European Urology Today January/February 2018

European Urology Today Official newsletter of the European Association of Urology

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Vol. 30 No.1 - January/February 2018

EAU18 Sneak Preview

Urodynamics for female SUI

Movember’s GAP3 initiative

From precision medicine to UROlympics, take a look on what to expect during the Annual EAU Congress!

UDS indications in female SUI? Prof. H. Hashim and Dr. R. Al Mousa provide an overview.

Movember's Global Action Plan focuses on active surveillance in low-risk PCa. Know the details of this initiative.

Prof. A. Stenzl

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Dr. Riyad Al Mousa

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Dr. Jozien Helleman

EAU18: Top picks for EAU18 by leading experts Key opinion leaders give a glimpse into the Plenary Sessions in Copenhagen Seven Key Opinion Leaders share their recommendations of innovative studies to be presented during EAU18’s Plenary Sessions. From the Nightmare Session of bladder cancer management, hot topics in andrology to precision medicine, participants can expect nothing less than pioneering research and cutting-edge technologies at the upcoming congress in Copenhagen. Meet the Plenary Sessions’ key opinion leaders.

"Hot topics, evidence quality and advances in andrology"

"Medico-legal issues in bladder cancer care"

Prof. M. Albersen (BE), Plenary Session 1: Hot Topics, evidence quality and advances in Andrology, Saturday, 17 March

Prof. Morgan Rouprêt (FR), Plenary Session 2: Nightmare sessions in bladder cancer care, Saturday, 17 March

In recent years, deteriorating semen quality has been increasingly observed. Researchers have identified changing lifestyle choices, such as delayed fatherhood and increased anabolic steroid abuse, but also increased exposure to environmental gonadotoxins as potential important causes of this phenomenon.

In this plenary, an overview of these issues will be given, and the urologist will be updated on surgical options for the management of male infertility problems.

Currently, the main methods of assessing surgical results for audit and quality assurance are mortality and morbidity. Although the incidence of postoperative complications is the most frequently used surrogate marker of quality in surgery, the direct cause–effect relationship between surgery and complications is often difficult to assess.

In the second half of the session, the focus will be on emerging therapies in andrology, which are claimed to possess potential curative capacities, such as low intensity shockwaves and cellular therapies. The quality of evidence supporting these novel therapies will be discussed in a case-based fashion.

You are invited!

In daily practice, this is particularly true for BCa patients, who are likely to undergo several surgical procedures along the natural history of the disease.

Their situation can become a “nightmare” and for the urologist as well in terms of surgical and medicolegal perspectives. Three distinct BCa cases will be discussed and examined by experts in the field during plenary session 2. A British lawyer Mr. Bertie Leigh, who specialises in medico-legal issues, will review the cases propose the course of action for urologists to undertake against “nightmare” cases.

"Urinary precision markers for decisionmaking in PCa"

"A changing therapeutic landscape"

Prof. Gert Attard (GB), Plenary Session 3: Prostate Cancer, Sunday, 18 March “Metastatic castration resistant prostate cancer is characterised by aberrations in the androgen receptor that can be detected in circulation and associate with significantly worse outcomes on androgen receptor (AR) targeting drugs but not taxanes. This introduces the opportunity for treatment selection.

Dedicated computational and sequencing approaches can also allow high sensitivity detection and quantitation of copy number aberrations and point mutations in plasma DNA that allow characterisation of other molecular types that can improve treatment selection, including aberrations in the DNA repair, PI3K/AKT and WNT pathways. These approaches can allow rational treatment selection in a rapidly changing therapeutic landscape, with treatments moving earlier in the management paradigm.

"Ameliorating lower urinary tract symptoms"

"LUTS and stable neurological disease"

Prof. Dr. Thomas Kessler (CH), Plenary Session 4: Contemporary storage Lower Urinary Tract Symptoms (LUTS) management, Sunday, 18 March Lower Urinary Tract Symptoms (LUTS) are highly prevalent and largely affect the quality of life of neurological patients. Spinal cord injury and spina bifida are generally considered stable neurological diseases, but is this really the case? No, not at all.

Modification of the urological management is often necessary over time. Urodynamics is essential in identifying risk factors that jeopardize the upper and lower urinary tract, as well as, guarantee an optimal customised treatment.

In this lecture, neurological mechanisms involved and consequent urological management strategies will be discussed to improve the outcome for prospective patients with stable neurological diseases.

"Stone treatment: What do we need for the future?"

EU Commissioner on Health and Food Safety Mr. V. Andriukaitis to open EAU18

Opening Ceremony, Friday, 16 March, 18.00 hrs, eURO Auditorium

Prof. Jack Schalken (NL), Plenary Session 5: Precision medicine, Monday, 19 March The PCA3 test was the first in class urine test to predict biopsy outcome (2006). This was a significant step forward, i.e the decision to propose a biopsy could be changed in 30-35% of patients. The biomarker on which the test was based, PCA3, however, was not a progression marker. Even more, some of the very aggressive cancers do not express PCA3. We then engaged in a discovery effort to find biomarkers for clinically significant prostate cancer, which led to a urine biomarker-based risk score that was launched as SelectMDx in 2016. With an NPV of 98% clinically significant PrCa can be excluded, leading to a 50% reduction in prostate biopsies. Furthermore, the test can also be a high potential stratification tool for state-of-the-art imaging-based biopsy procedures.

January/February 2018

Prof. Gary Lemack (US), Plenary Session 6: Preventing urological disease: Future Prospects, Monday, 19 March It has become increasingly clear that lower urinary tract symptoms (LUTS) are often associated with other systemic conditions such as obesity, COPD and sleep disturbances. Recent data suggest that treating these conditions may be equally effective if not more effective than directly treating the lower urinary tract, with little risk. Using a case based approach, Professors De Nunzio, Goessaert, and Van Houten will discuss the role of systemic disease treatment in preventing or ameliorating LUTS. Specifically, we will focus on the roles of improving cardiac health, treating sleep and pulmonary disorders, and taking steps to minimize the frailty associated with aging in improving bothersome LUTS.

Prof. Dr. Olivier Traxer (FR), Plenary Session 7: Stones, Tuesday, 20 March This lecture is an overview of how stone treatment will evolve in the near future. The use of (flexible) ureterorenoscopy has increased over the past years due to the technological advances of surgical armamentarium. This evolution will continue to advance as a result of the miniaturization of endoscopes and the development of smart systems.

Additionally, the lecture will examine and evaluate integrated pressure and temperature control systems in ureteral access sheaths or ureteroscopes, robotic systems, single-use instruments, laser systems and aspiration devices. Surgical treatment algorithms of urolithiasis will be discussed as well.

European Urology Today

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Join the EAU18 Patient Information Session in Copenhagen, 18 March 2018 This year, patient advocacy groups have played an important role in organising a truly patientfocussed meeting at the forthcoming Annual EAU Congress in Copenhagen.

"Patients at the Center of their Health Care"

Welcome by: Prof. Chris Chapple Moderator: Prof. Thorsten Bach

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Round Table: The unmet needs of urology cancer survivors Co-moderator: Dr. Selçuk Sarikaya

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Prostate Cancer – Mr. Ken Mastris, Europa Uomo

Including Q&A

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Bladder Cancer – Mr. Andrew Winterbottom, Fight Bladder Cancer UK

Including Q&A

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Urinary diversions – Ms. Kyla Rogers, Mitrofanoff Support Group (UK)

Including Q&A

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Kidney Cancer – Ms. Rachel Giles, IKCC

Including Q&A

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Fifteen minute coffee & finger food break in room

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Involving the Patient – Co-moderator: Dr. Sarah Ottenhof

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How patients and nurses communication influence outcome – Ms. Corinne Tillier, EAUN

Including Q&A

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EAU PI: Are we clear enough? (results URS survey) – Dr. Juan Luis Vásquez, EAU PI

Including Q&A

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How to address the illiterate patient – Dr. Michael Van Balken, Easy Peesy (NL)

Including Q&A

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Translating clinical science into practice – Mr. James Catto (UK)

Including Q&A

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Keynote Speech – Co-moderator: Dr. Giulio Patruno

• And much more!

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Giving patients a meaningful voice in the design and delivery of care – Ms. Sara MacLennan, UCAN, EAU Guidelines

Including Q&A

Join us!

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How to use policy papers to call for change at pan-European level – Ms. Lydia Makaroff, ECPC

Including Q&A

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How to increase the impact of an awareness campaign – Mr. Tit Albreht, CanCon Joint Action

Including Q&A

• We will get to see the results of a survey regarding the effectiveness of animated series conducted with patients in China, Germany and the UK. • We will learn how to develop and increase the impact of an awareness campaign.

Section Editors 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, Barcelona (ES) Dr. Z. Zotter, Budapest (HU) 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 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.

Prostatic diseases awareness Questionnaire-based study looks into public awareness of prostate diseases Dr. Selçuk Sarikaya EAU, Patient Information Working Group Co-Chair Ankara (TR)

Tugberk Korzay, Med.Student Turkish MSIC Student Group, Gulhane Medical Faculty Coordinator Ankara (TR)

The sixth and the last question ‘What would you prefer for the treatment if you have or if you would have benign prostatic hyperplasia?’ The respondents had the chance to choose multiple answers.

410 chose for ‘phytotherapy’, 554 answered with ‘pharmacologic treatment’ and 495 for ‘surgery’ options.

drselcuksarikaya@ hotmail.com

tugberkkor@ gmail.com

Prostatic diseases are common in male populations and it is very important to have enough awareness regarding these diseases. If they are not treated properly, they would cause severe health problems.

Considering these results, we as healthcare professionals must raise awareness regarding urological diseases to help improve the diagnosis and treatment process.

With prostatic diseases still not very well-known by many, it is important to raise awareness since many of the severe urologic diseases can be prevented or treated with early diagnosis and interventions.

The aim of this study is to assess public awareness related to benign and malignant prostatic diseases which involved an online questionnaire. The questionnaire consisted of six multiple choice questions.

The first question was about age groups, while the second and third questions were about the prostate gland. The fourth question was related to prostate cancer diagnosis, the fifth referred to knowledge on prostate cancer treatment, while the sixth and the last question assessed the preference of patients regarding benign prostatic hyperplasia treatment.

"Considering these results, we as healthcare professionals must raise awareness regarding urological diseases to help improve the diagnosis and treatment process."

A total of 1,013 volunteers participated in the study.

The ages were divided into five groups. 345 (34,1%) volunteers were 18-30 years. 260 (25,7%) were 31-40 years, 214 (21,1%) were 41-50 years, 167 (16,5%) were 51-60 years and 27 (2,7%) were over 60 years.

The second question ‘What is Prostate?’. 726 (71,7%) replied as ‘gland’ and 287 (28,3%) replied as ‘disease’.

The third question ‘In which genders, prostatic diseases. are seen?’ 749 (73,9%) the respondents replied as

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European Urology Today

Objective: To build the capacity of European prostate, kidney, and bladder patient advocacy groups to support their members and advocate for better care.

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• We will also learn what it means to involve patients in all aspects, from diagnosis to the selection of the appropriate treatment pathway, and how it may influence disease management.

Editor-in-Chief Prof. M. Wirth, Dresden (DE)

Sunday 18 March, 11.30 – 14.35 hrs. / GREEN Room 10

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• "We will hear about the unmet needs of urology cancer survivors from Europa Uomo, the European Cancer Patient Coalition (ECPC), Fighting Bladder Cancer UK, the International Kidney Cancer Coalition (IKCC) and the Mitrofanoff Support Group UK."

European Urology Today

EAU Patient Information Meeting – Copenhagen 2018

follows: ‘males’, 261 (25,8%) replied as ‘females’ and 3 (0,3%) replied as ‘both genders’. The fourth question ’Are the periodic follow-ups necessary for the early diagnosis of prostate cancer and what is the ideal age?’.

117 (11,5%) replied as ‘not necessary’, 699 (69%) replied as ‘necessary, 50 years’, 194 (19,2%) replied as ‘necessary, 60 years’ 3 (0,3%) replied as necessary ‘necessary, 70 years’. The fifth question ‘What are the treatment options for prostate cancer?’. 215 (21,2%) replied as ‘pharmacologic’, 41 (4%) replied as ‘surgery’, 15 (1,5%) replied as ‘radiotherapy’ and 742 (73,2%) replied as ‘all’.

European Association of Urology Patient Information (EAU PI) working group has initiated many activities regarding this important issue and EAU PI invites everyone to join and promote these activities. Do not miss the future activities and our special session during the EAU18 congress in Copenhagen.

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 2018!

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 2018

Update from the Guidelines Office EAU18 Copenhagen March will see the publication of the full text and pocket versions of the 2018 European Association of Urology Guidelines. As always, the Guidelines will be available to collect - free for EAU full members from the EAU Booth at the EAU18 exhibition.

