced within the panels were ultimately published in high impact journals including European Urology and Lancet Oncology. From these humble beginnings the programme has grown over the last five years to support the work of over 80 EAU Guidelines Associates.

Working model The working model for the programme relies on complete interaction between the Associates and their assigned panel. The core working group for each systematic review consists of 2 associates, 1 senior associate and a senior panel lead. The process starts at panel meetings where panel members define the clinical question in a PICO (Participant, Intervention, Comparator, Outcome) based protocol outlining the study eligibility criteria. In conjunction with an information specialist the Associates then define a comprehensive search strategy to identify all potentially relevant studies. The Associates subsequently select eligible studies based on predefined inclusion and exclusion criteria. Data from each individual study are extracted and the studies are individually appraised for their risk of bias. Results of included studies are combined in a narrative synthesis or, where appropriate, in a meta-analysis, whilst the overall quality of the evidence is assessed. This is a highly time consuming process as all steps are carried out by each of the two reviewers. The results of the systematic review are finally presented at guideline panel meetings. Based on the results of the systematic review, as well as on a number of other factors including the balance between benefits and harms and patients’ values and preferences, panel members issue appropriate recommendations. GO Methods Committee To date the Associates programme has published in excess of 20 systematic reviews with more than another 40 currently ongoing. The achievements of the programme would not be possible without the continued work of the Methods Committee, led by Prof. Richard Sylvester. Twice yearly the Methods Committee give a two day workshop on systematic reviews methodology and provide continuous methodological support to the Associates and panel members, ensuring that all systematic reviews are of the highest methodological quality. The Associates represent a wide European network of young urologists, who will be the future global opinion leaders in urology in the next seven to ten years and it has been our privilege to be involved in this dynamic and rewarding programme.

Your Credit Registry Report 2016

j.m.nijman@umcg.nl More than 15,000 urologists from Europe and beyond have already joined the EU-ACME programme including more than 4,000 EAU Junior Members. However, only 30% have collected CME/CPD credit points last year. Members of the EU-ACME programme are collecting CME/CPD credits in compliance with EBU/UEMS rules. The CME/CPD credit management system recommends obtaining a minimum of 300 credits in five years – 250 CME credits and 50 CPD credits. The EU-ACME programme provides access to the online CME/CPD portfolio, allowing its members to check and register activities at any time. Many members have already used our online system and have sent copies of documented proof of participation in an accredited event in 2016 to the EU-ACME office. Check your online account Log in to your online CME/CPD portfolio through www.eu-acme.org and check if all activities you have attended are properly listed under your name. If you miss any activity either register it directly online or send copies of documents, e.g. the certificate of attendance, written articles, text or copies of lectures delivered, etc., to the EU-ACME office.

January/February 2017

Make sure your personal data are correct, so that the EU-ACME office can send your Credit Registry Report 2016 to the correct address! Electronic Credit Registry Reports EU-ACME members may generate and print Credit Registry Reports online at any time. If you do not wish to receive a hard copy of the CRR, log in to your online account and check the box for the option: “I will generate and print my CRR online. I do not wish to receive a copy by regular mail.”

Alter your personal data on-line, fast and easy, at www.eu.acme.org

EU-ACME MCQ winners 2016 From January 1 to December 31, 2016, EU-ACME members answered multiple questions published in European Urology. Participants who answered most questions correctly were awarded with free registration for the 32nd Annual EAU Congress in London to be held from March 24 to 28 this year.

Your Credit Registry Report 2016. . . . . . . . . . .3 Evidence-based management of catheter-associated UTI . . . . . . . . . . . . . . . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . 8-11 EMUC16: New research points to personalize treatment. . . . . . . . . . . . . . . . 12-13 5th ESUI tackles challenges . . . . . . . . . . . . . 15 ESU section: A unique opportunity: Experiencing quality masterclasses. . . . . . . . . . . . . . . . . . 16 Masterclass Female & functional reconstructive urology . . . . . . . . . . . . . . . . . 17 ESU in Rhodos, Greece. . . . . . . . . . . . . . . . . 19 ESU Course in Vilnius. . . . . . . . . . . . . . . . . . 19 The development of British Urology. . . . . . . 22

EAU White Paper: More funding and awareness needed. . . . . . . . . . . . . . . . . 24 Ten questions. . . . . . . . . . . . . . . . . . . . . . . . 24 EBU section: Vestfold Hospital Trust secures EBU certification. . . . . . . . . . . . . . . . . . . . . . 25 EBU Certification Residency Training Programme in Urology. . . . . . . . . . . . . . . . . 25 ESUT section: ESU Course on Laparoscopic and Endoscopic Urology . . . . . . . . . . . . . . . . . . . 26 ESUT, Milan hospital collaborate in MIS programme. . . . . . . . . . . . . . . . . . . . . . 26 Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 27

The EU-ACME committee congratulates the winners for their successful participation in our online CME programme!

Call for EAU RF SATURN registry. . . . . . . . . . 29

All you need is a PC and internet access

Credits are attributed automatically 1 credit point per article allowing for a maximum of 50 credit points over a 5 year period.

Update from the Guidelines Office . . . . . . . . . 3

The 2016 winners are: 1. Mr. M.F. Saxby, United Kingdom (CME-000243) 2. Dr. D. Monakov, Russia (CME-110097) 3. Mr. F-J. Schattka, Ireland (CME-110659)

Gain your CME credits at home Visit www.eu-acme.org/europeanurology or http:// www.eu-acme.org/pediatric and answer a set of MCQs on-line. 80% of the answers need to be answered correctly to obtain 1 European CME credit point.

TRoMbone study to start accrual in Feb. 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Parkinson’s disease and Lower Urinary Tract Symptoms . . . . . . . . . . . . . . . . . . . . . . 23

Generate and print CRR online Prof. Dr. Rien Nijman Chair EU-ACME Office Groningen (NL)

EAU17 Preview: Prospects, trends and challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

This study method offers more flexibility where you can decide for yourself when and where you should like to study. CME is a lifelong commitment and CME credits are the ‘staples’ of staying in practice and keeping the office doors open. Good luck!

Update Membership Office. . . . . . . . . . . . . . 27 EUSP Clinical Visit. . . . . . . . . . . . . . . . . . . . . 28

EULIS section: Extracts from the ERA-EDTA Stone Symposium . . . . . . . . . . . . . . . . . . . . . . . . . 31 Live surgeries in urolithiasis workshop. . . . . 31 YUO/YAU section: Observership in endourology. . . . . . . . . . . . 32 YUO launches Leadership for Medical Professionals Course. . . . . . . . . . . . . . . . . . . 33 ESRU, CAU collaborates in Panama meeting. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 EAUN section: Health illiteracy in urological patients. . . . . . Book review. . . . . . . . . . . . . . . . . . . . . . . . . EAUN Nursing Workshop in Dubai. . . . . . . . Revisiting the Asia-Pacific Prostate Cancer Conference. . . . . . . . . . . . . . . . . . . . . . . . . . EAUN Fellowship Programme on robotic surgery. . . . . . . . . . . . . . . . . . . . . . .

36 36 37 38 39

European Urology Today

Cutting-edge Science at Europe’s largest Urology Congress

Prof. Morgan Rouprêt shares his ideal 24 hours at EAU17

The main congress highlights of Prof. James Catto

The highly-anticipated 32nd Annual EAU Congress (EAU17) in London is only a few months away. Abstract submissions for this Congress have already broken records of past congresses. Hybrid sessions and additional Plenary Sessions are few of the exciting changes in the Scientific Programme. One might wonder what other developments will EAU17 bring.

Rouprêt’s topics of interest Although onco-urology is Rouprêt’s field of expertise, particularly urothelial carcinomas of the bladder and of the upper tract, his interests go beyond this field. Rouprêt said, “I’m curious about everything; that’s why I try to keep an eye on every aspect of the Congress. A wide-ranged knowledge comes in handy when I address cases outside oncology. This is the reason why I remain open-minded. The Congress offers a variety of relevant, multidisciplinary topics. I also check Twitter for new exciting data and clinical experience which I look forward to learning about. I receive timely information thanks to social media.”

Editor-in-Chief of European Urology (EU), Prof. James Catto (UK) of the Sheffield Teaching Hospital shares his ideal day at the upcoming 32nd Annual EAU Congress.

Learning from the best Aside from lectures at the Congress, Rouprêt looks forward to attending lectures by fellow experts. “For me, Prof. Francesco Montorsi is always brilliant and didactic. His lectures are very educational. Another talented professor is Prof. Freddie Hamdy, whom I worked with in Sheffield a few years ago. I also look forward to his lectures. Prof. Alberto Briganti is also a notable example. He comes from a younger generation of urologists. He’s articulate with a broad-gauged knowledge in the field of prostate cancer, especially with regard to drugs and surgery.”

Prof. James Catto

My EAU Congress day “I’m always on the move from the beginning of my day until it ends. I enjoy my days to the fullest. The boost of energy and enthusiasm is the same for me whether I’m at the Congress or at the hospital in Paris,” said Rouprêt. “My ideal day at the Prof. Morgan Rouprêt Congress would be an early start. I catch up on the latest updates by reading the EUT Congress News during breakfast. Then I proceed to the venue to listen to the highlights from the day before and attend the Plenary Sessions. Afterwards, my schedule is dedicated to appointments with the scientific committee, companies, fellows, or colleagues until it’s lunchtime.” Even during breaks, Rouprêt makes the most out of every moment. “I like quick and light conversations at the Congress Centre. Lunchtime is a great time for networking. And if I have no further commitments, I check Twitter to see where the action is: interesting topics, ongoing debates, examination of urgent and controversial issues, etc. Sometimes I use Twitter to guide me which lecture room I should go to next. In the afternoon, I usually attend a sponsored session as it is always a good opportunity to learn from top experts in the field.” In the afternoon, as a member of the Scientific Committee Office, Rouprêt goes through the sessions he organised. “I evaluate the sessions and provide feedback to the EAU Executive Office to maintain what works and to propose changes for what needs to be improved for next year’s Congress. And what a great way to conclude the day; meet up with friends and colleagues, and maybe share a glass of (French) red wine in such a relaxing atmosphere.”

Take-home messages When asked what key messages from EAU17 he would like to bring back to his practice, Rouprêt discloses, “This is honestly one of the most difficult questions to answer. The upcoming EAU Congress is an assortment of significant developments within and outside urology. It is a special event full of surprises. But what I am sure of is that I will receive new insights and data from new immunotherapies in bladder cancer.” Business and pleasure The EAU Congresses are not only conducive to learning but also for building relationships, according to Rouprêt. “I enjoy these Congresses because I see my colleagues who are not in France. Of course, we keep in touch via WhatsApp, Skype, and email but I can assure you that there is nothing better than face-to-face interaction. And London is an amazing place to see them again during the biggest meeting of urologists in the world!” concludes Rouprêt.

Catto’s topics and lectures of interest Catto begins his Congress day early and productive. “During a light breakfast, I read the EUT Congress News to brush up on developments from the previous day. Afterwards, I consult the EAU17 Programme at a Glance for sessions I would like to attend,” said Catto.

Catto’s expertise is bladder cancer, but his interests also lie in topics outside his field. “I’m keen in the improvement of the outcomes of cystectomy, organising and refining of bladder cancer care, personalised treatment of cancers, to name a few. I attend diverse sessions, including Poster Sessions, because they interest me and they keep me updated.” When asked about lectures and sessions he looks forward to at EAU17, Catto said “I would like to attend the semi-live surgeries; the Surgery-inMotion-School Session (a European Urology session); the state-of-the-art lecture ‘MRI prior to biopsy – Results from the PROMIS trial’ which is under ‘Plenary Session 05: Management of prostate cancer’; the ‘Thematic Session 01: Personalised medicine in urological oncology’; the semi-live Thematic Session ‘Lymph node surgery in urooncology’; and my favourite: the late breaking news session on the last Congress day.” Learn from the best Catto names some of the speakers he admires and whose lectures he would like to attend. “Mr. Tim

O’Brien (UK) is brilliant; he presents his lectures in a fun, open and engaging manner. I also look forward to learning from Prof. Francesco Montorsi (IT) who is experienced, knowledgeable and straightforward; and from the astute Prof. Dr. Jürgen Gschwend (DE) who will give a state-of-the-art lecture on ‘The evidence for the extent of lymphadenectomy in TCC.’ There’s also the extremely clever Dr. Patrick Walsh (USA) who possesses vast experience and great insight. They are just a few of the many esteemed experts at EAU17,” said Catto. Take-home messages Catto looks forward to gaining knowledge in the latest surgical tricks. In the relatively-near future, he expects more high-quality randomised trials. And in the long term, he sees improvement in patient outcome and personalised care. Business and pleasure Constantly on the move, Catto combines his healthy routine and exploration of the venue. “I like walking in general. I walk to the venue and then check the EU booth on the exhibition floor. I usually do this twice a day,” said Catto. The EU booth will have its Platinum Hour every day at 16.00 to thank authors and reviewers for their contribution, and the readers for reading the journal. Not only because he is EU’s Editor-in-Chief, Catto likes seeing the best work in different fields on the exhibition floor and is keen in their progress. “I’m excited to see the latest developments in the industry and pharmaceutical stands, for example. I check Twitter for updates and then tweet some myself,” said Catto. Afterwards, he heads off to attend the Plenary Sessions until it is lunchtime. “I take a leisurely walk and then meet up with friends. Later on, I attend an afternoon session or two. I catch up with colleagues and friends then head to the hotel to change. And what a great way to end the day by going for a run?” shared Catto.

Section Meetings: A gathering of experts The Annual EAU Congress is also known for its well-attended EAU Section Meetings. Below summarises some of the goals and topics covered in the Section Meetings: EAU Section of Urolithiasis (EULIS) and the EAU Section of Uro-Technology (ESUT) A comprehensive update on stone disease will be examined during this meeting. Aside from recent developments in pathophysiology and epidemiology of stone disease, this session will also focus on the importance of new treatment modalities and the effects in both medical and surgical management of urolithiasis. Furthermore, there will be live surgery during the ESUT sessions, featuring spectacular 3D projection. The best practices will be shared by some of the world’s uro-surgical experts, and challenges and practical issues faced by surgeons will be also addressed. EAU Section of Transplantation Urology (ESTU) and the EAU Section of Oncological Urology (ESOU) This joint meeting aims to provide updates

regarding the incidence and therapeutical aspects of urological cancers in both candidates and kidney transplant receptors. EAU Section of Urological Pathology (ESUP) and the EAU Section of Urological Research (ESUR) Integrating clinic-pathologic data with emerging techniques of molecular profiling-based treatment will represent the future of personalised therapeutic approach for urogenital cancer. These and more will be discussed in the meeting. EAU Section of Female and Functional Urology (ESFFU) Revisiting the management of LUTS in neurogenic and non-neurogenic patients will be the focus of the meeting. EAU Section of Urological Imaging (ESUI), the EAU Section of Urological Research (ESUR) and the European Society of Nuclear Medicine (EANM) One of the goals of this meeting is to

congressesUrology and courses are accredited by the EBU in compliance with the UEMS/EACCME regulations 4 EAUEuropean Today

provide an extensive and critical overview on the evolution and development of the different imaging tools e.g. multiparametric MRI and ultrasound-based imaging techniques. EAU Section of Andrological Urology (ESAU) and the EAU Section of Infections in Urology (ESIU) Antibiotic resistance during the acute phase in infections, and the significant overlap between infections and andrological diseases during the chronic phase will both be addressed in this joint meeting. All Section Meetings take place on Saturday, 25 March.

Meet the Speakers of the Plenary Sessions Delegates are able to Meet the Speakers of the Plenary Sessions immediately at the end of the Plenary Sessions in the foyers of the eURO Auditorium (Level 0) and Room Copenhagen (North Hall, Level 1). Do not miss this opportunity to meet and greet the speakers and to consult them for any questions you may have.

January/February 2017

#EAU17 Cutting-edge Science at Europe’s largest Urology Congress

ESU social media courses at EAU17: Fine-tune your skills The growth of social media throughout the years has been colossal and it shows no signs of stopping. Given the massive scale of the reach in sharing information, plenty of industries such as healthcare have embraced the power of social media.

London to educate healthcare professionals about the benefits and risks of using social media.

Social media has broken down borders. Connecting with fellow physicians, nurses, residents, or patients is not a problem anymore, regardless of time and distance. And who knew that a humble hashtag can be used to filter enormous amounts of information? New technologies is an inevitable part of the landscape of present and future medicine. Social media is an open environment where everything posted is public domain. This means that patients and the general public can view posts and comments. This brings in some risks. It is important to define the appropriateness of the information posted and shared in health professional discussions to avoid medical and legal problems.

Personalised hands-on workshop for beginners For novices in the field of social media, there is a personalised hands-on workshop at the Social Media Helpdesk, which is located at the Boulevard. Representative of the Young Urologist Office (YUO) will be the designated guide. Each workshop will be tailored to personal interests, but topics could include: • Social media as added value for urology • Kinds of social media platforms • Terminologies used • How to set up a Twitter and/or Facebook account • What to post and/or tweet • Who to follow • Do’s & Don’ts From 25 to 27 March, every day four workshops will be held between 11.00 and 13.00. Each workshop will take approximately 30 minutes and only one to two delegates can participate per session. Registration fee is EUR 20. Advanced social media course: Take it to the next level The advanced course is for healthcare professionals who are already active in social media but would like

The European School of Urology (ESU) recognises the potential of social media in the field of urology. And that is why it offers several social media courses at the upcoming 32nd Annual EAU Congress (EAU17) in

to take it to the next level. The course will cover the following topics: • Source for scientific research • Dissemination of content • Interaction with patients • Guidelines in using social media • Reputation Management • Measurement and Analytics – Impact Factor The advanced course is classroom-based intended for a maximum of 100 participants. Various social media experts with a urological background will share their knowledge and experiences. The course will take place on Sunday, 26 March at 12.00 or 12.30 in Room 13. Registration fee is EUR 42 for EAU members. Residents pay EUR 30. Social Media Helpdesk For basic inquiries, please visit the walk-in Social Media Helpdesk at the Boulevard (Level 1) in front of the registrations area, where there will be live tweeting as well. The EAU Community Manager will answer basic questions, assist in creating social media accounts, and help post on various platforms from 11.00 to 13.00 on 25 to 27 March. No registration necessary. This service is for free.

Pre-register now online! Deadline: 6 March 2017

Your must-have Congress Tools For your optimal experience at the 32nd Annual EAU Congress (EAU17), you can have easy access to information in many ways: via the EAU17 Congress App, the EAU17 website, the Programme at a Glance and the EAU Programme Book. EAU17 Congress App Browse the complete Scientific Programme by day, topic, or speaker. You can even create your own personal programme thanks to the App’s Personal Planner feature! Find the rooms and exhibitor booths on the floorplans. Receive daily news. You don’t even need internet access; you can use the App offline! So go digital and help save the planet! EAU17.org website For a full-screen view of the EAU17 Congress essentials, you can always rely on the information found on eau17.org. All you need to know about the

Congress can be found here; the Scientific Programme, awards, registration information and how to get to the venue. You can schedule all the sessions you want to attend by creating a customised programme using the Personal Planner option. Programme at a Glance If you prefer something tangible – the feel of turning the pages with your fingers – without the hassle of carrying a heavy book around, then the new Programme at a Glance booklet is right for you. Although it is the “lighter” abridged version of the EAU Programme Book, you can still find the full programme overview of the Congress, the floorplans, and exhibitors’ information in it. And if you need more information, you can always use the EAU17 Congress App or visit the EAU17 website. EAU Programme Book The goal of the EAU is to organise green congresses

by reducing the use of printed materials. Therefore the production of the EAU Programme Book has decreased. If you still want the book, you can grab a copy at the Programme Book corner. An alternative is to print your preferred pages from the Programme Book via the EAU17 website. This feature will be available as of 1 March 2017. EAU17 on social media For EAU17 breaking news, key developments, insights from top lecturers, exclusive photos, to your guide to your next lecture, follow us on social media! Follow @Uroweb on Twitter, like us on Facebook at www.facebook.com/EAUpage, and view our photo reports on Instagram via @Uroweb.

• It is fully integrated with the scientific programme of the congress • You can select your priority sessions

January/February 2017

• You can export it to your Outlook or Google Calendar or print it out The App and the EAU17 website both offer congress planners. Kindly note that they are not exchanging data so it is recommended to use either the planner in the App or the one on te website.

• You can register online until 6 March 2017, after this date you can still register onsite • Abstracts are available online for EAU Members as of 24 February 2017 • As of 24 March abstracts are available for delegates in the EAU17 Resource Centre; eau17.org/rc • EAU News will send you daily updates and reports about the congress. • You can join the discussion via social media with the hashtag #EAU17

Cut ting -ed ge

Scie nce at Eur ope ’s larg est Uro log y Con gre ss

Your Personal Planner Do not miss anything during this year’s Congress, use the EAU Personal Planner!

Handy reminders

• The Certificate of Attendance can be printed as of Wednesday 29 March, through eau17.org • e-Posters can be explored at the e-poster area, the EAU17 Resource Centre and UROsource.com

Programme at

www.eau17.o rg

• For photos taken at the congress, please check our Facebook page regularly!

a Glance

• Share your congress photo’s on Instragram #uroweb #EAU17 EAU17

European Urology Today

Evidence-based management of catheter-associated UTI Most basic means of prevention are still the most effective Dr. Béla Köves Dept. of Urology South-Pest Teaching Hospital Budapest (HU)

bkoves@gmail.com

Prevention of CAUTIs Great effort have been invested and many different approaches have been investigated to prevent or at least delay catheter-associated bacteriuria or CAUTI. Although an ideal solution is not yet discovered, many important aspects regarding catheter care and catheter related infections are clear today. The possible methods of preventing catheter related infections can be sorted in the following groups:

costs. Even today the most efficient means are to avoid unnecessary catheterizations and to remove catheters as soon as possible. Implementation of reminder systems and infection control programs can effectively decrease the rate of CAUTIs, but an optimal catheter material or coating is still awaited. Evidencebased catheter management and adherence to guidelines is mandatory. References 1. Klevens RM, Edwards JR, Richards CL, Jr., Horan TC,

Gaynes RP, Pollock DA, et al. Estimating health Prevention of catheterization Urinary catheters represent one of the most basic care-associated infections and deaths in U.S. hospitals, The prevention of CAUTIs starts with the prevention of tools in urological practices, however their use is 2002. Public health reports. 2007;122:160-6. unnecessary catheterisations. Given that 30% of initial associated with potential morbidities as well. The 2. Johansen TE, Botto H, Cek M, Grabe M, Tenke P, urinary catheterizations are unjustified in a standard urinary tract is one of the most important sources of Wagenlehner FM, et al. Critical review of current hospital setting, and catheters are often „left in place” definitions of urinary tract infections and proposal of an healthcare associated infections and the presence of in patients without purpose, this is a very important a urinary catheter is one of the major risk factors as it aspect of good catheter care. EAU/ESIU classification system. International journal of is being linked to up to 80% of healthcare associated urinary tract infections (UTIs)1. The use of different reminder systems (e.g. electronic, nurse-based) can decrease the duration of Therefore, the appropriate prevention and catheterization. Institutions which have implemented management of catheters and catheter-associated and evaluated such monitoring systems uniformly UTIs is of utmost importance for every urologist. reported reduction in the duration of catheterisations and in the incidence of CAUTIs. Definitions It is very important to distinguish catheter-associated Institutional infection control programs and catheter asymptomatic bacteriuria (CAB) from symptomatic care practice bundles (education for catheter catheter-associated UTIs (CAUTIs). In the new UTI insertion, management, and removal; improving classification system of the EAU (ORENUC) CAB is part hand hygiene, etc.) can also effectively reduce the rate of the urological risk factors, but not regarded as a of CAUTIs and CAUTI related complications. separate type of UTI, and does not require routine treatment2. Alternative methods In appropriate patients, suprapubic catheters, In case of long-term catheterisation the presence of intermittent catheterisation or condom drainage CAB is universal. The reason for this is the formation systems might be preferable to indwelling urethral of biofilms on the catheter surface. Biofilms are catheterisation. Although limited evidence suggest structured communities of microorganisms that they can decrease the rate of infectious encapsulated within a self-developed polymeric complications, the available data is inconclusive4,5. The main problem with available evidence is that matrix adherent to a surface, like catheters. At the time of catheter insertion around 20% of patients most studies only report on the rate of CAB instead of will be colonized immediately, and then each the rate of CAUTIs, which would be the outcome of subsequent day with the catheter will increase the interest. incidence of bacteriuria with further 3-8%. Biofilm Antibiotic prophylaxis bacteria may differ from their planctonic counterparts in antibiotic susceptibility and In a 2013 meta-analysis6 antibiotic prophylaxis was phenotype explaining why antimicrobial therapies associated with a decreased rate of bacteriuria and effective against planctonic bacteria frequently fail to febrile mortality amongst surgical patients in case of eradicate bacterial biofilms on catheters and other short-term catheterisation (up to two weeks). There urological devices. The term CAUTI should be used was only limited evidence that prophylactic antibiotics only for symptomatic catheter-associated infections reduced bacteriuria in non-surgical patients. (bacteriuria + symptoms). Therefore, according to the relevant EAU and CDC guidelines in case of short-term catheterisation Diagnosis routine prophylaxis is not recommended. Data on The CAUTI symptoms are heterogeneous, such as prophylaxis in case of long-term catheterisation are fever; urethral, pelvic or flank pain; urethral sparse, therefore clear recommendation cannot be discharge. However, the symptoms are often not given. However, considering the possible collateral specific in many patient groups, like in elderly, effects of routine antibiotic prophylaxis in long-term diabetic or immunosuppressed patients. This is a catheterisation on antibiotic resistance and related common diagnostic problem leading to a significant morbidities, there is an expert consensus that the use amount of misdiagnosis regarding CAUTI. Since of long-term antibiotic prophylaxis is not studies have shown that UTI is the source of an recommended. unspecific febrile infections in less than 10% of Modification of the catheter material/coating catheterised patients it is very important to always Many efforts have been made in the last decades to rule out other sources of infection3. It is also important to emphasize that CAB is usually associated modify the different biomaterial surfaces to effectively delay biofilm formation. Such an ideal coating should with pyuria, which has no diagnostic value in prevent bacteria from adhering to the catheter and catheterised patients. Therefore, the presence or inhibit bacterial growth, thus preventing or at least degree of pyuria should not be used to differentiate delaying the onset of the bacteriuria and symptomatic CAB from CAUTI. infections. A variety of techniques have been designed for this purpose including: Treatment As the presence of CAB is universal in catheterised • Controlled release of antimicrobial agents patients and strong evidence shows that it cannot be incorporated in the device material (minocycline, eradicated on the long-term, screening and treatment rifampicin, nitrofurantoin) of CAB is not recommended, only in specific clinical • Surface coatings with antiseptic materials (silver settings (before urological procedures; pregnancy; alloy) high-risk of serious infectious complications). • Surface modifications to change hydrophobicity or In case of CAUTI urine culture (in septic patients also to create functional groups with intrinsic blood culture), must be taken before any antimicrobial activity antibacterial therapy is started. Empirical treatment • Anti-adhesive surfaces (heparin, phosphorylcolin, should be started with broad-spectrum antibiotics surface microtopography) ® based on local susceptibility patterns, then targeted therapy should be initiated according to urine culture Most of these modifications can decrease the M E TA L L I C U R E T E R A L S T E N T results (although the sensitivity results can be development of bacteriuria in case of short-term misleading). Because of the possible biofilm catheterisation, but they failed to show a significant formation on the catheter surface, it may be long-term effect. The main reason behind the reasonable to replace the catheter before the therapy decreasing efficacy with time is that the developing if it has been in place for more than seven days. biofilm on catheters alters the surface characteristics There is no general consensus about the duration of even in sterile urine. Therefore, their routine use is antibiotic treatment. In case of prompt resolution of not recommended. symptoms seven-day treatment might be applied, while for a delayed response 10-14 day treatment is A significant burden cookmedical.eu required. In mild infections, when only minor Despite the efforts in recent decades to decrease the symptoms are present a short course of oral rate of catheter related infections, CAUTI still antibiotics (three to five days) is usually sufficient. represents a significant burden in morbidity and

antimicrobial agents. 2011;38 Suppl:64-70. 3. Warren J, Bakke A, Desgranchamps F, Johnson J, Kumon H, Shah J, et al. Catheter-associated bacteriuria and the role of biomaterial in prevention. In: KG. N, editor. Nosocomial and health care associated infections in urology Plymouth: Health Publications Ltd, ; 2001. p. 153-76. 4. Kidd EA, Stewart F, Kassis NC, Hom E, Omar MI. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2015:CD004203. 5. Prieto JA, Murphy C, Moore KN, Fader MJ. Intermittent catheterisation for long-term bladder management (abridged cochrane review). Neurourology and urodynamics. 2015;34:648-53. 6. Lusardi G, Lipp A, Shaw C. Antibiotic prophylaxis for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev. 2013:CD005428.

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January/February 2017

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

Oliver.Hakenberg@ med.uni-rostock.de

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

Case study No. 50 A 49-year-old man was investigated for lower urinary tract symptoms and urethral bleeding and was diagnosed with an exophytic carcinoma of the bulbar urethra, verified by biopsy showing high-grade urothelial carcinoma. There was no relevant history at all. Complete staging including cystoscopy and MR urography did not give any evidence of other neoplastic lesions in the urinary tract. The patient had been advised to undergo radical urethrocystectomy with a urinary diversion. As he was quite averse to losing his urinary bladder he presented for a second opinion.

Case study No. 49 An 86-year-old woman presents with acute urinary clot retention. This is evacuated transurethrally and on endoscopy bleeding from the left ureteric orifice is seen. Retrograde ureteropyelography indicates a mass in the renal pelvis which is confirmed by ultrasound (Fig.1) and CT scan (Fig.2). Ureteroscopy also confirmed the presence of a papillary tumour of about 3 cm in the renal pelvis originating from Fig. 1: Ultrasound of the left kidney the lateral (parenchymal) area. Biopsy verified low-grade transitional cell carcinoma. diagnosis and options, she categorically stated that Two years previously, this lady had undergone right under no circumstances would she want to be nephroureterectomy for transitional cell carcinoma. dependent on dialysis at her age. Since then she had developed a mild degree of renal insufficiency with a stable serum creatinine Discussion point: of 120 µmol/l. When discussing the current • What treatment options - if any - can be offered?

Fig. 2: Abdominal CT scan

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

Primum non nocere - surveillance Comments by Prof. Morgan Rouprêt Paris (FR)

The patient underwent a "real" Uro-CT as she received an injection of contrast. In my opinion, there is no doubt about the differential diagnosis. Thus, a flexible ureteroscopy is not mandatory to assess the diagnosis. Secondly, I would check for renal function and for the haemoglobin level.

1. What is the likelihood of this patient having cancer? Obviously, we are dealing here with a panurothelial disease of the urinary tract. This old lady was treated for a primary upper tract urinary cancer (UTUC) two years ago. She underwent a radical nephroureterectomy. Thus, she has been living with a single kidney for two years and she ends up today with a renal function which is quite acceptable so far.

3. What management options are advisable? Indeed, there is no real therapeutic solution to propose and any further medical procedure could end-up into a worse situation for the patient. Another radical nephroureterectomy is not a serious option to consider. Conservative endoscopic management or percutaneous removal of the tumour would have been considered in a younger patient with a better life expectancy.

We are now facing a challenging and rare situation as UTUCs are scarce and of these really few are bilateral (synchronous 1.6%; metachronous 6.9%). I would be curious to know more about the pathological assessment provided after removal of the first tumour two years ago. Indeed, nephroureterectomy can be considered today as "overtreatment" when a low-risk UTUC has been diagnosed. It looks like a dead-end situation for this lady. In my opinion, there is no doubt that another UTUC is responsible for the clots and the blood in the bladder. 2. Are there any further useful investigation? Firstly, I would ask the radiologist if there is any argument for an active bleeding on the imaging.

If there is no evidence of active bleeding in this particular case then I would avoid any further procedure. After careful discussion with this lady and her family, I would advocate a simple surveillance. If the patient and/her family requests treatment rather than observation, then I would attempt to perform it by flexible ureteroscopy. However, this woman needs to understand that she may have to undergo several procedures and suffer from subsequent complications (bleeding, obstruction) and/or renal insufficiency due to the procedure itself. In addition, there is absolutely no guarantee that the treatment can be complete as the tumour size is more or less 3 cm. Being reasonable may be the best decision to take in such a difficult situation. This is the reason why I believe that we should stick to the principle "primum non nocere".

Percutaneous resection with minimal follow-up Comments by Prof. Dr. Thomas Knoll Sindelfingen (DE)

would be significantly impaired by the need for haemodialysis, leading to a remaining life expectancy of less than two years in many cases. So which options do we have?

First: observation. However, the patient had already urinary blood retention, so this may not be Is a large papillary tumour in the renal pelvis best the best concept. Therefore, I would recommend treated by nephroureterectomy, if the patient is an local therapy. Percutaneous resection would be the 86-year-old woman with solitary kidney? The best option and most likely lead to complete patient gave us her opinion: certainly not, as she remission. Alternatively, the tumour can be refuses to undergo haemodialysis. And she is right, vaporized by retrograde laser ablation, but this although radical resection is recommended for 3 approach will require two sessions. We usually cm upper tract urothelial cancers. follow-up such patients by flexible ureterorenoscopy every four to six months, but in But this case is different, as we are talking about a this specific patient, I would only recommend very old lady with solitary kidney. Quality of life limited follow-up by ultrasound and cytology with optional retrograde ureteropyelography.

January/February 2017

Case Study No. 49 continued The determining factors for the decision were that this lady was on the one hand symptomatic from the upper urinary tract tumour in the renal pelvis with intermittent macroscopic haematuria and had already experienced clot retention requiring hospitalisation; and that, on the other hand, this was her only kidney and she would not have chronic haemodialysis. Therefore, after detailed consultations with the patient and her family, percutaneous electroresection of the tumour was done. Histology was a pTa low grade urothelial carcinoma. We performed a secondary resection one week later which histologically was free of residual tumour. The patient tolerated both procedures well, renal function as evidenced by serum creatinine did not deteriorate but even improved slightly, and eventually the percutaneous nephrostomy and the mono-J catheter were removed and the patient discharged in good condition.

Discussion points: 1. Should radical urethrocystectomy be advised? 2. Are treatment alternatives possible and reasonable? Case provided by Oliver Hakenberg, Department of Urology, Rostock University, Germany. Email: oliver.hakenberg@med.uni-rostock.de Readers are encouraged to provide interesting and challenging cases for discussion.