European A ssociation of Urology

stress urinary incontinence • Testis Cancer - Should prognostic factors be used to drive treatment recommendations in Stage I Seminoma

• EAU Guidelines Poster Walk The Guidelines Office (GO) is pleased to announce that Saturday 17 March, 10:15-13:15 hrs. it will facilitate multiple interactive sessions during Take a guided tour through the 15 best poster EAU18, these include: abstracts from the EAU Guidelines Panels and Committees. Poster viewing will take place from • Interactive workshop on Guidelines Controversies 10:15-12:15 with an expert guided tour from - Saturday 17 March, 13.30-17.30 hrs.

12:15-13:15.

This session will see pro and con presentations on clinically significant areas within the EAU • EAU Guidelines Cup live finale on YUORDay18 Guidelines which have highly conflicting Saturday 17 March evidence. Each set of presentations will be The EAU Guidelines Cup is a new competition followed by a methodological comment/ which will determine who among the EAU elaboration, and audience voting. Topics to be members knows the EAU Guidelines the best. discussed include: The Cup will consist of three rounds. The first and second rounds will take place online and • Prostate Cancer - Combining systemic questions will be multiple-choice questions. treatments in Metastatic Hormone Sensitive The top three participants from the second round Prostate Cancer: for everyone or restricted to a will compete during the live finale on YUORDay18. few situations?

Could you be the first EAU Guidelines Cup • Bladder Cancer - Can organ preservation champion? become a second gold standard in Muscle Invasive Bladder Cancer?

• Two European School of Urology courses: • Urinary Incontinence - Mesh versus non-mesh • What’s new in the 2018 EAU Non-oncology surgery for genital prolapse and urinary Guidelines (Incontinence, Male LUTS, Male Infertility, Male Sexual Dysfunction and incontinence: Synthetic mid-urethral sling Thromboprophylaxis) - Sunday 18th 12.00-14.00. remains the gold standard for women with • Updated Renal, Bladder and Prostate Cancer Guidelines 2018: What’s changed? Guidelines Office Monday 19 March 08.30-11.30 hrs.

Guidelines

2018 edition

Omslag GL

2018.indd

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22-01-18

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EAU18: Top picks for EAU18 by leading experts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Both courses will offer a bird’s eye overview of changes in the recommendations of each Guideline and their relevance for clinical practice, giving attendees a quick insight into how the different fields are progressing.

Join the EAU18 Patient Information Session in Copenhagen, 18 March 2018. . . . . . 2

In addition to this exciting programme of events, the Guidelines Office will also have a presence at the EAU18 exhibition. We would encourage everybody to please stop by the EAU Publications booth and meet our dedicated Guidelines Office staff, who will be more than happy to answer any questions you may have regarding the many activities of the Guidelines Office.

Your Credit Registry Report 2017. . . . . . . . . . . 3

Prostatic diseases awareness. . . . . . . . . . . . . 3 Update from the Guidelines Office . . . . . . . . . 3

EAU18: High-quality abstracts to trigger dynamic discussions. . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Putting Office Urology up front. . . . . . . . . . . . 5 ESUI17: No more PIRADS 3 lesions!?. . . . . . . . 6 EULIS collaborates with IAU. . . . . . . . . . . . . . 6

Your Credit Registry Report 2017 Generate and print CRR online Prof. Dr. Rien Nijman Chair EU-ACME Committee Groningen (NL)

j.m.nijman@umcg.nl More than 16,000 urologists from Europe and beyond have already joined the EU-ACME programme including more than 5,000 EAU Junior Members.

However, only 38% 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.

Check your registered credits online

EU-ACME MCQ winners 2017 From January 1 to December 31, 2017, EU-ACME members answered multiple questions published in European Urology. Participants who answered most questions correctly were awarded with free registration for the 33rd Annual EAU Congress in Copenhagen to be held from March 16 to 20 this year.

The 2017 winners are: 1. Mr. H.S. Fernando, United Kingdom (CME-124253) 2. Mr. M.F. Saxby, United Kingdom (CME-000243) 3. Mr. F-J. Schattka, Ireland (CME-110659) The EU-ACME committee congratulates the winners for their successful participation in our online CME programme!

January/February 2018

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 2017 to the EU-ACME office.

delivered, copies of the programme with clearly stated your name and lecture title, etc.

Make sure your personal data are correct, so that the EU-ACME office sends your Credit Registry Report 2017 to the correct address!

Gain your CME credits at home All you need is a PC and internet access CME is a lifelong commitment and CME credits are the ‘staples’ of staying in practice and keeping the office doors open.

Good luck!

This study method offers more flexibility where you can decide for yourself when and where you should like to study.

Help urologists collect CME credits and register your activity today!

(Inter)National Urological Associations and the CME providers (organisers of CME activities) are invited and encouraged to send in requests to register nationally accredited CME activities or requests for European accreditation.

www.eu-acme.org

Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11 Ten Questions: Christian Gratzke. . . . . . . . . . 12

Log in to your online CME/CPD portfolio (MyCME) Electronic Credit Registry Reports through www.eu-acme.org and check if all activities EU-ACME members may generate and print Credit you have attended are properly listed under your name. 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 If you miss any activity register it directly online generate and print my CRR online. I do not wish to uploading documental proof, e.g. the certificate of attendance, written articles, text or copies of lectures receive a copy by regular mail.”

Visit www.eu-acme.org/europeanurology and answer a set of MCQs on-line. 80% of the answers need to be answered correctly to obtain 1 CME credit point per article.

Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7

www.eu-acme.org/europeanurology

Have you moved?

Changed name?

New employer?

Alter your personal data on-line: fast and easy -

www.eu.acme.org

Challenges in MDT care: Role of the lead specialist . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 EAU Research Foundation: SATURN Registry enrols 50th patient . . . . . . 13 ESU section: CAUREP 2018 gains momentum, spreads best practices . . . . . . . . . . . . . . . . . 14 ESUfocaltherapy17 takes on novel focal therapy management. . . . . . . . . . . . . . 15 Highlights of the ESU Masterclass on Lasers in Urology. . . . . . . . . . . . . . . . . . . . . 17 Best practices in laser technology at ESUlasers17. . . . . . . . . . . . . . . . . . . . . . . . . . 17 EUREP18 application. . . . . . . . . . . . . . . . . . . 18 ESFFU: When do we need urodynamics for female SUI?. . . . . . . . . . . . . . . . . . . . . . . 19 ESUT Brainstorming Meeting in Barcelona. . . 20 ESUT: Manila congress tackles latest trends in urology . . . . . . . . . . . . . . . . . . . . . 21 Penile cancer: What’s new? . . . . . . . . . . . . . 21 17th Congress of Russian Society of Urology. . . . . . . . . . . . . . . . . . . . . . . . . . 23 EUSP-EULIS offer new scholarships . . . . . . . 23 The EAU History Office in Copenhagen. . . . . 24 Movember's PCa Active Surveillance initiative (GAP3). . . . . . . . . . . . . . . . . . . . . . 25 New Clinical Patient Management System goes live for ERNs. . . . . . . . . . . . . . . 26 Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 26 The 3rd Urology Simulation Boot Camp . . . . 27 Obituary Rainer Engel . . . . . . . . . . . . . . . . . 27 YUO section: Editorial: Residents Around the Globe . . . . . 28 Urology Training Around the Globe. . . . . . . . 28 Social Media in healthcare campaigns. . . . . 28 EAUN section: ERUS-EAUN Robotics Meeting . . . . . . . . . . . 34 3rd ESUN Course ”Bladder Cancer in Depth”. . . . . . . . . . . . . . . . . . . . . . . . . . . 35 EAUN-EUSC Workshop on ERAS protocols after cystectomy . . . . . . . . . . . . . . 35

European Urology Today

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#EAU18 Cutting-edge Science at Europe’s largest Urology Congress

High-quality abstracts to trigger dynamic discussions Abstract selection- a challenge to expert reviewers

Prof. Arnulf Stenzl

The record number of accepted abstracts for EAU18 presented a major challenge to expert reviewers, but thanks to their commitment and critical eye for quality work congress participants can look forward to dynamic, interactive sessions in Copenhagen.

“In Amsterdam last December, a total of 1,427 abstract contributions were selected from more than 4,676 submissions based on a sophisticated rating system by over 300 reviewers. It was a challenge for all reviewers, and the work is complex considering the wide range of topics,” said Prof.

Arnulf Stenzl, Chair of the EAU Scientific Congress Committee.

Prostate, bladder and renal cancers were among the most investigated topics and made up for nearly half of the total accepted abstracts. A total of 4,676 abstracts were submitted compared to 5,039 submissions recorded for the 2017 congress in London. For the video presentations, 84 video abstracts passed critical scrutiny, a number similar to the 2017 congress.

Submissions came from 91 countries around the world, including many abstracts from Italy, which is very exceptional.

“We saw an increase in the quality of the abstracts submitted and it was very difficult to make the necessary selection without rejecting some interesting and useful submissions. This meant that we have slightly increased our acceptance rate,” Stenzl said. “With the commitment of the reviewers, we included more excellent work by both young and expert researchers from all over the world.”

Expert-Guided Poster Tours A new initiative is the “Expert-Guided Poster tour” (See Poster Tour Schedule). For three congress days (17 to 19 March) the selected posters will be presented in the central area for three hours with prominent urologists as ‘tour guides.’ The tour guides will moderate a discussion of the posters and the authors will be present to answer queries.

“This focused approach will enable good exposure to the selected abstract posters. The type of moderation - and the moderators themselves will enable optimal and direct interaction among participants and authors,” added Stenzl.

EAU Opening Ceremony & Networking Reception

Also prestigious EAU Awards will be handed out: the EAU Willy Gregoir Medal, the EAU Frans Debruyne Life Time Achievement Award, the EAU Hans Marberger Award, the EAU Crystal Matula Award, the EAU Prostate Cancer Research Award and the new EAU Ernest Desnos Prize.

After the Opening Ceremony you will have the chance to catch up with your colleagues from all over the world and make new contacts during the EAU Networking Reception. Join us at the eURO Auditorium to celebrate the start of EAU18!

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European Urology Today

Expert-Guided Poster Tours Poster tours, which will take around an hour, are scheduled on the following days: • EAU Guidelines Saturday, 17 March 2018, 12.15 - 13.15 • Urology by exploring: New experimental technologies and techniques in benign urogenital reconstruction Saturday, 17 March 2018, 16.00 - 17.00 • Following the path to optimised stone treatment Sunday, 18 March 2018, 12.15 - 13.15 • Prostate cancer: (Salvage) surgery and outcome Sunday, 18 March 2018, 15.45 - 16.45 • Prostate cancer: Diagnostics and active surveillance Monday, 19 March 2018, 12.15 - 13.15

Handy reminders • You can register online until 13 March 2018. After this date you can still register onsite •

Abstracts are available online for EAU Members as of 16 February 2018

• As of 16 March abstracts are available for all delegates in the EAU18 Resource Centre; eau18.org/rc • EAU News will send you daily updates and reports about the congress. Sign in now!

• The Certificate of Attendance can be printed as of Wednesday, 29 March through eau18.org

Interaction with experts With the success of the hybrid poster-video sessions in London, Stenzl said the format will be expanded in Copenhagen. “This topic-oriented discussion of posters combined with video presentations on the same topic was well received last year by many congress participants,” he said.

• e-Posters can be explored at the e-poster area, the EAU18 Resource Centre and UROsource.com

Besides the hybrid video-poster sessions, the Scientific Programme also includes semi-live sessions where surgeons will present and comment on their video clips of surgical techniques to prompt discussions led by expert panels. During the congress, several channels will facilitate interaction via social media such as Twitter and Facebook. Online comments will be picked up by moderators during the sessions. Thus, all efforts will be directed to prompt a more active exchange of ideas, expertise or experience whilst supporting professional networking goals.

• Share your congress photos on Instagram #EAU18

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

Join the conversation at twitter with the hashtag #EAU18

Are you up for the UROlympics?

Imagine this: A boxing arena with 2 working stations with endoscopic tests, fearless contestants from over 130 countries and a clock ruthlessly ticking away. That will be the setting of the first UROlympics which will take place at EAU18 in Copenhagen. We invite you to show off your endoscopic skills and challenge your peers from all over the world!

How can you join?

Qualifying rounds start on Saturday, 17 March at 9.30 hrs at the Innovation in Education square, located in front of the Hands-on Training session in the yellow area. In order to participate in these qualifications, you need to pick up your qualifying ticket at the COOK MEDICAL Booth, number G15.

These tickets are personal and cannot be transferred. Once you have your personal ticket, you can head to the Educational Square and prepare for your qualification. There you will take place behind one of the two stations and have one shot to set your best time for the endoscopic test.

On Friday, 16 March the EAU launches the 33rd Annual Congress with an official Opening Ceremony. During this festive opening, EAU Secretary General Chapple, together with EU Commissioner for Health and Food Safety, Mr. Andriukaitis, will welcome everybody to Copenhagen.

Friday, 16 March 2018 18.00 - 21.00 Green Area: eURO Auditorium

Abstract poster session moderators are chosen by their expertise in a certain subspecialty, and their performance in the review process, plus their contributions to EAU activities are considered.

a medal, the winners will receive one of the following educational funds which can be used for EAU events (travel, accommodation and registration): 1st prize: €250 educational fund and noise cancelling headphones 2nd prize: €250 educational fund 3rd prize: €150 educational fund

Throughout the day, the fastest times per country will be published around the arena, at the COOK MEDICAL booth, and via social media. At the end of the day, the best qualifier of 16 different countries will go to the 8th finale on Sunday. The draw at the booth of COOK MEDICAL will decide which countries will battle against each other the next day.

You are invited!

The finale On Sunday, the arena will be prepared for the finales. Starting at 12.00 hrs the finalists will battle against each other on the two stations. The one who finishes the test first will go directly to the quarter finals. The winners of the quarter finals will continue to the semi-finals, which will start around 16.00 hrs.

The winners will be honoured during the medal ceremony on the COOK MEDICAL booth. Asides from eternal fame as first winners of the UROlympics and January/February 2018

#EAU18

Putting Office Urology up front New ESUO takes up prostate biopsy issues in Copenhagen The new EAU Section of Urologists in Office (ESUO) will focus on prostate biopsy issues in Copenhagen during its ’first’ annual meeting, following its official launching last year in London. The topic is of prime concern to office urologists with recent and still evolving changes in prostate cancer detection such as new imaging techniques.

“We have headlined our Copenhagen meeting as “All about prostate biopsy in office,” as this reflects an important method in urologic office done in all countries,” said ESUO Chairman Prof. Dr. Helmut Haas (DE).

Haas said the session will be moderated by office urologists, with expert lectures by Profs. Maurice Stephan Michel (DE) and Jochen Walz (FR), and Drs. Stefan Czarniecki (PL), Stefan Haensel (NL), and Robert Schneider (CH). Michel will discuss indications for biopsy, patient’s preparation and biopsy procedures. Walz, meanwhile, will examine TRUS- and MRI-guided biopsies, going through patient selection, benefits, drawbacks and future prospects.

Management of biopsy complications will be taken up by Haensel, while Czarneicki will explore the role of biomarkers in prostate cancer treatment.

Schneider will look into pioneering experiences and lessons from a fusion biopsy network in Switzerland.

“We aim to have an interactive session as much as possible, stimulating the audience to provide critical views and feedback back to the panel of speakers,” said Haas. Aside from Haas, chairing the session are three ESUO members including Dr. Horst Brenneis (DE), Dr. Stefan Haensel (NL) and Dr. Robert Schneider (CH) who will provide preliminary remarks and lead the case discussions.

Haas said that as a new office under the auspices of the EAU, the section is taking all efforts for it to achieve its aims.

“Aside from promoting the ESUO to other EAU section offices and affiliates, we have conducted several surveys not only to find out the basic issues that concern office urologists but also to expand our contacts. We appreciate every little effort from our partners, both current and potential, that will help us expand the network of office urology,” Haas said. “To all office urologists, send us an e-mail (esuo@uroweb.org) with your expectations.”

Special itinerary In Copenhagen, the section has created an “itinerary” that will track and identify various meetings or sessions during the five-day EAU18 congress that will be relevant or of interest to office urologists.

know best the medical and patient-related considerations and administrative rules under which this can be done successfully,” Haas explained.

Haas said ESUO has been invited by the Slovak Urological Society to participate in the Slovak meeting of office urologists in April, where he will not only present the ESUO’s goals and projects but also the challenges and developments in office urology issues.

Nevertheless, he emphasized that a lot needs to be done by the ESUO for it to adequately cover or address the issues faced by office urologists.

Meeting Tip! ESUO Session, All About Prostate Biopsy, Saturday, 17 March 10.15 - 14.00 Prostate biopsy is a core procedure in urologic office. During the meeting all relevant aspects of prostate biopsy in an office setting will be presented by recognized specialists: indication, procedures, the management of complications, and modern imaging. The session is chaired by office urologists who will focus on the outpatient situation.

“Our section has created an itinerary for the upcoming congress in Copenhagen which flags the congress’ sessions according to their importance for office urologists. This will help our members or other office urologists to easily identify which sessions can add as priority to their congress agenda,” he said.

Offering its expertise He also mentioned that aside from collaboration with other offices, the ESUO is also ready to offer its own expertise.

“Our section offers collaboration, especially based on the fact that most of the new developments in diagnostics and non-surgical therapy have to be transferred to outpatients under outpatient conditions. This means either in outpatient departments or in urologic offices. Office urologists

ESUO’s meeting in Copenhagen will aim for more interaction and insightful discussions among office urologists and their colleagues.

ESUO Itinerary through EAU18

www.eau18.org

Sessions relevant and of interest to Office Urologists Friday, 16 March

Saturday, 17 March

Sunday, 18 March

Monday, 19 March

12.30 - 15.30 Green Area, Room 1 Specialty Session Common problems in bladder cancer; Evidence based debates

08.30 - 10.15 eURO Auditorium Plenary Session 1 Hot topics, evidence quality and advances in andrology

14.00 - 15.30 Red Area, Room 3 Poster Session 47 Non-interventional handling of stones. Imaging and conservative management

08.00 - 10.30 Green Area, Room 1 Plenary Session 6 Preventing urological disease.

Future prospects

12.30 - 14.00 Blue Area, Room 4 Poster Session 11 Management of urological trauma and emergencies. Towards individualized approaches

10.15 - 14.00 Blue Area, Room 2 ESUO Section Meeting All about prostate biopsy in an office urology and outpatient setting

15.45 - 16.45 Poster Walk Area Expert-guided Poster Tour 4 Prostate cancer. (Salvage) surgery and outcome

14.15 - 15.45 Blue Area, Room 3 Poster Session 15 Medical management of LUTS/ BPH. Finding the right treatment pathway

14.15 - 15.45 Green Area, Room 2 Poster Session 18 Infectious diseases 1. Lower urinary tract

15.45 - 17.15 Blue Area, Room 4 Poster Session 61 Paediatric Urology 3 Bladder and Vesicoureteral reflux

For a complete overview of the Scientific Programme go to www.eau18.org or download the EAU18 Congress app!

January/February 2018

Red Area, Room 2 Poster Session 19 Evaluation of LUTS in clinical practice

Blue Area, Room 5 Poster Session 62 The use of multi media in urology

Blue Area, Room 2 Poster Session 21 A focus on prostate cancer screening

Red Area, Room 1 Poster Session 55 Prostate cancer. Hormones and beyond

16.00 - 17.30 Red Area, Room 2 Poster Session 26 Urodynamics and beyond.

Explorations in functional urology and neuro-urology

10.30 - 12.00 Green Area, Room 2 Thematic Session 11 EAU Guidelines Session.

Management of muscle-invasive bladder cancer - When should the guidelines be ignored?

Blue Area, Room 1 Thematic Session 15 Active surveillance for low-risk prostate cancer 12.15 - 13.15 Poster Walk Area Expert-guided Poster Tour 5 Prostate cancer. Diagnostics and active surveillance 14.00 - 15.30 Blue Area, Room 3 Poster Session 80 New conservative treatment options in functional urology Blue Area, Room 5 Poster Session 82 Male sexual dysfunction. Focus on comorbidity and diagnostic innovation

European Urology Today

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No more PIRADS 3 lesions!?

16 November 2017 Barcelona, Spain

Post-meeting report on the 6th ESUI in Barcelona Prof. George Salomon Chair, EAU Section on Urological Imaging (ESUI) Hamburg (DE)

gsalomon@uke.de Shouldn´t we accept a higher false negative rate in the detection of prostate cancer?

This was one of the issues covered in a fantastic talk

by Prof. Monique Roobol from Rotterdam (NL) which triggered thought-provoking arguments in last year's 6th ESUI Meeting in sunny Barcelona, and which preceded the 9th European Multidisciplinary Meeting on Urological Cancers (EMUC).

The key issue for clear determination would be training and expertise for MR reading.

Last but not least, there is no doubt that interdisciplinarity is a must for good patient care and was demonstrated from a radiologists, pathologists and urologist´s viewpoint.

More than 20 abstracts have been submitted of which six posters have been chosen for oral presentations.

The award (sponsored by Exact Imaging in 2017 and also for the next ESUI meeting in Amsterdam) was given to Dr. Del Vecchio. She came all the way from Woolloongabba, Australia to Barcelona to present the distinction between malignant and clear cell renal cancers and indolent subtypes by MR spectroscopy.

This technique potentially might be able to differentiate between indolent small renal masses and those that are life threatening in the future.

Are we doing the right thing in debating about how to increase the detection rate of prostate cancer (PCa) or should we accept to overlook some cancers? In a survey by Rashid Khalid Sayvid et al. 65% of patients would accept a false negative rate of 5-20%, and for urologists even more (78%) would accept this rate, according to Prof. Roobol. In the ERSPC study after 15 years of follow-up, csPCa incidence, the rate of metastasis and mortality S. Del Vecchio receives the Best Abstract Award from G. were very low in men who had Salomon (left), and Randy AuCoin (right, Exact Imaging’s President and CEO) with M. Mischi watching (far left) a negative sextant biopsy (re-tested every four years in case of a negative sextant biopsy). (Slide 11) The fact that even a sextant biopsy which is not up to date nowadays was Prof. M. Roobol used as the detection method for PCa made this data even more thoughtful. She concluded that we all should realise that the risk of actually missing the diagnosis of a potentially metastatic or life threatening prostate cancer might be low. With this in mind, the results of the PROMIS trial with a NPV for mpMRI of 76% for Gleason >= 3+4 might be seen with more optimistic eyes.

Besides, the false negative rate of mpMRI PIRADS 3 lesions represents a difficult approach for decisionmaking whether to biopsy or not due to its inaccurate prediction of csPCa. Biomarkers might help and enhanced ultrasound methods such as micro ultrasound which may further define these lesions to increase the positive predictive value. Anyhow, and as stated by Prof. Hadaschik, the amount of PIRADS 3 lesions defined by the radiologists should be lowered as a clear statement of which men to biopsy or not.

Fig. 1: Prof. Roobols’ presentation

Drs. O. Rouviere, C. Moore and Prof. R. Montironi expressed the point of view of their respective specialism in the session "How to increase the performance of your prostate diagnostic team"

More than 180 participants reflected the growing interest on urological imaging and the quality of our meeting. We look forward to see you at EAU18 in Copenhagen during the Joint Meeting of the EAU Section of Urological Imaging (ESUI), the EAU Section of Uropathology (ESUP) and the EAU Section of Urological Research (ESUR) ‘How tumour heterogeneity influences our practice today and tomorrow’ on Saturday 17 March 2018 from 10.15 – 14.00 in Green room 3.

published in urology during the last year, will be handed out during this session. The award is supported by an educational grant of €1,500 by INIVIVO CORPORATION. You are invited to send a PDF copy of the published study or of the published/ accepted abstract together with a CV and publication list to esui@uroweb.org before the deadline of 31 January 2018, 23.59CET.

We also hope to see you at the 7th Meeting of the EAU Section of Urological Imaging on 8 November 2018 in The ESUI Vision Award, which will be given to the first Amsterdam for another interesting programme on author of the most innovative imaging study urological imaging!

Fig 2: Prof. Montironi's presentation (The pathologist's point of view)

EULIS collaborates with IAU China meeting focuses on trends and updates in stones treatment Prof. Christian Seitz Medical University of Vienna Dept. of Urology Vienna (AT)

drseitz@gmx.at Co-authors: Kemal Sarica, Thomas Knoll, Domenico Prezioso, Iliya Saltirov Founded 20 years ago, the EAU Section of Urolithiasis (EULIS) deals with all aspects of stone disease treatment, ranging from intervention to metabolics, nutrition, prevention and education. as well as the standardisation of endourological training.

The strength of EULIS lies in its multidisciplinary outlook and the practice of an integrated approach to urolithiasis. EULIS also works with the EAU sections such as the ESU, ESUT, EAU YUO, YAU and organisations such as the International Alliance of EAU Section of Urolithiasis (EULIS)

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European Urology Today

Urolithiasis (IAU) or ERA/EDTA. Moreover, it collaborates with nutrition scientists, research dieticians and other affiliated medical professionals.

EULIS held its biannual international meeting in 2017 in Vienna, Austria. Besides state-of-the-art lectures and debates regarding all issues in urolithiasis, special focus were given to basic research and live surgeries, which were transmitted from Pforzheim, Germany and the Medical University of Vienna (for detailed information take a look at the latest EULIS brochure and in the section blog for the latest news).

IAU Collaboration The International Alliance of Urolithiasis (IAU) was founded in 2012 in Guangzhou by Professors Zhangqun Ye, Guohua Zeng, and Kemal Sarica (current EULIS chair). The IAU established its permanent headquarter in Guangzhou, China.