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European Urology Today

Key articles from international medical journals Prof. Truls Erik Bjerklund Johansen Section editor Oslo (NO)

nursing homes (24%). The vast majority of ESBL isolates were E. coli (80%). The E tests for mecillinam and co-amoxiclav had concentration ranges from 0.16 mg/L up to 256 mg/L. The mean inhibitory concentration (MIC) of mecillinam ranged from 0.25 to 256 mg/L, while co-amoxiclav MICs ranged from 6 to 256 mg/L. The percentage of isolates resistant to mecillinam and co-amoxiclav was found to be 5.26 and 94.74 % respectively.

tebj@medisin.uio.no

…pivmecillinam in conjunction Zero hospital admissions after with or without co-amoxiclav is an transperineal biopsies appropriate and useful treatment for urinary tract infections caused by The aim of this study was to determine the rate of ESBL-producing organisms hospital admissions for infection after transperineal biopsy of prostate (TPB) with single-dose cephazolin prophylaxis using a prospective database. Between April 2013 and February 2016, 577 patients undergoing TPB had 2 g of cephazolin given intravenously at induction of anaesthesia. Data collected from these patients included age, PSA, prostate volume, number of cores taken and post-operative complications.

This study supports Australia's current Therapeutic Guidelines recommendation for TPB prophylaxis and the existing evidence that sepsis post-TPB is a rare complication No patients were readmitted to hospital with infection post-TPB. Seven patients developed acute urinary retention, and one patient developed clinical prostatitis that was treated with oral antibiotics in the community. Authors concluded that it is safe to use single-dose cephazolin only as antibiotic prophylaxis prior to TPB, negating the need for quinolones. This study supports Australia's current Therapeutic Guidelines recommendation for TPB prophylaxis and the existing evidence that sepsis post-TPB is a rare complication. Whether any antibiotic prophylaxis is needed at all for TPB is the subject of a future study.

Source: Zero hospital admissions for infection after 577 transperineal prostate biopsies using single-dose cephazolin prophylaxis. Pepdjonovic L, Tan GH, Huang S, Mann S, Frydenberg M, Moon D, Hanegbi U, Landau A, Snow R, Grummet J. World J Urol. 2016 Dec 16. DOI: 10.1007/s00345-0161985-1.

Pivmecillinam is useful for treatment of urinary tract infections caused by ESBLproducing organisms

This is the first study exploring the use of pivmecillinam in an Irish cohort. The authors concluded that pivmecillinam in conjunction with or without co-amoxiclav is an appropriate and useful treatment for urinary tract infections caused by ESBL-producing organisms.

Source: Characteristics of gram-negative urinary tract infections caused by extended spectrum beta lactamases: pivmecillinam as a treatment option within South Dublin, Ireland. O'Kelly F, Kavanagh S, Manecksha R, Thornhill J, Fennell JP. BMC Infect Dis. 2016 Nov 3;16(1):620 DOI: 10.1186/ s12879-016-1797-3.

Light of a new dawn? The recognition that PSA screening led to the detection of a proportion of clinical indolent prostate cancers drove the introduction of active surveillance. This policy of delayed intervention helps mitigate the consequences of overtreatment but with intervention rates of up to a third by 10 years. Intervention occurs because of upgrading on repeat biopsy, biochemical progression or patient choice. Focal therapy is also aimed at minimising the sequelae of intervention by only treating the more aggressive foci of tumour. This paper compares the efficacy and safety of focal therapy versus active surveillance, in men with low-risk, localised prostate cancer. The focal therapy group was achieved by vascular-targeted photodynamic therapy with padeliporfin (WST 11). Men with a predicted life expectancy of 10 years or more and Gleason 6 prostate cancer with a minimum of one core containing a 3 mm cancer focus or up to three cores with no cancer core length beyond 5 mm and clinically localised disease were included. Men with a PSA greater than 10 ng/ml or a prostate volume of over 75 cm3 were excluded, as were men where accurate reading of pelvic MRI was not possible and following a protocol amendment men who had undergone surgery for benign prostatic hypertrophy.

Men were randomised on a 1:1 ratio. Active surveillance consisted of a protocol-directed biopsy at 12-monthly intervals and PSA measurement plus DRE every three months. Men assigned vascular-targeted photo-dynamic therapy underwent a multiparametric MRI which was centrally reviewed and a The prevalence of urinary tract infections (UTIs) treatment plan agreed although this could be adapted caused by extended-spectrum β-lactamase (ESBL)by the treating surgeon. Treatment involved the producing Enterobacteriaceae is increasing and the intravenous infusion of 4 mg/kg padeliporfin over 10 therapeutic options are limited, especially in primary min and subsequent activation by laser light 753 nm care. Recent indications have suggested pivmecillinam with a fixed power of 150 mW/cm for 22 min 15 to be a suitable option. This pilot study aimed to seconds via optical fibers inserted into the prostate to assess the viability of pivmecillinam as a therapeutic cover the desired treatment zone. option in a Dublin cohort of mixed community and healthcare origin. Follow-up mirrored the AS protocol and retreatment of tissue positive for cancer at the 12-month biopsy A prospective measurement of mean and fractional was permitted. The co-primary endpoints were inhibitory concentrations of antibiotic use in 95 treatment failure (histological progression of cancer patients diagnosed with UTI caused by ESBLfrom low to moderate or high risk or death during 24 producing Enterobacteriaceae was carried out. 36% months’ follow-up) and absence of definite cancer patients were from general practice, 40% were (absence of any histology result definitely positive for admitted to hospital within south Dublin, and 25% cancer at month 24). Treatment was open-label, but samples arose from nursing homes. EUCAST investigators assessing primary efficacy outcomes breakpoints were used to determine if an isolate was were masked to treatment allocation. sensitive or resistant to antibiotic agents. 206 patients were randomly assigned to vascularSixty-nine percent of patients (N = 66) with urinary targeted photodynamic therapy and 207 patients to ESBL isolates were female. The mean age of females active surveillance. Median follow-up was 24 months was 66 years compared with a mean age of 74 years (IQR 24–25). The proportion of participants who had for males. Thirty-six percent of isolates originated disease progression at month 24 was 58 (28%) of 206 from primary care, hospital inpatients (26%), and in the vascular-targeted photodynamic therapy group Key articles

compared with 120 (58%) of 207 in the active surveillance group (adjusted hazard ratio 0.34, 95% CI 0.24–0.46; p < 0.0001). 101 (49%) men in the vascular-targeted photodynamic therapy group had a negative prostate biopsy result at 24 months post treatment compared with 28 (14%) men in the active surveillance group (adjusted risk ratio 3.67, 95% CI 2.53–5.33;p < 0.0001). Compared with the active surveillance group, fewer men in the vascular-targeted photodynamic therapy group subsequently had radical therapy in the form of surgery or radiotherapy (12 [6%] of 206 men in the vascular-targeted photodynamic therapy group vs 60 [29%] of 207 men in the active surveillance group; p < 0.0001). Vascular-targeted photodynamic therapy was well tolerated. The most common grade 3–4 adverse events were prostatitis (three [2%] in the vasculartargeted photodynamic therapy group vs. one [< 1%] in the active surveillance group), acute urinary retention (three [2%] vs. one [< 1%]) and erectile dysfunction (two [1%] vs. three [1%]). The most common serious adverse event in the vasculartargeted photodynamic therapy group was retention of urine (15 patients; severe in three); this event resolved within two months in all patients This paper has generated significant interest in the lay press although there remain a number of unanswered questions. Firstly, the rate of prostate cancer progression in these men seems surprisingly high over such short follow-up raising the possibility this reflects reclassification rather than progression. In addition even after vascular-targeted photodynamic therapy, 51% of men still had cancer in their prostate on biopsy two years later. It might not mater but it is not clear who will respond currently and one in three men will suffer a significant adverse event to treat one in two of them. As once said before, the difficulty is identifying those who need any treatment particularly for low-risk prostate cancer.

This paper has generated significant interest in the lay press although there remain a number of unanswered questions. Firstly the rate of prostate cancer progression in these men seems surprisingly high over such short follow-up raising the possibility this reflects reclassification rather than progression Source: Padeliporfin vascular-targeted photodynamic therapy versus active surveillance in men with low-risk prostate cancer (CLIN1001 PCM301): an open-label, phase 3, randomised controlled trial. Azzouzi, A-R, Vincendeau S, Barret E et al. Lancet Oncol. 2016; http://dx.doi.org/10.1016/s14702045(16)30661-1.

Shock, dialysis, and age over 60 years were independent risk factors for death in patients with carbapenemresistant Enterobacteriaceae (CRE) infections The aim of this study was to describe the clinical and microbiological data of carbapenem-resistant Enterobacteriaceae (CRE) infections, the treatment used, hospital- and infection-related mortality, and risk factors for death. A prospective cohort conducted from March 2011 to December 2012. Clinical, demographic, and microbiological data such as in vitro sensitivity, clonality, carbapenemase gene mortality related to infection, and overall mortality were evaluated. Data were analysed using Epi Info version 7.0 (CDC, Atlanta, GA, USA) and SPSS (Chicago, IL, USA). One hundred and twenty-seven patients were evaluated. Pneumonia, 52 (42%), and urinary tract infections (UTI), 51 (40.2%), were the most frequent

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com sites of infection. The isolates were polyclonal; the Bla KPC gene was found in 75.6 % of isolates, and 27% of isolates were resistant to colistin. Mortality related to infection was 34.6 %, and was higher among patients with pneumonia (61.4 %). Combination therapy was used in 98 (77.2%), and monotherapy in 22.8%; 96.5% of them were UTI patients. Shock, age, and dialysis were independent risk factors for death. There was no difference in infection-related death comparing colistin-susceptible and colistin-resistant infections (p = 0.46); neither in survival rate comparing the use of combination therapy with two drugs or more than two drugs (p = 0.32).

…CRE infection mortality was higher among patients with pneumonia. Infections caused by colistin-resistant isolates did not increase mortality It is concluded that CRE infection mortality was higher among patients with pneumonia. Infections caused by colistin-resistant isolates did not increase mortality. The use of more than two drugs on combination therapy did not show a protective effect on outcome. The isolates were polyclonal, and the bla KPC gene was the only carbapenemase found. Shock, dialysis, and age over 60 years were independent risk factors for death.

Source: A prospective study of treatment of carbapenem-resistant Enterobacteriaceae infections and risk factors associated with outcome. de Maio Carrilho CM, de Oliveira LM, Gaudereto J, Perozin JS, Urbano MR, Camargo CH, Grion CM, Levin AS, Costa SF. BMC Infect Dis. 2016 Nov 3;16(1):629 DOI: 10.1186/ s12879-016-1979-z.

Lipids in urinary exosomes a new prostate cancer biomarker? Cells release different types of extracellular vesicles such as exosomes, which can be found in biological fluids such as blood, urine, seminal fluid and breast milk. These contain tumour-related molecules that can be analysed and several exosomal molecules including proteins, lipids, mRNAs and microRNAs have been identified as potential non-invasive prostate cancer biomarkers. Lipid metabolism is often disturbed in cancer cells and consequently the exploration of lipids as cancer biomarkers is beginning. Interestingly, changes in lipids such as cholesterol (CHOL), sphingolipids and phosphoinositides have been associated with prostate cancer and several differences in phospholipid species have been associated with cancer phenotype, metastatic potential and cell morphology in mammary cells and breast cancer cells. To date 35 lipid species in plasma and 10 lipid species in urine have been identified as potential prostate cancer biomarkers and this paper evaluates them in vivo. Urine sample were collected from 13 healthy volunteers and 15 men, one to seven days prior to prostatectomy. Urinary exosomes were isolated by serial centrifugation and stored at -80˚C until further use. Lipids were extracted from the urinary exosomes using a modified Folch lipid extraction procedure and a high-throughput mass spectrometry quantitative lipidomic analysis was performed to reveal the composition. Control samples were first analysed to characterise the lipidome of urinary exosomes and test the reproducibility of the method. In total, 107 lipid species were quantified in urinary exosomes. The 36

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Dr. Francesco Sanguedolce Section editor London (UK)

fsangue@ hotmail.com most abundant lipid species representing 92% of the total lipid species identified in urinary exosomes were then quantified. Interestingly, the levels of nine lipids species were found to be significantly different (p < 0.05) when the two groups were compared. The highest significance was shown for phosphatidylserine (PS) 18:1/18:1 and lactosylceramide (d18:1/16:0) (p < 0.01), the latter also showed the highest patient-to-control ratio. The diagnostic performance of individual lipid species to identify prostate cancer was limited. However, combinations based upon the ratio of these lipid species and PS 18:0-18:2 distinguished the two groups with 93% sensitivity and 100% specificity (AUC 0.989). Finally, in agreement with the reported dysregulation of sphingolipid metabolism in cancer cells, alteration in specific sphingolipid lipid classes were observed

This paper suggests the intriguing possibility of identifying men with prostate cancer based upon a urinary test. Although not currently widely available it is expected that mass spectrometry will be implemented in clinical laboratories in the next few years This paper suggests the intriguing possibility of identifying men with prostate cancer based upon a urinary test. Although not currently widely available it is expected that mass spectrometry will be implemented in clinical laboratories in the next few years. Currently, there are available antibodies against lactosylceramide opening the possibility of analysing these lipids by antibody-based methods, which are widely available. Clearly, this work needs validation in a larger independent cohort but represents an exciting new field.

Source: Molecular lipid species in urinary exosomes as potential prostate cancer biomarkers. Skotland T, Ekroos K, Kauhanen D et al. Euro J Cancer. 2017; 70:122-132.

Predicting survival in mCRPC For men presenting with metastatic prostate cancer androgen deprivation with or without docetaxel, chemotherapy is the mainstay of treatment with a high proportion of response. However, responses are not durable with nearly all tumours eventually progressing to the lethal metastatic castrationresistant (mCRPC) state. Recently a plethora of new treatments have become available with more options in the pipeline, but how best to deploy them has not been ascertained. Improved prognosis modelling would allow homogenising of risk and thus smaller trial size. This paper presents a first attempt at using data made available via Project Data Sphere to design a better prognostic model for prediction of survival in patients with mCRPC. Data from the comparator arms of four phase 3 clinical trials in first-line mCRPC were obtained from Project Data Sphere, comprising 476 patients treated with docetaxel and prednisone from the ASCENT2 trial, 526 patients treated with docetaxel, prednisone, and placebo in the MAINSAIL trial, 598 patients treated with docetaxel, prednisone or prednisolone, and placebo in the VENICE trial, and 470 patients treated with docetaxel and placebo in the ENTHUSE 33 trial. Datasets consisting of more than 150 clinical variables were curated centrally, including demographics, laboratory values, medical history, lesion sites, and previous treatments. Baseline variables for each trial were similar. Data from ASCENT2, MAINSAIL, and VENICE were released Key articles

January/February 2017

publicly to be used as training data to predict the outcome of interest - namely, overall survival.

This study has shown the benefits of open data access at a time when clinicians, researchers, and the public are advocating for improved platforms and policies that encourage sharing of clinical trial data

transplantation. The protein profiles of the solutions were analysed using 2D gel electrophoresis/ MALDI-TOF and LC-MS/MS.

Mr. Philip Cornford Section editor Liverpool (GB)

206 proteins and peptides were identified and quantified, belonging to 139 different groups. Of these, 111 proteins groups belonged to kidney tissues. The identified proteins exhibited overrepresentation of glycolysis related proteins (p = 9.85E-13). The top three groups of the identified proteins had molecular functions related to structural constituents of the cytoskeleton (p < 1.1E-10), serine-type endopeptidase inhibitor activity (p < 7.74E-09), and peptidase inhibitor activity (p < 1.71E-08).

philip.cornford@ rlbuht.nhs.uk

Clinical data were also released for ENTHUSE 33, but data for outcome variables (overall survival and event status) were hidden from the challenge participants so that ENTHUSE 33 could be used for independent validation. Methods were evaluated using the integrated time-dependent area under the curve (iAUC). The reference model, based on eight clinical variables and a penalised Cox proportional-hazards model, was used to compare method performance. Further validation was done using data from a fifth trial—ENTHUSE M1—in which 266 patients with mCRPC were treated with placebo alone.

A large number of the identified proteins play a role in biological processes like cellular component organisation or biogenesis (p < 4.48E-16) and cellular component morphogenesis (p < 4.58E-14).

50 independent teams developed methods to predict overall survival and were evaluated through the DREAM challenge. The top performer was based on an ensemble of penalised Cox regression models (ePCR), which uniquely identified predictive interaction effects with immune biomarkers and markers of hepatic and renal function. Overall, ePCR outperformed all other methods (iAUC 0.791; Bayes factor > 5) and surpassed the reference model (iAUC 0.743; Bayes factor > 20). Both the ePCR model and reference models stratified patients in the ENTHUSE 33 trial into high-risk and low-risk groups with significantly different overall survival (ePCR: hazard ratio 3.32, 95% CI 2.39–4.62, p < 0.0001; reference model: 2.56, 1.85–3.53, p < 0.0001). The new model was validated further on the ENTHUSE M1 cohort with similarly high performance (iAUC 0.768).

There were significant correlations between the levels of proteins (based on their ion intensities) of preservation solutions and donors’ age (23 proteins), cold ischemia time (5 proteins), recipients’ serum blood urea nitrogen (12 proteins) and creatinine (7 proteins) levels. The authors concluded that the levels of these proteins in preservation solution can potentially be used as a reporter of marginality of kidney prior to transplantation. Additionally, the levels of these proteins could also be used to evaluate the viability of organs prior to transplantation.

Meta-analysis across all methods confirmed previously identified predictive clinical variables and revealed aspartate aminotransferase as an important, albeit previously under-reported, prognostic biomarker. The prostate cancer DREAM challenge resulted in an improved prognostic model using a network perspective of predictive biological variables and their interactions. It pointed to the important interaction effects with immune biomarkers and markers of hepatic and renal function. This study has shown the benefits of open data access at a time when clinicians, researchers, and the public are advocating for improved platforms and policies that encourage sharing of clinical trial data. Hopefully, this will help to bring a patient benefit for men with mCRPC following the sacrifice of patients contributing to these four negative studies.

Source: Prediction of overall survival for patients with metastatic castration-resistant prostate cancer: Development of a prognostic model through a crowdsourced challenge with open clinical trial data. Guinney J, Wang T, Laajala TD et al. Lancet Oncol 2016. http://dx.doi.org/10.1016/s14702045(16)30564-2.

The protein content of organ preservation solutions as an indicator of kidney viability? One of the issues in renal transplantation is the functional preservation of the organ until its transplantation into the recipient. While several organ preservation solutions have been developed empirically, and despite intensive efforts, the functional preservation period remains limited to hours. During this time, as a result of cellular injury, various proteins, peptides, and other molecules are released by the organ into the preservation medium. In this study, the authors tried to assess the problem the other way round, i.e. by looking at what is released by the kidney into the preserving solution by proteomic techniques to analyse the protein profiles in preservation solutions in which organs had been preserved prior to their transplantation. Samples were obtained from the preservation solutions of 25 deceased donor kidneys scheduled for

Source: Reconditioning by endischaemic hypothermic in-house machine perfusion: A promising strategy to improve outcome in ECD kidney transplantation. Gallinat A, Amrillaeva V, Hoyer DP, Kocabayoglu P, Benko T, Treckmann JW, van Meel M, Samuel U, Minor T, Paul A. Clin Transplant. 2016 Dec 30. doi: 10.1111/ctr.12904. [Epub ahead of print]

…the levels of these proteins in preservation solution can potentially Functional outcomes after be used as a reporter of marginality multimodal therapy for highof kidney prior to transplantation risk prostate cancer management

Source: proteomic analysis of kidney preservation solutions prior to renal transplantation. Coskun A, Baykal AT, Kazan D, Akgoz M, Senal MO, Berber I, et al. PLoS ONE 2016, 11(12): e0168755. doi:10.1371/journal. pone.0168755

A new way of improving marginal kidneys from braindead donors? Reconditioning by machine perfusion before transplantation This clinical study evaluates end-ischaemic hypothermic machine perfusion (eHMP) in extended criteria donor (ECD) kidneys. eHMP was initiated upon arrival of the kidney in the authors’ centre and continued until transplantation. Between 11/2011 and 8/2014, eHMP was performed in 66 ECD-kidneys for roughly six hours (369 minutes (98-912)) after roughly 14 hours of cold ischemia (863 (364-1567) minutes). In 49 out of 66 cases the contralateral kidney from the same donor was preserved by static cold storage (CS) only and accepted by another Eurotransplant centre. Five (10.2%) of these kidneys were ultimately judged as "not transplantable" by the accepting centre and discarded. After exclusion of early unrelated graft losses, 43 kidney pairs from the same donor were eligible for direct comparison of eHMP versus CS only: primary non-function (PNF) and delayed graft function (DGF) were 0% versus 9.3% (p<0.05) and 11.6% versus 20.9% (p<0.25). There was no statistically significant difference in 1-year graft survival (eHMP vs. CS only: 97.7% vs. 88.4%, p < 0.09).

eHMP thus seems a promising reconditioning technique which can improve the quality and acceptance rate of suboptimal grafts In a multivariate analysis, eHMP was an independent factor for prevention of DGF (OR: 0.28, p < 0.042). Development of DGF was the strongest risk factor for one-year graft failure (RR: 38.2, p < 0.001). eHMP thus seems a promising reconditioning technique which can improve the quality and acceptance rate of suboptimal grafts. The significant reduction in primary non-function as well as delayed graft function seen in this study warrants further exploration of this concept.

Multimodal therapy, defined by radical prostatectomy (RP) followed by radiation therapy, hormonal therapy, or both, is a valid treatment option in high-risk prostate cancer management. Nevertheless, the optimal use and timing of these secondary therapies after initial surgery remain debatable, with a controversial discussion on adjuvant versus early salvage treatment. Whereas the oncologic outcomes are well-assessed, scarce data have been published regarding functional outcomes and quality of life after this sequential treatment. In the present study, Adam et al. compared the impact of additional radiation therapy (RT) with or without androgen deprivation therapy (ADT) on quality of life, potency and urinary continence, in a large cohort of 13 150 RP patients. Patients were classified as RP only, RP + RT, RP + ADT, RP + RT + ADT. Functional data were collected prospectively by self-administered questionnaires including the number of pads used per day, IIEF and EORTC QOL-C30 questionnaires. All RP procedures were performed in the same institution whereas secondary RT was given in > 60 different institution using a 3D conformal approach (median dose 66.5 Gy). Overall, 1,593 patients underwent RT associated with ADT in 43% of cases. An additional 407 patients were treated by ADT only with a median of 12 months after RP. As expected, characteristics at the time of RP were different between groups, with increasing rates of positive surgical margins, not organ-confined and high Gleason score prostate cancer in multimodal treatment groups. For assessing the impact of multimodal treatment on functional outcomes, propensity score-matched analyses were performed in regression models using variables usually predictive of urinary/sexual function, and quality of life. On this basis, patients were then matched 1:1 and repeated analyses by adding the number of questionnaires answered and body mass index as possible confounding factors. The objective was to reduce the heterogeneity of all study groups at baseline.

Given that an increasing number of high risk prostate cancer patients are treated by RP as a part of a multimodal treatment, the functional impact of subsequent RT and ADT should be more discussed and integrated into our decision-making process At three years after RP, the probability of being as defined by the use of zero to one pad per day was decreased by 4.4% after secondary RT (87% versus 91% in RP + RT and RP only groups, respectively; p < 0.001). The addition of ADT also impaired continence recovery (-8%) with a three-fold increased risk of severe incontinence (2% versus 6%) compared with RP only. In patients receiving RP + RT + ADT compared with matched patients with RP + RT, continence was 81% and 86% (p < 0.001). Differences were more significant when assessing potency recovery. At three years, 58% of patients were potent

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Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de after RP only, compared to 40% after RP + RT. The addition of ADT clearly negatively influenced sexual function with a significant decrease in potency rates when comparison was done with RP only (55% versus 24%) or RP + RT (41% versus 24%, all p < 0.001). The use of RT, as well as the addition of ADT, also significantly worsened quality of life outcomes with statistically different results among groups over time. The integration of body mass index and number of questionnaires into multivariable models did support the data. Interestingly, secondary analyses tended to show that men receiving RT as a salvage treatment reported better outcomes in terms of potency compared to those treated by adjuvant RT. The timing of RT did not influence continence recovery results. Thus, despite the limitations of this retrospective study, the present series shows that secondary oncologic treatments after RP induced a significant additive impact of functional outcomes and quality of life. Each additional therapy (RT or ADT) worsens urinary and continence functions in a clinically significant manner. Given that an increasing number of high-risk prostate cancer patients are treated by RP as a part of a multimodal treatment, the functional impact of subsequent RT and ADT should be discussed more and integrated into our decision-making process. When considering RT, patients should be informed of the increased risk of severe incontinence (1%) and of erectile dysfunction (18%). If ADT is associated, additional risks of 3% and 18%, respectively, has to be considered. These data might influence the timing of secondary therapy by favouring early salvage rather than adjuvant treatment in selected patients.

Source: Functional outcomes and quality of life after radical prostatectomy only versus a combination of prostatectomy with radiation and hormonal therapy. Adam et al. Eur Urol 2016;doi 10.1016/j.eururo.2016.11.015.

Lack of effect of rituximab on antibody-mediated acute rejection Treatment of humoral rejection is difficult and outcomes are variable. The treatment of acute antibody-mediated rejection (AMR) is based on a combination of plasma exchange (PE), i.v. immunoglobulins (IVIg), corticosteroids (CS) and rituximab, but the place of rituximab is not clearly specified in the absence of randomised trials. In this phase III, multicentre, double-blind, placebocontrolled trial, patients were randomly assigned with biopsy-proven AMR to receive rituximab (375 mg/m2) or placebo at Day 5. All patients received PE, IVIg, and CS. The primary endpoint was a composite of graft loss or no improvement in renal function on Day 12.

After one year of follow-up, there were no additional effects of rituximab in patients receiving PE, IVIg, and CS for AMR Among the included 38 patients, at one year, there were no deaths but two graft losses, one in each group. The primary end-point frequency was 52.6% (10/19) and 57.9% (11/19) in the rituximab and placebo groups, respectively (p = 0.744). Renal function improved in both groups by Day 12 with no difference in serum creatinine level and proteinuria at one, three, six, and 12 months. Supplementary administration of rituximab and total number of IVIg and PE treatments did not differ between the two groups. Both groups showed Key articles

improved histological features of AMR and Banff scores at one and six months, with no significant difference between groups but with a trend in favour of the rituximab group. Both groups showed decreased mean fluorescence intensity of donorspecific antibodies on 12, with no significant difference between them but with a trend in favour of the rituximab group at 12 months. After one year of follow-up, there were no additional effects of rituximab in patients receiving PE, IVIg, and CS for AMR. The authors cautioned that their study was underpowered, that important differences between groups might have been missed and that complementary trials with long-term follow-up will be needed.

Source: One-year results of the effects of rituximab on acute antibody-mediated rejection in renal transplantation: RITUX ERAH, a Multicenter Double-Blind Randomized Placebo-Controlled Trial. Sautenet B, Blancho G, Büchler M, Morelon E, Toupance O, Barrou B, Ducloux D, Chatelet V, Moulin B, Freguin C, Hazzan M, Lang P, Legendre C, Merville P, Mourad G, Mousson C, Pouteil-Noble C, Purgus R, Rerolle JP, Sayegh J, Westeel PF, Zaoui P, Boivin H, Le Gouge A, Lebranchu Y. Transplantation. 2016 Feb;100(2):391-9.

Patient-reported outcomes after treatment for localised prostate cancer: Does ethnicity play a role?

Globally, the conclusion of this study could be that the effect of treatment does not vary significantly by race/ ethnicity. The only interaction found between race and outcomes was noted for the urinary incontinence domain. However, this interaction was secondary when compared with the role of chosen treatment and of baseline function.

Prof. Oliver Reich Section editor Munich (DE)

Moreover, the only study examining the interaction between ethnicity and functional outcomes had showed by contrast, that African-American reported better urinary outcomes. One can argue that both cohorts were neither contemporary nor comparable, and that, since the publication of this first study, techniques such as minimally invasive surgery and IMRT as well as active surveillance has gained wide acceptance. However, to date, race or ethnicity should not be considered as a strong predictor of functional outcomes after localised prostate cancer management in our daily practice.

oliver.reich@ klinikum-muenchen.de

Source: Racial variation in patient-reported outcomes following treatment for localized prostate cancer: Results from the CEASAR Study. Tyson et al. Eur Urol, 2016, doi/10.1016/j.eururo.2016.10.036

Vaginal mesh and risk of complications: The amount counts

Increasing the amount of mesh may be thought to improve success rates of both pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery. However, the use of synthetic graft is associated with After oncologic surgery, reported outcomes in terms several post-operative risks such as urethra fistula, health status and functional features largely vary at an mesh erosions, infections, and chronic pain. In these cases, a new operation for revising or removing mesh individual basis. The objectives of the oncologic treatment in terms of quality of life and adverse can be required. Moreover, long-term safety outcomes are lacking. Thus, in 2011, the US Food and Drug effects are not comparable between patients. Thus, Administration placed the use of mesh for POP under after radical prostatectomy, alterations in sexual and urinary functions may be influenced by a variety of scrutiny. factors including race and ethnicity. Some studies have previously reported that African-American men Herein, the authors conducted a population-based were more likely to have better continence results observational cohort study to identify the frequency of compared to their white counterparts. However, little mesh erosions and repeated surgery among patients is known about how ethnicity influences patientexposed to various amounts of mesh. Women reported outcomes after contemporary treatments for undergoing surgical surgery for POP or SUI with mesh localised prostate cancer. in 2008-2012 were identified in the New York State longitudinal database. Four study groups were compared according to the use (or not) of a In the present study, the authors assessed this transvaginal mesh and of a sling. Patients who had potential relationship into a prospective, populationprevious POP repair or SUI procedures were excluded based, observational study (CEASAR study) involving as well as women undergoing abdominal or 3708 patients newly diagnosed with a localised prostate cancer in 2011-2012 and undergoing radical laparoscopic repair. A minimal one-year follow-up prostatectomy, radiation therapy, or active was required, and the outcome events were defined by (i) repeated surgery, (ii) erosions requiring surveillance. Patient-reported function was captured using the 26-item Expanded Prostate Index Composite inpatient, emergency department, or ambulatory surgery management, and (iii) repeated surgery with (EPIC) questionnaire that evaluated urinary, sexual, bowel, and hormone domains. This assessment was concomitant erosion diagnosis. performed at baseline and at six and 12 months after enrollment. Racial/ethnic differences’ impact on Statistical analyses were based on Kaplan-Meier outcomes was evaluated by longitudinal models with method and competing risk analysis in a large adjustment for the several baseline factors that might population of 41,604 women (mean age 56.2 years). influence endpoints. Women undergoing POP surgery were older than those treated only by sling for SUI. During one-year 2.7% and 1.9% of patients in the mesh + Globally, the conclusion of this study follow-up, sling group and in the mesh group, respectively, could be that the effect of treatment experienced erosions requiring management with 1.6% of women in the sling group. does not vary significantly by race/ compared Kaplan-Meier time-to-event analysis also confirmed that the highest risk of erosions occurred in case of ethnicity vaginal mesh plus sling combination. Overall, 79% of enrolled men were white, 14% were African-American, and 8% were Hispanic. AfricanAmerican men were more likely to be diagnosed with high-risk disease and to undergo open surgery rather than robotic surgery. Differences in baseline functions were also reported as lower scores for sexual function were noted in African-American and Hispanic men. At one year after enrollment, the decline of adjusted mean score for urinary incontinence was greater for African-American than for white men (-8.4 points, p=0.01). Nevertheless, baseline function and primary treatment were the most important factor for predicting the decline in urinary function. Patients undergoing surgery, whatever the race, were more likely to have lower scores than those receiving radiation therapy or surveillance. Regarding sexual, bowel, and hormone function, no difference by race/ ethnicity was supported by statistical analyses. Sensitivity analysis taking into account only men receiving IMRT or undergoing a nerve-sparing procedure confirmed the results.

dose-response correlation between the amount of mesh used and the risk of subsequent erosions and repeated surgery. Moreover, previous studies have also suggested that repeated surgery after POP repair was much higher after mesh-based surgery compared with POP repair without mesh. Thus, mesh repair has to be considered with caution, particularly in young women, and patients should be informed of the risk of erosions and repeated surgery, and also that this risk increases with augmenting the amount of synthetic graft.

Source: Association between the amount of vaginal mesh used with mesh erosions and repeated surgery after repairing pelvic organ prolapse and stress urinary incontinence. Chughtal B et al. JAMA Surgery, 2016; doi:10.1001/jamasurg.2016.4200.

Auriculotherapy for LUTS in older men Lower urinary tract symptoms, which commonly occur among older men, include urinary retention, voiding difficulty, frequent feeling of urinary urgency, and nocturia. Auriculotherapy, a Chinese medicine approach, is a therapeutic method in which specific points in the auricle are stimulated to achieve specific therapeutic purposes. This randomised controlled pilot study aimed to determine whether magnetoauriculotherapy alone or in combination with laser auriculotherapy is more effective than placebo for symptom relief and enhancement of quality of life. Men aged at least 60 years with an International Prostate Symptom Score (IPSS) of 12 or greater (moderate to severe) were recruited from a residential home in Zhengzhou province, China. The investigators recruited 40 men and randomly allocated them to three groups decided by computer-generated randomised table: Group 1, combined auriculotherapy (laser auriculotherapy followed by magnetoauriculotherapy on six auricular points, N=14); Group 2, magneto-auriculotherapy only (placebo laser auriculotherapy followed by magneto-auriculotherapy, N=13); and control (placebo laser auriculotherapy followed by placebo magneto-auriculotherapy, N=13). To achieve the effect of evaluator blinding, another researcher who did not know the type of treatment modality received by the participants evaluated the treatment effect. Treatment was done on one ear at a time. The experimental objects were replaced every second day. Participants were assessed at baseline and after completion of the four-week treatment course. Outcome measures included IPSS; Quality of life due to urinary symptoms (0=delighted to 6=terrible); maximum urinary flow rate (Qmax); post-void residual urine test; and Pittsburgh sleep quality index.

The mean age of participants was 74,9 years [SD 6,30], with a mean duration of lower urinary tract symptoms of 4,89 years [SD 5,08]. In Group 1, improvements were seen from baseline in lower urinary tract symptoms (mean 20,50 [SD 7,44] vs. 13,08 [8,28], p = 0,028), quality of life (4,64 [0,50] vs. 3,17 [1,53], p = 0,016), post-void residual urine Same differences were reported when assessing the risk of repeated surgery with or without concomitant (190,43 [117,20] vs. 106,75 [79,72] mL, p = 0,019) and diagnosis of erosion. This risk of repeated surgery was sleep quality (7,86 [4,58] vs. 2,92 [2,58], p = 0,009). For patients in Group 2, significant improvement was increased by two-fold in the mesh + sling group noted from baseline in lower urinary tract symptoms (5.6%) compared with the sling only group (2.5%). (20,54 [7,86] vs. 13,92 [6,76], p = 0,007), quality of life Subgroups analysis after stratification by age confirmed these results in all age groups. Interestingly, (4,38 [1,19] vs. 3,46 [1,33], p = 0,01), and sleep quality the highest risks of erosions and repeated surgery (mean 8,46 [2,93] vs. 5,08 [2,96]). Although patients in the control group also reported improvement in were observed in the patients younger than 65 years. lower urinary tract symptoms (26,08 [8,14] vs. 19,00 This study is the first to assess the erosion occurrence [8,29], p = 0,003) and sleep quality (mean 7,38 [4,79] according to the mesh exposure. The conclusions are vs. 4,75 [4,09], p = 0,008), no significant differences that highest mesh erosion and repeated surgery risks were found for quality of life (4,54 [0,66] vs. 4,42 are found in women receiving a high amount of mesh [0,79], p = 0,739) or post-void residual urine (157,08 (transvaginal mesh plus sling). The lowest risk is [90,98] vs. 158,33 [124,08] mL, p = 0,583). There were reported in women receiving a sling only for isolated no effects on Qmax in any group. No adverse events SUI. These findings supported evidence that there is a were reported.