IAU is an emerging international alliance. The mission of IAU is to facilitate advancement of knowledge, investigation and treatment of urolithiasis and to promote dialogue, research, education and training into all aspects of urinary stone disease. The IAU strives to position itself as a major international platform to promote international academic exchange in the urolithiasis research field. The acronym IAU therefore, could also be understood as: Establishing International Activity in Unity.

Strengthening international cooperation The aim is to provide a platform for urologists across the world to exchange knowledge on urinary tract stone disease, and to establish professional links for research. Therefore, the IAU is a platform for scholar communication, achievement exhibition, endourology training and resource sharing, which complements the mission of EULIS. IAU in Shaoxing, China Shaoxing in Southeast China hosted the 6th IAU annual conference held from November 17 to 19 last year. An excellent programme included many excellent and inspiring talks and provocative debates by both eminent local and distinguished international faculty members. Renowned stone surgeons shared their experience in the Young Urology Section, highly appreciated by young urologists. Over 20 live surgeries demonstrated state-of-the-art and the latest endoscopic techniques in the management of challenging cases.

Meanwhile, the BJU International became an affiliated journal of the IAU. Matt Bultitude, Consultant Urologist and head of stone unit Guys and St Thomas urology, presented selected papers in the meeting.

Prof. Guohua Zeng, congress president and inventor the of super-mini PNL, gave a lecture on his experience. He demonstrated that intrarenal pressure

remained low, with shorter operative time and excellent stone clearance rates. He also demonstrated the treatment of a 3.5 cm lower pole renal stone during a live surgery session, completing the case in under 20 minutes, totally tubeless, and with visually complete stone clearance.

Brian Eisner (USA) demonstrated that with RIRS, stone clearance rates are approaching that of PNL but with favourable morbidity rates. However, seeing a live surgery of Prof. Guohua Zeng clearing a > 3.5 cm stone with a miniaturised PNL technique leaving the patient completely tubeless, challenged his RIRS recommendations.

Short presentations ensured that information was condensed. The meeting also provided the opportunity to network and collaborate. For stone specialists we recommend the IAU 2018 meeting in Istanbul, Turkey and the EULIS 2019 meeting in Milano, Italy.

I would also like to refer to the blog by Wayne Lam for further highlights from the 6th International Alliance of Urolithiasis Annual Meeting 2017 at the website of BJUI International (labeled: #IAU2017, BJUI Blog, BJUI Blogs, Blog, Blogs, Brian Ho, David Lam, IAU, International Alliance of Urolithiasis, Shaoxing, urolithiasis, Zhangqun Ye).

January/February 2018

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. 55

Case study No. 54 This 61 year-old-man presented with a lesion of the glans of the penis which according to him has been present for eight weeks (Figure 1) and palpably enlarged lymph nodes of the right groin (Figure 2) while the left groin is clinically normal.

Glansectomy with distal coporectomy and reconstruction with split skin grafting is done, showing invasion of the distal copora cavernosa but clear surgical margins (1 mm) and the histology of ‘usual type‘ squamous cell carcinoma grade 3 with lymphovascular invasion. Radical inguinal lymphadenectomy of the right groin was Figure 1

performed, yielding three nodes affected by metastases but no ectracapulsar extension.

Modified inguinal lymphadenectomy of the left side shows no lymphatic metastases.

Discussion points: 1. Are further investigations needed?

2. Is further treatment advisable?

Figure 2

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

Multimodal treatment should include strong adjuvant chemo Comments by Prof. Carsten Naumann Kiel (DE)

In penile cancer, patients’ lymphatic spread follows the anatomical route of penile lymphatic drainage in a stepwise pattern from superficial to deep inguinal lymph nodes, followed by ipsilateral pelvic nodes, the final site of locoregional disease. Further lymphatic spread to the retroperitoneal nodes is classified as systemic metastatic disease1.

In the case of the 61-year-old patient presented here, right-sided radical and left-sided modified inguinal lymph node dissection revealed unilateral

metastatic lymphadenopathy in three lymph nodes of the right groin. The ipsilateral pelvic lymph node involvement is considerable, up to 56% has been described in patients with more than two positive inguinal lymph nodes or extranodal extension2.

Current guidelines recommend assessment of distant metastases by abdominopelvic and thoracic-computed tomography in these patients. Although the diagnostic accuracy of PET/CT has improved, this imaging technique is no stand-alone staging modality and ipsilateral pelvic lymph node dissection (PLND) is indicated in this patient for accurate staging and potential improvement of survival with a multimodal treatment strategy1.

This multimodal treatment strategy includes the strong recommendation of adjuvant chemotherapy (e.g. cisplatin, 5-fluorouracil and paclitaxel) due to the inguinal pN2 stage, even if PLND does not show

A 75-year-old patient under investigation for persistent microscopic haematuria had a diagnostic ureteroscopy which showed diffuse reddening and contact bleeding of the ureteral mucosa. Several biopsies at different locations were taken. These all demonstrated carcinoma in situ.

The patient has a non-functioning kidney on the right side and the MRI (Figure 1) report showed a widening of the left ureter and thickening of the ureteral wall.

No definite tumours were reported for the left renal collecting system. The history also included testicular cancer with radical orchidectomy 40 years ago and curative radiotherapy for prostate cancer seven years ago. Cystoscopy had been normal. Obviously, the patient is not keen on haemodialysis.

any further lymphatic spread1. Although the patient is at a high-risk due to his metastatic disease, one should keep in mind the 1 mm tumor-free surgical margin of this G3 tumour and the necessity to perform thorough clinical follow-up examinations of the penis for local recurrence.

References 1. Hakenberg OW, Compérat EM, Minhas S, Necchi A, Protzel C, Watkin N; European Association of Urology.

EAU guidelines on penile cancer: 2014 update. Eur Urol. 2015 Jan;67(1):142-50.

2. Lughezzani G, Catanzaro M, Torelli T, Piva L, Biasoni D, Stagni S, Necchi A, Giannatempo P, Raggi D, Fare' E, Colecchia M, Pizzocaro G, Salvioni R, Nicolai N. Relationship between lymph node ratio and cancer-specific survival in a contemporary series of patients with penile cancer and lymph node metastases. BJU Int. 2015 Nov;116(5):727-33.

Discussion points: 1. Are further investigations needed?

2. What options can be offered?

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

CT scan of chest/abdomen for lymph node assessment Comments by Mr. Ben Ayres London (GB)

This case highlights a change in the TNM classification for penile cancer. In 2016 we moved from TNM 7 to TNM 8 in penile cancer. This tumour would be staged as pT2 pN2 Mx in TNM7 but is now pT3 pN2 Mx in TNM 8 as corporal cavernosal involvement has been given its own T category.

In TNM 8 pT2 is corpus spongiosum invasion only with or without invasion of the urethra and pT3 is invasion of the corpus cavernosum with or without urethral invasion. Lymph node staging has also changed in TNM 8. In TNM 7, pN2 represented multiple or bilateral inguinal lymph nodes without extracapsular spread, now in TNM 8 pN2 requires three or more unilateral inguinal nodes or bilateral nodes without extracapsular spread.

Are further investigations needed?

In line with EAU guidelines1, I would recommend a staging CT scan of his chest, abdomen and pelvis to assess for enlarged or suspicious pelvic and retroperitoneal lymph nodes and distant visceral metastases because he has right inguinal nodal disease. I would also recommend an MRI scan of the penis and pelvis, as in our own series we have found a higher rate of local recurrence in men with corpora cavernosal involvement and/or lymphovascular invasion due to “embolic” spread of penile cancer within the honeycomb vascular channels in the cavernosum, resulting in skip lesions developing more proximally within the corpora cavernosa despite a clear surgical margin2.

January/February 2018

MRI scan would also give further information on the pelvic nodes.

FDG-PET/CT scan has been shown in small studies to have high sensitivity and specificity in detecting involved pelvic lymph nodes (91% and 100% respectively)3 and detected more sites of malignant spread in advanced penile cancer than CT/MRI in 33% of patients4. In our practice, we perform FDG-PET/CT to assess suspicious CT scan findings (possible lymph nodes or metastases) during surveillance.

Is further treatment advisable?

The exact nature of additional treatment depends on the outcome of the imaging done for staging. We would review the case, including the imaging and pathology in a multidisciplinary setting. If there was metastatic disease beyond the pelvic nodes on the initial staging scans then we would recommend palliative chemotherapy using TPF (docetaxel, cisplatin and 5-fluorouracil)5. Otherwise, we would recommend a right-sided (i.e. ipsilateral) pelvic lymph node dissection, in line with current EAU guidelines1, since there was right inguinal node involvement. In our experience, the rate of microscopic ipsilateral pelvic lymph node involvement when three or more inguinal nodes are positive for penile cancer without extracapsular spread is high at 60%.

Following this, we would consider adjuvant treatment. The EAU guidelines recommend adjuvant chemotherapy in pN2/pN3 (TNM 7) penile cancer1, and this patient is pN2 at least (pN3 if pelvic lymph nodes are positive). Current recommendation would be for three to four cycles of TPF, with reports of 36.8% (95% CI 15.2-58.5) two-year disease free survival6. Others have also reported improved overall

survival in men with positive pelvic nodes managed with pelvic lymph node dissection and adjuvant chemotherapy (21.7 months (IQR 11.8-104) vs. 10.1 months (IQR 5.6-48.1) for those who did not receive adjuvant chemotherapy (p = 0.048))7.

These studies are all retrospective, with relatively small numbers of patients. Some penile cancer units use adjuvant chemoradiotherapy in men with pN3 penile cancer (pelvic node involvement or inguinal nodes with extracapsular spread) but evidence to support this is lacking and such an approach is not recommended in EAU guidelines1.

Prior to groin surgery this patient would have been suitable for the InPACT trial, a new international multicentre randomised controlled trial assessing the role of neoadjuvant chemotherapy, neoadjuvant chemoradiotherapy or adjuvant chemoradiotherapy in inguinal and pelvic lymph node surgery, which hopes to add to the evidence base outlined above.

References 1. Hakenberg OW, Comperat EM, Minhas S, Necchi A, Protzel C, Watkin N. EAU guidelines on penile cancer: 2014 update. Eur Urol 2015;67:142-50.

2. Sri D, Sujenthiran A, Lam W et al. The significance of close surgical margins in organ sparing surgery for penile squamous cell cancer. European Urology Supplements 2017 16.3:e1237.

3. Graafland NM, Leijte JA, Valdes Olmos RA, Hoefnagel CA, Teertstra HJ, Horenblas S. Scanning with 18F-FDGPET/CT for detection of pelvic nodal involvement in inguinal node-positive penile carcinoma. Eur Urol 2009;56:339-45.

4. Zhang S, Li W, Liang F. Clinical value of fluorine-18 2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in penile cancer.

Oncotarget 2016;7:48600-48606.

5. Nicholson S, Hall E, Harland SJ et al. Phase II trial of docetaxel, cisplatin and 5FU chemotherapy in locally advanced and metastatic penis cancer (CRUK/09/001).

Br J Cancer 2013;109:2554-9.

6. Nicolai N, Sangalli LM, Necchi A et al. A combination of cisplatin and 5-fluorouracil with a taxane in patients who underwent lymph node dissection for nodal metastases from squamous cell carcinoma of the penis: treatment outcome and survival analysis in neoadjuvant and adjuvant settings. Clin Genitourin Cancer 2016;14:323-30.

7. Sharma P, Djajadiningrat R, Zargar-Shoshtari K et al.

Adjuvant chemotherapy is associated with improved overall survival in pelvic node-positive penile cancer after lymph node dissection: a multi-institutional study. Urol Oncol 2015;33:496.e17-23

Case Study No. 54 continued T This man had a pT3pN3G3 ‘usual type‘ sqamous cell carcinoma of the penis with three metastatic lymph nodes without capsular penetration in the right groin and no positive lymph nodes in the left groin.

Radical pelvic lymphadenectomy was done on the right side yielding 18 lymph nodes without metastases. Four courses of adjuvant chemotherapy were administered using the Pizzocaro-regimen (cisplatin, paclitaxel, 5-fluorouracil). The patient experienced febrile leucopenia after the fourth course which ended six months ago. Close follow-up since then has, so far, not shown any sign of recurrence.

European Urology Today

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Key articles from international medical journals Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ hotmail.com

Bipolar androgen therapy: A way to overcome resistance in CRPC? Metastatic castration-resistant prostate cancer remains dependent on androgen receptor signalling often associated with upregulation of androgen receptor expression. Consequently, enzalutamide, an androgen receptor antagonist, is effective in inducing tumour responses resulting in a survival benefit for these men. When the tumour progresses despite treatment with enzalutamide response to further inhibition of androgen signalling is minimal and alternative approaches are needed to produce clinical benefit.

However, in the setting of overexpressed androgen receptor, the administration of sufficient testosterone to achieve supraphysiological serum concentrations has paradoxically been shown to result in prostate cancer cell death and tumour regression in preclinical models.

Theoretically, rapidly varying the androgen concentrations between the extremes of supraphysiological and near-castrate, a strategy termed bipolar androgen therapy (BAT), provides insufficient time for castration-resistant prostate cancer cells to adaptively regulate androgen receptor concentrations in response to androgen concentrations in the microenvironment resulting in cell death. It is also proposed that rapidly varying androgen concentrations might prevent re-adaptation and resistance. Following encouraging results from a pilot study this group sought to test BAT in patients with metastatic castration-resistant prostate cancer who previously progressed on androgen receptordirected therapies, including enzalutamide.

retreatment, no grade 3–4 toxicities occurred in more than one patient. No treatment-related deaths were reported during either BAT or enzalutamide retreatment.

The data included is interesting because it suggest annual biopsy might not be necessary as part of an BAT appears to be a safe therapy that resulted in AS protocol for men with very low-risk disease and as responses in asymptomatic men with mCRPC and also such might improve compliance with AS. It is not clear resensitisation to enzalutamide in most patients if this can be applied to other AS data sets where the undergoing rechallenge. The 8.6-month clinical or selection criteria differ. It also fails to consider the role radiological progression-free survival seen is clinically of MRI or biomarkers in determining if biopsy meaningful and delayed the addition of other schedules. treatment. The major focus of the past 25 years has been toward total androgen annihilation. This Source: Optimizing active surveillance strategies provocative study builds upon years of observations to balance the competing goals of early and mechanistic rationale to exploit tumour-adaptive detection of grade progression and minimizing resistance to androgen removal. It very possibly is one harm from biopsies. Barnett CL, Auffenberg GB, new move in the endocrine chess match of treatment Cheng Z et al. versus tumour.

Cancer.2017;http://dx.doi.org/10.1002 /cncr.31101

Source: Bipolar androgen therapy in men with metastatic castration-resistant prostate cancer after progression in enzalutamide: an open label, phase 2, multicohort study. Teply BA, Wang H, Luber B, et al.

Lancet Oncol. 2017; http://dx.doi.org/10.1016/ S14702045(17)30906-3

Optimising Active Surveillance As low-risk prostate cancer often demonstrates indolent clinical behaviour there is real concern that men with such disease risk over-treatment. Active surveillance (AS) is a form of expectant management that involves monitoring patients through regular clinical examinations, biomarker tests, radiologic imaging, and biopsies. It has been promoted as a way for low-risk men to delay and possibly avoid surgery or radiation treatment. However, many approaches to implementing AS have been recommended, and the best approach is unclear.

This study presents data from a large longitudinal AS cohort to determine whether the number of biopsies received over 10 years of AS could be reduced from an annual biopsy schedule without substantially increasing the time to detecting grade progression in cases where it occurred. They conduct a hidden Markov model (HMM) analysis to estimate the initial biopsy sampling error, biopsy accuracy, and the rate of progression from low- to intermediate- or high-grade prostate cancer over time. They then used this to evaluate all possible follow-up surveillance strategies as well as previously proposed strategies for AS found in the literature on the basis of the mean delay time to the detection of grade progression and the planned number of biopsies over the first 10 years after the initiation of AS.

BAT appears to be a safe therapy that resulted in responses in asymptomatic men with mCRPC and also resensitisation to enzalutamide in most patients undergoing rechallenge...

The data included is interesting because it suggest annual biopsy This study run at John Hopkins University, Baltimore might not be necessary as part of was an open label, phase 2, multi-cohort study enrolling asymptomatic men with mCRPC and no an AS protocol for men with very more than two previous second-line hormonal low-risk disease and as such might therapies. Men with high-risk lesions for tumour flare (> 5 sites of visceral disease or bone lesions with improve compliance with AS impending fracture) were excluded. In this paper patients had progressed on enzalutamide with a continued PSA rise after enzalutamide treatment discontinuation. Patients then received BAT, which consisted of intramuscular testosterone cipionate 400 mg every 28 days until progression and continued LHRH agonist therapy. Upon progression after BAT, men were rechallenged with oral enzalutamide 160 mg daily after a 28-day wash-out period. The co-primary endpoints were investigator-assessed 50% decline in PSA concentration from baseline for BAT (for all patients who received at least one dose) and for enzalutamide rechallenge (based on intention-to-treat analysis).

A total of 30 eligible patients were treated with BAT. Nine (30%; 95% CI 15–49; p < 0·0001) of 30 patients achieved a > 50% reduction in PSA to BAT. 29 patients completed BAT and 21 proceeded to enzalutamide rechallenge, of whom 15 (52%; 95% CI 33–71; p < 0·0001) achieved a PSA response. During BAT, the only grade 3–4 adverse event occurring in more than one patient was hypertension (three [10%] patients).

Other grade 3 or worse adverse events occurring during BAT in one [3%] patient each were pulmonary embolism, myocardial infarction, urinary obstruction, gallstone, and sepsis. During enzalutamide Key articles

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The optimal strategy suggested biopsy at one, three, five and eight years.

Data was collected from 1375 men with very low-risk prostate cancer (clinical T1c, PSA < 10 ng/ml, PSA density < 0.15, Gleason 6, no more than two positive cores and no more than 50% of one core involved) enrolled in AS at Johns Hopkins. Where the protocol includes semi-annual PSA and digital rectal examinations and annual prostate biopsy. If a patient’s biopsy results no longer meet the inclusion criteria, he is recommended for curative treatment.

1024 potential AS biopsy strategies for the 10 years after diagnosis were simulated. For each of these strategies, the model predicted the mean delay in the detection of disease with a Gleason score ≥7.

The model estimated the 10-year cumulative probability of reclassification from a Gleason score of 6 to a Gleason score ≥ 7 to be 40.0%. The probability of under-sampling at diagnosis was 9.8%, and the annual progression probability for men with a Gleason score of 6 was 4.0%. On the basis of these estimates, a simulation of an annual biopsy strategy estimated the mean time to the detection of disease with a Gleason score ≥ 7 to be 14.1 months; however, several strategies eliminated biopsies with only small delays (< 12 months) in detecting grade progression.

Radiosurgery: An alternative therapy for small renal masses?

Renal cell carcinoma is a common cancer and increased access to and use of cross-sectional imaging has led to a rapidly increasing incidence of small renal masses. Nonsurgical treatment options for this population of patients include radiofrequency ablation and cryotherapy. Although a recent analysis of the SEER database indicated that, among patients aged > 65 years who underwent nonsurgical management for T1a disease, the five-year survival was 46.4% versus 83.1% in those who underwent partial nephrectomy (p < 0.01).

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk maximum dimension and the receipt of multifraction SABR were associated with poorer progression-free survival (hazard ratio, 1.16 [p < 0.01] and 1.13 [p = 0.02], respectively) and poorer cancer-specific survival (hazard ratio, 1.28 [p < 0.01] and 1.33 [p = 0.01], respectively). There were no differences in local failure between the single-fraction cohort (n = 1) and the multifraction cohort (n = 2; p = 0.60). The mean (±standard deviation) estimated glomerular filtration rate at baseline was 59.92±1.9mL per minute, and it decreased by 5.51±3.3mL per minute (p < 0.01).

This study showed impressive preservation of renal function and a favourable toxicity profile. However, like other thermal ablative approaches there remains a lack of prospective data. It is possible that just as patients who have comorbid medical conditions now receive standard treatment with SABR for early stage lung cancer, a similar paradigm could unfold in patients who have RCC. Nonetheless, prospective, randomised trials and comparative-effectiveness studies are needed to further evaluate this ablative modality in the treatment of RCC.

Source: Pooled analysis of stereotactic ablative radiotherapy for primary renal cell carcinoma: a report from the international radiosurgery oncology consortium for kidney (IROCK).

Siva S, Louie AV, Warner A et al.

This study showed impressive preservation of renal function Cancer. 2017; http://dx.doi.org/10.1002 /cncr.31156 and a favourable toxicity profile.

However, like other thermal ablative approaches there remains a lack of Early PSA response correlated with improved survival in the prospective data two arms of the CHAARTED trial The number of deaths attributed to RCC was four times higher in those who did not undergo surgery, confirming surgery as the most effective treatment.

However, in an elderly comorbid population many of whom require continuous anticoagulative medication this remains an option.

Stereotactic ablative radiotherapy (SABR), is an emerging treatment option in the context of medically unfit patients with primary kidney cancer. This paper is a pooled, multi-institutional analysis of patient outcomes. The objectives of this study were to assess safety, efficacy, and survival in a multi-institutional setting. In particular, outcomes between the two most common approaches—single-fraction and multifraction SABR—were compared.

Individual patient data sets from nine IROCK institutions with previously published data on SABR for the treatment of primary RCC across Germany, Australia, the United States, Canada, and Japan were pooled. Toxicities were recorded using Common Terminology Criteria for Adverse Events, version 4.0.

Patient, tumour, and treatment characteristics were stratified according to the number of radiotherapy fractions (single vs multiple). Survival outcomes were examined using Kaplan-Meier estimates and Cox proportional hazards regression.

Of 223 patients, 118 received single-fraction SABR, and 105 received multifraction SABR. The mean patient age was 72 years, and 69.5% of patients were men.

The maximal tumour dimensions were 43.6±27.7 mm.

The patients who received single-fraction SABR were younger, had better performance status, and harboured smaller tumours (P<0.01). The median dose for single-fraction SABR was 25Gy (range, 14-26 Gy); and, for multi-fraction SABR, it was 40 Gy (range, 24-70 Gy) delivered in two to 10 fractions. The rates of local control, cancer-specific survival, and progression-free survival were 97.8%, 95.7%, and 77.4%, respectively, at two years; and they were 97.8%, 91.9%, and 65.4%, respectively, at four years.

There were 83 patients with grade 1 and 2 toxicity (35.6%) and 3 with grade 3 and 4 toxicities (1.3%). On multivariable analysis, tumours with a larger

In 2017, two drugs have proven to be effective as life-prolonging agents in metastatic hormonesensitive prostate cancer (docetaxel and abiraterone) in addition to luteinising hormonereleasing hormone agonists. The CHAARTED trial was one of the three pivotal trials investigating the impact of docetaxel at the diagnosis of metastatic disease. In this sub-group analysis, the authors have assessed the impact of seven-month PSA response on disease outcomes and survival.

Indeed, previous studies of pure androgen blockade in this setting have suggested that patients who achieved a low nadir of PSA had a significantly longer survival compared with those who did not. As docetaxel does not act directly on androgen receptor and on PSA expression at the cell level, such a biochemical surrogate of survival outcomes could not be so relevant in docetaxeltreated patients.

The hormonal response of metastatic disease, whatever the treatment, is a strong predictor for prolonged survival. This response outperforms the type of treatment received when evaluating the subsequent risk of mortality under treatment Overall, 719 patients with at least a seven-month PSA follow-up were included: 358 in the androgen deprivation therapy arm, 361 in the docetaxel arm.

Patients who progressed before seven months were included in the seven -month PSA > 4 ng/ml group.

PSA responses at seven month were divided as follows: PSA < 0.2 ng/ml, PSA > 0.2 to 4, PSA > 4 ng/ ml. Median follow-up time was two years. At the three different time points evaluated, the lower the PSA at seven months, the longer was the survival.

Median survival was five years with a PSA < 0.2 ng/

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Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de ml, 51 months with a PSA 0.2-4, and 22 months with a PSA > 4 ng/ml (p = 0.001). Visceral location of metastatic disease was correlated with a weak PSA response at seven months.

The achievement of a seven-month PSA below 0.2 was significantly associated with the use of docetaxel, as well as low-volume disease, prior local therapy, and lower baseline PSA levels. Thus, 45.3% of patients in the docetaxel arm experienced a sevenmonth PSA < 0.2 ng/ml compared with only 28.8% of patients in the androgen deprivation therapy arm. In multivariable analysis, a longer survival was still associated with a PSA < 0.2 ng/ml at seven months, demonstrating the predictive value of the PSA response on subsequent survival.

Was the impact of PSA response modified by to the extent of metastatic disease, given that docetaxel failed to show a significant survival benefit in the sub-group of patients with low-volume disease?

However, in patients with a high-volume disease, seven-month PSA significantly correlated with survival. The median overall survival of patients with low-volume disease had not been reached in the majority of subsets.

The hormonal response of metastatic disease, whatever the treatment, is a strong predictor for prolonged survival. This response outperforms the type of treatment received when evaluating the subsequent risk of mortality under treatment. Indeed, in multivariable analysis, the assigned therapy failed to predict the risk of death whereas the reduction risk predicted by a seven-month PSA below 0.2 ng/ml was evaluated at 82% (95%CI 0.12-0.28, p<0.001). Thus, PSA represents an easy, inexpensive, intermediate clinical end point ad could be a reasonable surrogate for overall survival. On-therapy biomarkers (genetics, circulating tumour cells, circulating androgens) could also improve disease response modelling in the near future. The clinical aim of the use of such biomarkers would be to identify refractory disease patients who could be good candidates for earlier new line therapies.