…mesh repair has to be considered with caution, particularly in young women…

EAU EU-ACME Office

European Urology Today

January/February 2017

The authors concluded that Magneto-auriculotherapy alone or in combination with laser auriculotherapy can improve LUTS, quality of life, and sleep quality in men aged 60 years or older with lower urinary tract symptoms. Future studies with a larger sample size should be done to investigate a causal relationship between treatment and effect.

replacement in patients with impaired cognition, such as people with Alzheimer's disease.

The trial is registered at ClinicalTrials.gov, number NCT02330107.

The TEAAM trial is registered with ClinicalTrials.gov, number NCT00287586.

Source: Auriculotherapy for lower urinary tract symptoms in older men: A 4-week, randomised controlled pilot study. Suen L, Hon W, Yeung KW, Yeh CH, Wong HF.

Source: Effects of long-term testosterone administration on cognition in older men with low or low-to-normal testosterone concentrations: a prespecified secondary analysis of data from the randomised, doubleblind, placebo-controlled TEAAM trial. Huang G, Wharton W, Bhasin S, Harman SM, Pencina KM, Tsitouras P, Li Z, Hally KA, Asthana S, Storer TW, Basaria S.

Lancet 2016 Oct;388 1:S66. doi: 10.1016/S01406736(16)31993-6.

Effects of long-term testosterone administration on cognition in older men The effects of testosterone on cognitive function in older men are incompletely understood. The investigators aimed to establish the effects of long-term testosterone administration on multiple domains of cognitive function in older men with low or low-to-normal testosterone concentrations. The authors randomised, double-blind, placebocontrolled, parallel-group TEAAM trial at three medical centres in Boston, Phoenix, and Los Angeles, USA. Men aged 60 years and older with low or low-to-normal testosterone concentrations (3·47-13·9 nmol/L, or free testosterone < 173 pmol/L) were randomly assigned (1:1), via computer-generated randomisation, to receive either 7·5 g of 1% testosterone gel or placebo gel daily for three years. Randomisation was stratified by age (60-75 years vs. > 75 years) and study site. The testosterone dose was adjusted to achieve concentrations of 17·3-31·2 nmol/L. Participants and all study personnel were masked to treatment allocation. Multiple domains of cognitive function were assessed as pre-specified secondary outcomes by use of standardised tests at baseline and months six, 18, and 36. The investigators did analyses by intention to treat (in men who had baseline assessments of cognitive function) and per protocol (restricted to participants who completed the study drug and had both baseline and 36-month assessments of cognitive function).

…testosterone administration for 36 months in older men with low or low-to-normal testosterone concentrations did not improve cognitive function Between 2004, and 2009, 308 participants were randomly assigned to receive either testosterone (n = 156) or placebo (n = 152). 280 men had baseline cognitive assessments (n = 140 per group). Mean follow-up time was 29·0 months (SD 11·5) in the testosterone group and 31·1 months (9·5) in the placebo group. The last participant completed the study on May 11, 2012. In the testosterone group, mean concentrations of serum total testosterone increased from 10·6 nmol/L (SD 2·2) to 19·7 nmol/L (9·2). In the placebo group, mean concentrations of serum total testosterone were 10·7 nmol/L (SD 2·3) at baseline and 11·1 nmol/L (3·2) post-intervention.

factors with significant higher prevalence of pT3, N+ and positive surgical margins. On multivariate analysis extravesical disease, nodal involvement and Funding: AbbVie Pharmaceuticals, Aurora Foundation, presence of any complication were associated to an Boston Claude D Pepper Older Americans early recurrence (OR: 3.73, 2.14, 2.87, respectively); Independence Center, and Boston University's Clinical also these outcomes are in line to those found in the and Translational Science Institute. ERUS study and those reported in literature for ORC.

Lancet Diabetes Endocrinol. 2016 ;4(8):657-65. doi: 10.1016/S2213-8587(16)30102-4. Epub 2016 Jul 1.

Dilemma of unusual sites and early recurrences after radical cystectomy for MIBC: Results from large cohort studies on robotic assisted radical cystectomy In one of the latest EUT issues, we reported about a multicentre cohort study from the EAU Section in Uro-Technology (ESUT) which raised concerns about unusual sites of recurrence/progression (n = 27; 8.7%) of ≤ pT2 bladder cancer after laparoscopic radical cystectomy, as recorded within 24 months from procedures. Among the theories proposed to explain the events, pneumoperitoneum, tumour spillage and pulsatile insufflation were identified as possible factors related to the technique. Even more recently, two large multicentre cohort studies of robotic-assisted radical cystectomy (RARC) have analysed early oncologic outcomes in an attempt to better investigate this phenomenon. The EAU Robotic Urology Section (ERUS) has collected prospectively data from 717 patients at nine European institutions with at least one year of follow-up (1). Early recurrence (defined as ≤ 2 years) was observed in 4.1% of the cases within three months post-op, 19.8% at 12 months and 25.4% at two years, which the authors found comparable to outcomes from open radical cystectomy (ORC) series reported in literature; at multivariate analysis, these events were strongly correlated to stage and lymph nodes involvement (HR 3.8 ≤ pT2 vs > pT2, p < 0.0001; HR > 3.6 N0 vs. N+, p < 0.0001, respectively). Unusual sites of recurrence/progression were observed only in seven cases with five peritoneal carcinosis and two metastasis at port (wound) sites: notably, four out of the five of the patients with peritoneal carcinosis presented with multiple metastasis and the tumours were locally advanced at the specimen. Also on this regard, authors did not find any difference of unusual site of recurrence compared to ORC series.

…different pneumoperitoneum pressures were not found to be associated to recurrences

No differences in changes were recorded betweengroup in visuospatial ability (mean difference: Complex Figure Test -0·51, 95% CI -2·0 to 1·0), phonemic or category verbal fluency (phonemic fluency test 0·90, -1·3 to 3·1; categorical fluency test 1·1, -0·3 to 2·6), verbal memory (paragraph recall test 0·29, -1·2 to 1·8), manual dexterity (Grooved Pegboard Test 4·2, -1·3 to 9·7), and attention or executive function (Stroop Interference Test -2·6, -7·4 to 2·3) after adjustment for age, education, and baseline cognitive function. In both the intention-to-treat and per-protocol (n = 86 per group) populations, changes in cognitive function scores were not related significantly to changes in total or free testosterone, or oestradiol concentrations.

The International Robotic Cystectomy Consortium (IRCC) is a worldwide network of 29 institutions sharing data of 2460 cystectomy patients; they recently identified 1,380 patients with bladder cancer treated with RARC since 2003, with complete data for the study purposes (2).

The authors concluded that testosterone administration for 36 months in older men with low or low-to-normal testosterone concentrations did not improve cognitive function. Future long-term trials are needed to investigate the efficacy of testosterone

Incidence of early recurrence was 5% (n = 71) which was comparable to the 4.1% observed in the ERUS study. With respect to patients experiencing recurrence > 3months or no recurrence at all, patients with early recurrence had worse prognostic

Also in this case, authors investigated results of early oncologic results: conversely to former study from ERUS, they defined any early relapse if it happened within 90 days from intervention. This cut-off was chosen by the authors as deemed more likely reflecting the eventual relationship of events with surgical technique rather than stage of disease, in their view.

Peritoneal carcinomatosis and port-site metastasis were observed in 1% (n = 17) and 0.4% (n = 5) of the cases, but the authors did not specified at what time in follow-up they occurred. Finally, different pneumoperitoneum pressures were not found to be associated to recurrences. Overall, these findings may suggest that RARC does not increase incidence of early recurrences or unusual sites of them. Sources: 1) Early recurrence patterns following totally intracorporeal robot-assisted radical cystectomy: Results from the EAU Robotic Urology Section (ERUS) Scientific Working Group. Collins JW, Hosseini A, Adding C, et al. Eur Urol. 2016 Nov 2. pii: S0302-2838(16)30744-8. doi: 10.1016/j.eururo.2016.10.030. [Epub ahead of print]

2) Early oncologic failure after Robot-assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium. Hussein AA, Saar M, May PR, et al. J Urol. 2016 Dec 16. pii: S0022-5347(16)31985-1. doi: 10.1016/j.juro.2016.12.048. [Epub ahead of print]

Efficacy of Desmopressin for men with persistent nocturia on α-blocker monotherapy for LUTS The authors investigated the efficacy and safety of desmopressin add-on therapy for men with persistent nocturia on α-blocker for lower urinary tract symptoms in this placebo controlled study. The study included men 40 to 65 years old with lower urinary tract symptoms and persistent nocturia despite α-blocker therapy for at least eight weeks. Patients were randomised to once daily placebo or desmopressin 0.2 mg for eight weeks. The primary end point was to assess changes in the mean number of nocturia episodes from baseline to the final assessment. Other secondary end points and adverse events were evaluated.

…desmopressin add-on therapy in men 40 to 65 years old with persistent nocturia on α-blocker monotherapy for lower urinary tract symptoms is effective and welltolerated A total of 86 patients were randomised to treatment, including placebo in 39 and desmopressin 0.2 mg in 47. Baseline characteristics were similar in the 2 groups. The desmopressin add-on group was significantly superior to placebo in terms of the change from baseline in the mean number of nocturia episodes (-1.13 ± 0.92 vs -0.68 ± 0.79, p = 0.034), the changes in nocturnal urine volume (p <0.001), total I-PSS (International Prostate Symptom Score) (p = 0.041), the nocturnal polyuria index (p = 0.001) and ICIQ-N (International Consultation on Incontinence Questionnaire-Nocturia) (p = 0.001), and the willingness to continue (p = 0.025). The incidence of adverse events in the desmopressin add-on group was similar to that in the placebo group. Most adverse events were mild. The investigators concluded that desmopressin add-on therapy in men 40 to 65 years old with persistent nocturia on α-blocker monotherapy for lower urinary tract symptoms is effective and well-tolerated.

Source: Efficacy and safety of desmopressin add-on therapy for men with persistent nocturia on α-blocker monotherapy for lower urinary tract symptoms: a randomized, double-blind, placebo controlled study. Kim JC, Cho KJ, Lee JG, Seo JT, Kim DY, Oh SJ, Lee KS, Choo MS, Lee JZ. J Urol. 2016 Sep 10. pii: S0022-5347(16)31228-9. doi: 10.1016/j.juro.2016.08.116.

Stone-free rate after active treatment of renal stones: New insights from a systematic review based on non-contrasted computer tomography outcomes Several systematic reviews (SR) have been published in recent years to provide higher level of evidence for the outcomes achieved by performing active treatment of renal stones with Shock Wave Lithotripsy (SWL), Retrograde Intrarenal Surgery (RIRS) and Percutaneous Lithotripsy (PCNL) in different settings of patients. The main problem undermining the results of these SR is the large heterogeneity of the studies, especially in terms of type of research performed and the way the outcomes are reported. The most regarded parameter to assess efficacy of the treatments is the stone-free rate (SFR) which can vary considerably according to definition of SFR (< 2mm, < 4mm, < 5mm, etc.) and the imaging used to evaluate it: on this latter regard, it is well-known that non-contrasted computer tomography (NCCT) is the gold standard as other tests like plain X-ray can underestimate presence of significant residual fragments in almost 50% of the cases. A recent SR and meta-analysis has been performed in order to assess efficacy of SWL, RIRS and PCNL considering only reports which included NCCT as the imaging tool used in the follow-up. As somehow expected, SFRs for SWL and RIRS were lower than otherwise reported in literature ranging 35%-61.3% and 34.8%-59.7%, respectively; on the other hand, SFR for PCNL were more in line with literature (20.8%-100%). Interestingly, authors were able to determine efficacy of treatments by considering another parameter defined as stoneclearance rate (SCR) when the residual fragments were < 4mm: accordingly, SCR for SWL and RIRS increased to 43.2%-92.9% and 48%-96.7%, respectively, whilst for PCNL did not differ significantly (43.2%-92.9%). However, it is important to note that mean stone size differed significantly across the subgroups of treatment analysed, ranging 5-25 mm for SWL patients and 5-50 mm for RIRS ones; for PCNL patients a precise estimation of stone size could not be reported as most of patients harboured staghorn and size was measured in mm2. Other outcomes reported included the need of ancillary/secondary treatments in 16%-67.7%, 3.7%-35% and 0%-30.18% for SWL, RIRS and PCNL, respectively; post-operative complications varied by 7.6%-23%, 10.9%-21.3% and 6.4%-22.1% for SWL, RIRS and PCNL, respectively, even though only in one of the studies selected they were stratified according to Clavien classification. Timing of post-operative NCCT also varied significantly across the studies ranging from first day post-op to three months; of course, this is a relevant detail as early imaging may underestimate SFR/SCR because of presence of dust which can mimic significant fragments or because of residual fragments which are expected to pass within a few weeks from the procedure. Interestingly, the authors of the SR proposed one-month NCCT as the ideal timing; however, considering that many practitioners are used to check the SFR at two weeks before eventual JJ stent removal (if inserted prior or during treatment), the one-month time-point may prolong stent-related symptoms to patients who may not necessarily get benefit from a delayed follow-up interval. Regardless the data showed in the current SR, which are not providing more robust evidences already available in literature, the authors should be congratulated for their effort in highlighting the several issues in reporting outcomes of active treatments for renal stones that should be properly addressed.

Source: Uncovering the real outcomes of active renal stone treatment by utilizing non‑contrast computer tomography: a systematic review of the current literature. Theodoros Tokas, Martin Habicher, Daniel Junker, et al. World J Urol DOI 10.1007/s00345-016-1943-y. 2016 Oct 13. [Epub ahead of print]

Key articles

January/February 2017

European Urology Today

EMUC16: New research points to personalize treatment Gene research, pathology updates dominate plenary sessions By Joel Vega

(mostly with kidney tumours).”

Among the highlights in Epstein’s presentation are: Individualized medicine was a distant prospect in • Prostate cancer: Intraductal carcinoma of the previous years, but today’s new developments in prostate that has some features of high-grade genetic research and deeper insights into the pathology prostatic intraepithelial neoplasia; of oncological diseases are pushing the frontiers of • Kidney cancer: Clear cell papillary RCC- initially multi-disciplinary care in urological cancers. described in end-stage kidneys but now “We do not only aim to carefully examine the areas recognized as more commonly seen sporadically where we can bring improvements, but also push the and a distinct entity with different morphology traditional boundaries of multi-disciplinary care. This and genetics; is the motivation and main goal of this annual event • Bladder cancer: In T1 bladder disease, several which, since our first meeting in 2007, has now grown sub-staging strategies have been proposed to to be the biggest, most comprehensive meeting of improve outcome prediction, but none have been experts in urological malignancies,” said EAU Adjunct routinely adopted; and Secretary General for Education Hein Van Poppel (BE) • Testis cancer: Germ Cell Neoplasia In Situ (GCNIS) during the opening session of the 8th European replaces ‘intratubular germ cell neoplasia, Meeting on Urological Cancers (EMUC16) held from unclassified (IGCNU). November 24 to 27 in Milan, Italy. Amin summarized the changes that will appear in the Joining Van Poppel were EMUC co-organisers Thomas 8th edition of the AJCC Cancer Staging Manual. “There Powles (GB) of the European Society for Medical are updated staging systems in several chapters, Oncology (ESMO), Peter Hoskin (GB) of the European updated content in each chapter, updated illustrations SocieTy for Radiotherapy & Oncology (ESTRO), and histologic classifications and updated WHO/IARC Raymond Oyen (BE) of the European Society of histology codes,” he said. Moreover, the AJCC Urogenital Radiology (ESUR), and Rodolfo Montironi Prognostic Groups are redefined for all sites and that (IT) of the EAU Section of Uropathology (ESUP). the AJCC TNM is transitioning to a more individualized approach. Amin’s take-home messages are: With around 1,360 participants from nearly 70 countries in Europe, the Americas, Asia, Middle East • Important additional information on prognostic and other nearby regions, EMUC has reinforced its factors for staging, clinical use, emerging in goal to serve as a platform for onco-urological clinical practice, risk assessment models, for experts to find common ground, share expertise, clinical trials; and consult with their peers and refine their treatment • Summary of prognostic factors collected by strategies within the context of multi-disciplinary registries is outlined in each chapter. perspectives. Both Powles and Hoskin welcomed the occasion to highlight specific issues which pose not only clinical challenges but also present a window of opportunity for cancer specialists to improve treatment approaches. Two pre-EMUC meetings took place on November 24 with the 5th Meeting of the EAU Section of Urological Imaging (ESUI16) [Read Full Report on Page 15] and the 2016 EMUC Symposium on Genitourinary Pathology (ESUP), corollary events that provided a deeper understanding of urological cancers. The European School of Urology (ESU) organised two highly-attended courses which tackled the management of advanced Over 1,300 participants attended EMUC16 and metastatic prostate cancer, and another on the multidisciplinary approach to genito-urinary cancers. Both courses fulfilled EMUC’s aim to provide quality “It is also worth mentioning that Chapter 1 of the continuing medical education. manual on general staging rules is important to be familiar with,” he said, adding that the 8th edition is Updates in pathology effective starting with cases diagnosed from January Organised by ESUP, the Symposium on Genitourinary 1, 2018. The symposium presented a roundtable on Pathology and Molecular Diagnostics presented kidney, prostate and urothelial carcinomas with both updates in genitourinary pathology, particularly new pathologists and urologists providing their views, classifications and genetic findings in prostate, kidney, including how recent developments in pathology can bladder, penile and testis cancers. translate into clinical practice. Presenters were Holger Moch (CH), Borje Ljunberg (SE), Cristina Magi-Galluzzi (USA), Nicolas Mottet (FR), Arndt Hartmann (DE) and Andrea Necchi (IT). Prostate cancer: locally advanced and high-risk diseases Day 1 was dominated by prostate cancer (PCa) issues with three sessions looking into high-risk disease, uro-genital cancer variants and recurrent PCa. Session 1, Plenary Session Chairs (from left): Profs. R. Montironi, H. Van Poppel, R. Oyen, P. Hoskin, T. Powles chaired by Manfred Wirth (DE), Susanne Osanto (NL) and Peter Hoskin Keynote lectures by Jonathan Epstein (USA) and Mahul (GB), tackled locally advanced and high-risk PCa. Amin (USA) reported on the new additions in the WHO Urologist Robert Jeffrey Karnes (USA), medical morphological classifications of genitourinary cancers, oncologist Karim Fizazi (FR), urologist Karim Touijer and a summary of the forthcoming 8th edition of the (USA) and radiation oncologist Gert De Meerleer (BE) TNM staging (American Joint Committee on Cancer or presented on PCa genomic features, adjuvant therapy, AJCC and UICC) of genitourinary (GU) tumours and the multi-modal approach for node positive disease and implications in clinical practice. salvage radiotherapy (RT) for locally recurrent disease. “Between 2004 and 2016 WHO Editions on the classification of Tumours of the Urinary System and Male Genital Organs, there have been many changes in nomenclature, new entities, and understanding of previously described tumours,” said Epstein as he noted that molecular information on GU tumours is “rapidly expanding.” For the 2016 edition Epstein said “there are only a few specific examples of incorporating molecular tests into clinical practice 12

European Urology Today

future changes indicate a more personalized approach. “We hope to see prognostic signatures to better identify ‘aggressive’ disease and risk-stratify such as in the Decipher study,” he said. Fizazi looked into adjuvant systemic approaches following curative treatment, and said patients with high-risk disease should have a local treatment. He posed the query: “The EMUC Best Poster Award winners worse the prognosis, the higher the benefit from docetaxel?” to which he answered in the affirmative. histologic variant of metastatic CRPC is the According to Fizazi, chemotherapy provides benefit in Intermediate Atypical Prostate Carcinoma (IAC). “IAC high-risk localized PCa. “Docetaxel improves is an aggressive cancer and when combined with recurrence-free survival (RFS) such as shown in the t-SCNC (treatment associated-small cell GETUG 12, RTOG 0521 and STAMPEDE trials,” he said. neuroendocrine carcinoma) accounts for 42% of all But docetaxel’s effect on overall survival is still samples. IAC and t-SNCC do not appear to be unknown, although new insights can be learned in AR-silent and offer an opportunity for co-targeting the next few years. strategies,” said Evans. Touijer examined the best multi-modal approach for node-positive disease and mentioned there is no clear consensus regarding management. Node-positive disease is a heterogeneous group and maximizing local control with radiation therapy in combination with ADT improves survival. “Multimodality therapy with radiation and ADT after surgery is of greatest value in patients with the worst pathologic features,” said Touijer. Regarding future prospects, molecular imaging could refocus the debate. “We need better staging and image-guided therapies,” he said. De Meerleer presented current developments in salvage RT for locally recurrent disease, and examined issues such as when and how to deliver the treatment. “Early salvage equals adjuvant radiotherapy,” De Meerleer said as he stressed adjuvant hormonal treatment improves biochemical relapse free survival (bRFS), distant metastases free survival (DMFS), overall survival, cancer-specific survival (CSS). Regarding metastatic prostate cancer, urologist Anders Bjartell (SE) discussed oligo and polymetastatic PCa, which he said “…are more than two distinct entities.” He emphasized the need for “a more sensitive and quantitative imaging stratification tools.” “Location of metastases may be more important than number of lesions with regards prognosis and treatment,” said Bjartell. Clinical oncologist Malcolm Mason (GB) gave an update on using chemotherapy in hormone-sensitive PCa and said current guidelines recommend castration combined with chemotherapy to patients whose first presentation is M1 disease and who are fit enough for chemotherapy. But systemic treatment such as docetaxel is “not a trivial treatment” and chemotherapy-related deaths do occur, warned Mason. “We need greater biological understanding of who benefits,” he said. Uro-genital cancer variants The session on uro-genital cancer variants took up prostate, renal cell and bladder cancer variants with dual views from either a pathologist and a urologist or that of pathology and medical oncology. Montironi discussed PCa variants and said awareness of unusual patterns may be critical in avoiding diagnostic misinterpretation. “Some types may be associated with a different clinical outcome, and some may have a different therapeutic approach,” he pointed out. Christopher Evans (USA) discussed PCa variants within the metastatic setting and said a new

Karnes discussed post-operative radiation therapy timing, the findings regarding genomic classifiers in the Decipher study, and various translational studies that examined adjuvant radiation therapy (aRT) versus salvage RT (sRT). “At present we have hypothesisgenerating genomic studies (2015-2016) on postoperative RT. Modelling studies indicate costeffectiveness, and the next step is the application to EMUC Speaker Gert De Meerleer randomized trials,” said Karnes while noting that

Medical oncologist Gabriel Malouf (FR), meanwhile, examined RCC variants and noted renal cell carcinoma subtypes include conventional (clear cell), non-clear cell) and sarcomatoid de-differentiation. In bladder cancer (BCa), pathologist Antonio Lopez-Beltran (PT) discussed morphological variants and the implications on diagnosis and prognosis. “WHO 2016 mostly refines previous concepts in morphologic variants of invasive urothelial carcinoma with some new entries,” he said. “Recent advances in molecular pathology may be relevant diagnostic tools and/or therapeutic targets in advanced bladder cancer with variant histology.” Finally, Maria De Santis (GB) took up the medical oncology viewpoint and examined how BCa variants can lead to different therapeutic approaches and conflicting clinical outcomes. Among the treatment regimens she mentioned were pre-operative chemotherapy, neoadjuvant chemo and, ultimately, radical cystectomy for high-risk disease. Session 3 focused on recurrent PCa with speakers Steven Joniau (BE), Barbara Jereczek-Fossa (IT), George Thalmann (CH) and Cora Sternberg (IT). “Approximately 15% to 40% of men will go on to have recurrent disease following an attempt at curative therapy for PCa,” said Joniau as he discussed surgical benefits. Although there are novel PET-imaging techniques, these often only show the tip of the iceberg, limiting the definition of oligometastatic disease. “Oligometastatic recurrence is often not curable with surgery as monotherapy. And the desired outcome of metastasis-directed therapy should mainly consist of delaying the natural course of the disease, causing few side effects,” said Joniau. Surgery is increasingly being considered in oligometastatic recurrence “as it is hypothesized that progression to CRPC may be delayed and survival may possibly be improved.” He added: “Surgery alone is often not enough to guarantee cure, therefore multimodal treatment may be the preferred approach.” Jereczek-Fossa discussed the role of ablative radiotherapy, looking into when and how ablative RT can be carried out in clinical practice. “Ablative radiotherapy has a different biology,” said Fossa as she noted the procedure offers excellent local control (> than 90%) with minimal toxicity. Furthermore, in ablative RT there is a two to three-year progression free survival (PFS) of about 50% and more for intraprostatic failure. “However, more investigation is warranted and we need to look how to combine it with systemic therapy,” she said. Thalmann examined focal therapy in treating cancer recurrence and provided a comprehensive overview on various imaging procedures, RT failure, salvage cryoablation, salvage brachytherapy, radiofrequency interstitial ablation (RITA) and nanoparticle thermotherapy, among others. “Defining local recurrence after radiotherapy remains a difficult multi-task objective,” he said, as he underlined that therapeutics aim for cancer control and reducing morbidity. “Multicentre collaboration is also essential,” Thalmann said. January/February 2017

Sternberg discussed image-guided approaches in the era of early chemotherapy, an issue that is replete with challenges. She looked into Prostate-Specific Membrane Antigen (PSMA) in targeting PCa, its various characteristics and how they affect the treatment scenarios for resistant disease.

Thomas Powles lectured on metastatic renal cell carcinoma and asked the audience: “Which agent would you routinely use as first-line therapy? Audience voting showed majority (64%) favored “PSMA PET/CT has high specificity and is valuable in sunitunib, 32% for pazopanib and 4% voted for planning therapy for patients with biochemical cabozantinib. In another query to the audience, recurrence (BCR),” said Sternberg as she noted that around 68% said they would not routinely use novel radio-labelled tracer with PSMA ligand will be sunitinib as adjunct therapy in high-risk RCC, with very useful. She, however, cautioned that PSMA PET is 27% saying they would use some other agents, and not ready to be used to base decisions on 5% would use most of the currently available agents chemotherapy when finding multiple small (nivolumab, cabozantanib, axitinib, etc.). metastases, especially lymph nodes. Powles capped his presentation with the thought that Managing kidney cancer there are some combination therapies which may Session 4 on Day 2 took up challenges in kidney emerged as frontline options in future strategies such cancer with Antonio Lopez-Beltran (PT), Laurence as ipilumumab + nivolumab, bevacizumab + Albiges (FR) and Alex Bex (NL) leading the session atezolizumab, avelumab + axitinib, pembrolizumab + that covered active surveillance, nephron-sparing axitinib, and the combination pembrolizumab + surgery, implications of new pathological findings, lenvatinib. follow-up management and metastatic disease. Best abstract winners Speaker Tobias Klatte (AT) presented the case of a To encourage innovative research, the EMUC selected 73-year-old woman with a 3.5cm in the left kidney but the best abstracts and presentations. G. Sonpavde with no evidence of metastases, a history of coronary (GB) was awarded the Best in Oral Presentation for heart disease (bypass), hypertension, fibromyalgia his research “Circulating tumor (ct)-DNA profiling for and obesity. Laboratory test results were normal with potentially actionable targets in prostate cancer.” a creatinine of 0.86 mg/dl. Klatte said he looked for Sonpavde’s work was selected from the top six contrast enhancement (21 -76 HU), renal tumour abstracts. complexity, perinephric fat, among others. In the Best Unmoderated Posters of Day 1, G. Van In the audience voting, 75% of audience Leenders (NL) won the first prize with his study recommended a renal tumour biopsy while the rest “Prostate cancer outcomes of men with biopsy Gleason voted ‘No.’ Around 48% also recommended partial score 6 and 7 without cribriform or intraductal nephrectomy, 23% active surveillance, 19% radical carcinoma.” S. Feyerabend (DE) received the second nephrectomy while 10% opted for renal tumour prize for the study “Prospective, non-interventional ablation. The audience responded ‘No’ (85%) to the study on the influence of adherence measures on question ‘Would you do an intra operative frozen abiraterone acetate + prednisone/prednisolone therapy section examination?,’ and 46% said they would of patients with metastatic, castration-resistant prostate recommend abdominal CT/MRI in six months. carcinoma (IMPACT).” Third prize winner was A. Alberts (NL) for the study “Multivariable risk-based Speakers Phillip Peirorazio (USA), Van Poppel (BE), patient selection for targeted prostate biopsy in case of Amin (USA), Antonio Alcaraz (ES) and Powles (GB) suspicious Magnetic Resonance Imaging could reduce addressed the issues of active surveillance, partial unnecessary biopsy procedures.” nephrectomy, pathological implications, follow-up management and treatment of metastatic disease. Day 2 winners of the Best Unmoderated Posters were Peirorazio discussed the safety and benefits of active first prize winner C. Fragkoulis (GR) for his study surveillance (AS), patient selection for AS and “Multiple reaction monitoring study for bladder cancer follow-up care and said AS remains underutilized. diagnosis using novel urine biomarkers.” C. Buonerba “Oncologic outcomes from prospective studies and colleagues (IT) won second prize for their study indicate AS is non-inferior to primary intervention on the prognostic classification of patients with with intermediate-term follow-up.” He said advanced penile squamous cell carcinoma (PSCC) cancer-specific and metastases-free survival rates are receiving salvage systemic treatment. A multiexcellent. “AS is a management option for all patients institutional study conducted by radiation oncologists with cT1a (<4cm) renal tumours and a primary option led by Sang Jun Byun (SKR) won the third prize which for elderly patients and for those with tumours less investigated bladder-preserving therapy for stage 2-4 than 2cm,” added Pierorazio. bladder cancer. Van Poppel listed the benefits for partial nephrectomy vis-à-vis radical prostatectomy, and noted that the procedure poses technical challenge and requires surgical expertise. Preserving renal function is a goal and surgeons should not remove “too much healthy parenchyma,” he advised. “We should not resect kidneys if it is safe to do otherwise, and small renal masses (SRMs) will often be amenable for an oncologically and technically safe partial nephrectomy,” said Van Poppel. Larger and more complex RCCs can be subjected to elective nephronsparing surgery. “But this is allowed only if oncologically and technically 100% safe,” he stressed.

16-19 November 2017 Barcelona, Spain

and strategies to achieve good survival, less costs and radiation exposure.

EMUC Hands-on Training Courses. Other courses included the ESU-ERUS HOT Robotic Surgery and the Advanced Virtual Robotic Procedural Training. The ESU/ESUT/ESUI HOT MRI Fusion biopsy Hands-on Training and the ESU/ESUT Hands-on training in Laparoscopy – Virtual Procedural Training were also well–attended. A Uropathology Training Workshop for clinicians took place on Day 2. ESTRO organised a FALCON delineation contouring workshop while the EAU Young Academic Urologists Meeting was held on the closing day.

kinetics as trigger and the emergence of mpMRI use, among others. Giving a summary of what is known regarding staging, Klotz said molecular genetics of Gleason pattern 3 resemble normal cells and that pattern 4 has many molecular hallmarks of cancer. “The metastatic potential of Gleason 3 is zero. But pathologic miss of co-existent higher grade cancer is the major limitation of current diagnostic strategy,” noted Klotz. He said that although true biological grade progression occurs, it is uncommon. He gave a succinct view of what he called as the “new grey zone” in active surveillance, while noting that compared to previous years this grey zone has somewhat “shrunk.” “The new grey zone includes extensive Gleason 6, Gleason 6 in men younger than 50 years, Gleason 7 with less than 10%, Gleason 4 or favourable genetic score,” said Klotz as he mentioned

Active surveillance in PCa Day 3’s concluding session focused on how to improve active surveillance protocols in prostate cancer. Chaired by Chris Bangma (ML) and Francesco Montorsi (IT), lecturers were urologists Peter Carroll (USA), Laurence Klotz (CA) and Caroline Moore (GB), and pathologist Sara Falzarano (USA). “The negative public pressure on PSA early detection may be tempered, but it will not go away,” said Carroll as he pointed out that there is an increasing sense that prostate cancer is “a spectrum of disease influenced by host and tumour environment.” “Active surveillance although increasingly recognised as a relatively safe option will be challenged by focal forms of therapy,” said Carroll. With the entry of sophisticated imaging and advanced molecular techniques, treatment of high-risk disease will be better personalised.

that the “black zone” in AS would be Gleason 6 which is non-extensive disease, non-suspicious MRI and a low PSA density. Klotz recapped his lecture by concluding that Gleason 3 lacks most hallmarks of cancer; the presence of Gleason 4 confers significant increased metastasis risk at 15 years; today’s grey zone includes high-volume Gleason 6 in young patient; and that most Gleason 7 should be treated. In their closing remarks, organisers ESMO, ESTRO and the EAU as represented by Manuela Schmidinger, Peter Hoskin and Hein Van Poppel, respectively, highlighted the need for better collaboration among the disciplines and the challenges in the coming years as technology and medical research evolve and prompt further adjustments in treatment strategies. The next and 9th EMUC will return to Barcelona next year from November 16 to 19.

Abstract submission deadline 1 July 2017

16-19 November 2017, Barcelona, Spain

“AS appears safe in well-selected patients, and race alone should not be a contraindication to AS,” Carroll said. Moreover, younger men have lower progression rates and that selected patients with GS 3-4 disease are candidates for AS.