Source: Seven-month Prostate-Specific Antigen is Prognostic in Metastatic Hormone Sensitive Prostate Cancer Treated with androgen deprivation with or without docetaxel.

Harshman et al.

endpoint was the ADT-free survival. ADT was started at symptomatic progression, radiologic progression, or local progression. Overall, the trial has included 62 patients.

One metastasis was treated in 58% of patients, and nodal location was found in 54.8% of cases. Bone and non-nodal metastases were treated in 45.2% of cases. Median PSA at inclusion ranged from 3.8 to 5.3 ng/ml according to the allocated treatment.

Approximately two-thirds of patients had received radical prostatectomy plus salvage radiotherapy before inclusion. The type of metastasis-directed therapy was stereotactic body radiotherapy in 25 patients and surgery in six patients (salvage pelvic lymph node dissection and lung metastasectomy).

The median ADT-free survival was 13 months for the surveillance group compared with 21 months in the treatment group (p = 0.11). Statistical significance was not achieved for the per-protocol and for the intention-to-treat analyses. In total, 74% of patients treated had a PSA decline, as compared with 42% (false positive cases by imaging?) in the surveillance arm. The median time until PSA progression was six months for the surveillance group, as compared with 10 months in the metastasis-directed therapy group (HR 0.52, p = 0.02). No grade 2-5 toxicity occurred.

Only 17% of patients experienced a grade 1 toxicity in the treatment group. Quality-of-life at three months and one year was similar among arms.

This trial is the first randomized trial assessing the impact of metastasis-directed therapy (versus surveillance alone) for patients with oligorecurrent metastatic prostate cancer This trial is the first randomized trial assessing the impact of metastasis-directed therapy (versus surveillance alone) for patients with oligorecurrent metastatic prostate cancer. Findings demonstrated that such an aggressive therapy delay the time to PSA progression, and could also postpone the use of androgen deprivation therapy. Further phase III trials with larger patient cohorts, with longer follow-up, and with stronger clinical endpoints (cancer-specific and overall survival) are awaited to confirm these findings and individually adapt the strategy according to the site of metastases, the PSA kinetics, the use of life-prolonging drugs in this setting (docetaxel, abiraterone).

Source: Surveillance or Metastasis-directed Therapy for oligometastatic Prostate Cancer recurrence: a prospective, randomized, multicenter Phase II trial. Ost, et al.

J Clin Oncol 2017 doi: 10.1200/JCO.2017.75.4853

J Clin Oncol 2017 doi: 10.1200/JCO.2017.75.3921.

Evidence-based benefit from metastasis-directed therapy in oligo-recurrent prostate cancer While the role of prostate cancer local failure treatment is widely accepted and recommended in current clinical practice given that it leads to decrease the risk of progression, no strong evidence supports the oncologic impact of salvage treatment in the presence of non-local recurrent disease. Traditionally, lymph node involvement has been treated only by androgen deprivation therapy (ADT) that was considered as the optimal treatment option in this setting. Local therapy of oligometastatic recurrence is a novel approach with a fast evolving literature.

Thus, recent published series of salvage lymph node dissection and of salvage radiotherapy have reported good outcomes associated with an acceptable toxicity.

Nevertheless, until recently, no prospective head-tohead trial was available to prove the real oncologic benefit of such a metastasis-directed approach.

In this randomized phase II trial, asymptomatic prostate cancer patients who had biochemical recurrence after primary treatment were randomly assigned to either surveillance or metastasis-directed therapy of all detected lesions (by surgery or radiotherapy). Only patients with a testosterone level > 50 ng/ml and with three or less extracranial lesions on choline PET/CT were included. The primary Key articles

January/February 2018

Overall, four of the 366 evaluable patients had at least one confirmed seizure within four months of enzalutamide initiation (rate: 1.1%). Three additional patients (0.8%) experienced seizure after four new months. The incidence of confirmed seizure was 2.6 per 100 patient-years. Mean duration of enzalutamide was 223 day, with only 17.7% of patients receiving treatment for more than one year. Overall, 48.5% of patients reported at least one treatment-related adverse effect. The frequently reported treatmentemergent adverse events were fatigue, asthenia, decreased appetite, anaemia, back pain, and nausea.

Thirty-eight deaths occurred during treatment with four cases considered as drug-related by the investigator. No seizure-related death was reported.

…based on this large study in patients with seizure risk factors, enzalutamide seems to represent a safe option in this subgroup of men, input from neurology specialists before initiation remains recommended

This study was a prospective, multicentre, post approval safety study involving 73 sites in 20 countries, and including 423 patients receiving enzalutamide. Patients had at least one risk factor for seizure at baseline. These factors were medications that lowered seizure threshold in 57.2% of cases, history of brain injury in 26.5% of cases, and history of cerebrovascular accident or transient ischemic attack in 22% of cases. It is worthy to note that some pre-existing seizure risk factors such as history of seizure or brain arterioveinous malformations were underrepresented. The primary endpoint was the percentage of evaluable patients with at least one independently confirmed seizure during the initial four-month treatment period. One secondary endpoint was the cumulative proportion of all patients with seizure events.

oliver.reich@ klinikum-muenchen.de Men with higher post-diagnosis vegetable intake reported higher urinary incontinence scores (72 vs. 76 comparing lowest to highest quintile; p-trend = 0.003).

Similarly, higher vegetable intake and lower polyunsaturated fat intake were associated with higher urinary irritation/obstruction scores (vegetable: 80 vs. 84 comparing lowest to highest quintile, p-trend = 0.01; polyunsaturated fat: 84 vs. 78 comparing lowest to highest quintile, p-trend = 0.005), however these associations were observed only among men with urinary symptoms prior to their prostate cancer diagnosis.

The authors concluded that among men with prostate cancer, diet intake after diagnosis was not significantly associated with urinary or sexual Given this post-approval safety profile of enzalutamide, function, although some relationships appeared to the authors concluded that the incidence of seizures in differ among men with and without symptoms prior a population of mCRPC patients with seizure risk to their prostate cancer diagnosis. Higher vegetable factors was comparable to that reported in another intake and lower polyunsaturated fat intake after large retrospective analysis of patients having the same prostate cancer diagnosis may be associated with profile. However, no head-to-head comparison was better urinary function. However, this analysis was available and this comparison should be considered exploratory, and further research is needed to better with caution. Nevertheless, based on this large study in delineate these relationships and guide dietary patients with seizure risk factors, enzalutamide seems recommendations for men with prostate cancer. to represent a safe option in this subgroup of men, Source: Mediterranean diet after prostate cancer input from neurology specialists before initiation diagnosis and urinary and sexual functioning: remains recommended.

Source: Seizure rates in enzalutamide-treated men with metastatic castration-resistant prostate cancer and risk of seizure – The UPWARD study. Slovin et al.

The health professionals follow-up study.

Bauer SR, Van Blarigan EL, Stampfer MJ, Chan JM, Kenfield SA. Prostate. 2017 Dec 1. doi: 10.1002/pros.23457.

[Epub ahead of print]

JAMA Oncology 2017, http://dx.doi.org/10.1001/ jamaoncol.2017.3361

Metabolomics approach for male lower urinary tract Mediterranean diet after prostate cancer diagnosis and symptoms: Biomarkers and urinary and sexual functioning potential targets Men with prostate cancer often experience urinary and sexual dysfunction after treatment. Previous studies have demonstrated a relationship between dietary factors and these symptoms among men with diabetes or metabolic syndrome. However, there are limited data on whether diet after prostate cancer diagnosis, including a Mediterranean dietary pattern, affects urinary and sexual function among prostate cancer survivors.

Men diagnosed with non-metastatic prostate cancer in the Health Professionals Follow-up Study (n = 2,960) from 1986 to 2012 were prospectively followed for a median of 8.3 years after treatment.

Enzalutamide is now a standard of care for patients Participants completed validated dietary with metastatic castration-resistant prostate cancer questionnaires every four years and a health-related quality of life assessment in 2010 or 2012. The (mCRPC). Seizure is a known adverse effect of this investigators used generalised linear models to treatment with 2% of reported cases in phase 1 and examine associations between post-diagnosis 2 studies. In subsequent phase III trials (AFFIRM, Mediterranean Diet Score (including individual score TERRAIN, PREVAIL, STRIVE), this rate ranged from 0.3 to 0.6% only. components and dietary fat subtypes) and quality of life domains (sexual functioning, urinary irritation/ obstruction, urinary incontinence) assessed using the However, patients with a history or risk factors for Expanded Prostate Cancer Index Composite Short seizure were excluded. The aim of the present Form (score 0-100; higher scores indicate better UPWARD study was to address requests from the US FDA and the EMA for additional information regarding function). the risk of seizure in enzalutamide-treated patients.

Neurologic safety of enzalutamide

Prof. Oliver Reich Section editor Munich (DE)

The authors of this interesting trial identified metabolites using a metabolomics approach and investigated the association between these metabolites and lower urinary tract symptoms (LUTS).

A 24-hour bladder diary and International Prostate Symptom Score (IPSS) were used to assess micturition behaviours and LUTS in a total of 58 male patients without apparent neurological diseases. LUTS was defined as a total IPSS score of ≥ 8 (the LUTS-group), while patients with a score of < 7 were placed in the Control-group. A comprehensive study of plasma metabolites was also conducted by capillary electrophoresis time-of-flight mass spectrometry.

Metabolites were compared between the LUTS-group and Control-group using Mann-Whitney U test, and biomarkers for male LUTS from the metabolites were analysed using a multivariable logistic regression analysis to show the odds ratio.

…male LUTS may occur due to abnormal metabolic processes in some pathways..

Of the 58 patients, 32 males were placed in the LUTS-group and the remaining 26 males in the Control-group. A 24-hr bladder diary showed that the However, this analysis was nocturnal urine volume, 24-hr micturition frequency, nocturnal micturition frequency, and nocturia index exploratory, and further research significantly higher in the LUTS-group. is needed to better delineate these were A metabolomics analysis identified 60 metabolites from the plasma of patients. A multivariate analysis relationships and guide dietary identified that an increase in glutamate level and recommendations for men with decreases in arginine, asparagine and inosine monophosphate levels were significantly associated prostate cancer with LUTS in males. Decreases in levels of citrulline and glutamine could be also associated with male No statistically significant relationships were observed LUTS. between the Mediterranean Diet Score after prostate cancer diagnosis and urinary or sexual function.

The investigators concluded that male LUTS may occur However, the associations did vary depending on due to abnormal metabolic processes in some pre-diagnosis urinary and sexual dysfunction for pathways. Potential new treatments for LUTS may be urinary irritation/obstruction and sexual function developed by identifying changes in the amino acid scores, respectively (p-interactions < 0.0001). profiles.

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9

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

tebj@medisin.uio.no

Source: Metabolomics approach for male lower urinary tract symptoms: An identification of possible biomarkers and potential targets for new treatments. Mitsui T, Kira S, Ihara T, Sawada N, Nakagomi H, Miyamoto T, Shimura H, Yokomichi H, Takeda M. J Urol. 2017 Nov 21. pii: S0022-5347(17)77960-8. doi: 10.1016/j.juro.2017.11.070. [Epub ahead of print]

Antibiotic susceptibility testing may be performed in less than 30 min by new technology Antibiotic resistance is a global threat to human health and the emergence and spread of antibiotic-resistant bacteria are aggravated by incorrect prescription and use of antibiotics. A core problem is that there is no sufficiently fast diagnostic test to guide correct antibiotic prescription at the point of care.

Of 17 228 599 commercially insured men in the 75 DMAs, 1 007 990 (mean age, 49.6 [SD, 11.5] years) had new serum testosterone tests and 283 317 (mean age, 51.8 [SD, 11.3] years) initiated testosterone treatment.

Advertising intensity varied by geographic region and time, with the highest intensity seen in the southeastern United States and with months ranging from no ad exposures to a mean of 13.6 exposures per household. Non-branded advertisements were common prior to 2012, with branded advertisements becoming more common during and after 2012.

…among US men residing in the 75 designated market areas, regional exposure to televised direct-to-consumer advertising was associated with greater testosterone testing, new initiation, and initiation without recent testing Each household advertisement exposure was associated with a monthly increase in rates of new testosterone testing (rate ratio [RR], 1.006; 95% CI, 1.004-1.008), initiation (RR, 1.007; 95% CI, 1.0041.010), and initiation without a recent test (RR, 1.008; 95% CI, 1.002-1.013). Mean absolute rate increases were 0.14 tests (95% CI, 0.09-0.19), 0.05 new initiations (95% CI, 0.03-0.08), and 0.02 initiations without a recent test (95% CI, 0.01-0.03) per 10 000 men for each monthly ad exposure over the entire period.

Prostate Cancer. Eva Shrestha, James R. White, Shu-Han Yu, Ibrahim Kulac, Onur Ertunc, Angelo M. De Marzo, Srinivasan Yegnasubramanian, Leslie A. Mangold, Alan W. Partin, Karen S. Sfanos.

J Urol January 2018 Volume 199, Issue 1, Pages 161–171.

DOI: http://dx.doi.org/10.1016/j.juro.2017.08.001

Dusting or basketing? The eternal dilemma in Retrograde Intrarenal Surgery for the treatment of renal stones The treatment of renal stones by means of flexible ureteroscopy (fURS) - known also as retrograde intrarenal surgery (RIRS) - has become one of the most popular endourological procedure in the last decade.

The technique is standardised even though some variants may be applied by surgeons according to their experience and skills.

One of the most debated issues concerns the best way a renal stone should be fragmented, i.e. dusted or basketed. The former technique consists in fragmenting stones in as much as smaller particles by modulating the laser setting appropriately, i.e. with high frequency at low energy and longer pulses, so that manipulation of upper urinary tract is minimised.

The authors investigated if it was possible to develop a The latter involves a higher energy at lower frequency point-of-care susceptibility test for urinary tract The authors summarised that among US men residing with shorter pulses to grossly break the stone in infection, a disease that 100 million women suffer from in the 75 designated market areas, regional exposure smaller fragments that can be basketed, so that to televised direct-to-consumer advertising was patient may be immediately stone-free. annually and that exhibits widespread antibiotic associated with greater testosterone testing, new resistance. Bacterial cells were captured directly from Recently, a study has compared for the first time the samples with low bacterial counts (104 cfu/mL) using a initiation, and initiation without recent testing. custom-designed microfluidic chip and then monitored technique on a prospective multicentric trial conducted by members of the Endourologic Disease their individual growth rates using microscopy. By Source: Association between direct-toGroup for Excellence (EDGE) of the United States. They averaging the growth rate response to an antibiotic consumer advertising and testosterone testing recruited 84 and 75 patients for the dusting and over many individual cells, the detection time could be and initiation in the United States. Layton JB, basketing group, respectively, with 5-20 mm renal pushed to the biological response time of the bacteria. Kim Y, Alexander GC, Emery SL It was possible to detect changes in growth rate in JAMA. 2017 Mar 21;317(11):1159-1166. doi: 10.1001/ stones. Patients were allocated in the relevant group response to each of nine antibiotics that are used to jama.2016.21041. according to centre/surgeon’s usual practice; all of treat urinary tract infections in minutes. In a test of 49 them had a JJ post-operatively (4-14 days), were clinical uropathogenic Escherichia coli (UPEC) isolates, prescribed Tamsulosin 0.4 mg for 30 days, and had all were correctly classified as susceptible or resistant stone-free rate (SFR) state assessed with Study suggests prevalence of their to ciprofloxacin in less than 10 minutes. imaging studies at 4-6 weeks.

The total time for antibiotic susceptibility testing, from loading of sample to diagnostic readout, was less than 30 minutes, even if the bacterial concentration in the urine was very low. The technology allows the development of a point-of-care test that can guide correct treatment of urinary tract infection.

Source: Antibiotic susceptibility testing in less than 30 min using direct single-cell imaging. Özden Baltekin, Alexis Boucharin, Eva Tano, Dan I. Andersson, and Johan Elf. PNAS. Vol. 114 no. 34. 9170–9175, doi: 10.1073/pnas.

1708558114 .

Association between directto-consumer advertising and testosterone testing and initiation in the United States Testosterone initiation increased substantially in the United States from 2000 to 2013, especially among men without clear indications. Direct-to-consumer advertising (DTCA) also increased during this time.

The authors investigated the associations between televised DTCA and testosterone testing and initiation in the United States.

This was a ecologic study conducted in designated market areas (DMAs) in the United States. Monthly testosterone advertising ratings were linked to DMA-level testosterone use data from 2009-2013 derived from commercial insurance claims.

Associations between DTCA and testosterone testing, initiation, and initiation without recent baseline tests were estimated using Poisson generalised estimating equations.

The main outcomes and measures were (1) rates of new serum testosterone testing; (2) rates of testosterone initiation (in-office injection, surgical implant, or pharmacy dispensing) for all testosterone products combined and for specific brands; and (3) rates of testosterone initiation without recent serum testosterone testing.

Key articles

10

pro-inflammatory bacteria and uropathogens in the urinary tract of men with prostate cancer

Studies demonstrating bacterial DNA and cultivable bacteria in urine samples have challenged the clinical dogma that urine is sterile. Furthermore, studies now indicate that dysbiosis of the urinary microbiome is associated with pathological conditions. The authors of this paper proposed that the urinary microbiome may influence chronic inflammation observed in the prostate, leading to prostate cancer development and progression. Therefore, they profiled the urinary microbiome in men with positive versus negative biopsies for prostate cancer.

Urine was collected from men prior to biopsy for prostate cancer. DNA was extracted from urine pellet samples and subjected to bacterial 16S rDNA Illumina® sequencing and 16S rDNA quantitative polymerase chain reaction. Investigators determined the association between bacterial species and the presence or absence of cancer, cancer grade, and type and degree of prostate inflammation.

Urine samples revealed diverse bacterial populations.

There were no significant differences in α or β diversity and no clear hierarchical clustering of benign or cancer samples. A cluster of pro-inflammatory bacteria previously implicated in urogenital infections was identified in a subset of samples. Many species, including known uropathogens, were significantly and differentially abundant among cancer and benign samples, in low versus higher grade cancers and in relation to prostate inflammation type and degree.

The authors claimed theirs is the most comprehensive study to date of the male urinary microbiome and its relationship to prostate cancer. Their results suggest a prevalence of pro-inflammatory bacteria and uropathogens in the urinary tract of men with prostate cancer.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

SFR was defined as no fragment on imaging (either X-ray or/and US or/and CT) as by the radiologists report.

Overall, the two techniques have pros and cons that may counterbalance each other; it may be also difficult to apply exclusively either a technique or the other because in many occasions most depends on the stones composition At univariate analysis SFR was in favour of the basketing group (74.7% vs. 58.1%, p = 0.04) even though dusting group was affected by significantly larger stone size (96.3 vs. 63.3 mm2, p<0.001); in fact, at multivariate analysis no more significant difference was found after adjusting for the different stone size (p = 0.11).

Similarly, the readmission rate was comparable between the two groups of patients, as well as the need of ancillary procedures for clinically significant residual fragments.

Moreover, dusting procedures were faster with a reduction of 44% of operative time: this factor may contribute to a reduction of operative costs together with a significantly less use of UAS (100 vs. 15.6%, p < 0.001).

On the other hand, basketing allowed stone analysis in a significantly higher proportion of patients (98.9 vs. 83.2 %, p < 0.01); laser time was also shorter, so that if reusable laser fibres are utilised, dusting technique may involve higher costs on this regard.

Finally, no difference in complication rates were observed.

Overall, the two techniques have pros and cons that may counterbalance each other; it may be also Source: Profiling the Urinary Microbiome in Men difficult to apply exclusively either a technique or the with Positive versus Negative Biopsies for other because in many occasions most depends on

g.ploussard@ gmail.com

the stones composition. As a consequence the appropriate approach –including a hybrid oneshould be tailored according to the circumstance and not to surgeons’ preference.

Source: Dusting versus basketing during ureteroscopy - Which technique is more efficacious? A prospective multi-center trial from the EDGE Research Consortium.

Humphreys MR, Shah OD, Monga M, et al.

J Urol. 2017 Dec 15. pii: S0022-5347(17)78115-3. doi: 10.1016/j.juro.2017.11.126. [Epub ahead of print].

Expanding indication for the endoscopic nephron-sparing approach for the treatment of upper urinary tract urothelial cancer (UTUC) The gold standard for the treatment of UTUC has been historically and exclusively the radical nephroureterectomy. Conservative approach for UTUC has been considered a treatment option only in selected patients with imperative conditions such as solitary kidney, bilateral UTUC, severe comorbidities, or chronic kidney disease.

However, the improvements in endoscopic technologies and techniques have recently expanded the indications for a nephron-sparing approach. In the last editions of the EAU Guidelines, UTUC patients were stratified in low and high-risk to be considered for either a conservatory or radical treatment.

Low-risk UTUC approachable endoscopically should be unifocal, < 1 cm in size, low grade on cytology and on biopsy, and should not have invasive aspect at CT-urography.

However, some of these criteria have been challenged in recent publications from Prof. Traxer series as the largest one in literature on the endoscopic management of UTUC. Authors reviewed outcomes of 92 patients with a median follow-up time of 52 months (minimum 12 months) who were selected for endoscopic treatment with laser ablation of lesions detected in upper urinary tract, either for elective (64.2%) or imperative (35.8%) reasons. Notably, median tumours size was 14 mm and nearly half of the patients had multifocal lesions (46.7%), as well as no tumour grade was available in a similar proportion of patients (47.8%).

They also highlighted that the threshold of 1 cm size as inclusion criterion may be too restrictive, as authors offered electively and successfully endoscopic treatment to larger UTUC as long as complete endoscopic ablation could be achieved and no high grade tumour were present Local recurrence occurred in 70 patients (76.1%) and when possible or indicated were treated with flexible ureteroscopy (fURS).

Disease progression was detected in 31 patients (33.7%) and disease progression-free (DPF) survival was 86% and 77% at first and second year, respectively. Twenty-one patients (22.8%) needed finally a radical nephrureterectomy. Interestingly, no difference of DPF survival rates were found when comparing patients with UTUC of ≤ 1 cm vs. > 1 cm in size (log rank 0.86). Moreover, on multivate Cox regression analysis the only prognostic factor

EAU EU-ACME Office

European Urology Today

January/February 2018

significantly associated to disease progression was the tumour grade at first fURS (HR 5.16).

On the basis of their findings, authors suggested an early endoscopic check after primary fURS because of the 50% chance of persistent or recurrent UTUC. They also highlighted that the threshold of 1 cm size as inclusion criterion may be too restrictive, as authors offered electively and successfully endoscopic treatment to larger UTUC as long as complete endoscopic ablation could be achieved and no high grade tumours were present.

In line with this latter recommendation, a recent update of the EAU guidelines on UTUC has been revised and extended to 2 cm the size limit criterion for the low-risk patients that can be considered tributary for endoscopic approach.

Finally, new technologies are in development to support endourologists to identify in real-time those patients with high-grade tumours not suitable for fURS management.

Eur Urol. 2018 Jan;73(1):111-122. doi: 10.1016/j. eururo.2017.07.036. Epub 2017 Sep 1.

3) Correlation Between Confocal Laser Endomicroscopy (Cellvizio®) and Histological Grading of Upper Tract Urothelial Carcinoma: A Step Forward for a Better Selection of Patients Suitable for Conservative Management. Breda A, Territo A, Guttilla A, et al.

Source: An In-vivo Prospective Study of the Eur Urol Focus. 2017 Jun 4. pii: S2405-4569(17)30127-X. Diagnostic Yield and Accuracy of Optical Biopsy doi: 10.1016/j.euf.2017.05.008. [Epub ahead of print] Compared with Conventional Renal Mass Biopsy for the Diagnosis of Renal Cell Carcinoma: The Interim Analysis. Buijs M, Wagstaff P.G.K., de Bruin D.M. et al..

Optical coherence tomography: Eur Urol Focus (2017), https://doi.org/10.1016/j.

A new technology for the euf.2017.10.002 characterisation of renal masses without tissue sampling Anticardiolipin antibodies are associated with early loss of Optical coherence tomography (OCT) is a recently introduced technology for performing high-resolution graft function imaging. OCT is analogous to ultrasound imaging,

Sources: 1) Which Patients with Upper Tract Urothelial Carcinoma Can be Safely Treated with Flexible Ureteroscopy with Holmium:YAG Laser Photoablation? Long-Term Results from a High Volume Institution. Villa L, Haddad M, Capitanio U, et al.

except that it uses light instead of (ultra)sound. OCT can provide cross-sectional images of tissue structure on the micron scale. Using OCT in combination with probes -like endoscopes, catheters or even needlesenables high-resolution imaging of organs. As a consequence, OCT can function as a type of real-time in-situ optical biopsy without the need to collect a sample of the targeted tissue for histopathological examination OCT.

J Urol. 2017 Aug 15. pii: S0022-5347(17)77316-8. doi: 10.1016/j.juro.2017.07.088. [Epub ahead of print]

OCT may be then particularly useful in those patients

with coagulation disorders or bleeding diathesis 2) European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: where standard excisional biopsy needs to be 2017 Update. Rouprêt M, Babjuk M, Compérat E, performed. et al.