EMUC Speaker Tom Powles

Amin stressed that staging and grading of renal cancer is important, as well as various factors such as histologic type, coagulative tumour necrosis, TNM staging, tumour size and ISUP/Fuhrman nuclear grade, among others. “Accurate subtyping of renal epithelial tumours is a clinically important exercise,” he said. Alcaraz examined follow-up care in kidney cancer, which he said “is not an easy topic because the science is not of high quality and studies were based on prospective studies.” He underlined the importance of using different imaging frequencies January/February 2017

Falzarano surveyed pathology’s role in prostate cancer and AS, and the expected potentials of genomic tests in PCA. She discussed the changes in the Gleason grading scheme and took note of relevant PCA patterns such as the Intraductal Carcinoma of the Prostate (IDC). “Biomarkers are offering independent prognostic information beyond traditional risk stratification tools to deliver the right care to the right patient at the right time,” said Falzarano. Costbenefits of genomics-driven care must also be weigh against that of traditional approaches. “Changes in pathology practice affect patient risk stratification and active surveillance eligibility,” said Falzarano. Klotz gave a well-applauded presentation on whether AS is justified in 3+4 cancers (prognostic group Grade 2). Among the changes in the AS landscape include the nature of occult high-grade disease, flaws of PSA

9th European Multidisciplinary Meeting on Urological Cancers In conjunction with the • European School of Urology (ESU) • 6th Meeting of the EAU Section on Urological Imaging (ESUI) • European School of Oncology: Personalised approach to prostate cancer management

www.emuc17.org European Urology Today

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January/February 2017

5th ESUI tackles challenges Changing paradigms in prostate cancer diagnosis and treatment Dr. Vincenzo Scattoni Dept. of Urology Ospedale San Raffaele University Vita-Salute Milan (IT) scattoni.vincenzo@ hsr.it

Dr. Joana Neves Division of Surgery and Interventional Science University College London London (GB) j.neves@nhs.net In a rainy and rather cold day in November last year, the 5th meeting of the EAU Section of Urological Imaging (ESUI16) took place in Milan, Italy, a day before the 8th European Multidisciplinary Meeting on Urological Cancers (EMUC). ESUI16 marked the third time the ESUI meeting has been organised in conjunction with EMUC and other activities such as the European School of Urology (ESU) courses, the EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) and the EAU Young Academic Urologists (YAU) Meeting. The meeting’s success was remarkable due to the high audience number and a high level of interaction among the speakers and participants (Figure 1). The main topics has been divided in three main sessions, namely: 1) Imaging with multiparametric MRI (mpMRI) and target biopsies 2) Molecular imaging in urology (Joint session of ESUI and EANM), and 3) Improving imaging for urothelial cancer.

During the afternoon session on changing paradigms in prostate cancer treatment, J. Walz (FR) and the author tackled the hot topic of mpMRI and active surveillance (AS) in cases of a visible lesion. Both speakers concluded that mpMRI and target biopsies have important roles in selecting and following men on AS. Progression on mpMRI may predict the risk of pathological progression and patients with stable imaging have a low rate of progression. Ideally, as imaging and target biopsy technology evolve the number or frequency of biopsies in men on AS may potentially be reduced. Furthermore, mpMRI may allow for expanded AS criteria, permitting more men to participate in AS with higher confidence in accurate monitoring of disease progression (Figures 3-4). G. Thalmann (CH) discussed the pilot research into focal therapy, using technologies derived from image-guided biopsy. Meanwhile, A. Villers (FR) and J. Futterer (NL) discussed the training of urologists and radiologists on how to read a prostate mpMRI and the expertise needed in this area, respectively. Molecular Imaging in Urology: Joint ESUI-EANM Session As done in previous years, ESUI16 held a joint ESUI and European Association of Nuclear Medicine (EANM) session that focused on two main themes: the clinical utility and pitfalls of nuclear medicine imaging in urological oncology, and the use of Prostate specific membrane antigen- positron emission tomography (PSMA PET) in prostate cancer.

Oral presentation of H. Ahmed with moderators M. Ritter, V. Scattoni and ESUI Chairman J. Walz

Role of mpMRI and target biopsy mpMRI combining T2-weighted, diffusion-weighted, and contrast-enhanced dynamic imaging is recognized as the most accurate imaging modality for prostate cancer detection and characterization. As everybody has anticipated, mpMRI of the prostate has become an exploding phenomenon that can no longer be ignored. Even if mpMRI has a strong indication only before a second biopsy (see EAU Guidelines), speakers N. Mottet (FR) and H.U. Ahmed (GB) have both supported the use of mpMRI before the primary biopsy in their point-and-counterpoint discussion in prostate cancer diagnosis. The conclusion was that, despite the costs which are still high, mpMRI will be used more in the future.

In conclusion, molecular imaging has contributed and is envisioned to continue to contribute to advances in urological oncology. PSMA PET’s most consensual use is still as an end-of- line imaging tool in prostate cancer, when clinical queries persist and more definitive answers are needed to change clinical management. New tracers and the combination of PET and MRI can impact the diagnostic setting but efforts to produce more robust and consistent evidence on the benefits of molecular imaging should be sought out.

Refinements in MRI are in the horizon, and radiologists trained to perform and interpret prostate MRI will increase in number. Industry-driven improvements in image-fusion hardware and software are also expected due to the large market potential for improving prostate biopsy. Image fusion devices will also become smaller and easier to use. Co-registration accuracy will increase, and graphical user interfaces will become more intuitive. Already, targeted prostate biopsy has a serious online visibility, and various support groups are making it a priority item. Attempts to image CaP via modalities simpler than MRI (e.g., elastography, contrast-enhanced ultrasound (US), high frequency US, Anna/c-TRUS) have been shown during the meeting by other renowned experts. Following the session Joana Neves (UK) won the ESUI Best Poster Award with her study titled “Combining mpMRI sequences for the diagnosis of prostate cancer – the value of adding diffusion and contrast enhancement to T2W on 3Tesla: Outcomes from the PICTURE Trial” (See Box, Figure 2).

All speakers were unanimous in saying that, to date, the biggest contribution of nuclear medicine to urological oncology has been to aid in lymph node and distant disease staging and that, for prostate cancer, PSMA PET appears to perform better than other nuclear medicine imaging modalities. Despite this, while PSMA PET is able to detect prostate cancer nodal recurrence earlier than other imaging modalities, doubts still exist as to whether any change in clinical management at this point is warranted or beneficial. Alberto Briganti (IT) revealed recent analyses by his group which showed that, when compared to extended bilateral salvage pelvic and retroperitoneal lymph node dissection, PSMA PET scan can underestimate the burden of nodal metastasis and may not be appropriate to guide limited dissection. Lars Budaus (DE) also presented evidence that micrometastatic disease (below the 5mm threshold) can be overlooked by PSMA PET in prostate cancer.

ESUI16

24 November 2016 Milan, Italy

Joana Neves receives the ESUI Best Poster Award from T. Loch and P.A. Geavlete

Tobias Maurer (DE) presented potential uses of PSMA PET, such as targeted radiation therapy, and also disclosed preliminary results on the use of a PSMA intracorporeal gama probe to guide lymph node dissection. Stefano Fanti (IT) (stepping in for F. Giesel [DE]), presented Giesel’s early data suggesting a good diagnostic performance of PSMA PET in early, localised prostate cancer. The use of fluorinated PSMA (18F-PSMA-1007) instead of gallium could be a game changer as this tracer has no urinary excretion, allowing for better assessment of the bladder and eliminating the production of radioactive urine, which can contribute to a more widespread use. In his own lecture, Fanti also mentioned other new tracers in prostate cancer such as the anti-1-amino-3-18Ffluorocyclobutane-1-carboxylic acid or FACBC and the recently FDA-approved 18F-fluciclovine, and the possible uses of molecular imaging to assess clinical response to systemic therapies such as docetaxel. Antoni Vilaseca Cabo (ES), the only speaker to move away from prostate, discussed the clinical usefulness of molecular imaging in bladder cancer. Computerised tomography (CT) is still the gold standard for nodal and distant disease staging in bladder cancer and the use of choline or FDG PET CT do not seem to improve on the diagnostic ability of CT alone. However, in the near future, evidence may show that PET MRI supplants CT. In the more distant future, molecular imaging radiomics may be the key to improve staging in bladder cancer.

Improving imaging for urothelial cancer This session mainly focused on technologies to improve urothelial cancer in the bladder and in the ureter by photodynamic diagnosis (PDD) versus Narrow Band Imaging (NBI) versus Storz professional image enhancer system (SPIES) or Optical coherence tomography (OCT), as nicely shown by B. Geavlete (RO) and M. Bus (NL). Even if they are not really new instruments, these technologies had reached a very high level of visualisation and they are considered all good alternatives. Last but not least, N. Cowan (GB) has shown the importance of the perfect Uro-CT in the detection of urothelial cancer and the need for standardisation. The 5th ESUI Meeting has proven to be a successful meeting with excellent speakers and a responsive audience who actively participated in the discussions. The Scientific Programme covered all the major topics in urological imaging and this achievement is a sound basis for the next meeting in Barcelona, Spain in November this year.

Dr. Jochen Walz, ESUI Chair

Combining mpMRI sequences for the diagnosis of prostate cancer – the value of adding diffusion and contrast enhancement to T2W on 3Tesla: Outcomes from the PICTURE trial The study aimed to assess the value of adding diffusion-weighted (DWI) and contrast enhancement (DCE) sequences to T2-weighted (T2W) images in men who had prior 12-core transrectal biopsies and needed further risk stratification. Clinically significant cancer found on biopsy was defined using two definitions: UCH1 (Gleason≥4+3 and/or maximum cancer core length (MCCL)≥6mm) and UCH2 (Gleason≥3+4 and/or MCCL≥4mm). Analysis of sequential reporting done by an experienced uro-radiologist on 3T mpMRI showed only a trend towards better sensitivity to adding DWI to T2W and no benefit of adding DCE to DWI and T2W images.

p=0.55

p=0.79

Figure 1: AUROC curves for UCH definition 2

Figure 2: AUROC curves for UCH definition 1

In the same session, the presentation of T. Cai (IT) on how to overcome the problem of sepsis prompted a long and interesting discussion, even if the problem of the higher rate of sepsis remains unresolved. Subsequently, A. Postema (NL), G. Salomon (DE) and M. Ritter (DE) presented interesting insights on multiparametric ultrasound, new ultrasound-based technologies and the various weapons or tools when performing a biopsy, respectively. In the replay session (called ‘How I Do It’) of prerecorded videos, various speakers have presented different technologies. The conclusion of the session was that, like any valuable new technology, targeted prostate biopsy is evolving rapidly, and current methods would certainly improve in the near future. EAU Section of Urological Imaging (ESUI)

January/February 2017

Figure 3-4: Fusion biopsy with BK ultrasound system. The green line has been drawn to overlap the profile of the prostate with MRI and TRUS. The red line defines the ROI (Region Of Interest) or the target area to be biopsied.

European Urology Today

A unique opportunity: Experiencing quality masterclasses Young urologists get exceptional chance to join expert masterclasses Dear Colleagues The European School of Urology (ESU), in collaboration with the Sections of the EAU, has organised its forthcoming educational activities that cover the most important topics in urology into educational and practical masterclasses. Why? We believe that this presents the opportunity to share knowledge, concerns, future prospects, drawbacks and critical questions in urology in a comprehensive manner way that will fulfil our goals.

How do we implement this? We will work with good experts from various specialities which will lead to a more dynamic atmosphere and interactions with the ESU faculty. Moreover, the inclusion of live and semi-live surgeries will provide insights, through direct mentorship with the expert surgeon, on what has to be done, how it can be done and what to avoid.

but also EAU members coming from other parts of the world. So stay updated for announcements since there are several masterclasses already scheduled and more will come in the future! The European School of Urology focuses on a closer mentorship between its faculty and participating urologists. Join us and benefit from the rewards!

Where are the potential venues? We have chosen different cities across Europe to facilitate access and good attendance, not only by European urologists

Dr. Joan Palou

Dr. Joan Palou Chairman European School of Urology

Rewards from ESU masterclasses Dr. Vikiela Galica Resident in Urology Campobasso (IT)

to optimise the laser performance and management of principal complications. It was a great opportunity to watch experts such as Dr. Gomez Sancha and Prof. Traxer in the live surgery session and having the chance to interact with them. From this session, it was clear that lasers will become more integrated in the urological armamentarium.

vikelagalica@ yahoo.com

With my productive experience from the Masterclass on Lasers, I felt excited to attend the next in Berlin a few weeks later on Female and Functional Reconstructive Surgery.

About 40 participants attended the courses for a two-day intensive examination of the current EAU Guidelines which led to enthusiastic discussions. My “Masterclass experience” began in Barcelona last 3 to 4 November with the 3rd edition of the ESU Masterclass on Lasers in Urology. Course directors Drs. Breda, Palou and Ass. Prof. Liatsikos, with support from a great faculty, gave an interesting overview on basic concepts and physical principles of all contemporary laser systems. The lectures provided a detailed description on the use of laser technology in urology including the management of prostatic obstruction, bladder and upper tract tumours and stone disease. An excellent presentation by Dr. Traxer, including videos and animations, gave a realistic insight on physical concepts of laser technology and their clinical application in daily practice. It was surprising to learn about “The Snowball model” introduced by Dr. Traxer as a new concept on dusting in stone surgery. Theoretical sessions were combined with live and semi-live surgery sessions on the principal use of lasers in urological practice, showing tips and tricks

Masterclass directors Dr. Heesakkers and Prof. De Ridder provided a course programme that gave an overview of current state-of-the-art in functional and reconstructive surgery. The masterclass was divided in nine modules and each one was carried out by different faculty members who aimed to provide a high-level training in all pelvic-related topics, including constipation and anal incontinence. The masterclass was also remarkable for the case presentations which provided us the best chance to improve our medical decisions with insights from the expert faculty, enabling us to gain an international

Dr. Barret : “A la carte approach”

perspective when managing difficult cases. Young urologists always have something to learn as during the session led by Prof. De Ridder when he described the anatomic components involved in male continence. For each module the multidisciplinary approach gave a full view of the problems physicians faced in Barcelona-Berlin-Paris daily practice and the importance to fit the guidelines in decision-making. With the withdrawal of a selected participant from the 1st ESU Masterclass on Focal therapy for localised prostate cancer in Paris, I had the opportunity to attend the course. Thanks to a wonderful staff all the travel arrangements were coordinated. The new course, which is the first of its kind, was directed by Dr. Eric Barret and took place at “L’Istitut Mutualiste Montsouris” in Paris last December. The comprehensive programme focused on the various aspects for focal therapy in PCa management. The topic coverage was comprehensive such as definition of localised prostate cancer, diagnosis, patient management to energy source selection, among other issues. New techniques in biopsy using MRI fusion software were one of the most challenging sessions in the PCa diagnosis. A radiologist and a radiotherapist also joined the urology faculty and provided the latest updates in how to target the right

area where the cancer is located and its implications in focal treatment. Interesting case presentations of pre-recorded fusion biopsy and focal therapy were shown, raising the quality of discussions among the participants. The second day of the masterclass featured the hands-on training course. Different techniques in focal therapy were provided step-by-step by experts, using ‘phantoms’. 3D prostate biopsies in MRI\US imaging using the latest technology available in the market were also provided. Dr. Barret gave the key message that an “à la carte” approach to the patient should respect the oncological outcomes. For me, the Masterclass experience represents a new high-level training for urologists to improve their knowledge, exchange experience and create new professional links and friendships.

Barcelona Masterclass surpassed expectations Dr. Mohamed Fadi Dalati CHU St Pierre Bruxelles Urology Dept. Brussels (BE)

@Urology_fadi As a urologist in the 21st century, we have the need to learn novel treatments and modalities and the urge to seek better training. Easier said than done in today’s fast-changing medical world and in modern urology where it’s a constant challenge to stay up-to-date and most importantly get the best information from reliable sources. This is why I consider the ESU Masterclasses important due to a careful selection of topics in the programme, and presented by experts, with hands-on training led by pioneers. Moreover, the ESU Masterclasses are known for their insightful discussions and interaction. Simply put, these courses are a gathering of great minds and great potentials in urology. I had the pleasure and the chance to participate in three masterclasses; the BPO, the Lasers and the PCa focal therapy. It was not my plan to attend them all, but after going to the first one, the masterclasses seemed like such a huge opportunity not to be missed. Getting to meet the pioneers in their 16

European Urology Today

respective fields and learn from them, acquire tips and tricks on new approaches in patient care are among the key reasons why I find these Masterclasses very important. The first Masterclass was in Heilbronn, Germany. I was pleasantly surprised how the masterclass covered almost all aspects of Benign Prostatic Obstruction (BPO), ranging from basic diagnosis, therapeutic choices to the gold standard and future prospects. There were live surgeries of various techniques, done by pioneers in the field. It was an enormous training opportunity, where you could ask all the questions you have, listen to a rich discussion and get updated about issues in BPO. The next was a masterclass on lasers in Barcelona. Two of my favourite things in one package; learning more about different lasers in urology and an excuse to go back to one of the most amazing cities in

Europe. Not only did the Barcelona Masterclass meet my expectations, it actually surpassed them! There were enthusiastic discussions on how and when to use the different lasers, various techniques, and the conflicting viewpoints which made the discussions even better.

I recommend these masterclasses to all urologists who are keen to learn from the best experts, and I hope the ESU would expand its masterclasses programme to cover more topics, and maintain its priority to provide one-to-one interaction, which is key to the success of these events.

The cherry on the top was Paris, the city of romance and wine, with a carefully selected and highly debated topic for a masterclass—prostate cancer (PCa) and focal therapy. Since my training didn’t involve a lot of PCa focal treatment this masterclass is just too good to miss. In the last five years, the PCa topic has been subjected to revision and discussion to the extent that we are changing our approach to the disease on an almost daily basis. The Masterclass reflected this diversity and uncertainty with the discussion on innovations and out-of-the-box thinking, and the challenges to what was once considered as written-in-stone recommendations. It was refreshing to hear all different points of view, learn from the vast experience of pioneers, and witness how the simulations work. Masterclasses is a great idea and I am convinced that to gather 20 to 30 urologists with pioneers from a urological specialty and present the novelties that enable direct or one-to-one interaction is the way forward for urological training. The ESU has found an effective formula to provide the best training and one-of-a-kind experience to advance urological training. There is no doubt the EAU is the pioneer in urological education worldwide, and its keen emphasis on continuous training reflects this excellence. January/February 2017

Masterclass Female & Functional Reconstructive Urology Challenges and prospects in functional reconstructive urology Dr. Mariangela Mancini Dept. of Surgical and Oncological Sciences Padova (IT)

mariangela. mancini@unipd.it

Dr. Dimitri Barski Lukaskrankenhaus Neuss Urologische Klinik Neuss (DE)

barskidimitri@ gmail.com

Dr. Michela Pisani Specialty Doctor in Urology Worthing Hospital Western Sussex Hospitals NHS Worthing (UK) michelapisani@ libero.it

Dr. Vikiela Galica L’Aquila University, Hospital “San Salvatore” Aquila (IT)

Overactive bladder (OAB), Pelvic Organ Prolapse POP), Male incontinence, Diversion surgery, and Neurogenic bladder, respectively. The evidence was presented in full accordance with the EAU Guidelines with commentary on how to implement them in everyday practice, and, most interestingly, a critical “real-life” approach to complex and rare cases was presented. As participants we consider it a unique opportunity to present cases from our work experience and discuss different approaches with international colleagues and well-known experts. Following a brief introduction by Dr. Heesakkers, Day 1 started with a comprehensive insight on SUI diagnostics, treatment and complications management by Prof. George Kasyan. Challenging cases were presented, with images and surgical videos of fistulas cases and urinary tract complex reconstructions. Prof. Matzel, a general surgeon, emphasised that urologists should ask patients about intestinal symptoms, anal incontinence and constipation, which are very often linked to urological symptoms, but not revealed by the patients unless they are specifically asked. He presented diagnostic and treatment standards, an extremely valuable opportunity for urologists to learn about the intestinal aspects of complex urological cases. Meanwhile, Prof. Matzel, provided a 360-degree view on bowel conditions and faecal incontinence recalling the importance of an integrated multidisciplinary approach to the pelvis as a tri-compartmental but unique structure (Module 2).

Faculty and participants of the 9th ESU Masterclass on Female and Functional Reconstructive Urology in Berlin last November

There are different kinds of meshes available in Europe. In many countries meshes for vaginal application are no longer available. All the participants agreed that surgical training, careful patient selection and close follow-up are mandatory before mesh surgery. Another aspect is patient characteristics, with potential high-risk after multiple previous surgeries, radiotherapy, additional treatments, anatomical malformations, old age and comorbidities. Better evidence could be expected by projects at the level of the EAU Section of Female and Functional Urology (ESSFU), such as the establishment of a registry with over 1,000 patients in several European centres.

In Module 3, Prof. Burkhard discussed the classification and management of urethral diverticula and urethral fistulae. In the same session, Prof. Kasyan focused on a specific clinical situation represented by radiation fistulae, while Prof. De Ridder illustrated the potential surgical approaches in different clinical scenarios, concentrating on urethral reconstructive surgery.

Prof. Costantini (Module 4) presented a novel and challenging clinical topic when she reviewed female sexual dysfunction, and stressed the value of research and public awareness on this unexplored topic. There was general agreement with the message of Prof. Costantini (IT) that a urogynaecologist should learn The 9th Masterclass on Female and Functional vaginal surgery and investigate sexual abuse in women Reconstructive Urology, organised by the European School of Urology (ESU) on November 17 to 18, 2017 in with BPS or vaginismus. Meanwhile, a thorough assessment of the OAB was shown by Prof. Heesakkers Berlin, attracted 25 urologists from from all over who explained the new Forta (Fit for the aged) Europe and beyond (US and North Korea). As part of the educational platform of the ESU the main goal of classification of drugs, based on evidence, efficacy and the Masterclass was to improve training and support safety. He discussed clinical decision-making in difficult exchange among urologists from Europe and abroad. overactive bladder (OAB) cases, especially in high-risk elderly and neurological patients. At present there are no guidelines for treating elderly fragile patients with multiple comorbidities and multiple medications. Urologists must be careful about side effects of drugs, like cardiovascular effects for Mirabegron and cognitive effects for antimuscarinics. The approaches and application of botulinum A neurotoxin (BoNTX) and sacral nerve stimulation (SNS) are still not standardised in Europe. The first randomised multicentre trial on BoNTX (200 U of onabotulinumtoxin A) vs sacral neuromodulation (SNM) treatment, involving 381 women with recurrent OAB, showed a slightly favourable results for BoNTX, however subgroup analysis and further trials should be awaited (Amundsen, 2016; doi: 10.1001/ jama.2016.14617). vikelagalica@ yahoo.com

The masterclass offers a compact and comprehensive course for experienced urologists

Highly motivated and experienced in treating Pelvic Organ Prolapse (POP) and Stress Urinary Incontinence (SUI) the participants came from the Netherlands, Italy, Malta, South-Korea, Belgium, USA, Great Britain, Ireland, Germany, France, Russia, Egypt and Lithuania. With course directors Dr. John Heesakkers (NL) and Prof. Dirk De Ridder (BE) and faculty members Professors Fiona Burkhard (CH) and Elisabetta Costantini (IT), three new experts presented their topics, namely Professors George Kasyan (RU) and Klaus Matzel (DE) and Mr. Nikesh Thiruchelvam (UK). The masterclass was organised in nine modules such as Stress incontinence, Faecal incontinence, Female reconstructive urology, Female sexual dysfunction, January/February 2017

all the faculty members and audience. The highlighted key messages were extensively discussed from conservative strategies to the artificial sphincter and complication management. Prof. Fiona Burkhard gave a useful overview on diversion surgery and management of complications and made us fully aware of the challenges ahead and how to best resolve potential issues of the diversion urinary surgery for functional reasons in daily practice. At the end, difficult cases of neurogenic bladder were presented by Prof. Heesakkers and Nikesh Thiruchelvam, with videos and a discussion of challenging cases contributed by the participants, which led to a dynamic and enthusiastic interaction between participants and faculty members. There are always different issues to consider in neurogenic bladder dysfunction. Prof. Heesakkers and Dr. Thiruchelvam clearly summarised the prognostic factors and criteria that indicate conservative management versus surgical managements and vice versa. The main aim of treatment is to protect the upper tract, and then treat the symptoms. The important lesson is that urologists should be cautious in the treatment and follow-up of neurogenic patients.

In his closing remarks, Prof. Heesakkers pointed out the growing need for well-trained functional On the other hand, the evidence on male SUI is very urologists, and the demand for high-level training in scarce. Only small prospective trials are available. functional and reconstructive urology. As many Prof. Heesakkers recently published a review on European countries don`t offer specialised National intraoperative surgical factors contributing to Fellowship Programmes in this field, the EAU aims to incontinence after surgery, which shows that the level establish the standards on research and clinical of evidence of most trials is low (Heesakkers, 2016; practice in functional and reconstructive urology. In 10.1016/j.eururo.2016.09.031). Despite the lack of this regard, the ESU Masterclass can be seen as an rigorous comparative studies among different devices important step in the right direction, since it offers a for male post-operative incontinence, the sub-urethral compact and comprehensive course for experienced slings seem to offer a good alternative to the artificial urologists interested in fine-tuning their skills. sphincter, with patient selection as a critical element. In each module the multidisciplinary approach gave The afternoon sessions by Professors Kasyan and De a full view of the problems physicians face in daily Ridder and Dr. Heesakkers (Module 7) and Prof. practice and the importance of complying with the Burkhard and Mr. Thiruchelvam (Module 8) mainly guidelines in decision-making. As participants, we focused on male incontinence and management experienced a unique opportunity to boost our (conservative, male slings, artificial sphincter knowledge, explore new topics, extend our insertion and management of complications) and on “comfort-zone” in treating complex cases, and share the decision-making process when offering surgical our experiences and questions with world renowned diversion in patients not responding to conservative experts and international colleagues in an informal treatment. The surgical aspects of the most popular and cordial setting, with the beautiful city of Berlin techniques were described with tips and tricks from as venue.

The compact programme of the first day ended and faculty and participants all joined for a nice dinner. What better occasion of getting to know each other in a friendly atmosphere with delicious food and good wine? Difficult cases and complications management Day 2 started with a comprehensive overview on female anatomy and female physical examination by Prof. Costantini (Module 6), followed by a lecture on male anatomy by Prof. De Ridder. Rigorous knowledge of anatomy is one of the most important requirements for successful treatment of functional reconstructive cases. The question “mesh or not mesh?“ for female POP is still under debate at the clinical and public level, and was analysed in detail by Prof. De Ridder including the needs of modern reconstructive surgery, the rules, legislations, FDA safety warnings, approvals and manufacturing requirements. Prof. De Ridder: "Urogenital diaphragm - does it exist?

European Urology Today

www.baltic17.org

www.esusalzburg17.org

BALTIC17

ESU - Weill Cornell Masterclass in General urology

4th Baltic Meeting in conjunction with the EAU 26-27 May 2017, Vilnius, Lithuania An application has been made to the EACCME速 for CME accreditation of this event

9-15 July 2017, Salzburg, Austria An application has been made to the EACCME速 for CME accreditation of this event

Call for Abstracts Deadline: 1 April 2017

Education Online

www.esuurolithiasis17.org

Improve your skills: e-learning at your own convenience

1st ESU-ESUT Masterclass on Urolithiasis

New EAU Education Online course:

16-17 June 2017, Patras, Greece An application has been made to the EACCME速 for CME accreditation of this event

Metastatic Prostate Cancer Get a complete view on clinical aspects, diagnosis and treatments of Metastatic

4 CME c

redits

Prostate Cancer (mPCa)

The development of this course has been supported by JANSSEN and IPSEN with a concession of an educational grant

An application has been made to the EACCME速 for CME accreditation of E-Learning Material (ELM)

uroweb.org/education 18

European Urology Today

January/February 2017

ESU in Rhodos, Greece Positive feedback for PCa management course Assoc. Prof. Athanasios Papatsoris Member, EBU Board Member, YAU Working Group Endourology & Urolithiasis Athens (GR) agpapatsoris@ yahoo.gr

In the second part, Van Der Poel discussed the use of biomarkers in prostate cancer. Meanwhile, Prof. Rocco lectured on how to handle complications in laparoscopic/robotic prostate surgery. Both topics raised questions from the audience, especially managing complications in laparoscopic prostate surgery.

Lastly, an interactive case discussion took place moderated by the two ESU speakers and Prof. Liatsikos and the author. Two very interesting and complicated cases where presented by Drs. Kalogeropoulos and Ploumidis, regarding the diagnosis of localised prostate cancer, the selection of treatment modality, the early diagnosis of severe complications with laparoscopic and robot assisted surgical approach and the definite patient

management and follow-up. Both cases raised many questions among the presenters, panel members and the audience. More than 200 Greek colleagues participated in the ESU course and were handed the slides of the lectures upon entrance. The participants gave positive feedback regarding the scientific quality of the presentations and the interaction.

Another successful European School of Urology (ESU) course took place on 22 November 2016 in Rhodes, Greece, during the biannual Panhelenic Urological Congress. The ESU course on “Localised prostate cancer” was chaired by Prof. Henk Van Der Poel (NL) who discussed the ESU’s role in urological education. In the first part of the course, Van der Poel lectured on the EAU guidelines on localised prostate cancer while Prof. B. Rocco (IT) discussed robot-assisted radical prostatectomy. Discussion followed regarding the question if robotic radical prostatectomy is the new gold standard.

Thu, 23 February, 2017, from 6:30 to 7:30 PM CET Registration: www.uroweb.org/webinar

ESU Course in Vilnius Lithuanian urologists examine male chronic pelvic pain topics Dr. Marius Kincius National Cancer Institute Dept. of Urology Vilnius (LT)

marius_kincius@ yahoo.com

Prof. Dr. Mindaugas Jievaltas President, Lithuanian Association of Urologists Head, Urology Dept. Lithuanian University of Health Sciences Kaunas (LT) jievaltas@outlook.com The European School of Urology (ESU) organised a course on Male chronic pelvic pain at the annual meeting of the Lithuanian Society of Urology and elicited enthusiastic response for its comprehensive programme from both participants and meeting delegates. Knowledge of the topic is essential to the daily practice of the urologist since male chronic pain represents one of the most common complaints in adult men. Meeting participants included the registered congress attendees and Lithuanian residents in urology.

January/February 2017

The high quality, well-structured thematic discussions included lectures by Prof. M. Grabe and Dr. D.S. Engeler whose presentations examined the topic clearly and concisely. The first half of the course overview examined causes, classification and the current EAU guidelines recommendations on male chronic pelvic pain. M. Grabe discussed chronic pelvic pain pathophysiology in detail and clearly explained proposed aetiological pathways. He highlighted that chronic pelvic pain is not necessarily related to prostatic pathology. Dr. Engeler, who chaired the EAU chronic pelvic pain guidelines panel, added that the approach to this problem, especially in difficult cases, should be discussed in the multidisciplinary team, which could consist of a urologist, colorectal surgeon, gastroenterologist, pelvic floor physiotherapist, psychologist, sexologist and pain specialist. The second half of the course described the evaluation approach and current treatment options for patients with chronic pelvic pain. Lecturers emphasised the importance of defining the main symptoms profile of each patient. Prof. Grabe distinguished symptom classification according to UPOINT (U- urinary disturbances, P – psycho-social factors, O – organ specific, I – infection of the urogenital tract, N – neurological/systemic, T - tenderness). Further, Dr. Engeler covered the chronic pelvic pain syndrome treatment options. He underlined that treatment selections should depend on the spectrum of complaints and patients should be offered different possibilities.

The course ended with remarkable clinical case presentations given by local urologists Dr. R. Mickevicius and Dr. T. Simaska which led to an exciting discussion between the panel and the audience.

We are grateful to the ESU for organising this quality course which improved our knowledge and helped us offer quality management to our patients.

www.esubpo17.org

2nd ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction 19-20 May 2017, Heilbronn, Germany An application has been made to the EACCME® for CME accreditation of this event

European Urology Today

Teaching activities 2017 European School of Urology March 24-28

July ESU Courses, Hands-on Training courses, Innovation in Education at the time of the 32nd Annual EAU Congress, London (GB)

April 8

ESU course on New treatments and techniques in Uro-oncology at the national congress of the Macedonian Association of Urology, Skopje (MK) ESU course on Management of BPO: From medical to surgical treatment at the national congress of the Moroccan Urological Association, Skhirat (MA) ESU course on Management of bladder cancer at the national congress of the Cyprus Urological Association, Limassol (CY)

27 29

19-20

2nd ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction, Heilbronn (DE) ESU course on Flexible URS (RIRS: retrograde intra-renal surgery) at the 4th Baltic Meeting in conjunction with the EAU, Vilnius (LT)

8 16 16 16-17 20 30

1-6 25

ESU course at the national congress of the Slovak Urological Society, Trencianské Teplice (SK) ESU course at the national congress of the Romanian Association of Urology, Bucharest (RO) ESU course on Urolithiasis at the national congress of the Ukrainian Urological Association, Kiev (UA) 1st ESU-ESUT Masterclass on Urolithiasis, Patras (GR) ESU course on Urethral reconstruction at the national congress of the Polish Urological Association, Katowice (PL) ESU course on Prostate diseases at the national congress of the Kyrgyzstan urology and andrology Association, Cholpon Ata (KG)

15th European Urology Residents Education Programme (EUREP), Prague (CZ) ESU-ERUS courses at the 15th Meeting of the EAU Robotic Urology Section (ERUS), Bruges (BE)

October 12-13

ESU Masterclass at the European Lower Urinary Tract Symptoms meeting (ELUTS17), Berlin (DE) 4th Confederación Americana de Urologia Residents Education Programme (CAUREP), Santa Cruz (BO)

November 6 16-19

June

ESU – Weill Cornell Masterclass in General urology, Salzburg (AT)

September

May 27

9-15

23-24

ESU course on The current role of laparoscopy in urology at the national congress of the Scientific Society of Urologists of Uzbekistan, Tashkent (UZ) ESU courses at the 9th European Multidisciplinary Meeting in Urological Cancers (EMUC), Barcelona (ES) 4th ESU-ESUT Masterclass on Lasers in urology, Barcelona (ES)

December 7-8 8

2nd ESU-ESUT Masterclass on Focal therapy for localised prostate cancer, Paris (FR) ESU course on Bladder cancer and endoscopic stone management: 2017 update, at the national congress of the Algerian Association of Urology, Algiers (DZ)

Contact: esu@uroweb.org

Preliminary ESU programme in London ESU Courses

Adrenals • Advanced course on upper tract laparoscopy (UPJ, adrenal and stones) • Adrenalectomy Andrology • Office management of male sexual dysfunction • The infertile couple - Urological aspects Female Urology • Prolapse management and female pelvic floor problems • Advanced vaginal reconstruction Infections • Dealing with the challenge of infection in urology Kidney transplantation • Renal transplantation: Technical aspects, diagnosis and management of early and late urological complications Male LUTS • Management of BPO: From medical to surgical treatment • Post-surgical urinary incontinence in males Neurogenic and non-neurogenic voiding dysfunction • Chronic pelvic pain in men and women • General neuro-urology • Lower urinary tract dysfunction and urodynamics • Video and imaging urodynamics

European Urology Today

#EAU17

ESU Hands-on Training Courses

Paediatric urology • Paediatric urology for the adult urologist 1 and 2

Trauma • Urinary tract and genital trauma

Penis/testis • Testicular cancer • Penile diseases

Unclassified and miscellaneous topics • How to write an introduction and material and methods • How to write results and discussion • What has changed in the non-oncology guidelines • Advanced social media course: Take it to the next level • Evaluation of risk in comorbidity in onco-urology • How to proceed with a haematuria • Surgical anatomy • Ultrasound in urology • Laparoscopy for beginners • Update renal, bladder and prostate cancer guidelines 2017. What is changed? • Basic surgical and endo urological skills

Prostate cancer • Robot-assisted laparoscopic prostatectomy • Retropubic radical prostatectomy – Tips, tricks and pitfalls • Focal treatment in prostate cancer • Surgery or radiotherapy for localised and locally advanced prostate cancer • Prostate cancer imaging: When and how to use it • Screening and active surveillance – where are we now • Prostate biopsy - tips and tricks • Metastatic prostate cancer • Oligometastatic prostate cancer Renal tumours • Robot renal surgery • Small renal masses: From concepts to tips and tricks in daily management • Advanced course on laparoscopic nephrectomy • Surgery for renal cancer beyond minimally invasive approaches : Opportunities and limits Stones • Percutaneous nephrolithotripsy (PCNL) • Update on stone disease • Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips and tricks, indications

Urethral strictures • Advanced course on urethral stricture surgery Urothelial tumours • Practical management of non-muscle invasive bladder cancer (NMIBC) • UTUC: Diagnosis and management • Laparoscopic and robot-assisted laparoscopic radical cystectomy • Management and outcome in invasive and locally advanced bladder cancer • Nerve-sparing cystectomy and orthotopic bladder substitution - Surgical tricks and management of complications • How will immunotherapy change the multidisciplinary management of urothelial bladder cancer

www.eau17.org

Robotic surgery • ESU/ERUS HOT in Robotic surgery intro course • ESU/ERUS HOT in Robotic surgery advanced virtual robotic procedural training Laparoscopy • ESU/ESUT HOT in Basic laparoscopic skills (E-BLUS training) • E-BLUS exam Diagnostics and follow-up • ESU/ESFFU HOT in Urodynamics • ESU/ESUT/ESUI HOT in MRI fusion biopsy Functional urology • ESU/ESFFU HOT in OnabotulinumtoxinA administration for OAB • ESU/ESFFU HOT in Sacral neuromodulation procedure standardisation Endoscopy • ESU/ESUT HOT in Transurethral therapy of LUTS - bipolar TURP • ESU/ESUT HOT with Thulium laser for vaporesection of prostate • ESU/ESUT/EULIS HOT in Ureterorenoscopy

January/February 2017

EUREP17 15th European Urology Residents Education Programme 1-6 September 2017, Prague, Czech Republic

www.eurep17.org Unique and exclusive training opportunity General information Participation and contribution This teaching programme has been developed and created exclusively for all European urological residents. The EUREP provides an almost complete update and overview of modern urological practice presented by a distinguished European faculty. The EUREP is an initiative of the European School of Urology in collaboration with the European Board of Urology. The written part of the FEBU exam (Fellow of the European Board of Urology) will take place at a later date in different cities throughout Europe. Further information will be available on www.ebu.org. Format The format is a full six-day course comprising five modules. Each day is made up of two sessions that last around seven hours. Morning sessions feature state-of-the-art lectures, while afternoon sessions offer interactive case discussions, video, and test-your-knowledge sessions. The hands-on-training sessions will take place around the modules. The training which is sponsored by Olympus helps the participants sharpen their skills and offers hands-on interaction with state-of-the-art equipment. Venue of the EUREP Meeting The EUREP will be organised in Prague, Czech Republic. The venue at the Clarion Congress Hotel provides excellent facilities and the four-star hotel has all the necessary facilities needed for both the scientific programme and social activities. Travel Arrival date: Thursday, 31 August 2017 Departure date: Wednesday, 6 September 2017 after the modules end.

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

Preliminary programme 2017

Registration information

Module 1 Urological cancer

Important dates Online registration opens on 9 January 2017. The selection process will be made after the close of registration on 1 May 2017. A total of 360 participants will be selected. Participants will be notified by email if they have been selected. If selected, the deadline for cancellation is 1 August 2017. After this time a cancellation fee of €500 will be charged.

Testis & Penile cancer Treatment of localised and metastatic testicular cancer Treatment of localised and metastatic penile cancer Non-muscle invasive bladder cancer Diagnosis, staging and risk stratification Management of low, intermediate and high risk disease Upper urinary tract cancer

Selection criteria Registrations can only be submitted through the online registration system. The registration will only be considered complete if the registration is accompanied by: • A letter from the head of department indicating the date that the participants training will end • A copy of your passport

Muscle invasive bladder cancer Surgical and non-surgical treatment options Neoadjuvant and adjuvant chemotherapy

As an essential part of the European Urology Residents Education Programme (EUREP) in Prague, intensive hands-on training will be delivered. This year's programme consists of hands-on interaction with state-of-the-art equipment in laparoscopy, ureteroscopy (URS) and transurethral resection (TUR) -all of which sponsored by Olympus. The workshop provides the participants with a unique opportunity to train basic techniques with complex training models and under expert supervision. Thanks to the intense tutoring scheme -with a personal tutor per training station- a fast learning effect can be expected. The courses in laparoscopy are specifically designed for individuals with minimal or no prior experience in laparoscopic suturing. Tutors will, of course, gladly adapt tasks for more experienced individuals. Basic techniques will be trained in a dedicated step-by-step programme including Scientific secretariat ESU Office January/February 2017

F. Liedberg (SE)

S. Shariat (AT)

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

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

Additional criteria 1. EAU membership. Priority is given to those who are or become a member before the registration deadline 2. Year of training. Priority is given to residents in their final year of training (i.e. training should be finished before September of the following year based on the information received from the proof of status) 3. It is required to obtain CME credits by completing European Urology multiple choice questions (MCQ’s). For further information please check www.eurep17.org 4. First come – first served 5. English skills 6. Target per country 7. It is only allowed to attend the EUREP course once

M. Graefen (DE), A. Briganti (IT) Chair

A. De La Taille (FR) S. Joniau (BE)

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

Module 3 Andrology, stones and upper tract endourology Andrology Physiopathology diagnosis and treatment of erectile dysfunction Penile curvature Priapism and metabolic syndrome Male infertility diagnosis and treatment Surgery for male infertility and vasectomy Male hypogonadism

For further detailed information regarding the registration rules for the 15th EUREP course we strongly recommend that you visit www.eurep17.org

Stones Aetiology, management and prophylaxis of urolithiasis ESWL treatment of urolithiasis Percutaneous and open surgery

Registration non-European residents If you are a non-European resident that is interested in taking part in the 15th EUREP course please go to www.eurep17.org for the rules and regulations regarding participation.

E. Liatsikos (GR), Chair

S.S. Minhas (GB) I. Moncada (ES)

C.M. Scoffone (IT)

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

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

Hands-on-training workshops Sharpening Your Skills: TUR, URS, and Laparoscopy

M. Roupret (FR), M. Hora (CZ) Chair

intracorporeal suturing depending on individual skill level. The training curriculum for the ureteroscopy workshop is designed by Prof. Olivier Traxer of Tenon Hospital, Paris. Residents will learn about the proper use of flexible ureteroscopes using a variety of stone disposables in order to remove kidney stones. The course in transurethral resection of the prostate gives residents the great opportunity to learn more about the basics of high-frequency surgery, the instruments needed, as well as tips and tricks for daily surgery.

J. Khastgir (GB), Chair

J. Heesakkers (NL) G. Kasyan (RU)

K.D. Sievert (AT)

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

C. Radmayr (AT), H. Abol-Enein (EG) Y.F. Rawashdeh (DK) F. Wagenlehner (DE) Chair

Trauma Diagnosis and management of kidney, bladder and urethral trauma

Participants can only participate in 1 session Lap plus a TUR or URS. Places for URS and TUR are limited. More information about the different training modules can be found at www.eurep17.org The hands-on-training workshops are sponsored by an unrestricted educational grant from:

T +31 (0)26 389 0680 F +31 (0)26 389 0674

“If you meet the criteria we would encourage you to register for this opportunity, “ Prof. Palou, course director

eurep@uroweb.org European Urology Today

The development of British Urology EAU Congress comes to the city of key surgical pioneers Mr. Jonathan Goddard University Hospitals of Leicester NHS Trust Curator of the Museum of Urology, BAUS Leicester (GB) jonathan.goddard@ uhl-tr.nhs.uk

Mr. Peter Thompson EAU History Office King’s College London (GB)

St. Peter’s drew together and nurtured several generations of famous British urologists. Its first surgeon Sir Thomas Spencer Wells is not well remembered as a urologist but his work to popularise laparotomy led to the establishment of renal surgery. William Coulson was surgeon to St. Peters for twenty-five years and steered it through its early troubled life. Edwin Hurry Fenwick pioneered and popularised British cystoscopy, also being an early advocate of radiology. St. Peter’s actively sought out the best urological surgeons. Reginald Harrison was brought down from Liverpool for his expertise in stricture disease and Peter Freyer was appointed because of his skill in blind litholapaxy.

The coming together of British Urologists Historically, there was a great resistance in Great Britain to surgical specialisation. Urology in particular was late to specialise. Surgeons preferred to train and practise in a wide range of areas remaining general surgeons even though some clearly had a particular interest and skill in genitourinary disease. The reasons behind this are many but include the association with urology and venereal disease and the potential loss of private income from specialising. From the 18th century, British surgeons gave their services to the great hospitals voluntarily, their income came from private practice. Nevertheless, those surgeons with an interest in urology were keen to meet and share their ideas, cases and problems.

In the early 20th century, Hurry Fenwick proposed a section of the London-based Royal Society of Medicine be dedicated to Urology. The Royal Society of Medicine (RSM) was formed in 1907, merging the A selection of William Cheselden’s instruments Medico-Chirurgical Society of London with other pmturology@aol.com smaller specialist societies, with different specialities holding regular meetings. The First World War put a As EAU17 will be coming to London, the History Office Cheselden returned to London and began anatomical temporary hold on Freyer’s plan but in 1920 the of the EAU will be presenting a Special Session studies to determine the exact technique of this new Urology Section of the Royal Society of Medicine was dedicated to the history of urology in Great Britain. lateral lithotomy. William Cheselden was one of the Sir Peter Freyer formed with Sir Peter Freyer as its first President. most gifted anatomists and surgeons of the time. He Peter Freyer, later Sir Peter made his name at St. Peter’s This was the first British Urological society and British Urologists and experts in medical history will experimented with the perineal dissection on for his success with open prostatectomy. Although he brought together surgeons, physicians and tell the story of how urology developed from an cadavers and mastered the technique that made him pathologists with an interest in urological disease called it “my operation for total enucleation of the unregulated practice to a surgical science in the probably the best lithotomist of his age. With a prostate” it was Arthur McGill of Leeds who first and continues to this day. Eighteenth Century, through the advances of Victorian mortality rate of 6% in his first 100 patients, his performed this in Britain (possibly the World). Freyer England and the struggle of the speciality’s fastest time from knife to skin to stone extraction was however, had performed 1,674 procedures by 1920 and In 1944, the concept of the British National Health acceptance to the formation of national urological 54 seconds. popularised it throughout the world. Service was being discussed and Ronald Ogier societies which continue to lead and educate the Ward, a well-known urologist and Brigadier in the specialty today. At about the same time James Douglas, a Scottish Freyer’s position at St. Peter’s was taken over by his Royal Army Medical Corps was asked to set up a former assistant Sir John Thomson Walker. Walker surgeon and anatomist, was conducting anatomical national association to represent urology. A group of Stonecutters to surgeons experiments on the different surgical approaches to also made his name for open prostatectomy revising surgeons with an interest in urology met in his old boss’s technique to make it safer. Although, From ancient times specialist surgeons were called the bladder. His brother John, also a surgeon, used December 1944 at the London house of Sir Eric upon to carry out perineal lithotomy to remove this information to show that suprapubic lithotomy even though his complications were fewer, his Riches and planned the British Association of bladder stones. Hence, urology is known as the oldest was possible and a viable alternative to the perineal mortality rate was similar to Freyer’s. However, less Urological Surgeons (BAUS). The first meeting of surgical specialty. But these stonecutters were procedure. Both Cheselden and the Douglas brothers gifted surgeons struggled with his method and stuck BAUS was 1 March 1945 and Ogier Ward was the separated from surgeons who had undertaken an published their findings thus finally applying science to the Freyer technique. A more straight forward way first President. apprenticeship and then been admitted to a guild or to the dark art of the stonecutter and bringing urology of removing the benign prostate was to come later college. They were often looked down upon, and towards acceptance in Britain. with Terrence Millin. The St. Peter’s Hospital Group and its academic away from large towns and cities were felt to be at wing the Institute of Urology, the Urology Section of best just itinerant travelling practitioners, and at Sir Henry Thompson the RSM and BAUS brought together British "Historically, there was a great worst dangerous quacks. Henry Thompson was born in 1820 in Suffolk, the son Urologists throughout the Twentieth Century but it of a tallow chandler. He died in 1904 a knight and a was as late as 1996 that John Blandy wrote “the resistance in Great Britain to renowned surgeon famous for his skills in urology The technique of perineal lithotomy remained battle to establish urology as a separate specialty in surgical specialisation. Urology in unchanged from ancient times until Marianus described even before the specialty developed. A typical the British Isles has been won”. Victorian gentleman, his lifespan closely mirrored the particular was late to specialise." a modified more complex technique in the sixteenth century. In the eighteenth century a different technique years of Victoria’s reign (1837-1901). emerged in Italy, and was popularised in France by Frère Jacques de Beaulieu. Frère Jacques unfortunately Thompson seems to have taken an early interest in Terrence Millin typified the unqualified travelling stonecutter. urological conditions. Interestingly, he heard of and St. Peter’s was not the only urology hospital in possibly saw the new instruments of Civiale’s lithotrity London, as All Saints’ Hospital was established by In the Eighteenth Century William Cheselden, an as a boy. Later he was winner of two Jacksonian Edwin Canny Ryall in 1911. Canny Ryall was a great English surgeon and member of the London-based prizes from the Royal College of Surgeons of England advocate of endoscopic surgery, revolting against the College of Barber Surgeons travelled to Holland to for essays on stricture and the prostate and in 1862 open surgery of St. Peter’s. Canny Ryall’s assistant observe this new technique with Jacobus Rau. Rau gave the Lettsomian lectures on the subject of and pupil in this was Terrence Millin. Ryall and Millin had learned it from Frère Jacques but was reluctant to “Practical Lithotomy and Lithotrity”. carried out the first TURPs in Britain at All Saints’ and share the surgical details. Millin took over the hospital on Ryall’s untimely death Thompson was particularly adept at passing in 1934. Millin became the new advocate of TURP, designing his own resectoscope. instruments urethrally and championed per-urethral lithotrity against open stone surgery. In 1847 However, during the Second World War diathermy Thompson travelled to France to be elected as a equipment became difficult to source, the electrical member of the Societé de Chirurgie and at that time components being requisitioned by the War Office for was taught the technique of lithotrity by Civiale himself. His public fame stemmed from his successful use in Radar. Millin began to look into other techniques and in 1946 presented his method of open lithotrity of the bladder stone of Leopold, King of the retropubic enucleation of the prostate. This technique Belgians in 1863. Thompson was called in for his was easier for non-urologists without endoscopic opinion after both Civiale and Langenbeck had failed skills to perform and it became quickly very popular. to rid the king of his stone. Within two years he was able to report 1,700 operations by 16 surgeons with a mortality of 5.3%. Ronald Ogier Ward, the first BAUS President Thompson was later called upon to treat the bladder stone of Napoleon III of France. He passed his lithotrite on 2nd January 1873 and again on the 6th. Unfortunately the Emperor died on the 9th of chronic obstructive uropathy and urosepsis. Despite this unsuccessful operation Thompson’s reputation remained intact. The History Office has two new publications on • Saturday, 25 March, 8:30-11:30, Room 9, offer in London. EAU Members can pick up their Capital Suite (Level 3) Special Session of the Thompson was the first well-known British surgeon annual copy of De Historia, already on its 24th History Office whose practice was almost entirely urological and volume, at the EAU Booth. EAU17 also marks the along with Cheselden vies for the title of the first launch of the book Urology Under the Swastika, the • Sunday, 26 March, 12:15-13:45, Room 7, Capital British Urologist. culmination of a multiyear research effort under Suite (Level 3) Poster Session 38: History of Prof. Schultheiss. The project will also be Urology St. Peters Hospital for the Stone discussed at the Special Session of the History In 1860, the first hospital in Britain to specialise in a Office on Saturday. The Historical Exhibition • Publication of De Historia Urologiae Europaeae urological condition, the treatment of bladder stone, features historical instruments, some of which Vol. 24 and Urology Under the Swastika. was opened. St. Peter’s Hospital however was heavily discussed in this article. criticised by the London medical establishment who A “spy” cartoon of Henry Thompson from Vanity Fair in 1874 • Historical Exhibition at the EAU Booth: British argued that specialist hospitals were not needed and Pioneers of European Urology that the great London teaching hospitals should look after all patients. Nevertheless, St. Peter’s survived to EAU History office become a well-respected urological centre.

The History Office at EAU17

European Urology Today

January/February 2017

Parkinson’s disease and Lower Urinary Tract Symptoms Parkinson’s disease has a significant effect on patient’s quality of life Dr. Sarah Itam Fellow in Functional Urology Institute of Urology, University College London Hospitals (GB) sitam@nhs.net

Dr. Rizwan Hamid Consultant Urological Surgeon Institute of Urology, University College London Hospitals (GB) rizwan.hamid@ rnoh.nhs.uk

in men or pelvic examination in women to exclude a prolapse is important. The clinical examination also serves to exclude any red flag features that require urgent referral and investigation. A urinalysis will highlight any haematuria or glycosuria which could point to a diagnosis of malignancy or diabetes respectively; and review of a bladder diary will indicate the functional bladder capacity, the frequency of voids, the voided volume, nocturia, as well as any incontinence episodes. Uroflowmetry and post-void residual management are non-invasive tests which are useful to identify flow rate and a raised post-micturition volume. There are no validated LUTS questionnaires in PD; however the IPSS may serve as a good starting point in males, although pertinent to the PD it lacks an incontinence domain9. The investigations are summarised in Table 1. Clinical history of storage and voiding symptoms Red flag features

Parkinson’s disease (PD) is a progressive neurological disorder which is estimated to affect 100–180 per 100,000 of the population1. It becomes more debilitating with advanced disease, though mild stages of the disease may not always be apparent. PD is characterised by gradual dopaminergic neuronal loss in selected areas in the brain; this results in various clinical symptoms and signs that are a consequence of biochemical and pathophysiological changes. Since the definition of PD in essence is a post-mortem finding, the diagnosis remains a challenge to neurologists. They must rely on clinical symptoms and signs, as there is no premorbid test to identify those with the condition. Motor symptoms such as bradykinesia, resting tremor, rigidity as well as extrapyramidal signs are characteristic of PD. Whilst movement related manifestations of PD can have a profound impact upon quality of life, non-motor disorders including neuropsychiatric problems, sleep disturbance and autonomic dysfunction are probably equally bothersome. Lower urinary tract symptoms (LUTS) are common sequelae of this autonomic disruption and the overall impact on the patient cannot be overemphasised. Prevalence of LUTS in PD Primarily PD involves the loss of dopaminergic neurones within the substantia nigra pars compacta (SNC); however, it may also involve other locations in the brain and additional neurotransmitters than dopamine. Subsequently, replacing dopamine alone with therapies such as L-dopa or Apomorphine do not always improve LUTs2.

Urinalysis Bladder diary QoL questionnaires (not validated specifically for PD) Uroflowmetry Urodynamics Table 1: Investigating LUTS in a PD patient Videourodynamic (VCMG) assessment of patients is an invasive yet informative test and is strongly recommended before any surgery is planned. In the storage phase neurogenic detrusor overactivity (NDO) is demonstrated (Figure 1) in up to 81% of patients10,11. There may also be reduced bladder capacity, volume at first desire and cystometric capacity; these are often related to disease severity, although not exclusively11,12. During the voiding phase patients may have hypocontractility and post-void micturition volume may be correlated to disease severity12. VCMG is sometimes helpful to distinguish between PD and multiple system atrophy (MSA). In the latter condition detrusor sphincter dyssynergia occurs in almost 50% of cases, compared to PD where it is found in less than 5% of patients8,12. It is possible for both NDO and bladder outflow obstruction to coexist in PD and may be as high as 18%13. Crucially, it is important to distinguish the diagnosis of MSA from PD as the former have a distinctively different and probably worse prognosis and require specific management strategies.

The aetiology of LUTs in PD is not fully understood. The commonly accepted hypothesis is that the loss of neurones within the SNC interrupts the normal inhibitory influence on the micturition reflex resulting in detrusor overactivity3. The prevalence of LUTS is reported to range from 27-85%. In PD storage LUTs predominate with the majority of patients presenting with nocturia, frequency, urgency and urgency incontinence4,5. Nocturia is most prevalent but whether it is caused by the disrupted sleep that is commonly a feature of PD or a direct consequence of the disease, is yet to be determined6,7. Patients may also report voiding LUTS, although it is thought to affect patients to a lesser degree4,8. Notably, there seems to be no clear link whether the duration of the disease or the stage impacts upon the severity of LUTS experienced6. Admittedly, the limitation with many studies evaluating the prevalence of LUTS in PD is the lack of validated questionnaires for this specific population. Diagnosis of LUTS in PD It is mandatory to take a careful history with salient features of their presentation including any pre-existing LUTS. Elucidating any significant past medical history, as well as comorbidities, may highlight any precipitating factors. It is equally important to identify any drugs that could be exacerbating LUTS. An examination of the abdomen, external genitalia, and assessment of prostate size EAU Section of Female and Functional Urology

January/February 2017

Pharmacological therapies Anti-muscarinics are the mainstay of medical therapy for the treatment of storage LUTS, but this can be controversial as many with patients with PD already have constipation and cognitive impairment, known side effects of the antimuscarinics. Although these are widely prescribed, few studies have evaluated these in PD patients. A small study of 23 patients has shown a decrease in urinary incontinence but no significant improvement in number of micturition episodes over 24 hours. Nonetheless, the suggested algorithm by Winge and Fowler is underpinned by the use of antimuscarinics and teaching of self catheterisation where necessary, which can itself be problematic in a population who already may have dexterity problems15. To overcome the problem associated with cognitive decline, clinicians may use antimuscarinics such as Trospium chloride that do not cross the blood brain barrier. More recently, M3 muscarinic receptor-specific antagonists such as solifenacin and darifenacin have been suggested. The cognitive impairment in PD is a particular issue. Additionally, over the years there is increasing concern of potential dementia with long-term anticholinergic usage. Whilst there are no specific studies with selective β3 adrenoceptor agonists, it is postulated that this may be a better drug choice and cognitive decline has not been reported16. Hence, the results from the pilot study to evaluate the efficacy of Mirabegron in PD are eagerly awaited (ClinicalTrials. gov – identifier NCT02092181). Desmopressin has been used to control nocturia in general population for sometime. The most significant side effect is hyponatremia. There are some small studies demonstrating significant reduction in nocturnal voids with increased sleep and improvement in QoL in PD patients but can lead to hyponatremia. It is not licenced for use in nocturia by NICE guidelines in UK. A number of dopaminergic medications have been evaluated in PD patients. It has been suggested that effects of these medication on LUTS are variable and quite often the urinary symptoms initially worsen before improving. Minimally invasive therapies Intravesical botulinum toxin A has been successfully utilised in a number of neuropathic conditions to control neurogenic detrusor overactivity. Several studies have demonstrated the efficacy of botulinum toxin in the management of refractory NDO in PD patients. It led to a decrease in number of incontinence episodes and improved QoL. There was increase in post-void residue and patients need to be made aware of this potentially significant complication. However, the progressive decline in motor function with worsening of PD can make self-catheterisation, should it be required, difficult. An emerging field is the use of posterior tibial nerve stimulation; this has been shown to improve storage symptoms but results in PD are lacking17. Transcutaneous tibial nerve stimulation has been evaluated in PD patients demonstrating reduced urgency and nocturia. Similarly, sacral neuromodulation has been shown to be efficacious in neuropathic patients but has not been specifically evaluated in PD patients17.

Figure 1: Urodynamic trace of neurogenic detrusor overactivity in Parkinson’s patient

Management of storage LUTS in PD The management of storage LUTS in PD begins with conservative measures first and is not too dissimilar to the non-neurogenic patients presenting with LUTS. Conservative strategies Behavioural modification strategies including bladder re-training, fluid management avoiding precipitants, pelvic floor exercises and patient education may be all that is required to improved symptoms. It is important to analyse the completed bladder diary as this may help customise strategies in managing patients. Small-scale studies have shown a trend to improvement of symptoms with bladder re-training, but high-quality studies are lacking specific to PD14.

Management of voiding LUTS in PD The patients who present with voiding LUTS may be treated with apha blockers and/or 5 alpha reductase inhibitors. Should their symptoms be refractory to treatment, then a VCMG should confirm bladder outflow obstruction before surgery is recommended. It is, however, important that patients are carefully counselled as the risk of urinary incontinence following surgery in PD may be higher than in the non-neurogenic population. Bladder outflow obstruction surgery is a relative contraindication in MSA as it carries a de novo incontinence rate as high as 100%18 and, therefore, medical therapy is the ceiling of treatment. It is therefore imperative that the urologist distinguishes these two conditions, especially in the context of MSA where LUTS tends to pre-exist the motor manifestation4. In the carefully selected patients with PD, 70% had successful TURP with minimal incidence of incontinence and many having an improvement in both their storage and voiding LUTS19.

Conclusions • PD has a significant effect on quality of life • Long-term sequelae is one of progressive decline and disability • There is a high incidence of storage LUTS in patients with PD • Urodynamic studies are helpful in diagnosing the presence and type of bladder dysfunction • Conservative management should be the first-line treatment • One might cautiously use medications to improve LUTS • Where indicated, surgery may be appropriate References 1. Yeo L, Singh R, Gundeti M, Barua JM, Masood J. Urinary tract dysfunction in Parkinson’s disease: a review. International urology and nephrology. 2012;44(2):415-24. 2. Sakakibara R, Kishi M, Ogawa E, Tateno F, Uchiyama T, Yamamoto T, et al. Bladder, Bowel, and Sexual Dysfunction in Parkinson's Disease. Parkinson's Disease. 2011;2011:924605. 3. Blackett H, Walker R, Wood B. Urinary dysfunction in Parkinson's disease: A review. Parkinsonism & related disorders.15(2):81-7. 4. Kapoor S, Bourdoumis A, Mambu L, Barua J. Effective management of lower urinary tract dysfunction in idiopathic Parkinson's disease. International journal of urology : official journal of the Japanese Urological Association. 2013;20(1):79-84. Epub 2013/01/04. 5. Ransmayr GN, Holliger S, Schletterer K, Heidler H, Deibl M, Poewe W, et al. Lower urinary tract symptoms in dementia with Lewy bodies, Parkinson disease, and Alzheimer disease. Neurology. 2008;70(4):299-303. Epub 2008/01/23. 6. Campos-Sousa RN, Quagliato E, Silva BBd, Carvalho Jr. RMd, Ribeiro SC, Carvalho DFMd. Urinary symptoms in Parkinson's disease: prevalence and associated factors. Arquivos de neuro-psiquiatria. 2003;61:359-63. 7. Winge K, Skau A-M, Stimpel H, Nielsen KK, Werdelin L. Prevalence of bladder dysfunction in Parkinsons disease. Neurourology and urodynamics. 2006;25(2):116-22. 8. Sakakibara R, Shinotoh H, Uchiyama T, Sakuma M, Kashiwado M, Yoshiyama M, et al. Questionnaire-based assessment of pelvic organ dysfunction in Parkinson's disease. Autonomic Neuroscience: Basic and Clinical.92(1):76-85. 9. Araki I, Kuno S. Assessment of voiding dysfunction in Parkinson's disease by the international prostate symptom score. Journal of Neurology, Neurosurgery & Psychiatry. 2000;68(4):429-33. 10. Campos-Sousa RN, Quagliato EMAB, Almeida KJ, Castro IADd, Campelo V. Urinary dysfunction with detrusor hyperactivity in women with Parkinson's disease cannot be blamed as a factor of worsening motor performance. Arquivos de neuro-psiquiatria. 2013;71:591-5. 11. Stocchi F, Carbone A, Inghilleri M, Monge A, Ruggieri S, Berardelli A, et al. Urodynamic and neurophysiological evaluation in Parkinson's disease and multiple system atrophy. Journal of neurology, neurosurgery, and psychiatry. 1997;62(5):507-11. Epub 1997/05/01. 12. Araki I, Kitahara M, Oida T, Kuno S. Voiding dysfunction and Parkinson's disease: urodynamic abnormalities and urinary symptoms. The Journal of urology. 2000;164(5):1640-3. Epub 2000/10/12. 13. Yamamoto T, Sakakibara R, Uchiyama T, Liu Z, Ito T, Awa Y, et al. Neurological diseases that cause detrusor hyperactivity with impaired contractile function. Neurourology and urodynamics. 2006;25(4):356-60. Epub 2006/03/15. 14. Vaughan CP, Juncos JL, Burgio KL, Goode PS, Wolf RA, Johnson TM, 2nd. Behavioral therapy to treat urinary incontinence in Parkinson disease. Neurology. 2011;76(19):1631-4. Epub 2011/05/11. 15. Winge K, Fowler CJ. Bladder dysfunction in Parkinsonism: mechanisms, prevalence, symptoms, and management. Movement disorders : official journal of the Movement Disorder Society. 2006;21(6):737-45. Epub 2006/03/30. 16. Sakakibara R, Tateno F, Nagao T, Yamamoto T, Uchiyama T, Yamanishi T, et al. Bladder function of patients with Parkinson's disease. International Journal of Urology. 2014;21(7):638-46. 17. Sanford MT, Suskind AM. Neuromodulation in neurogenic bladder. Translational Andrology and Urology. 2016;5(1):117-26. 18. Chandiramani VA, Palace J, Fowler CJ. How to recognize patients with parkinsonism who should not have urological surgery. British journal of urology. 1997;80(1):100-4. Epub 1997/07/01. 19. Roth B, Studer UE, Fowler CJ, Kessler TM. Benign prostatic obstruction and parkinson's disease--should transurethral resection of the prostate be avoided? The Journal of urology. 2009;181(5):2209-13. Epub 2009/03/20.

European Urology Today

EAU White Paper: More funding and PCa awareness needed EAU’s PCa recommendations to EU policymakers By Joel Vega More funding for research that leads to better diagnosis and treatment, and implementing effective public awareness programmes are among the key elements to keep prostate cancer high in the healthcare agenda, according to the recently launched EAU White Paper on prostate cancer. “We need the help of the European Union (EU) to make people aware of prostate cancer and its risks. As one of the cancers with significant mortality rates in Europe, there is a need to focus on specific awareness programmes,” said EAU Adjunct Secretary General for Education Prof. Hein Van Poppel (BE). “Moreover, there is a lot to be done in research that directly leads to improved diagnosis and treatment.”

The EAU White Paper was presented in Brussels on January 24 during the seventh Prostate Cancer Europe Roundtable organised by the International Centre for Parliamentary Studies (ICPS), a UK-based group which promotes effective policy making and good governance. Hosted by roundtable chair and former MEP John Bowis OBE, the meeting gathered patient advocates, medical, research and healthcare professionals to discuss proposals, strategies and issues affecting the diagnosis and treatment of prostate cancer patients. “Prostate cancer awareness still requires more effort from all concerned to keep it high on the agenda. What we aim is to closely look into patients’ needs and the views of various experts, and from there present a set of recommendations to government and members of the parliament,” said Bowis. Bowis was joined in the roundtable discussion by Marilys Corbex of the World Health Organisation (WHO) Regional Health Office for Europe, Prof. Hein Van Poppel and Jan-Willem Van de Loo representing the European Commission. Around 35 participants attended the day-long meeting which covered topics such as challenges in treatment and research, breakthroughs and new technologies, and public awareness programmes, among others. In the 22-page White Paper, the main issues in prostate cancer care were examined including risk factors, prevention, diagnosis, treatment, survivorship plans, the role of the EAU, and current EU activities in cancer control. And although there is limited, conflicting or low-level evidence to directly link PCa to obesity, poor diet and lack of exercise, the White Paper still recommends the importance of early detection.

The EAU White Paper and corporate brochure (foreground) during the launch in Brussels

Equitable healthcare access and actively promoting cancer awareness are among the proposals that topped the EAU recommendations. During the roundtable Van Poppel also emphasized the work done by professional medical groups such as the EAU

creating evidence-based guidelines for urologists and supporting patient advocates through EAU Patient Information Initiative. With help of the national societies of urologists, the EAU Patient Information has been translated to over 20 languages, while the EAU guidelines have been endorsed by all 28 member states and have been translated into 30 languages. He also mentioned the active Around 35 participants gather in Brussels for the 7th ICPS roundtable on prostate cancer collaboration with other medical disciplines such as oncology and radiology through joint research and scientific meetings. Aside from stressing equitable healthcare, the EAU recommendations also anticipates that the future “European authorities and Member States need to would include risk-adapted treatment programmes ensure that PCa patients receive high-quality that require contemporary imaging and diagnostic standardised and integrated care with a focus on a tools. The other EAU recommendations were: patient-centred multidisciplinary approach,” said Van Poppel, citing one of the EAU’s recommendations. • Access to innovative treatments and personalised medicines should be made fast and equitable for all PCa patients; • Prompt and consistent Health Technology Assessment (HTA) should be performed on all new screening diagnostic, therapeutic and rehabilitation technologies to provide the base for effective, efficient and targeted allocation of resources; • Sustaining awareness campaigns, both at European and national levels, and to help achieve the main goals set out in the paper, and • The EU and Member States should promote the implementation of survivorship plans including plans for PCa patients to facilitate Prof. H. Van Poppel presents the EAU White Paper on the return to a normal life for all European prostate cancer PCa patients.

• What is the biggest problem in Europe’s healthcare system? One challenge is the sustainability of health systems related to key factors such as changing demography and the rise in chronic non-communicable diseases. Another is growing costs related to health technologies which contribute to lower mortality rates. The challenge is how to reconcile these opposing trends and keep budgets under control. • As a public health campaigner what is the most significant lesson you have gained? One has to work with teams and we need to involve a broad range of professionals which includes both clinicians and NGOs such as patient advocacy groups. The interests vary and one must do skilful coordination. • As a bridge between government and the health sector, what makes communication among these groups more difficult? Governments think that doctors are only interested in expanding the services. On the other hand, clinical researchers are innovators and research has a price. There are also external pressures within governments. With areas of potential conflicts, communication is disrupted. • What areas in healthcare you think need more attention? Disease prevention is a priority and in the EU it accounts for only less than 3% of total expenditure. We need novel means of communication. Ensuring good access to quality care is another challenge. Third is independent research and in cancer this is a very vital issue. • If you look back in your career what would have you done differently? I would sooner get more involved in inter-disciplinary work. The advantages I’ve seen from international projects are really great. When you have the energy of people from different professions and countries, you get more power in intellectual debate and finding new ideas. • What important advice can you give to a young doctor just starting his career? I sympathize with young doctors today because they are flooded with knowledge and research. They have to know their main objective or focus, and just stick to it and go forward. But they shouldn’t forget the big picture and the patient is the key element of this big picture. • What do you do to avoid burnout? I travel and I like to go to the sea, the coast. • What’s the last wonderful book you have read? The last remarkable book I’ve read was “The Wind-up Bird Chronicle” by Murakami, an excellent book I got as a present from a dear friend. • What’s your favourite hour in a day and why? If I am home that would be the afternoon hours when I can enjoy the outdoors, go walking and cycling. I am very productive at night. Mornings are definitely not my type.

TEN QUESTIONS Interview by Joel Vega Photography by Denis Abbonato-Bei

European Urology Today

Age: 55 Specialty: Public Health & Social Medicine City: Ljubljana Current Posts: Associate Professor and Head of the Centre for Health Care, National Institute of Public Health, Ljubljana, Slovenia; Project Coordinator, Cancer Control (CanCon) Joint Action, European Commission

• What is your biggest fear? The loss of a loved one…And receiving, for instance, news of the sudden death of someone in an accident because it’s uncontrollable and unchangeable.

Tit Albreht January/February 2017

Vestfold Hospital Trust secures EBU certification Working towards high quality training programmes for future urologists Dr. Dag Gullan Dept. of Urology Vestfold Hospital Trust Tønsberg (NO)

DAGGUL@siv.no

Dr. Stein Øverby Chair, Dept. of Urology Vestfold Hospital Trust Tønsberg (NO)

stein.overby@siv.no Vestfold Hospital Trust is situated in Tønsberg, Norway, just south of Oslo. The town offers direct access to the beautiful Skagerrak archipelago. A summer attraction for Norwegian and Nordic tourists, the archipelago ensures Tønsberg a pulsating life in the summer months. The town itself is the oldest in Norway and has long been associated with ship building. Viking ships excavated from this area include the famous Oseberg and the Gokstad, two of the best preserved Viking ships that are on show for the public. In later times the ship building industry provided ships for many famous polar expeditions including those of Roald Amundsen (Gjøa), Fridtjof Nansen (Fram), Ernest Shackleton (Endeavour), and Eduard Toll (Zarya). First built in 1879 our present hospital is the result of a centralisation process that saw the merging of four EBU Certified Centres

district hospitals into a single hospital trust in 2000. The Department of Urology is one of 31 Departments and is staffed by nine consultants, one specialist trainee and one to two residents. Approximately 1,700 surgical procedures are performed annually with 2,000 admissions and 650 day case procedures. Operative stone treatment totals to approximately 850 whilst cancer operations total more than 500.The outpatient department sees over 9,000 patients annually. A total of 20 beds are available for urological patients with three of these allocated to our palliation/oncology section. The hospital serves as a secondary referral centre for Vestfold municipality with a population of circa 250,000. The hospital also has tertiary referral responsibilities including uro-oncology and stone disease. Our department provides care for muscle-infiltrative urothelial cancer with a catchment population of approximately one million. We have over the years established ourselves as a comprehensive stone care centre offering all modern treatment modalities, receiving referrals from centres across Norway. EBU certification EBU certification has, over the years, become the European hallmark of top-quality teaching programmes that adhere to a standardised basic education syllabus within urology. Certification offers an international, independent and external approval of training. Our programme is annually externally validated by our own National Specialisation Committee but we wished to compare ourselves with that of the other high-profile and prestigious institutions across Europe. We believe that European standardisation of training will facilitate cross-border communication between urologists which will in turn benefit our patients. Resident training programme Fulfilment of specialist training in General Surgery has long been a requirement in Norway in order to commence training in urology. This training includes at least one year of urological training as well as the necessary training in basic and advanced general surgical skills. Rotations also include gastro-intestinal,

vascular and breast/endocrine surgeries. Candidates must complete an operation log book and obligatory courses with in-built assessment as well as receive approval from departmental consultant staff.

Over the years awareness of the FEBU examinations has increased in Norway and our staff members are welcome to enrol in the process, often with prearranged sabbaticals for revision purposes.

In addition to becoming General Surgeons each candidate will have to complete a three-year programme within Urology. Operative lists, obligatory courses and peer-approval must again be completed or obtained prior to certification as an urologist. The training includes all areas of urology excluding advanced uro-oncology, renal transplantation and advanced paediatric urology. Operative lists cover all aspects of urology from cancer care to stone disease and urodynamics.

Mentorship With nine consultants employed in our department and only one specialist trainee, there is ample room for discussion on all matters related to urology. The daily activity of the department is to a great extent consultant-led. Trainees have therefore great opportunities to tailor their work so as to complete their training in a more-than-satisfactory manner. Candidates are expected to focus on one specific area at a time and their activity in both theatre and the outpatients department is tailored correspondingly.

The in-house oncology services work in close cooperation with our department. Trainees gain an invaluable insight into advanced cancer care via this synergy including obligatory weekly multidisciplinary prostate, kidney and urothelial cancer meetings. Presentation of patients at these meetings is expected. University hospital training has traditionally been mandatory for a limited period to ensure exposure to specific areas such as nationally centralised functions (certain areas of reconstructive urology, advances testicular and penile cancer care). Our department enjoys a fruitful affiliation with other university hospitals so that sabbaticals can be planned to facilitate completion of training for each resident. Research opportunities are made readily available to trainees. Several consultants are affiliated with external academic institutions and encourage trainee participation. Our primary focus has been surgical database implementation and research as well as extensive bio-banking of cancer tissue for future collaborative projects with external groups. Candidates are expected to actively participate in in-house teaching sessions as well as present at national meetings. Participation in the annual EBU assessment is expected of our trainees and encouraged for our consultants.

Each trainee has an individualised written training plan that they must adhere to. They are allocated a clinical tutor (consultant) with whom they are expected to complete eight formal meetings each year to assess their progression and plans. In addition each candidate is evaluated twice a year by our educational board including their tutor and all consultant staff. These reviews take into consideration both academic and personal factors and have proven to be an extremely valuable tool in guiding candidates through their training. The future New criteria for specialist training are due to be imposed in Norway in the next few years. These changes will herald a new era in training where general surgery disappears and urology departments nationwide will be wholly responsible for each candidates training. Increasing political and public pressure on hospital services is also demanding more consultant-led treatment to ensure the highest level of patient care. These challenges to training programmes have to be properly addressed. EBU accreditation of our programme proves that we offer standardised and high-quality teaching today. This validation provides a solid backbone with which we can meet the demands of the future.

EBU Certification Residency Training Programme in Urology Standardisation at Belgium’s Onze Lieve Vrouw Hospital Aalst Dr. Ruben De Groote Senior Resident Urology Urology Dept. OLV Aalst Aalst (BE) degroote.ruben@ gmail.com

Prof. Dr. Alexandre Mottrie Head of Department Urology Dept. OLV Aalst

Alex.Mottrie@ olvz-aalst.be The Onze Lieve Vrouw Hospital Aalst is a private clinic that exists in its present form since 1970 with a capacity of 844 beds and a number of 34,180 admissions were noted in 2015. A new wing of the hospital, including a new operation theater, is operational since 2009. The urology department comprises 30 beds with 1,914 admissions, 3,894 day care procedures, over 600 robotic procedures last year and a personnel of 12 physicians, including five urologists, three residents, one clinical fellow and three scientific fellows. Within the department, emphasis is on super-specialisation with specific focus on robotic surgery, laser treatment and medical oncology. Cooperation with national and international institutes is encouraged to enhance EBU Certified Centres

January/February 2017

scientific knowledge and obtain a more cost-effective medical treatment. In order to strive for further professionalisation of the department, to ensure continuity of medical care and to contribute to scientific evolutions, training of residents, clinical and scientific fellows is regarded as mandatory. The high quality standards that the department is trying to offer to the patients, are also adopted for training purposes. To do this in a standardised way and to externally validate these training purposes, the urology department in the OLV Aalst recently met the criteria to obtain the certificate as a, “EBU Certified Centre”. This label has become a distinctive measure of quality control since the European Board of Urology (EBU) conducts an objective evaluation of the Residency Training Programme in Urology (RTPU). Moreover, it reflects the intention of this centre to perform urological healthcare and train future colleagues in a transparent and standardised manner.

residents are encouraged to participate scientifically, to attend congresses, to gather monthly interesting papers to present in a journal club, to publish the results and outcomes of different procedures and treatments and to present them on national and international conferences. As part of the training curriculum and to compare themselves with their national and international counterparts, residents systematically participate in the EBU in-service assessment. Moreover, senior residents routinely follow the European Urology Residents Education Programme (EUREP) and pass the EBU written and oral examinations to become FEBU (Fellow of the European Board of Urology), since the FEBU diploma is considered a mark of excellence.

In association with ORSI Academy, the urology department enables the residents and fellows to fulfil their training in a systematic, validated and standardised way in the professional environment of a high-volume robotic centre. This includes a combination of wet and dry lab training in ORSI Academy, table side assistance during live robotic cases and progressively augmenting their surgical experience on the robotic console. This step-by-step learning process is considered of utmost importance to improve patient safety, shorten the learning curve and to obtain better surgical outcomes.

The availability of the dual console system of the da Vinci® Si and Xi system enables ideal training circumstances. The control over the instruments can be easily and quickly exchanged during surgery, enabling the mentoring surgeon to hand over control of the Multidisciplinary approach instruments to the resident or fellow at any time. This The principles of super-specialisation with integration enables a see-and-repeat model of instruction of all the different aspects of urology are a high priority designed to accelerate the learning curve. Because of a for this department. This is reflected by the weekly high throughput of patients, in 2016 a total of 660 At present there are three residents, one clinical fellow Multidisciplinary Oncological Consult meeting in which robotic procedures have been executed, residents and and three scientific fellows active in the OLV Hospital residents are actively involved to present and discuss fellows get a large exposure of cases so that they learn Aalst on a continuous basis. Minimum duration of the patient cases. This is also regarded as a teaching to appreciate the importance of systematics and residency training programme is 12 months. The moment and to test and adapt to theoretical standardisation. cornerstone of the training programme is to obtain a knowledge of residents and fellows. A six-monthly broad urological base with emphasis on superinter-vision meeting with the coordinating staff Moreover, decision-making skills and stress resistance specialisation according to the interests of the resident. member is foreseen during the programme. At this are stimulated by a large number of live-surgery cases. This training programme includes a rotation between occasion positive and negative aspects of each resident In combination with the presence of a high-volume urological sub-specialties, particularly uro-oncology, are reviewed and, together with the resident, an surgeon and expert in the field (Prof. Dr. Alexandre endo-urology and functional urology. Junior and senior optimal continuation of the rest of the programme is Mottrie), the OLV Hospital Aalst can be regarded as a residents are involved in the daily clinical work such as discussed. high-quality centre for training of future urologists. The operation theater, outpatient clinic and follow-up and application for the EBU-Residency Training Programme treatment of the in-patients. Since there is a high The urology department of the Onze Lieve Vrouw in Urology (RTPU) certification indicates the ambition throughput of patients and a very active workflow, Hospital excels in the robotic training programme. For of the OLV Aalst urology department to further invest in senior residents progressively introduce junior robotic surgery, residents and fellows are given the standardised, validated and structured training. residents in basic and advanced diagnostic, medical possibility to participate in the “CC-ERUS” (Certified and surgical skills under direct supervision of different Curriculum of ERUS) for robot-assisted radical Future prospects are to further systematise and staff members. prostatectomy, as well as for upper tract robotic standardise the residents training programme by surgery endorsed by the European School of Urology international exchange projects to see and learn from The second cornerstone of the training programme is (ESU) and EAU Robotic Urology Section (ERUS) to other leading urological centres and to broaden the scientific involvement and development. Fellows and become a certified robotic surgeon. view within the urological specialty. European Urology Today

ESU Course on Laparoscopic and Endoscopic Urology A rewarding intensive workshop in Caceres, Spain Dr. Andrei Sorin Nedelea Hospital Clinic "Prof. Dr. Th. Burghele" Dept. of Urology Bucharest (RO)

There were four days of intensive training in laparoscopic and endoscopic urology. Dr. Ben Van Cleynenbreugel (BE) and Dr. Oscar Rodriguez Faba (ES) were the EAU-assigned trainers. The support staff was from the JUMISC professional teams led by Drs. Idoia Diaz-Guemes (Laparoscopy) and Francesco Soria (Endoscopy).

snedelea@ yahoo.com

A training partner was assigned to all participants and each day consisted of a theoretical training in the morning, followed by hands-on training, first on simulators and later on animal models. We learned and practised basic gestures to more complex interventions like semi-rigid and flexible ureteroscopy, laser nephron/ureterolithotripsy, and percutaneous access to the kidney, partial nephrectomies, prostatectomies and others.

My colleague, Gabriel Predoiu, and I were among the 22 young urologists selected to participate in the European School of Urology’s (ESU) intensive course on Laparoscopic and Endoscopic Urology which took place last February 2016 in Caceres, Spain. With the Minimally Invasive Surgery Centre “Jesus Uson” (JUMISC) as venue, Caceres is around five hours drive from the closest airport in Madrid. Thankfully, after the long drive, the JUMISC is located in a very quiet area in the outskirts of Caceres. JUMISC is involved in translational research and covers several specialised areas such as Laparoscopy, Endoscopy, Microsurgery, Endoluminal Therapy and Diagnosis, Anaesthesiology, Pharmacology, Bioengineering and Medical Devices, Stem Cell Therapy and Assisted Reproduction.

EAU Section of Uro-Technology (ESUT)

The training facility exceeded all our expectations. There were simulators for every urological procedure, many of them developed right there at the centre. Every team had a dedicated trainer from JUMISC who was ready to help and answer any questions. The daily schedule was very regulated but well-thought with short breaks and lots of training time.

JUMISC Central Hall

ESU Chairman Dr. Joan Palou joined us on the last day of the course. He emphasised the importance of practical hands-on training for surgeons and encouraged us to participate in urological educational activities. We really benefited from this training programme and learned new techniques learned. For this unique opportunity, we are grateful to the ESU and JUMISC! Dr. Predoiu (Romania) practising laser lithotripsy

Dr. Idoia Diaz-Guemes (Head of Laparoscopy Department) explaining basic use of instruments

ESUT, Milan hospital collaborate in MIS programme Milan hospital examines new trends in minimally invasive surgery Dr. Giovannalberto Pini Dept. of Urology Ospedale San Raffaele - Turro Milan (IT)

www.urologia-pini.com With collaboration from the EAU Section on Urotechnology (ESUT), the San Raffaele Turro Hospital in Milan, Italy, led by Dr. Gaboardi, has organised a meeting that explored minimally invasive surgeries (MIS). Following the 2015 edition which was known as "San Raffaele Turro Meets the Bordeaux School of Urology" (led by Drs. Gaston and Piechaud), the 2016 meeting succeeded to repeat the success of 2015. The meeting non only fulfilled the goals of the hospital but is also in line with San Raffaele Turro policy. The hospital is known as one of the first centres in Italy (if not in Europe) to perform laparoscopy and robot-assisted surgery, cryoablation, brachytherapy and laparoendoscopic single site (robotic and laparoscopic). In the meeting now known as “San Raffaele Turro Meets Jens Rassweiler and the Heilbronn School of Urology,” the faculty included Drs. Gaboardi and Giusti and Professors Rassweiler (Figure 1), Teber and Gozen.

Figure 3: Prof. Rassweiler and the AVICENNA Roboflex Figure 2: Single-Site Robot-Assisted Radical Prostatectomy. a: home-made multiport configuration for a practical access to 3 robotic arms and 2 assistant trocars. b: final wound view (3.5cm scar)

The live surgeries demonstrated techniques in laparoscopy, robotics and endourology, and reflected the experience and expertise of the ESUT, which is renowned for its emphasis on new technological developments in urology and their application in clinical practice. The surgical sessions opened with a single-site robotic radical prostatectomy performed by Dr. Gaboardi. After the first six cases, the participants were shown techniques that aim for both excellent clinical and aesthetic results, and without reducing the ability to perform a nerve-sparing approach (Figure 2). Prof. Rassweiler then performed a robotic radical prostatectomy using the Heilbronn technique, which meant a special apical dissection and early dissection of the bundles in retrograde fashion.

Figure 1: Dr. Gaboardi and Prof. Rassweiler at San Raffaele Turro (Milan, Italy)

EAU Section of Uro-Technology (ESUT)

European Urology Today

The next three laparoscopic partial nephrectomies showed two cases of retroperitoneal access and a “zero ischemia” procedure. An interesting and very educational moment has been the different approaches showed by different surgeons in performing the “nephrorraphy” (parenchyma

suturing): sliding-clips technique with monofilament and sliding-clip with absorbable Lapra-ty and barbed suture. The second day focused on stones surgery and demonstrated new techniques/technologies and new materials. Prof. Rassweiler performed a retrograde intra-renal surgery (RIRS), mastering the AVICENNA Roboflex consoles for a lower-pole stone (Figure 3), while Dr. Giusti performed a Combined Endoscopic Intra-Renal Surgery (ECIRS) for high-burden complex kidney stones (Figure 4).

robotic radical prostatectomy with special emphasis on improving functional post-operative aspects and total anatomical reconstruction presented by Prof. Porpiglia and Dr. Fiori, and a demonstration of the Retzius sparing approach by Drs. Bocciardi and Galfano. The organisers were not only satisfied of the successful meeting, but due to the enthusiastic response of the participants they are now preparing for the 2017 meeting, also in collaboration with the ESUT and EAU.

The surgical sessions alternated with interesting updates on new technologies such as navigation and imageguided in soft-tissue surgery presented by Dr. Teber, an update on the San Raffaele Turro experience on robotic radical cystectomy (RARC) by Dr. Pini, updates on new technical details in Figure 4: Dr. Giusti performing a Combined Endoscopic Intra-Renal Surgery (ECIRS) January/February 2017

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

paul.meria@ sls.aphp.fr

How Not to Write a Medical Paper: A Practical Guide

demonstrating various mistakes likely to make a paper unsuitable for publication. “Bad examples” were analysed by the author and a short comment was provided to give the reader some practical tips to improve the quality of his publications. The author also gave advice on how to improve the quality of an article based on reviewers’ comments. The last chapter was considered as a “final advice” intended to conclude the book.

Wetting in Children and Adolescents/Soiling in Children and Adolescents Wetting and soiling in children and adolescents are afflictive problems which are not only unacceptable to them, but also to their parents and their teachers. These conditions are also challenging for caregivers. Alexander Von Gontard, a specialist in child and adolescents psychiatry, wrote the second and third editions of these original textbooks for parents and caregivers to provide them with practical solutions.

about wetting and soiling was addressed in the first chapters including definitions, characteristics and assessment of the problems. Associated disorders and psychological problems were also considered in the assessment of young patients. The author focused on the managements of wetting and/or soiling in children and adolescents, and presented the underlying psychological problems. Each textbook was completed by a chapter dedicated to concluding remarks and various charts and questionnaires of assessment were included in the appendices.

This textbook will be helpful to scientists and physicians, whatever their level of expertise. The recommendations found in the book will help authors avoid mistakes and pitfalls. We are grateful to the author for his contribution to medical writing and editing.

Writing a medical paper and making it suitable for publication is always challenging, even for experienced practitioners. The authors must be compliant to various requirements and rules determined by the editor’s policy. Many pitfalls must be avoided and each author must be able to bring out his work accordingly. Markus K Heinemann, a cardiothoracic surgeon and editor-in-chief of a scientific journal, assembled in this pocketbook recommendations intended for practitioners and researchers who aim to improve the quality of their publications. He considered such a book as similar to a “travel guide”. Based on his expertise, the author focused on various mistakes he collected from submissions to his journal. A short chapter revealed the 10 good reasons for manuscript rejection and 10 other reasons for manuscript acceptance, focusing on the procedure of evaluation. Various types of scientific articles were described in the following chapter before an exhaustive chapter dedicated to manuscript components. In this chapter, the author focused on selected examples Book reviews

Editor ISBN e-Book Published Publisher Edition Binding Illustrations Price Pages Website

: M. K. Heinemann : 978-9-38506-229-2 : available : 2016 : Thieme Publishing Group : 1st : soft :: 9.99 euro : 104 : www.thieme.com

The structure of both pocketbooks is identical with the short and very clear recommendations and advice. After a step-by-step demonstration, the final objective was to explain how to achieve dryness and/or anal continence. The author based his works on European and North American practice parameters and on the recommendations and updated publications of the International Children’s Continence Society. The preliminary chapters included the instructions for use; the questions which must be asked at the beginning of the management of wetting or soiling were listed and the reader was guided according to the clinical description and referred to another dedicated chapter accordingly. General information

Undoubtedly, these original pocketbooks are useful either for caregivers or parents who are in need of a better understanding of different mechanisms leading to wetting and/or soiling whilst aiming to obtain good therapeutic results. Editor ISBN e-Book Published Publisher Edition Binding Illustrations Price Pages Website

: A. Von Gontard : 978-0-88937-488-1 & 978-0-88937-487-4 : available : 2016 : Hogrefe : 1st : Paperback : 10 resp. 11 : 8.95 euro each : 80 resp. 96 : Hogrefe.com

Update Membership Office Four countries sign up for EAU en-bloc membership National urological associations in four countries have signed up with the European Association of Urology (EAU) for en-bloc membership, bringing the estimated total of EAU members from around the world to more than 16,000 members.

Apply for your EAU membership online!

“We welcome the new members from the urological associations of Algeria, Greece, Nigeria and the Philippines. Their joining the EAU will not only nurture stronger international links among urologists, but also contribute to meaningful exchanges in education, research and clinical experience,” said Prof. Igor Korneyev (RU), EAU board member and chairman of the EAU Membership Office. Korneyev said the Membership Office have exerted efforts in recent months to clearly convey to various urological associations the EAU’s core goals of boosting urological knowledge-sharing and professional exchanges. Representatives of the Membership Office have not only maintained through the years dynamic contacts with urologists in many countries but also created new ties, particularly with young urologists in regions outside Europe.

Regional meetings, specialty-oriented conferences, training, scholarships, CME-accredited courses organised by the European School of Urology (ESU), exchange programmes and direct research funding are only a few of the EAU activities that allow us to link up with colleagues from overseas,” added Korneyev. He also mentioned that besides the EAU Annual Congress which is known to many urologists outside Europe, the EAU Guidelines and scientific journal, European Urology, have gained the esteem of the international urological community. As of early January this year, there were approximately 15,667 EAU members from 134 countries, not including the new members recorded in recent weeks. The national associations from Greece and the Philippines brought in around 500 members and 68 residents, respectively, while the latest numbers of new members from Algeria and Nigeria are still to be confirmed.

Membership Office

January/February 2017

Urological associations joining the EAU through en bloc arrangements collectively enjoy benefits including full print and on-line access to the EAU Guidelines and publications, eligibility for its members to a range of grants and awards and discounted meeting fees, among other benefits.

Would you like to receive all the benefits of EAU membership, but have no time for tedious paperwork?

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

European Urology Today

EUSP Clinical Visit Excellent observer programme at Hamburg-Eppendorf, Germany The clinic has four da Vinci robotic systems and every day they perform around 10 RRP, half of them are robotic, and half are open surgeries.

Dr. Arif Aydin N.E.Ü. Meram Medicine Faculty Urology Dept. Konya (TR) Prof. Dr. Margit Fisch (Chairman)

Dr. Roland Dahlem (Vice Chairman)

aydinarif@gmail.com Universitätsklinikum Hamburg-Eppendorf (UKE) in Hamburg, Germany is a high-volume center for reconstructive urology and the Martini Clinic is one of the famous complex centres for prostate cancer treatment in Europe. Hamburg is Germany’s second largest city and the eighth largest in the European Union. It is the second smallest German state by area. Its population is over 1.7 million people, and the Hamburg Metropolitan Region has more than five million inhabitants. The city is situated on the river Elbe. Hamburg is a transport hub with the second largest port in Europe, and is an affluent city with a bustling media and industrial centre, with plants and facilities belonging to Airbus.

in 2010. And the UKE is also one of the most developed medical centres in Germany. The chief of the Urology Department is Prof. Margit Fisch, an excellent urologist who manages the clinic professionally. She specialises in reconstructive urology and paediatric urology but also manages other urologic procedures in the clinic except prostate cancer. Within the university hospital there is an autonomic clinic, the Martini Clinic which is specialised in prostate cancer, where all prostate cancer treatments and procedures are performed.

Hamburg has 54 hospitals. The University Medical Center Hamburg-Eppendorf, with about 1,450 beds, houses a large medical school. There are also smaller private hospitals. On 1 January 2011 there were about 11,350 hospital beds. The city had 5,663 physicians in private practice and 456 pharmacies

The daily morning meeting

University Hospital Hamburg-Eppendorf European Urological Scholarship Programme Office

With Luis, an excellent friend

I’m interested in reconstructive urology and prostate cancer and the UKE urology clinic and Martini Clinic were very helpful and I am grateful to the EAU scholarship program and the professors of these clinics. I began my European Urological Scholarship Operation room at the Martini Clinic Programme (EUSP) clinical observer programme on September 1 with the kind assistance of Mrs. Silke Merzenich of the international office. On the first day I met Dr. Luis Kluth in the policlinic and he briefed me regarding the clinic’s guidelines. The daily routine starts at 7:30 and ends around Epispadias surgery 8:00 pm. I attended the surgical activities at the operation room and observed the reconstructive and uro-oncology cases. radical prostatectomies every day and other procedures such as MRI fusion biopsy, The UKE urology clinic has two operation rooms but brachytherapy, HIFU, etc.… For their guidance my on Mondays they have access to three operation specials thanks to Professors Graefen, Haese, rooms; one room is almost always reserve for Stauber and Tilki. reconstructive urology. Having this arrangement was a wonderful opportunity since I saw a lot of My stay in Hamburg gave me special memories. procedures such as buccal mucosa urethroplasty, I experienced the October Fest with the clinic staff proximal hypospadias, penile urethral stricture, members and joined parties and special dinners epispadias, SIS corporoplasti, artificial sphincter with my friends. I met Indonesian and Macedonian involvement, gender transformation and others. colleagues Gampo and Ilia and we developed good There were also onco-urology cases such as radical friendships. I aim to create a reconstructive unit in cystectomy and ileal loop (also miles procedure, my university after gaining valuable experience in double pouch diversion) partial and radical Hamburg. nephrectomies. My heartfelt thanks to all the staff of the Department I worked in the Martini Clinic from 24 October to of Urology at UKE Hamburg and the EUSP Office for 4 November. Martini Clinic performs about 10 giving me this priceless opportunity!

European Urology Today - Manuscript Submission European Urology Today, the EAU newsletter is published five times each year. Its main role is to function as the European Association of Urology’s bulletin, as a platform for the EAU to present their meetings, the various sections and offices, as well as discuss general issues of interest to their members. Another important objective is to have a platform that allows for the inclusion of a range of scientific papers which are considered of interest to a large readership.

Editorial Policy Manuscripts are submitted with the explicit understanding that the decision to include material will be made by the Editor-in-Chief in conjunction with his Section Editors. All authors have read and approved the manuscript subject to submission. It is the author’s responsibility to obtain permission to reproduce any parts of other publications (i.e., tables, figures). Precise reference to the original work must be given in the legends. Statements in articles or opinions expressed by any contributor in any article are not the responsibility of the editors or the publisher. The publisher is not responsible for the loss of manuscripts through circumstances beyond their control.

European Urology Today

The publisher will commit itself to make judicious use of the article in accordance with the aims and objectives of the association and make the article available to medical professionals at no cost.

Proofs must be returned within the deadline specified by the publisher.

Types of Articles Manuscript Submission Manuscripts and questions regarding manuscript submission may be directed to: European Urology Today Editorial Office E-mail: EUT@uroweb.org Submission of an article signifies the author’s consent to transfer copyright to the EAU, publisher of European Urology Today.

Submission platforms All material is to be submitted in English, as Word file for text and JPG, TIFF, PPT, PDF for illustrations (minimum 300 dpi). For files over 10 MB WeTransfer can be used. Word count for authors is available on request at the EUT Editorial Office.

This section is reserved for articles of which the first author is a resident in training. All material is to be submitted for consideration to the Section Editor responsible for this section, Dr. M. Behrendt, markbdt@gmail.com

Original articles Original articles may be solicited by the editorial board or submitted to the editorial board for consideration. In case of doubt, authors are encouraged to check with the editorial board describing the content of their article before submission. Maximum word count for original articles is approximately 1,800 words, exclusive of references and illustrations. In case authors provide large reference files, the Editorin-Chief may decide to either limit the total number of references included in the print, or make references available on request through EUT@uroweb.org.

Reports General reports and papers on interesting developments/urology departments/accreditation etc. may be submitted for consideration to the Editorin-Chief. Illustrations are welcome. Word count for reports are approximately 900/1,000 words.

Reviews of books and new media Books and new media to be considered for review may be sent to the EUT Editorial Office.

Meeting Reports

Maximum word count for submitted articles is approximately 1,000, exclusive of illustrations. Accepted manuscripts will be copy-edited to bring them Only reports of EAU related meetings accompanied by into conformity with the journal’s style. high resolution photos will be published. All material is Unless otherwise indicated, proofs are sent in PDF format to be submitted initially to the EUT Editorial Office, via e-mail to the corresponding author. EUT@uroweb.org

Proofs

Young Urologists/Residents Corner

Letters to the editor Authors are welcome to submit letters to the editor. The text of letters should be limited to 500 words. Letters to the editor will be published as space permits.

January/February 2017

Call for EAU RF SATURN registry EAU RF sets up European registry for male SUI patients Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ uroweb.org

Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ uroweb.org The artificial urinary sphincter (AUS) has been used since 1972 for the treatment of severe urinary incontinence1. After several technical evolutions that led to significant improvement of surgical and functional results, the device reached maturity in 1987 with the release of the narrow-back cuff AMS800 device (AMS, Minnetonka, MN, USA)2. The device is largely unchanged in current practice apart from small changes (e.g., antibiotic coating). Some innovative devices such as FlowSecure and Zephyr ZSI 375 have been presented as potential alternatives, but only a few preliminary results are available3,4. It is currently estimated that >150 000 patients worldwide have been implanted with an AUS, the vast majority with AMS8005. This large number of cases, potentially with extremely long follow-up, is barely reflected in the literature, and most data on AUS outcomes come from older retrospective cohort studies. Randomised controlled trials (RCTs) were not performed due to the lack of a comparator5. Nonetheless, AUS implantation has been the standard of care for refractory male stress urinary incontinence (SUI) for a considerable time with high success rates (defined as 0-1 pad per day) up to 80-90%6-7. Looking closer to success rates and the reported de facto dry rates (use of no pads or 1 light security pad), dry rates vary from 4 to 86%8 which highlights the need for standardised definitions enabling comparisons. Results of prospective studies suggest a dry rate of about 50% after midterm follow-up, but a cautious approach to this value is needed due to limitations regarding the lack of standardised definitions8. The risk of complications and revisions are reported to be between 8 and 45% for mechanical failure and for non-mechanical failure such as erosion, urethral atrophy and infections between 7 and 17%9-12. In recent years, with an increasing patients’ demand for minimally invasive treatment options, new surgical alternatives claim to be safe and effective13,14. Among these new devices, male slings are increasingly used and have been given the same level of recommendation (grade B) as AUS, according to the 2016 European Association of Urology guidelines5. However, the recommendation for male slings is to offer them in patients with mild-to-moderate post-prostatectomy incontinence whereas the recommendation for AUS is to offer them in patients with moderate to severe post-prostatectomy incontinence. Given the respective histories of the two techniques and the differing profiles of the most suitable patients, the equivalent grading of their recommendation in patients with moderate postprostatectomy incontinence obscures an uncertain picture. The reported cure rates (no pad or one dry security pad) of male slings vary from 50-73% (average estimated ~65%) while explantation rates vary from 0-30%6,15-19. Hence, we want to prospectively collect data on two main surgical interventions using medical devices such as AUS and male slings for the treatment of stress urinary incontinence in males. At present, there are no randomised controlled trials available to quantify the success and revision rates of these procedures. EAU Research Foundation

January/February 2017

We plan to collect prospective data from multiple centres and surgeons in Europe to evaluate the short and long-term success of these interventions along with an evaluation of the impact on Quality of Life. It is envisaged that over a period of time we will not only have a large database from multiple European centres to compare the outcomes and complication profiles of these procedures but also will be able to direct clinical research in this field to improve patient outcome. The primary objective of this study is to evaluate the cure rate of procedures for treatment of male stress urinary incontinence at five years of study follow-up. Cure rate will be the main endpoint of the study, and is defined as urinary continence with no need for use of pads or the use of one light security pad. The cure rate after five years of study follow up will be calculated together with its 95% Confidence Intervals, for the total patient group as well as for each device subtype. Secondary objectives and endpoints To determine other outcomes of surgical treatment of male stress urinary incontinence for each of the devices and to perform a prognostic factor analysis to identify clinical and surgical variables that correlate with (in)continence or revisions for each of the device subtypes. Secondary endpoints that will be evaluated are: • Time being incontinence-free defined as the interval from the date of surgery to the date of incontinence recurrence. Patients who die will be censored at time of death. Overall time of being incontinence free will be presented using the Kaplan-Meier curve, for the total patient group as well as for each device subtype. • Time being revision-free defined as the interval from the date of surgery to the date of revision. Patients who die will be censored at time of death. Overall time being revision-free will be presented using the Kaplan-Meier curve, for the total patient group as well as for each device subtype. • Safety. Number of patients with complications such as: urinary retention, scrotal hematoma, perineal pain, haematuria, or other local or general problems will be presented in a tabular format. • Change in quality of life versus baseline (presurgery) The change in quality of life compared with baseline (pre-surgery) will be reported at week 12, year 1, and then yearly up to and including year 5. • Change in the results of the incontinence questionnaire versus baseline (pre-surgery). The change in the results of the incontinence questionnaire compared with baseline (presurgery) will be reported at week 12, year 1, and then yearly up to and including year 5. • Number of patients with postoperative specific events related to the surgical procedure or the sling / prosthesis (e.g. pump/reservoir/cuff failure, erosion of the device through the skin or urethra). Study participants A total of 500 male patients undergoing surgery for treatment of stress urinary incontinence with medical devices such as AUS or sling in a given centre. Study procedures and assessments Study visits for patients undergoing surgery for stress incontinence with medical devices such as AUS or male sling are typically conducted before surgery, and after the surgical procedure at six weeks (activation of AUS in case of AUS surgery), 12 weeks and one year post-surgery. These visits will be the minimum anticipated follow up requirements in the protocol. Long-term follow up will consist of yearly visits after visit at one year post-surgery up to and including year 5. Study assessments will be undertaken at the local centres as per local arrangements. Pre-operative data (e.g., patient characteristics, Charlson co-morbidity index, 24 h pad test, urodynamic results), perioperative data (e.g., details on surgery type of prosthesis, cuff size and location, pressure of regulating balloon, presence of double cuff, type of peri-operative antibiotics, type of associated procedures (e.g. penile prosthesis), use of suprapubic or transurethral catheter or drain) and post-operative data (e.g., time of presence of suprapubic or transurethral catheter, presence of postoperative retention, scrotal hematoma, perineal or groin pain, haematuria, swelling or other problems) will be entered into the electronic CRF.

The ICIQ Male LUTS Questionnaire SF and EQ-5D-5L questionnaires will be handed over or posted out to the patients at 12 weeks after surgery and then yearly up to and including year 5 by the Local Consultant or Research Coordinator, if required on the prompt from the central data manager. The results of patient reported ICIQ Male LUTS Questionnaire & EQ-5D-5L at 12 weeks post-surgery, and consequently year 1, and yearly up to and including year 5 will be entered into the database. References: 1. Scott FB, Bradley WE, Timm GW. Treatment of urinary incontinence by an implantable prosthetic urinary sphincter. J Urol 1974;112: 75–80. 2. Light JK, Reynolds JC. Impact of the new cuff design on reliability of the AS800 artificial urinary sphincter. J Urol 1992;147:609–11. 3. Knight SL, Susser J, Greenwell T, Mundy AR, Craggs MD. A new artificial urinary sphincter with conditional occlusion for stress urinary incontinence: preliminary clinical results. Eur Urol 2006;50:574–80. 4. Alonso Rodriguez D, Fes Ascanio E, Fernandez Barranco L, Vicens Vicens A, Garcia Montes F. One hundred FlowSecure artificial urinary sphincters. Eur Urol Suppl 2011;10:309. 5. F.C. Burkhard, M.G. Lucas, L.C. Berghmans, J.L.H.R. Bosch, F. Cruz, G.E. Lemack, A.K. Nambiar, C.G. Nilsson, A. Tubaro (Guidelines Associates), D. Bedretdinova, F. Farag, B.B. Rozenberg: Guidelines on urinary incontinence, 2016. European Association of Urology Web site: http://uroweb.org/guideline/urinaryincontinence/#4 6. Kim SP, Sarmast Z, Daignault S et al. Long-term durability and functional outcomes among patients with artificial urinary sphincters: 1 10-year retrospective review from the University of Michigan. J Urol 2008;179:1912-16. 7. Venn SN, Greenwell TJ, Mundy AR et al. The longtermoutcome of artificial urinary sphincters. J Urol 2000;164:702-6. 8. Van der Aa F, Drake M, Kasyan GR et al. The artificial urinary sphincter after a quarter of a century: A critical systematic review of its use in male non-neurogenic incontinence. Eur Urol 2013;63(4):681-689. 9. Ray GV, Peterson AC, Toh KL, Webster GD. Outcomes following revisions and secondary implantation of the articificial urinary sphincter. J Urol 2005;173:1242-5. 10. Elliott DS, Barrett DM. Mayo Clinic long-term analysis of the functional durability of the AMS 800 artificial urinary sphincter: a review of 323 cases. J Urol 1998;159:1206-8. 11. Lai HH, Hsu EI, The BS, Butler EB, Bonne TB. 13 years of experience with artificial urinary sphincter implantation at Baylor College of Medicine. J Urol 2007;177:1021-5. 12. Farag F, van der Doelen M, van Breda J, D'Hauwers K, Heesakkers J. Decline in artificial urinary sphincter survival in modern practice-Do we treat a different patient? Neurourol Urodyn. 2016 Aug 31. doi: 10.1002/ nau.23110. [Epub ahead of print] PubMed PMID: 27580297. 13. Bauer RM, Gozzi C, Hubner W, et al. Contemporary management of postprostatectomy incontinence. Eur Urol 2011;59:985–96. 14. Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn 2010;29:213–40. 15. Herschorn S, Bruschini H, Comiter C, Grise P, Hanus T, Kirschner-Hermanns R, Abrams P; Committee of the International Consultation on Incontinence. Surgical treatment of stress incontinence in men. Neurourol Urodyn. 2010;29(1):179-90. 16. Bauer RM, Soljanik I, Füllhase C, Buchner A, May F, Stief CG, Gozzi C. Results of the AdVance transobturator male sling after radical prostatectomy and adjuvant radiotherapy. Urology. 2011 Feb;77(2):474-9.

17. Bauer RM, Soljanik I, Füllhase C, Karl A, Becker A, Stief CG, Gozzi C. Mid-term results for the retroluminar transobturator sling suspension for stress urinary incontinence after prostatectomy. BJU Int. 2011 Jul;108(1):94-8. 18. Cornu JN, Sèbe P, Ciofu C, Peyrat L, Cussenot O, Haab F. Mid-term evaluation of the transobturator male sling for post-prostatectomy incontinence: focus on prognostic factors. BJU Int. 2011 Jul;108(2):236-40. 19. Hübner WA, Gallistl H, Rutkowski M, Huber ER. Adjustable bulbourethral male sling: experience after 101 cases of moderate-to-severe male stress urinary incontinence. BJU Int. 2011 Mar;107(5):777-82.

Participation Project: The participation will be by open invitation to all members of the Female & Functional Section of the EAU (ESFFU) along with other urologists undertaking these procedures. This is a call of the European Association of Urology Research Foundation (EAU RF) to all European Urologists to register for database entry. There will be no restriction on the number of patients enrolled as long as they are consecutive. The aim is to have a long-term collection of the data set from as many European centres as possible. An initial assessment for the robustness of the data collection will be undertaken at three months by a nominated steering committee. However, the first clinical evaluation of the data collected will commence at one year by the steering committee. There will be a Steering Committee Meeting and an Investigator Meeting at the occasion of the EAU Annual Congress in London. The final protocol is accepted by the ethical committee of the Radboud UMC Nijmegen to start recruitment and currently we are developing the web-based data management system for the collection of patient data. Are you interested to participate in the SATURN registry? Please contact: EAU RF Central Research Office PO Box 30016, 6803 AA Arnhem, The Netherlands E-mail: r.schipper@uroweb.org Phone: +31 (0) 26 38 90 677 Sponsor: European Association of Urology Research Foundation Study team: Principal Investigator: Rizwan Hamid, Assistant Professor of Urology Consultant Urological Surgeon Department of Urology, University College London Hospitals London, United Kingdom Protocol Writing and Steering Committee: • Rizwan Hamid, United Kingdom • Nikesh Thiruchelvam, United Kingdom • Frank Van Der Aa, Belgium • John Heesakkers, The Netherlands • Wim P.J. Witjes, EAU Research Foundation, The Netherlands EAU Research Foundation Wim Witjes, Scientific and Clinical Research Director Raymond Schipper, Clinical Project Manager Christien Caris, Clinical Project Manager Joke Van Egmond, Clinical Data Manager

Join the EAU Research Foundation Meeting at EAU17 in London! Saturday, 25 March 2017 from 12.00 – 14.15 hrs. European Urology Today

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Research Fellowship Special session during EAU17 Date: Friday, 24 March 2017 Time: 12.15 - 13.30 hrs

The California Urology Foundation, in association with the Société Internationale d’Urologie, announces the availability of a Urologic Research Fellowship for a fully-trained Urologist from Africa to conduct research for one year in a medical laboratory of the University of California in San Francisco (UCSF). This award is intended to prepare the candidate for an academic

career in his or her home Incountry; a firm commitment to return will mation Patient Information Patient Information Patient be a material consideration in the evaluation of candidates. This fellowship carries a stipend of $50,000 USD, of which $14,000 is ient Information Patient Information Patient Information used to cover medical insurance and administrative fees. EAU Patient Information Applications for this fellowship Setting standards in cooperationPatient and care Information mation Patient Information Patient In- will be evaluated by a joint SIU/ UCSF Committee and must include a proposed urology research project, a detailed CV, and a minimum of 3 letters of professional • From the perspective of national societies, residents, ient Information Patient Information Patient Information references. References must be received for a candidate to be doctors, nurses and patients considered. An application missing any of the items listed above • The future of EAU Patient Information in daily practice mation Patient Information Patient Information Patient Inwill be considered incomplete. Speakers: The Information deadline for the July 2018-June 2019 fellowship will ient Information Patient Information Patient • Prof. Christopher Chapple, EAU Secretary General (GB) be February 28, 2017. Application forms are available on the • Prof. Dr. Thorsten Bach, EAU Patient Information Chairman (DE) SIU website www.siu-urology.org under Scholarships and mation Patient Information Patient Information Patient In• Prof. Carlos Llorente, Hospital Universitario Fundación Alcorcón, (ES) Training→Fellowships. • Dr. Giulio Patruno, EAU Patient Information Board member (IT) Applications must be submitted online. Any questions or concerns • Mr. Andrew Winterbottom, Co-founder Fight Bladder Cancer (GB) Patient ient Information Patient Information Information should be directed to the SIU Central Office at the coordinates below. • Ms. Corinne Tillier, EAUN Board Member (NL) mation Patient Information Patient Information Patient InCome join us in London!Information Patient Information ient Information Patient SIU CENTRAL OFFICE 1155 Robert-Bourassa Blvd., Suite 1012, Montreal, Quebec, Canada H3B 3A7 Telephone: +1 514 875 5665 Fax: +1 514 875 0205 central.office@siu-urology.org

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Extracts from the ERA-EDTA Stone Symposium ‘Nephrolithiasis and CKD’ at Vienna meeting Prof. Robert Unwin University College London London (GB)

robert.unwin@ ucl.ac.uk At the ERA-EDTA meeting in May 2016 in Vienna, a joint ERA-EULIS clinical session was held, which covered several topical aspects of renal stone disease and its management (chaired by Professors Christian Seitz (AT) and Robert Unwin (GB)). These were: stones and polycystic kidney disease (PKD) (Prof. Dominique Chauveau, FR), struvite or infection stones that are difficult to treat and prevent (Professors Giovanni Gambaro, IT and Christian Türk, AT), the risk of chronic kidney disease with stones (Dr. Pietro Manuel Ferraro, IT), and the incidence of end-stage renal disease in symptomatic stone-formers (Prof. Alberto Trinchieri, IT). What follows is a brief summary of these presentations. Polycystic Kidney Disease (PKD) Kidney stones are an important and common cause of flank pain in patients with PKD and can be difficult to diagnose and distinguish from an infected cyst or acute bleed into a cyst. Stones occur in roughly a fifth of patients, but detection can be challenging, because of the distorted renal anatomy and the frequent finding of parenchymal and cyst wall calcification. Computed tomography (CT) is the most sensitive means of detecting stones and calcification, and urography is still the best means of visualising the collecting system. Treatment and surgical intervention are no different from managing stones in general, including lithotripsy and percutaneous nephrolithomy (PCNL). Factors that favor stone formation in PKD include larger kidneys, urinary stasis and metabolic factors such as a low urine pH, reduced ammonium excretion (which may explain the low urine pH), and hypocitraturia. Stone type is typically uric acid or calcium oxalate. Hyperuricosuria is also sometimes found, as is hyperoxaluria, though not hypercalciuria. Unusually, distal acidification defects EAU Section of Urolithiasis (EULIS)

can also occur. However, many of these metabolic features can be found in PKD patients without kidney stones. It seems likely that intrarenal obstruction is a particularly important factor. Struvite (infection) stones This presentation was a comprehensive treatise on struvite stones, their pathogenesis, urological treatment and prevention. Although the prevalence of these stones is decreasing, reported in an Australian study from 14% of all stones in 1970 to 7% in 2013, they still represent an important threat to the kidney and to the patient. If untreated, they cause significant mortality and severe renal damage that can lead to end-stage renal disease. Furthermore, they have a very high risk of recurrence after treatment, especially in the presence of any residual stone fragments. Urinary infections should be treated pre-operatively and following any urological treatment, but their eradication can be almost impossible if stone fragments are not cleared completely. Furthermore, there are no clear guidelines on how to give antibiotic treatment in these patients: the EAU’s guidelines are ambiguous about the duration of antibiotic therapy; the AUA guidelines are unclear on whether the treatment should be prophylactic or suppressive. These uncertainties are important drawbacks at a time of increasing rates of antimicrobial resistance. Evidence is needed to justify the use of prolonged antimicrobial therapy in this patient population. Although generally advocated as a useful measure to prevent struvite stone recurrence, the evidence supporting active urinary acidification is scanty. Acetohydroxamic acid (not available in Europe because of its severe side effects) is suggested by the AUA guidelines only for patients with residual or recurrent struvite stones. Experimental and small clinical studies suggest that increased urinary citrate might be a useful preventive measure. However, stronger clinical data are needed. Since even 50% of struvite stones develop on top of metabolic stones, metabolic risk factors should be looked for in all struvite stone patients, because their treatment could be a useful adjunct and preventive measure. Risk of chronic kidney disease (CKD) with stones Kidney stones are increasingly common in the general population, with an estimated prevalence of about 8%. Despite being traditionally considered a benign condition, several reports suggest an association between a history of kidney stones and the risk of

plasma flow (RPF) and glomerular filtration rate (GFR), as measured by DMSA and DTPA renal scanning, were decreased after open surgery. However, even the less invasive treatments such as shock wave lithotripsy (SWL) and less invasive endourological procedures are associated with the potential for renal damage.

Figure 1: Urinary enzyme excretion after open surgery and minimally invasive treatment of renal stones (modified by Trinchieri et al 1988)

developing CKD, a condition characterised by progressive impairment of renal function, and in some cases reaching end-stage renal failure (ESRD) requiring renal replacement therapy (dialysis or transplantation). Such deleterious effects on renal function might be explained by a number of potential mechanisms, including acute and chronic obstruction, inflammation and recurrent infections. Most studies published to date provide limited information on the risk of CKD based on a history of kidney stones and their inherent design limitations; however, more recent and powerful studies with a longitudinal design have been consistent in suggesting that a history of kidney stones is associated with up to doubling of the risk of kidney damage, even when controlled for other known risk factors such as high blood pressure and diabetes. Future studies will need to investigate what characteristics of kidney stone disease are more likely to expose the patient to the risk of CKD. Cumulative incidence of end-stage renal disease (ESRD) Repeated obstructive episodes and invasive surgical intervention are a possible cause of the increased risk CKD in renal stone-formers. Urological treatment may involve direct trauma to the renal parenchyma and/or post-surgical complications such as obstruction and infection, which further increase the risk of renal damage. Traditional ‘open renal surgery’ was associated with a severe risk of renal injury when it required parenchymal incisions or led to renal ischemia due to temporary clamping of the renal pedicle. Renal

SWL produces moderate tissue damage by a direct effect of the shock waves and is associated with obstructive uropathy and urinary infections as a result of the passage of stone fragments. Experimental studies show focal histological lesions of the parenchyma (subcapsular hematomas, endothelial damage, fibrosis) and transient decreases in RPF and GFR after SWL. Imaging studies have confirmed morphological alterations of the kidneys, and urinary enzymes as markers of tubular injury were found to be higher after SWL. Percutaneous nephrolithotomy (PCNL) is sometimes associated with renal haemorrhage, extravasation, infection and sepsis. In contrast, the trauma following dilation of the PCNL tract is limited with any resulting scarring < 2% of the total cortical volume. Experimentally, the reduction in RPF and GFR reverts to baseline values by 72 hours. Retrograde intra-renal surgery (RIRS) avoids parenchymal trauma, but it is associated with a risk of high pressure in the collecting systems caused by irrigation. Peaks of intrarenal pressure can be 30-fold higher than normal during ureterorenoscopy with a risk of renal damage and confirmed again by significant increases in urinary tubular enzymes, as well as a risk of septic complications. On the other hand, even conservative treatment is associated to transient but repeated episodes of ureteral obstruction that, if unresolved, can evolve to progressive irreversible renal damage. A timely and less aggressive approach to urological treatment can limit the risk associated with prolonged obstruction of the urinary tract, and trying to reduce stone recurrence medically can reduce the need for repeated urological procedures. References 1. El-Zoghby ZM, Lieske JC, Foley RN, et al. Urolithiasis and the risk of ESRD. Clin J Am Soc Nephrol. 2012 Sep;7(9):1409-15. Epub 2012 Jun 28. 2. Trinchieri et al. Renal tubular damage after renal stone treatment. Urol Res 1988;16:101-4

Live surgeries in urolithiasis workshop Sofia, Bulgaria hosts 1st SEGUR Workshop on Urolithiasis "Contents presented during the 1st SEGUR Workshop on Urolithiasis can be accessed for free on this website: http://urolithiasis.endourology.bg"

Prof. Iliya Saltirov Military Medical Academy Department of Urology and Nephrology Sofia (BG) saltirov@vma.bg Bulgaria’s capital city Sofia hosted early this year the 1st SEGUR Workshop on Urolithiasis– an international educational project for theoretical and practical training in urolithiasis management organised by the South-Eastern Group for Urolithiasis Research (SEGUR). The workshop took place during the first day of the 7th Meeting Endourology and Minimally Invasive Surgery. The scientific programme included state-of-the-art lectures, Live Surgery sessions and Hands-on-training delivered by a distinguished and internationally renowned faculty. With expert trainers participants honed their surgical skills and were given an

EAU Section of Urolithiasis (EULIS)

January/February 2017

overview of the latest developments in endoscopes, energy sources and disposables.

sessions. Selected sessions were transmitted through live streaming in the meeting’s website.

Those who weren’t able to attend had the opportunity Contents presented during the 1st SEGUR Workshop to directly access the meeting via their PC, laptop and on Urolithiasis can be accessed for free on this tablet and watch the lectures and Live Surgery website: http://urolithiasis.endourology.bg European Urology Today

Young Urologists/Residents Corner Observership in endourology The "Milanese" experience Dr. Moisés Rodríguez Socarrás @moisessocarras Urology Resident @ESRUrology Webmaster, NCO - Spain @ResidentesAEU Vigo (ES)

Dr. Leonardo Tortolero @DrTortolero Urologist Scientific activities manager @ResidentesAEU Elche (ES)

Endourology is growing at an amazing speed and the use of new technologies is expanding the diagnostic and therapeutic possibilities in levels that seem to be without limits. With such changes there lies the prospect of more rapid growth in the coming years. In recent years, advancements in the endourological armamentarium, the downsizing of flexible ureteroscopes, the entry of digital technology and single-use disposable instruments, introduction of holmium laser lithotripters, plus the rising demand for minimally invasive procedures, have made endourology increasingly attractive and widespread, gaining more practitioners.

Ospedale San Raffaelle - Turro Milan, known for its fashion, glamorous shops, the Duomo and cuisine, is also home to San Raffaele´s Hospital (@SanRaffaeleMI) with its well-known urology department. In addition, the Urology Department of Ospedale San Raffaele-Turro is the home base of expert endourologists such as Dr. Guido Giusti (@GuidoGiusti) and Dr. Silvia Proietti (@sproietti81). Our two-week clinic visit was organised and facilitated by these two renowned endourologist, who were not only friendly but also extended all the assistance we need. They explained innumerable tips and tricks of endurological procedures in PCNL, flexible ureteroscopy for the treatment of lithiasis and the treatment of urothelial tumours of the upper urinary tract. We observed procedures and surgeries in challenging cases that require a high level of expertise and surgical skills such as RIRS in transplanted kidneys, RIRS in patients with ureteral reimplants, PCNL in horseshoe kidneys and endoscopic treatment of ureteral strictures. Although our clinic visit was focused on endourology, we learned other high-level surgeries such as Holmium laser prostate enucleation (HoLep), laparoscopic surgery and robotic surgery expertly performed by Prof. Gaboardi, head of the Ospedale San Raffaele-Turro Urology department). The whole team of urologists, residents and nurses offered their help in a professional way, always friendly and made us feel part of the family. The European Training Center of Endourology (ETCE), based in the San Raffaele - Turro Hospital and directed by Dr. Guido Giusti, offers more than 20 courses per year of endourology updates to participants from many countries. During our stay we participated in one of their courses, the 82nd ETCE

The authors posing with the highly professional team of urologists, residents and nurses

event which provided excellent lectures and live surgery cases during the two full days of the course. Mentorship and teamwork Perhaps the most important lessons during our two-week stay came in the form of a lot of advice from Dr. Giusti, not only about endourology but also in professional career development. His passion for endourology is remarkable and he emphasized the important role of mentorship in a successful career. He also counselled us on the role of commitment and other essential values such as discipline in scientific

activity, social abilities and friendship. His enthusiasm and dedication was inspiring which is also reflected by his team, showing us that their professional excellence is due to the friendly relation among them. Our experience at the Ospedale San Raffale-Turro in Milan was truly positive and amazing and we hope to visit the centre in the future. And we encourage all those who want to gain experience in a field as exciting as endourology to gain the experience in specialised centres.

Impressions from the Milanese experience

Dive into the history of 32 EAU Congresses! If you’re interested to find out more about the long history of the Annual EAU Congress, be sure to visit the interactive Congress History website. Explore more than forty years of congresses, including the cities, presidents and interesting statistics. The site also includes highlights from each congress, like scientific breakthroughs, congress innovations, and anecdotes about memorable events. The Congress History site uses a map and detailed timelines to allow you to navigate the past in dynamic way. Prepare for EAU17 by taking a walk down memory lane and revisiting some of our Association’s greatest achievements!

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January/February 2017

Young Urologists/Residents Corner YUO launches Leadership for Medical Professionals Course Do you wish to hone your management and leadership skills or sharpen your decision-making abilities? The EAU Young Urologists Office (YUO) may have the right programme for you in London during the Annual EAU Congress. The YUO will hold a new course on Monday 27 March 2017, from 08:30 to 11:30, to provide recommendations on how to develop leadership and management skills.

professionals who have the potentials to be future leaders in national and international urology.

“The emphasis is on the development and successful implementation of a personal and creative leadership style and business strategy. After the course, participants will learn to be more decisive in reacting on developments within their organization, more “Around 30 participants from across Europe will be selected for the three-hour course which will provide effective and efficient in management-skills,” said skills training in various areas including management, Sedelaar. decision-making and presentation skills, among others,” said YUO Chairman Prof. Michiel Sedelaar. The following are the application criteria: The YUO is working on its Personal Development Programme where courses will focus on management and communication skills, leadership, finances, etc. The first part of this programme is a course on Leadership for Medical Professionals, designed for young (under 45 years) urologists and related health

• Urologists under the age of 45; • A letter of motivation stating the applicant’s interest for the course; • Recommendation letter from applicant’s immediate superior or supervisor; • Proven fluency in English; and

• Readiness to submit essay-type articles in preparation for the course. “This is an exciting programme for young urologists and regardless of their career plans and ambitions, the course will provide stimulating ideas, tips and other valuable strategies to boost one’s managerial and decision-making capacities,” Sedelaar said. The YUO board will review all applications on a first-come, first-served basis and selected participants will come from countries across Europe. A small token fee of €50 will be required to ensure attendance by selected applicants. The course will be handled by a Dutch management and communications specialist team led by Herman Rijksen and Jaap Zijlstra. For interested candidates, inquire for details or email the YUO at a.terberg@uroweb.org

ESRU, CAU collaborates in Panama meeting Successful meeting among residents from Latin America and Spain Moisés Rodríguez Socarrás ESRU Webmaster. NCO - Spain RAEU Workgroup team member Vigo (ES) moisessocarras@ hotmail.com

Juan Gómez Rivas Chairman, Spanish residents workgroup ESRU Secretary YUO-EAU Board Member Madrid (ES) juangomezr@ gmail.com The American Confederation of Urology (CAU) represents the third international urological association in terms of associates’ numbers, after the European Association of Urology (EAU) and American Urological Association (AUA). CAU encompasses more than 20 national urological associations in Latin America, in addition to Brazil, AUA and the Spanish Association of Urology (AEU). From the 4 to 8 October 2016, the exotic Panama City with its famous canal, wonderful historical city centre and its important financial centre, hosted the 35th Congress of the American Confederation of Urology (#CAU16), held concurrently with the 21st Congress of the Iberoamerican Society of Pediatric Urology and the 12th Congress of the Panamanian Society of Urology. Thousands of urologists and residents from Latin America, North America and Europe gathered at the Megapolis Convention Center. The scientific content was of the highest level with renowned professors sharing their expertise in a cordial

Social Media Course supported by ESRU

January/February 2017

speakers such as Rafael Sánchez Salas (FR) and Ramón Rodríguez Lay (PA), Arturo Rodríguez (MX), Christopher Dixon (USA), Fernando Bianco (USA). Finally, Dr. Xavier Cathalineau (FR) led the closing plenary session on intermittent hormone therapy in prostate cancer.

atmosphere. There were simultaneous translations in three official languages: Spanish, English and Portuguese. On the first congress day, Dr. Hugo Davila (CAU general secretary-Venezuela) and Prof. Joan Palou (Spain) moderated the Resident Educational Program CAU-REP. Several EAU professors participated in the session, such as Dr. Evangelos Liatsikos (GR) with a lecture regarding percutaneous lithiasis approach data and tricks, Prof. Arnulf Stenzl (DE) and Dr. Ignacio Moncada (ES) who discussed erectile dysfunction in Peyronie's disease. CAU16 courses More than 30 courses in various topics were given by renowned international professors from Latin America, USA and Europe. Among the topics and speakers were management of prostate cancer, CPRC, percutaneous nephrolithotomy by Dr. Jorge Gutierrez; robotic surgery, laser photovaporisation for the treatment of BPH by Prof. Manoj Monga (USA), a forum on new technologies and innovations led by Hugo Dávila (VE) and Dr. Gabriel Ogaya (USA), focal surgery for kidney and prostate cancer with Prof. Inderbir Gill (USA), Dr. René Sotelo (USA), Dr. Fernando Bianco (USA) and Dr. Rafael Sanchez Salas (FR). The European Society of Residents in Urology (ESRU) collaborated with the interactive course on Urology and Social Media directed by Stacy Loeb (USA), with the participation of the authors. The audience was highly motivated, interested in the use and expansion of Social Media in Latin America. With the official hashtag #CAU16 we have had a remarkable with 875,625 impressions and 672 Tweets. Plenary Sessions #CAU16 There were masterful plenary sessions in oncology, laparoscopy, robotics, lithiasis and andrology. Highlights on robotic surgery included updates in robot-assisted radical nephrectomy with vein thrombus by Prof. Gill, moderated by Prof. Monga and the participation of Dr. René Sotelo (USA) in complex reconstructive robotic surgery. Prof. Joan Palou lectured on robotic renal donor nephrectomy while Dr. Leticia Ruiz (PA) gave an update on the future of robotic surgery. Prof. Vipul Pattel (USA), Hugo Dávila and Rafael Sanchez Salas shared their opinions regarding preserving sexual function in robot-assisted radical prostatectomy. In laparoscopy and oncology, ESRU Secretary and YUO board member, Dr. Juan Gómez Rivas (ES) gave a lecture on laparoscopic radical cystectomy with nerve preservation and improving the functional results of laparoscopic radical prostatectomy. Furthermore, Prof. Evangelos Litatsikos (GR) presented his lecture titled “Robotic or Laparoscopic Prostatectomy: Is there really a difference?” Dr. Fernando Secin (AR) examined the limits for laparoscopic partial nephrectomy while Dr. Antonio Peña (ES) looked into retroperitoneoscopic offclamping in partial nephrectomy.

ESRU, RAEU and the CAU Residents Office The framework of the congress was a fitting venue for the ESRU and CAU Resident's Office. In a successful and friendly meeting held between Dr. Juan Gómez Rivas as ESRU Secretary, YUO/EAU board member and RAEU Chairman, and Dr. Fernando Santomil (AR) chairman of CAU Residents' Office, the groups’ common interests were discussed to strengthen the links of these two associations. Plenary sessions and CAU residents office and ESRU meeting

Comprehensive lectures included antiangiogenic therapy of renal cancer by Dr. José Manuel Cózar (AEU President, ES), prostate cancer markers and its role in active surveillance by Dr. Stacy Loeb (USA), and the role of cystectomy in bladder tumour pT1G3 treatment and immunotherapy in prostate cancer by Prof. Arnulf Stenzl (DE). In functional urology, among the highlights were Dr. Juan Carlos Castaño (CO), the clinical applications of integral theory by Dr. Paulo Palma (BRl) and painful bladder syndrome by Dr. Victor Nitti (USA). In andrology, there was a state-of-the-art lecture about erectile dysfunction by Cleveland Beckford (PA) and Pablo Mateo (DO) as well as the role of low-intensity shockwaves in the treatment of erectile dysfunction by Prof. Javier Angulo (ES) and a lecture by Dr. Hernán Carrión (USA) titled “Past, Present & future of prosthetic surgery in erectile dysfunction.” The International Society of Urology (SIU) participated during #CAU16, especially in the topic of focal therapy in prostate cancer, with well-known moderators and

On the last day of CAU16, presentations were made regarding education, training and the research interest of residents and young urologists in presentations such as "The CAU Resident's Office" by Fernando Santomil (AR), "The Training of Urological Residents in the European Union" and “The importance of Social Media in Urology Training” by Dr. Juan Gómez Rivas. Information on CAU training scholarships in Spain was given by Dr. Manuel Esteban (ES), while Dr. Gerardo López Secchi (UY) gave a presentation on the CAU Research Office. Drs. Hugo Dávila (VE) and Javier Angulo (ES) led an educational forum on postgraduate training in the CAU environment. Finally, we want to highlight the warm reception by the organizing committee and the efforts of the organisers such as Dr. Javier Angulo, Dr. Ramon Rodriguez Lay, Dr. Cleveland Beckford (PA), Dr. Irela Soto (PA) and Dr. Katherine Henriquez (PA). We hope that in the future, meetings and works of scientific interest will continue to be organised by the residents section of the CAU, RAEU and ESRU. We look forward to the next CAU Congress in Santa Cruz, Bolivia on October 17 to 21, 2017, which will surely provide us with a great scientific content.

#CAU16 data (From: Symplur.com)

European Urology Today

www.esui17.org

PCa17

ESUI17

EAU Update on Prostate Cancer

6th Meeting of the EAU Section of Urological Imaging

15-16 September 2017 Vienna, Austria

16 November 2017, Barcelona, Spain

www.pca17.org In conjunction with the 9th European Multidisciplinary Meeting on Urological Cancers

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

New technologies and limited resources

ERUS17

Robotic Live Surgery

14th Meeting of the EAU Robotic Urology Section Experts of today vs. rising stars of tomorrow

#ERUS17

In 2017, the annual EAU Robotic Urology Section (ERUS) meeting is coming to Belgium!

26-27 September 2017, Bruges, Belgium

The ERUS meeting is the scientific platform for every urologist interested in the latest technical developments and the continuous progress of urological science and practice. The meeting’s aim is to educate the urological community on robotic surgical techniques with the ultimate goal of improving the level of patient care.

Additional events on 25 September: • Junior ERUS-YAU Meeting • ERUS-EAUN Robotic Urology Nursing Meeting • European School of Urology (ESU) Courses • EAU Young Academic Urologists (YAU) Meeting • Technology forum on new robotic technologies

The 14th edition of the ERUS meeting will take place from 26-27 September 2017 and is preceded by the Junior ERUS-YAU Meeting on 25 September. Also on the 25th, the Young Academic Urologists and the EAUN (Nurses) will hold their own respective meetings.

Additional events on 26 & 27 September: • ESU/ERUS Hands-on Training in Robotic Surgery

ERUS17 will feature high-quality robotic surgery by international experts with interactive moderation. The focus of the meeting will be on practical instructions on robotic surgery with live-surgery sessions, courses by the European School of Urology and hands-on training sessions. The highly interactive format of the meeting invites fruitful discussions. A technical exhibition will be held jointly with the meeting, where manufacturers will be showcasing the latest breakthroughs. For all the latest on registrations, abstract submission and the scientific programme, please visit: www.erus17.org.

Registration is now open!

European Urology Today

Early fee registration and Abstract submission deadline: 1 June 2017

January/February 2017

EULIS17

#EULIS17

4th Meeting of the EAU Section of Urolithiasis 5-7 October 2017, Vienna, Austria Prof. Dr. Christian Seitz

Abstract submission deadline: 5 June 2017

EULIS goes to Vienna: New advances in preventing and reducing stone risk Breakthroughs in the medical and surgical management of urolithiasis will be analysed and shared in the upcoming 4th bi-annual meeting of the EAU Section of Urolithiasis (EULIS17) in Vienna, Austria. According to Prof. Dr. Christian Seitz of the Medical University of Vienna, these breakthroughs will include insights in stone development and methods to predict stone-growth risk; and personalised lifestyle and dietetic measures to reduce stone risk. Seitz further disclosed that the latest developments will also consist of new lithotripsy technology and fragment dislocation; complete removal of residual fragments and stone dust; and miniaturization of instruments, perfection of disintegration techniques and the safety measures. Internationally-known experts will convene at EULIS17 to present new research findings in the diagnosis, pathophysiology, metabolic evaluation, medical and surgical treatment of stone disease. The impact on the Quality of Life of patients will be examined as well. “We also aim to address current major challenges in the treatment of stone disease such as reducing the recurrence risk of stone formation; and achieving a stone-free status with a single procedure removing all fragments safely and without the necessity of tubes or stents,” said Seitz.

www.eulis17.org

In the coming years, Seitz looks forward to more growth and progress in the field. “I anticipate new percutaneous lithotripsy

devices that will have the ability to dust all different stone compositions. There will be simple removal of all residual stone material independent and regardless of size. I expect prediction of stone risk and stone recurrence through genetic counselling, as well as, recurrence prevention through basic research on receptors and genetic counselling,” said Seitz. EULIS17 will deliver the best in the field of care and treatment of stone disease. Distinguished experts will demonstrate and share their surgical skills and knowledge through live and semi-live surgery sessions, informative lectures and point counterpoint debates. Be fully updated in three days with these latest developments and more! Send in your abstracts for EULIS17 now! Submit your abstract(s) for EULIS17 as the meeting will provide you a unique opportunity to present and discuss scientific work with colleagues and experts in the field. “Based on content, originality and quality, most of the selected abstracts will be part of the poster sessions and few will be in the plenary or sub-plenary sessions,” said Seitz. Submit your abstracts now via the online abstract submission system www.abstracts.uroweb.org/SignIn and get the chance to present to an esteemed expert audience! Looking forward to see you in Vienna!

www.esur17.org

ESUR17 24th Meeting of the EAU Section of Urological Research 12-14 October 2017, Paris, France

ELUTS17 European Lower Urinary Tract Symptoms meeting

12-14 October 2017 Berlin, Germany

www.eluts17.org

January/February 2017

European Urology Today

Health illiteracy in urological patients Helping illiterate patients achieve optimal healthcare Dr. Michael Van Balken Rijnstate Hospital Dept. of Urology Arnhem (NL)

mvanbalken@ rijnstate.nl

Today, however, when there is an increasing amount of our information presented to our patients such as printed brochures and websites, problems arise: the health standard of millions of people in Europe who are unable to read and write at a proper level will further fall behind. Illiteracy is the inability to read or write and in the Netherlands alone, 250,000 men and women out of a population of 17 million are identified as illiterates. Even more people – 2.5 million over the age of 18 - are considered to have low literacy skills: they have trouble fulfilling tasks most of us think are easy such as reading a menu, writing an email or finding out a train schedule. Most of these people lack other abilities as well, such as digital skills and mathematical calculation. Almost all of them should be regarded as being ‘health illiterate’, meaning they lack knowledge, motivation and competencies to access, understand, appraise, and apply health information to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion, or to maintain or improve quality of life. If these figures surprised you they are worse for most of the other European countries. In the “Comparative Report on Health Literacy in Eight EU Member States” (2012), health Illiteracy was investigated in Austria, Bulgaria, Germany (North Rhine-Westphalia), Greece, Ireland, Netherlands, Poland, and Spain, showing inadequate to problematic health literacy in 28.7% of the study participants in the Netherlands and up to 62.1% in Bulgaria (mean 47.6%). Unfortunately, these numbers are unlikely to change within a short time. European Association of Urology Nurses

Patients with low health literacy skills often miss their appointments. Or show up on the wrong date or location. They visit the hospital more often than literate people do, as they don’t understand the given information very well, or follow instructions wrongly. Please note that words that seem so clear to us, like ‘impotence’ or ‘incontinence’ are only understood by a minority of people. But illiteracy also results to, for example, not stopping anticoagulants before an operation or having eaten while not allowed to, leading to the cancelation of procedures. In the Netherlands, it is estimated that these issues result in extra costs of 127 million euros every year. More importantly, besides logistic and financial consequences, health illiteracy results in worse health outcome parameters, partly because of the fact patients only seek help in a more advanced stage of their disease, and partly because of the impact of not understanding instructions on treatment outcome. Especially the proper use of medication can be a real challenge. Vaginal ovules don’t do very well when swallowed. Injection therapy practiced on an orange, should not be continued on oranges at home. Medication intended for chronic use should not be stopped because the pharmacist only gave pills for two weeks to start with, to make sure there are no side effects. These examples may sound funny, but they do happen. Mortality rates among illiterates Sadly, all things combined even lead to higher (complication and) mortality rates in health illiterate patients. In a large Swedish study (S.K. Hussain, 2007) positive association was found with the mortality rates in 13 different cancer types, four of them urological: kidney, bladder, prostate and testicular cancers. Adjusted for all kinds of other socioeconomic factors, compared with women and men completing <9 years of education, university graduates were associated with a significant 40% improved survival for all cancer sites combined. As health illiteracy is

5 Verdere plan

Blaastumor 1 Kijkonderzoek

Een dokter onderzoekt de tumor in het laboratorium. Dit duurt ongeveer 10 dagen.

5 Verdere plan

De uroloog heeft in uw blaas gekeken. Daar zag hij een tumor.

2 Voorbereiding operatie

De uroloog praat met u over de uitslag. Wat moet er gebeuren? U krijgt misschien een kijkonderzoek, een operatie of medicijnen.

De uroloog zal de tumor weghalen met een operatie.

U krijgt een afspraak bij de anesthesist (slaapdokter) om de verdoving te bespreken.

In health care, having a patient optimally informed is of the utmost importance. Well-informed patients take better care of themselves, tend to have fewer complications, have better treatment outcomes and feel more in charge of their own health.

Obviously this has consequences on issues regarding health promotion and disease prevention. In case people are unable to access, understand, interpret and judge the relevance of information on risk factors or health issues, undoubtedly this will affect their health. For urological patients: will they act on alarm symptoms appropriately? Know the effects of smoking on the risk of bladder cancer? Or erectile dysfunction? Will they be able to outweigh the pros and cons of PSA testing? To use decision aids once urological disease is diagnosed? Will they really be able to participate in shared decision-making?

Part of a bladder cancer patient information leaflet for illiterate patients of the Dutch Urological Association (NVU)

more often seen in people with lower education, results like this are of big concern. What makes it difficult to act on the problem of low health literacy skills is the lack of awareness amongst those who deliver care (“I hardly ever see a patient that can’t read”), but also the tendency amongst patients not to come forward as someone with reading problems. Many of these patients feel ashamed, not in the least because of a society that equals illiteracy with stupidity. They’ve become masters in coming up with excuses like “I forgot my glasses”, “I’ll fill out the form later” or “Oh dear, I forgot to bring the form”. More awareness of the problem and especially a noncondemning attitude amongst care-givers may ease patients to come forward, so extra help can be offered.

leaflets full of text into leaflets with hardly any text at all, but consisting of easy to understand images. The leaflets are made by urologists and low literate people together, as are the corresponding animations. As all of us who can read perfectly are already shifting from text to images and video’s on our smartphones, tablets and desktops, and the use of spoken animations will not only benefit those who have low heath literate skills. It is known that those who can’t read obtain the same level of information after watching spoken animations as literate people do.

The European Association of Urology is well on its way to invest in new ways of patient education. Challenges include how to make sure these animations reach people that not only have low literacy, but also low Another big step is to adjust the way we hand out - or digital skills, as well as how to make the animations less fancy and ‘professional’. The more simple the text seek for - information. Instead of forms, leaflets and and the visuals the better the understanding will be. websites full of text, images, speech and animations Collaboration with experts in the field and patients should be used. It has been shown that the therefore is of the utmost importance. International Prostate Symptom Score can easily be replaced by one consisting of only a few images, with comparable results. The same goes for voiding diaries Learn more about this important topic at the dedicated session at the 18th International EAUN with pictograms. Websites full of text could be Meeting, London. The session will take place: provided with a ‘read out aloud’-button (also Monday, 27 March, 9.45 – 10.15 hrs., convenient for the visibly impaired). In the Room 3/4 (Level 3). Netherlands, the Dutch Urological Association State-of-the-art 6: Illiteracy and health literacy embraced the ‘Aap-Noot-Nier’-project (a urological, in patients humoristic reference to the first three words Dutch Dr. M.R. Van Balken, Arnhem (NL) people used to learn reading), a project turning

Book review SUNA Core Curriculum for Urologic Nursing Stefano Terzoni, Rn, PhD EAUN Chair Milan (IT)

Two separate parts of the book are dedicated to caring for women and men, respectively, and cover incontinence, sexual dysfunction, chronic pelvic pain, and infertility. Genitourinary cancers are treated in a dedicated section, with single chapters covering s.terzoni@eaun.org renal, bladder, urethral, prostate, penile, and testicular cancer. Other urologic conditions such as The Society of Urology Nurses and Associates (SUNA), polycystic kidney disease, stones, obstructions, based in the USA, has just released the first edition of infections, neurogenic lower urinary tract dysfunction, its Core Curriculum for Urologic Nursing. stomas, and trauma are covered by other specific chapters, one for each topic. Perioperative and Edited by Diane K. Newman, Jean F. Wyman, and post-operative care are thoroughly discussed; specific Valre W. Welch, this book gives an outstanding considerations are made for older urologic patients. contribution to education in urological nursing. The book is divided into 51 chapters, grouped into nine All topics are presented through a consistent scheme sections for a total of around 750 pages, and covering in all chapters, which cover the full pathway of various aspects of the subject. patients and provides information on definitions, epidemiology, aetiology and pathophysiology, clinical manifestations, screening and assessment, After an overview of urologic nursing and health promotion, care of infants and children is discussed management, and follow-up. The chapters are rich in in-depth, from embryology and development of the figures and tables; all essential points are presented urinary tract, to assessment, malformations, disorders as bullet lists, so that the reader can easily find the of the genitalia, and common problems such as most relevant information. This makes the book stones, voiding dysfunctions, infections, and cancer. valuable not only for studying, but also as a reference Urologic care of adults is divided into several sections, manual for clinical nursing. European Association of Urology Nurses

European Urology Today

provided to ensure the best possible patient outcomes. Considerations on advanced nursing practice are presented in tables and schemes.

with each section examining specific issues. Assessment of male and female patients is covered, as well as laboratory tests, imaging, endoscopy, interventional radiology, and urodynamics.

Practical information is provided, both as suggestion regarding procedures, and relevant clinical data such

All references are reported at the end of each chapter, thus allowing further readings; all relevant guidelines, including those published by the EAU and EAUN, are present. Thousands of other important and recent papers are cited; overall, the bibliography is up-to-date to 2016, and most articles have been published in the last five years. This book is very complete and concise at the same time; evidence-based and best practice recommendations are highlighted. The typesetting allows quick retrieval of relevant information, thus making the Core Curriculum valuable for both education and clinical practice in all settings. Overall, the goal of providing the readers with the means to build competence as advanced practice nurses, as stated in the foreword by the editors, is fully achieved. as pressure levels, dosage of drugs, and expected duration of conditions and treatments. Comparative tables allow deeper understanding of the many characteristics of the medical devices used in urology (e.g. stents, tubes, and catheters), which are described and depicted in detail, to help the reader take note of important features or caveats. Urologic tools, such as endoscopes, are depicted and described as well; so are urodynamics diagrams, with the clinical significance described in detail. Manual procedures such as dressings are presented as checklists, and best practice recommendations are

Editors : D. K. Newman, J.F. Wyman, V.W. Welch ISBN : 978-1-940325-28-6 e-Book : available Published : Nov. 2016 Publisher : SUNA Edition : 1st Binding : soft Price : 199$ (SUNA members 149$) Pages : 700+ Website : www.suna.org/core Sponsors : 180 Medical, Hollister, Sagent Urology January/February 2017

EAUN Nursing Workshop in Dubai EAUN joins 5th Emirates International Urological Conference Simon Borg EAUN Board Member Mater Dei Hospital Inpatients Theatre Msida (MT)

than Susanne Vahr because of her salient contribution to this topic. She expertly guided the participants on the importance and applicability of such guidelines and the importance of an evidence-based practice and guideline development. It was very encouraging to hear that many participants, who informed us later in the day, are well acquainted with our guidelines and use it as reference in their practice.

Former EAUN Chair Bente Thoft Jensen discussed “Anatomy and Neurological Control of the Bladder – Assessments and Anamnesis. Bente Thoft Jensen’s The 5th Emirates International Urological Conference expertise on this subject and her unique immersive (EIUC) held from 15 to 17 December last year in Dubai yet friendly presentation skills, held the delegates was a true testament of the Emirates Urological attention to this extensive topic. Her presentation was Society’s (EUS) mission to strengthen and promote very detailed yet easy to follow with practical the practice of urology medicine, disseminate explanations on a topic that is not always well knowledge and promote innovation. understood by the nursing community. The nurses took very well to her presentation, as was very evident With over 70 expert speakers in this field, disseminating further on in the day during the practical sessions. excellent work in a multitude of workshops and symposia, the 5th EIUC could be truly described as a Enthusiastic discussions gem in the urological conferences calendar. The EAUN Board member Corinne Tillier presented on European Association of Urology Nursing (EAUN) is “Rationale and indications for pelvic floor muscle proud and grateful to participate in this event by training – How to teach pelvic floor exercises effectively organising the full-day nursing workshop presentation to patients.” Tillier’s extensive and well-prepared on December 16, thanks to Dr. Yasser Farahat and the presentation was a credit to her expertise and EUS for inviting us for the second time. The nursing competence. It appeared that for many of the nursing workshop was attended by 68 nurses. delegates the topic was somewhat new, and they found her presentation of great interest and easy to We started the day with my introduction to the EAUN. follow. Their eagerness to know more was very In this short opening speech, I addressed the EAUN’s tangible during the practical session that followed the core objectives and function, with an overview of our presentation. organisation’s history, growth and international educational partnerships. This was also an opportunity During the practical session the delegates were to mention the benefits of an EAUN membership and I divided into groups with Bente and Corinne expertly ended the talk with an invitation to join us in our going through the practical side of their respective upcoming EAUN Annual conference in London. presentations. This was well-received, with enthusiastic participation and eagerness to know I was followed by an excellent presentation by EAUN more and try on, “hands-on,” the exercises illustrated Chair Elect Susanne Vahr, on “How to Read Guideline- in the previous two presentations. The evidence base for developing guidelines.” Our various EAUN Guidelines are actually our “tour de After a sumptuous lunch break, Susanne Vahr force” and there isn’t a more versed expert in this field discussed “Recommendations for insertion and care of s.borg@eaun.org

Workshop presenters (from left): Simon Borg, Bente Thoft Jensen, Corinne Tillier and Susanne Vahr

an indwelling catheter”. This presentation followed very closely the EAUN’s Indwelling Catheter Care Guidelines which Susanne Vahr has extensively worked on. In a sense, it was a follow-up update of last year’s excellent guideline presentation, this time focussing on the specific criteria for insertion and care of indwelling catheters. After Susanne Vahr’s second presentation, I presented “Management of Endoscopes: Fundamental principles for Nurses”. This, like all the preceding presented topics, was very broad and difficult to compress in the allocated time. I discussed the different stages that our expensive endoscopes go through with an emphasis on cost management applications and practical examples as reference. The emphasis of this presentation was to give the delegates a window on the science that goes into our endoscopic work with attention to health and safety aspects. There was a sponsored presentation on laser use and the science behind it from a surgeon’s perspective that, in many ways, concurred with a part of my presentation. The EAUN workshop was also held in a larger hall than last year due to the bigger attendance and we had five “hands-on” tables as opposed to just one

during last year for our practical sessions. A pleasant surprise was the availability of local product specialist representatives who conducted most of the individual practical sessions themselves. This gave us the opportunity to answer the many questions during our talks. It was also noted that there is a need to elaborate more on the nursing role in Urodynamics Studies, which is a recurrent issue. Another topic that led to a surprisingly many interesting queries was on laser safety application during endoscopic lithotripsy, a topic that was mentioned briefly due to time constraints. Just as with the urodynamic studies, these laser safety issues are of concern to the participants and may warrant further dedicated workshops in the future. At the end of the day, we conducted a test with a selection of questions dedicated to each presentation. We were pleased that the average mark was very high and that was a great reward and a positive way to end this all-day Nursing Workshop. At the end of the conference we were all treated to a delightful Conference Dinner at Al Qasr, a fitting and lasting testament to the EUS’s excellent hospitality and organisational credentials that are second to none.

www.erus17.org

ERUS17 14th Meeting of the EAU Robotic Urology Section

Robotic Live Surgery

25-27 September 2017, Bruges, Belgium

Special ERUS-EAUN Robotic Urology Nursing Programme

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

37th

Congress of the Société Internationale d’Urologie Centro de Congressos de Lisboa

www.siu-urology.org

OCTOBER 19–22, 2017

Featuring the SIU-ICUD Joint Consultation on Bladder Cancer and the 3rd SIU Nurses’ Educational Symposium ABSTRACT SUBMISSION DEADLINE: APRIL 3, 2017 EARLY REGISTRATION DEADLINE: JUNE 2, 2017

An Exciting New Development in eLearning! You can now access all the educational activities available on SIU Academy from your iPhone/iPad and Android devices wherever you are!

January/February 2017

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Client:

SIU 2017

2017-01-12 2:39 AM European Urology Today 37

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Revisiting the Asia-Pacific Prostate Cancer Conference Four-day multidisciplinary conference gives insights on PCa nursing care Sue Osborne Urology Nurse Auckland (NZ) •

sue.osborne@ waitematadhb.govt.nz

•

In the December edition of this newsletter, I reported on my attendance at the Asia – Pacific Prostate Cancer • Conference which ran from 31 August to 3 September 2016 at the Melbourne Convention and Exhibition Centre in Australia. My column focused on some of the sessions of particular interest to me, from the medical stream of the multidisciplinary programme. • This column revisits the same conference, this time reporting on some of my key learning’s from the excellent nursing and allied health programme.

that GB men often felt their prostate cancer treatments had ‘aged them’ before their time. For some GB men, loss of sexual functioning meant loss of functioning in their community. Prostate cancer treatments like radical prostatectomy challenged gay identity as well as masculine identity because of ejaculate loss. Ejaculation is an important measure of pleasure from sexual activity for GB men. Urinary incontinence is more worrying for GB men. It appeared to create more situations of embarrassment particularly in the context of casual relationships. Both GB and heterosexual men felt that the loss of penile length associated with radical prostatectomy was not really known in advance. GB men appeared to find this treatment complication especially worrying. GB men commonly redefined sex after prostate cancer treatments. They identified sex was not solely defined by ‘penetration’, and reported more use of sexual aids and experimentation to reclaim their sexuality. GB men also demonstrated an ability to redefine intimacy. An observation was made that heterosexual men may benefit from widely adopting similar strategies. Both GB and heterosexual men reported a loss of desire associated with a prostate cancer diagnosis. Both experience changes in erectile function and strength of orgasm plus sexual pain related to orgasm. GB and heterosexual men reported a threat to their masculinity with emotional consequences, including depression, observed in both groups. Heterosexual men tend towards being more resigned to the changes in their sexuality, rationalising that they ‘were getting old anyway’ or that ‘their sex life was good, but now it’s over’. These sentiments are not similarly expressed by GB men, with this group more commonly tending to resist and renegotiate the changes.

‘Let’s talk about Gay Sex’ was a very informative and thought-provoking session, exploring gay and bisexual (GB) men’s experience of prostate cancer. The session was delivered by Ms. Janette Perz on • behalf of University of Western Sydney Professor Jane Ussher, who was unable to attend the conference at the last minute. The content focused on the findings of an Australian mixed method research project funded by the Prostate Cancer Foundation of Australia. This charitable organisation is a leader in funding research into the impacts of prostate cancer on GB men and in publishing information specifically for this group. The research findings indicate that GB men have significantly higher psychological distress and prostate cancer anxiety compared to heterosexual men. GB men also reported being less satisfied with the prostate cancer-related psychological and medical care they received than heterosexual men (70% GB men were happy with their care, compared to 85% heterosexual men). As I left this session, I found myself reflecting on the care the urology team at my workplace deliver to men Prof. Jane Ussher alerted health professionals as to who identify as GB. Another session that had a similar how the differences in the relationship contexts of GB effect on me was the breakfast workshop presentation men affect the care and support they may require, on Motivational Interviewing, delivered by health and following a prostate cancer diagnosis. Key messages well-being training consultant, Genevieve Muirfrom this session included: Smith. She challenged us to consider how we engage and communicate with our patients in a manner that • GB men are more likely to be in newer will motivate them for change, rather than against it. relationships, of less than 10 years duration, than heterosexual men. They are also more likely to An example of a prostate cancer-related scenario have had more than two partners in the previous where motivational interviewing techniques could six months. prove useful would be a therapeutic interaction with • GB men value youth. The speaker advised that it an overweight man on androgen deprivation therapy takes confidence to age in the gay community and who is resistant to engaging in any form of exercise. Muir-Smith outlined how the use of a decisional balance tool can help a patient evaluate their European Association of Urology Nurses situation in a supportive, non-threatening way.

The tool encourages the patient to examine their view on the pros and cons of their current behaviour (e.g. sedentary lifestyle) and a preferred behaviour (e.g. 15 minutes daily aerobic exercise). Thought-provoking questions include ‘What makes change difficult for you?’, ‘What would be difficult about undertaking the preferred behaviour (daily exercise)?’, ‘What would be good about making this change (daily exercise)? ’and ‘How would it feel to achieve this goal?’ The communication techniques suggested to deal with a patient’s resistance are well familiar to nursing: the use of open ended questions, reflective listening, summarising what has been said and affirming the positive change. The audience was reminded to ask questions that seek an emotional response not a factual one as people are more likely to change behaviours based on emotions. This sense of reflection was a common experience for me at the end of many of the multidisciplinary presentations over the four-day conference, invigorating me in a way that only education and networking with like-minded experts can. With the EAU/EAUN Congress fast approaching I know many of you will be looking forward once again to the

opportunity to explore your units urological practice in light of new evidence and the shared experiences of experts.

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

Stefano Terzoni (IT) Susanne Vahr (DK) Lawrence DrudgeCoates (UK) Paula Allchorne (UK) Simon Borg (MT) Linda Söderkvist (SE) Corinne Tillier (NL) Jeannette Verkerk (NL) Giulia Villa (IT)

www.eaun.uroweb.org

HYPERLINKS

The International Journal of

Urological Nursing

- the official Journal of the BAUN International Journal of

Urological Nursing the journal of the baun

ISSN 1749-7701

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European Urology Today

Associate Editor Jerome Marley wileyonlinelibrary.com/journal/ijun

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

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European Association of Urology European Nurses Association of Urology Nurses

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

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Visit: www.wileyonlinelibrary.com/journal/ijun

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Volume 10 • Issue 2 • July 2016

January/February 2017

EAUN Fellowship Programme on robotic surgery Practical lessons for nurses at OLV Hospital in Aalst, Belgium Elisabeth Rundin Clinical Manager Urology Surgery Dept. Karolinska University Hospital Solna (SE) elisabeth.rundin@ karolinska.se

Linda Söderkvist Urology nurse Urology Surgery Dept. Karolinska University Hospital Solna (SE) Linda.soderkvist@ karolinska.se

OLV hospital in Aalst, front view

nursing care for these patients, pre, peri and post-operatively.

We work at the Urology Surgery Department at Karolinska University Hospital in Stockholm as operating room nurses specialised in urology surgery and robotic-assisted surgery, and our department mainly treats prostate and bladder cancer patients.

With our motivational letter, application, clinical history and CV, we received approval from the EAUN Board and we spent one week from 17 to 21 of October 2016 in Aalst, Belgium to learn from Dr Alex Mottrie, one of the world leading experts in urological oncology, with a specialty in partial nephrectomies, and his operating team.

These surgeries are almost exclusively performed robotically today. We do around 600 robotic-assisted cases every year. In 2018 we will move to the new Karolinska University Hospital which will mainly focus on providing healthcare to patients that need highly specialised surgery and hospital care. It will comprise a larger robotic centre and due to organisational matters and centralised care more advanced robotic-assisted urology surgery will be performed. Not only will we move to a new building, the patients that will be treated here will have different needs.

“Dr. Mottrie and his operating room staff offered us crucial knowledge regarding the standardisation of the surgical procedures for partial nephrectomies to maintain patient safety during surgery”

To meet the future needs of urology surgery that most likely will be performed at the new hospital, we applied for the EAUN Fellowship Program to gain clinical competence in treating patients suffering from kidney cancer since we felt we lack this competence as operating room nurses. We already know that performing robotic-assisted partial nephrectomies requires a well-prepared operating team with experience and knowledge. The risk of serious complications such as bleeding and converting to open surgery is always high. The renal artery is clamped prior to the actual partial nephrectomy and the surgeon must operate under ischemia time. Clamping the renal artery and the removal of the clamp is associated with the high risks mentioned above. Also, the positioning of these patients must be performed with great anatomical knowledge to avoid pressure wounds and nerve damage. The fellowship program would allow us the opportunity to get in-depth knowledge regarding

OLV Hospital The surgical department at OLV Hospital in Aalst, Belgium has 17 operating rooms. Urology surgery is performed in three to four of these operating rooms every week, depending on the day. The department has three Da Vinci systems and one of these is the latest version called Xi. Approximately 570 to 600 robotic-assisted urologic cases are performed here every year covering prostatectomies, partial nephrectomies and cystectomies. The hospital performs around 100 robotic-assisted partial nephrectomies every year, or around two cases a week. The Urology Clinic and its surgical department together with ORSI, a clinical training site with dry and wet lab for robotic assisted surgery located some kilometres from Aalst, form a training centre, one of four in Europe. The other three centres are located in Paris, Strasbourg and Stockholm.

European Association of Urology Nurses

January/February 2017

Meeting training goals Based on our goals, we are satisfied with all the new knowledge and competence we gained from this experience. We have realised that spending time at a hospital outside your own country can provide much more. By learning from others, we started a process

of reflecting why we do things the way we do and how we can improve our work. Moreover, it also made us proud of what we have accomplished in our own hospital. Educating ourselves creates an awareness of how we can be the best nurses and provide the best care to our patients.

Post-op unit in the early morning. Very bright and spacious!

Fellowship Programme European Association of Urology Nurses

As a training centre, the urology surgery department has many visitors from all over the world. Doctors and operating teams that undergo training here are visiting both the hospital and ORSI as part of their training. We could tell that they were very used to educate and teach clinically, something we experienced during our fellowship. Learning outcomes Dr. Mottrie and his operating room staff offered us crucial knowledge regarding the standardisation of the surgical procedures for partial nephrectomies to maintain patient safety during surgery. The head surgeon (a urologist) and one of the assistant residents showed us how to position the patient prior to surgery and they went through all aspects. The operating room nurses showed and explained all the instruments used and what to have nearby the operating room and what to have ready on the table in case of bleeding or converting to open surgery. The technical aspects of handling the robot during these specific procedures were also explained.

Me on the OR

Dr. Mottrie and us in the hospital

The first assistant taught us port placement for the procedure and what to consider placing these, docking the arms and handling any external conflicts of the robotic arms during this type of surgery. Postoperatively, we followed the patients to recovery room and further to the urology ward. We interviewed an intensive care nurse and a urology ward nurse to find out the crucial aspects of nursing for patients that underwent a partial nephrectomy or a nephrectomy to learn what a normal and expected postoperative recovery is and what is not. The same went for preoperative examination and information to the patient.

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 31 August 2017 • Only EAUN members can apply • Host hospitals in Belgium, Denmark, the Netherlands, Sweden, Switzerland and the United Kingdom • A great way of widening your horizon For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

European Association of Urology Nurses

European Urology Today

Online registration deadline: 6 March 2017

25-27 March 2017, London, UK Stefano Terzoni, Chair EAUN

Scientific Programme at a glance Saturday, 25 March 09.00 - 10.00 Plenary Session Specialist nursing and nursing specialists. Are they the same and why should we care? 09.00 - 09.05 Welcome to EAUN17 S. Terzoni, Milan (IT) 09.05 - 09.10 Welcome to London C.R. Chapple, Sheffield (GB) 09.15 - 09.35 Advancing urological practice. Challenges from the literature? J.T. Marley, Newtownabbey (GB) 09.35 - 09.55 Nurse-led clinic for men with suspected prostate cancer - exemplar P. Aslet, Basingstoke (GB) 10.15 - 11.15 10.15 - 10.20 10.20 - 10.35 10.35 - 10.50 10.50 - 11.05

Thematic Session 1 Female urology Introduction Female urology L.S. Mertens, Amsterdam (NL) Genitourinary Syndrome of Menopause (GSM) D. Holloway, London (GB) Bladder prolapse. Symptoms and treatment C.I. Carvalho Ferreira, Matosinhos (PT)

10.15 - 11.15 10.20 - 10.35 10.35 - 10.50

Thematic Session 2 Challenges in testicular cancer Testicular cancer. An overview and update M.P. Laguna, Amsterdam (NL) Nursing support and follow-up in testicular cancer care L. Shephard, London (GB) Exploring the treatment challenges in men with an intellectual disability and testicular cancer N. Love-Retinger, New York (US)

10.50 - 11.05 11.30 - 12.30 11.35 - 11.50 11.50 - 12.05 12.05 - 12.20

Thematic Session 3 Advanced urodynamics Future trends in urodynamics P.F.W.M. Rosier, Nijmegen (NL) Urodynamics in women. Current issues, challenges and practice T.A. Schwennesen, Århus (DK) Urodynamics in men. Current issues, challenges and practice T.A. Schwennesen, Århus (DK)

11.30 - 12.30 11.30 - 12.30

Special Session Nursing solutions in difficult cases Deviating from the standard – Stoma care of a patient with trisomy and autistic tendencies C. Hübsch-Aepli, Zürich (CH) 11.45 - 11.55 Robotic surgery in kidney transplantation. Nursing role in the first European case T. Alonso Torres, Barcelona (ES) 11.55 - 12.05 Post-operative complications post Radical Robotic Prostatectomy T.b.c. 12.05 - 12.15 Treating 'complications' post Radical Robotic Prostatectomy M. O'Brien, Dublin (IE) 12.45 - 13.45 Thematic Session 4 Joint EAUN-ICS Session. Challenges with urine incontinence 12.50 - 13.05 ICS Lecture. Intervening when patients are not able to use standard CIC S. Eustice, Truro (GB) 13.05 - 13.20 The effect of urinary incontinence on health related quality of life. Is it similar in men and women? D.A. Bedretdinova, Paris (FR) 13.20 - 13.35 Is surgery the answer for urinary incontinence? W. Naish, Redhill (GB) 14.15 - 16.00 Poster Session 1 Chairs: B.T. Jensen, Århus (DK) J.T. Marley, Newtownabbey (GB) 14.15 - 15.15 14.20 - 14.35 14.35 - 14.50 14.50 - 15.05

Thematic Session 5 Acute and chronic kidney failure Acute and chronic renal insufficiency F.M.E. Wagenlehner, Giessen (DE) Patient counselling for chronic kidney disease G. Rütti, Berne (CH) The importance of diet for patients with chronic renal insufficiency M. Borre, Århus (DK)

15.30 - 16.00 State-of-the-art 1 A summary of the intermittent catheterisation guidelines S. Vahr Lauridsen, Copenhagen (DK) 16.15 - 17.15 16.20 - 16.40 16.40 - 17.05

Thematic Session 6 High-risk non-muscle invasive bladder cancer. What's new? Innovations in treatment for high-risk nonmuscle invasive bladder cancer K. Hendricksen, Amsterdam (NL) Unmet psycho-social needs in bladder cancer N. Mohamed, New York (US)

in conjunction with

European Urology Today

#EAUN17

16.15 - 17.15

16.40 - 17.05

Thematic Session 7 Nursing research in urology. Who's afraid of the big bad wolf? Exploring the anatomy of a urological research paper R. Leaver, London (GB) Statistics without tears - it can be done P. Slater, Coleraine Co. Londonderry (IE)

17.30 - 18.00

State-of-the-art 2 E-health and empowerment F. Geese, Berne (CH) L. Shephard, London (GB)

16.20 - 16.40

Sunday, 26 March 08.30 - 09.30 Thematic Session 8 Tomorrow is already today. Urology healthcare in the near future 08.35 - 08.55 e-Health in urology. What can we expect? H.G. Van Der Poel, Amsterdam (NL) 08.55 - 09.10 Online health information seeking among patients J. Moreland, Elgin (GB) 09.10 - 09.20 Urology nursing tomorrow. Web consultation W.M. De Blok, Utrecht (NL) 08.30 - 09.30 Thematic Session 9 Challenges and opportunities in geriatric onco-urology care 08.35 - 08.50 Improving care of elderly persons affected by urological cancer. The place of the advanced nurse specialist in geriatrics/oncology A. Roveri, Rennes (FR) 08.50 - 09.20 Person-centred cancer care in the elderly B. McCormack, Musselburgh (GB) 09.45 - 10.15 State-of-the-art 3 Exploring patients' lack of engagement with structured education - Lessons from diabetes care D. Chaney 09.45 - 10.15 State-of-the-art 4 Survivorship care programme in surgical oncology T. Juul, Århus (DK) 10.30 - 12.15 Poster Session 2 Chairs: B.T. Jensen, Århus (DK) J.T. Marley, Newtownabbey (GB) 10.30 - 11.30 10.35 - 11.00 11.00 - 11.25

Thematic Session 10 The urology nurse as patient advocate. Forgotten role? Nurse advocacy. Is it hiding in plain sight? H.A.M. Van Muilekom, Amsterdam (NL) Nurse advocacy. What does ethics tell us? D. Watson, Amsterdam (NL)

11.45 - 12.15 11.45 - 11.55

Special Session Nursing research competition Quality of life in penile cancer patients. A survey of patient reported outcomes t.b.c. 11.55 - 12.05 Improving quality of life in patients with neurogenic bladder V. Katsarou, Athens (GR) 12.05 - 12.15 DACOACH - Feasibility of self-tracking and data-guided health-coaching via personal, mobile and wearable devices in chronic care management L.F. Øbro, Vejle (DK) 12.30 - 15.00 EAUN-ESU Course 1 Learning curve in urological surgery 12.30 - 12.50 Indications and limitations of robot assisted surgery J.W. Collins, Stockholm (SE) 12.50 - 13.10 Starting with robot assisted surgery in your OR. Wisdom, warnings and what I wish I would have known A. Hartman 13.10 - 13.30 Patient installation and robot positioning J.W. Collins, Stockholm (SE) A. Hartman 14.00 - 14.20 Learning curve for the surgeon J.W. Collins, Stockholm (SE) 14.20 - 14.40 Learning curve for the nurse A. Hartman

15.45 - 16.15

Corinne Tillier, Chair SCO

Proposer. B. McGowan, Newtownabbey (GB)

16.30 - 17.30 Thematic Session 11 Joint EAUN-BAUN session. Current issues in urological care 16.40 - 16.50 Brexit - in or out? J. Brocksom, Leeds (GB) 16.50 - 17.00 The recovery package M. Bagnall, Wallsend (GB) 17.00 - 17.10 A novel APP approach to nurse-led renal catheter care K. Melchiorsen, Århus (DK) 17.10 - 17.20 Leadership driven care implementation. From bench to bedside L. Aarvig, Århus Nord (DK)

Monday, 27 March 08.30 - 09.30 Thematic Session 12 Lymphoedema in urological patients after pelvic lymph node dissection 08.35 - 08.50 Lymfoedema after pelvic lymph node dissection. Defining, preventing and treating I. Schollema-Noordhoff, Drachten (NL) 08.50 - 09.05 Pre- and post-operative evaluation of patients at risk of lymphoedema M. Pinto, Naples (IT) 08.30 - 09.30 Thematic Session 13 Drug-resistant microorganisms in urology. Is there an avalanche coming? 08.30 - 08.45 The global prevalence of infections in urology study. A long-term, worldwide surveillance study on urological infections F.M.E. Wagenlehner, Giessen (DE) 08.45 - 09.05 Antibiotics. Has the urological time bomb exploded? t.b.c. 09.05 - 09.20 What is the role of nurses in the prevention of CAUTI (catheter-associated urinary tract infections)? N. Bartlomé-Wyss, Aarau (CH) 09.45 - 10.15 State-of-the-art 6 Illiteracy and health literacy in patients M.R. Van Balken, Arnhem (NL) 09.45 - 10.15 State-of-the-art 7 Unlocking the potential of social media in nursing T. Chinn, Bristol (GB) 10.30 - 12.30 EAUN-ESU Course 2 Urostomy/urinary diversion. Clinical pathway for the management of patients who undergo a cystectomy 10.30 - 10.45 Oncological and non-oncological indications for cystectomy J.A. Nieuwenhuijzen, Amsterdam (NL) 10.45 - 11.00 Stoma or continent reservoir? O.W. Hakenberg, Rostock (DE) 11.00 - 11.15 What, when and how to explain to a patient everything about a urostomy S.P. Fillingham, Kent (GB) 11.15 - 11.30 Continent Urinary Diversion. A patient's view (Mitrofanoff Support UK) K. Rogers, Bournemouth, Dorset (GB) 11.45 - 12.00 Complications after radical cystectomy J.A. Nieuwenhuijzen, Amsterdam (NL) 12.00 - 12.15 Follow-up after cystectomy O.W. Hakenberg, Rostock (DE) 10.30 - 11.30 10.30 - 10.50 10.50 - 11.10 11.10 - 11.30

Thematic Session 14 Rare cases and diseases in urology Urachuscarcinoma M.A. Behrendt, De Meern (NL) Adult hypospadias P. Hoebeke, Gent (BE) Penile carcinoma. An update N.M. Graafland, Woerden (NL)

11.45 - 12.45

Thematic Session 15 Urology nurses. Demonstrating our worth to the people who matter Valuing what we do, so that we can do what we value A. Leary, London (GB) Recognition of urology nurses in the south of Europe T. Santos, Barreiro (PT)

11.50 - 12.20 12.20 - 12.35

14.00 - 14.45 Video Session Chair: S.J. Borg, St. Julians (MT)

13.00 - 13.45 Special Session General Assembly

15.15 - 15.45 15.20 - 15.45

State-of-the-art 5 Prostatitis, types and treatment J. Shah, London (GB)

14.00 - 14.15

15.45 - 16.15

Special Session 'Westminster House of Commons' Session. This house believes that patients do not know what treatment is best for them Opposer. D. Watson, Amsterdam (NL)

15.45 - 16.15

Award Session

Registration for hospital visits, urowalk and nurses' dinner through the online system or send an e-mail to eaun@uroweb.org