Postoperative antibiotics is not associated with lower rates of postoperative urinary tract infection (UTI) in patients with nephroureterolithiasis The aim of this study was to determine compliance with American Urological Association (AUA) antimicrobial prophylaxis best practice statement and whether the use of postoperative antibiotics is associated with lower rates of postoperative urinary tract infection (UTI) in patients with nephroureterolithiasis and a negative preoperative urine culture undergoing ureteroscopy.

A retrospective review of all adult patients undergoing ureteroscopy from 2013-2014 for stone disease with a negative preoperative urine was conducted. Patients who did and did not receive postoperative oral antibiotics beyond 24 hours of surgery were identified. The rates of culture-proven postoperative UTI and unplanned postoperative encounters were determined for both groups. Between group comparisons were made using independent t-test and chi-square analyses.

A total of 1,068 patients met inclusion criteria and only 31.6% were managed in accordance with the AUA best practice statement by not receiving antibiotics beyond 24 hours of surgery.

Overall, 33 patients developed a culture-proven UTI within 30 days following surgery, with no difference in UTI rate between patients who did and did not receive home-going antibiotics (2.9% vs. 3.6%, respectively; p = 0.5). Rates of unplanned hospital encounters also did not differ between groups (23.7% vs. 27.0%, respectively; p = 0.2). On multivariate regression, culture-proven UTI within one year prior to surgery was the only factor associated with post-operative UTI (OR 10.8, p < 0.0001).

Following initial successful performance of OCT in ophthalmology, a pivotal study in urology has been started on October 2013 evaluating the diagnostic accuracy of percutaneous OCT compared to renal masses biopsy (RMB) for the characterisation of renal masses.

The rational stands in minimising the risk either of indicating extirpative surgery (i.e. partial or radical nephrectomy) for benign renal masses or of obtaining a non-diagnostic biopsy for the characterisation of kidney lesions.

An interim analysis has been just published after recruiting half of the 194 patients needed, according to sample size calculation. Primary end-points included diagnostic accuracy of distinguishing between benign and malignant renal masses and characterising oncocytomas to renal cell cancer (RCC).

OCT were performed with a needle inserted percutaneously in the targeted area of the kidneys, followed by standard RMB. Reference standards were anatomo-pathological specimen when extirpative surgeries were performed, otherwise a second procedural biopsy was taken into account when ablation of the lesions was the treatment undertaken.

Authors have justified these controversial results by a technical issue related to the images of OCT as randomly selected within the tumour region, which may cause misinterpretation in case areas of necrosis, inflammation or cystic are involved in the relevant images

While sensitivity and positive predictive value were comparable between OCT and RMB in both differentiating between benign and malignant, as well as between oncocytoma, and RCC, specificity and It is concluded that patients who did and did not negative predictive value were lower for OCT. On the receive home-going antibiotics following ureteroscopy other hand, RMB was non-diagnostic in 21% of the cohort, against only one observed in the OCT group: demonstrated similar rates of postoperative UTI and unplanned hospital encounters. These results suggest according to this outcome, the added value calculated for OCT with respect to RMB was 15%. there is no benefit to extended antibiotics following ureteroscopy. The minority of patients managed in Authors have justified these controversial results by a accordance with the AUA best practice statement technical issue related to the images of OCT as highlights room for quality improvement. randomly selected within the tumour region, which Source: American Urological Association may cause misinterpretation in case areas of necrosis, Antibiotic Best Practice Statement and inflammation or cystic are involved in the relevant Ureteroscopy - Does Antibiotic Stewardship images.

Help? Greene D, Gill BC, Hinck B, Nyame YA, Almassi N, Venkatesh K, Noble M, Sivalingam S, Monga M. J Endourol. 2017 Nov 27. DOI: 10.1089/end.2017.0796 PMID: 29179565 Key articles

January/February 2018

Overall, this technique is indeed promising even though some setting issues still need to be addressed to standardise its use in clinical practice.

Adjustments and further analysis with full sample inclusion are expected to confirm the potential advantages.

Another important limitation of the study was the heterogeneous reference standard, even though a subset analysis with only surgical specimen seemed to show similar outcomes.

Graft function after renal transplantation is influenced by numerous factors many of which are still poorly understood. This retrospective analyses examined the relevance of anticardiolipin (ACL) antibodies. ACL without antiphospholipid syndrome (APS) are found in up to 38% of transplant patients and could be associated with thrombotic events (TEs). However, the prognostic role of ACL regarding kidney transplant and patients‘ outcomes have still not been welldefined.

The authors undertook an observational, monocentric, retrospective cohort study including 446 kidney transplant recipients and standardised follow-up: 36-month allograft and patient survival, 12-month estimated glomerular filtration rate (eGFR) and three- and 12-month screening biopsies.

… ACL (without APS) before kidney transplantation is an independent risk factor of eGFR decline within the first year post-transplant with no influence on thromboembolic events ACL tests were run on 247 patients, 101 were positive (ACL+ group, 41%) and 146 were negative (ACLgroup, 59%). Allografts survival, patient survival, rate of thromboembolic events were not different between both groups within 36 months [HR = 1.18 and HR = 0.98, respectively]. The 12-month eGFR was significantly lower in the ACL+ group [median (95% CI) 48.5 (35.1-60.3) versus 51.9 (39.1-65.0) mL/min/1.73 m2, p< 0.043]. ACL+ was independently associated with eGFR decrease p < 0.05). In 12-month screening biopsies, tubular atrophy was significantly more severe in the ACL+ group compared to the ACL- group (p = 0.02).

The authors concluded that ACL (without APS) before kidney transplantation is an independent risk factor of eGFR decline within the first year post-transplant with no influence on thromboembolic events. They suggested that specific immunosuppressive therapy with mammalian target of rapamycin inhibitors should be discussed in these patients.

Source: Anticardiolipin antibodies and 12-month graft function in kidney transplant recipients: a prognosis cohort survey. Gauthier M, CanouiPoitrine F, Guéry E, Desvaux D, Hue S, Canaud G, Stehle T, Lang P, Kofman T, Grimbert P, Matignon M. Nephrol Dial Transplant. 2018 Jan 16. doi: 10.1093/ndt/ gfx353. [Epub ahead of print]

Discarding of HCV-positive organs may be reduced by patient counselling Despite effective antiviral treatment, hundreds of kidneys from deceased donors with hepatitis C virus (HCV) are discarded annually. Little is known about the determinants of willingness to accept HCVinfected kidneys among HCV-negative patients.

At two centres, 189 patients undergoing initial or re-evaluation for transplant made 12 hypothetical decisions about accepting HCV-infected kidneys in which we systematically varied expected HCV cure rate, allograft quality and wait-time for an uninfected kidney.

Only 29% of participants would accept an HCVinfected kidney under all scenarios, while 53% accepted some offers and rejected others, and 18% rejected all HCV-infected kidneys. Higher cure rate (OR 3.49, 95% CI 2.33-5.24 for 95% vs. 75% probability of HCV cure), younger donor (OR 2.34, 95% CI 1.91-2.88 for a 20-year-old vs. a 60-year-old hypertensive donor), and longer waiting time for an uninfected kidney (OR 1.43, 95% CI 1.22-1.67 for five vs. two years) were associated with greater willingness to accept an HCV-infected kidney. Black race modified the effect of HCV cure rate, such that willingness to accept a kidney increased less for blacks vs. whites as the cure rate improved. Patients > 60 years and prior kidney recipients showed greater willingness to accept an HCV-infected organ.

… discarding of HPV-positive organs is a great problem in view of the organ shortage The discarding of HPV-positive organs is a great problem in view of the organ shortage. From their study, the authors concluded that most patients will consider an HCV-infected kidney in some situations.

They advocated that trials should be undertaken using HCV-infected kidneys which might enhance enrolment by targeting older patients and prior transplant recipients.

Source: Race, Risk, and Willingness of Endstage Renal Disease Patients Without Hepatitis C (HCV) to Accept an HCV-infected Kidney Transplant. McCauley M, Mussell A, Goldberg D, Sawinski D, Molina RN, Tomlin R, Doshi SD, Abt P, Bloom R, Blumberg E, Kulkarni S, Esnaola G, Shults J, Thiessen C, Reese PP. Transplantation. 2018 Jan 18. doi: 10.1097/ TP.0000000000002099. [Epub ahead of print]

Higher recipient age is associated with reduced risk of acute rejection It is well known that cold ischemia time (CIT) impacts on acute renal transplant rejection (ARTR) rates.

However, the quantitative relationship has not been fully studied in a large cohort of renal transplant patients.

The authors analysed 63,798 deceased donor renal transplants performed between 2000 and 2010 from the Organ Procurement and Transplantation Network database for the association between CIT and ARTR and for that between recipient age and ARTR. 6,802 patients (11%) were clinically diagnosed with ARTR. Longer CIT was associated with an increased risk of ARTR. After multivariable adjustment, compared with recipients with CIT < 12h, the relative risk of ARTR was 1.13 (95% CI 1.04-1.23) in recipients with CIT ≥ 24h. The association of CIT and ARTR was more pronounced in patients undergoing retransplantation: compared with recipients with CIT < 12h, the relative risk of ARTR was 1.66 (95% CI 1.01-2.73) in recipients with CIT ≥ 24h. Additionally, older age was associated with a decreased risk of ARTR.

Older age was associated with a lower risk of ARTR which is an important finding Compared with recipients 18-29 years old, the relative risk of ARTR was 0.50 (95% CI 0.45- 0.57) in recipients ≥ 60 years old. Longer CIT was also associated with increased risk of death-censored graft loss. Compared with recipients with CIT<12h, the hazard ratio of death-censored graft loss was 1.22 (95% confidence interval 1.14,1.30) in recipients with CIT ≥ 24h.

Prolonged CIT is associated with an increased risk of ARTR and death-censored graft loss. Older age was associated with a lower risk of ARTR which is an important finding.

Source: Association of Cold Ischemia Time with Acute Renal Transplant Rejection. Postalcioglu M, Kaze AD, Byun BC, Siedlecki A, Tullius SG, Milford EL, Paik JM, Abdi R. Transplantation. 2018 Jan 18. doi: 10.1097/ TP.0000000000002106. [Epub ahead of print]

EAU EU-ACME Office

European Urology Today

11

• What do you think is the biggest challenge in urology?

The biggest challenge is to offer individualised treatment to our patients as much as we can, in oncology but also in benign disease.

• If you were not a urologist, what would you be?

A hockey player. I come from an area where hockey is very popular. I used to play.

• What is your most important piece of advice for doctors just starting out?

Just do what you feel like doing or what you're interested in, and not go into what is currently popular. Follow your interests, continue to work hard and stick to what you believe is important.

• What is the most rewarding aspect of being a doctor?

It is rewarding to see the patient benefiting from your treatment. Patients trust us doctors, so to call the patient's relatives after surgery telling them the procedure went as planned is rewarding.

• What is your advice to other physicians on how to avoid burnout?

It’s very important to spend quality time outside work. Not looking at your smart phone all day, but putting it off for some hours to avoid pressure. I spend time with my family and do sports, one of the best ways to clear your mind.

• If you could change something in the healthcare system, what would it be?

The healthcare system should provide equal care for everyone which is not the case throughout the world. And also a fair offer of adequate treatment for our patients based on their individual needs.

• What´s the last wonderful book you have read?

That would be Haruki Murakami’s “South of the Border, West of the Sun.” • What’s the last thing that surprised you?

When my daughter sang a birthday song for me in a video clip. That was very sweet. She’s turning four.

• What’s your favourite hour in a day and why?

The very early morning hours because your mind is clear, one is full of energy, and the day is just coming up.

TEN QUESTIONS Interview and Photography by Joel Vega

Age: 41 Specialty: Uro-oncology, BPH and prostate disease City: Munich (DE) Current Post/Awards: Winner, 2017 EAU Crystal Matula Award; Professor, LMU-Klinikum der Universität München, Munich (DE); Editor-in-Chief, European Urology Focus; Lead investigator, metastatic prostate cancer and radical prostatectomy, male LUTS.

• What do you most often wish you could say to patients, but did not?

‘Everything’s going to be all right.’

CHRISTIAN GRATZKE

Challenges in MDT care: Role of the lead specialist

By Joel Vega A multidisciplinary team (MDT or ‘tumour board’) is now a standard practice for cancer patients. Various medical professionals are involved in cancer therapy that patients nowadays expect a seamless and coordinated care, which can only be possible with effective inter-disciplinary approach.

But with the work load and time pressures in daily clinical routines experienced by physicians, nurses and other specialists, MDT meetings can be a potential and a real source of delay in implementing crucial decisions. In these meetings it is not uncommon to hear comments such as: “The meetings become a sounding board with everyone putting forward their opinions, but no one steps in to actually say, ‘This is the decision we’re going to take.’” It becomes an exercise in airing out a set of interventions but with no clear agreements or consensus at the end of the meeting.”

Thus, although the MDT may seem a well-executed if not standard procedure, in the real world and within the walls of the board meeting, the process is still saddled with practical barriers. Technical problems in video-conference sessions are often encountered.

Scratchy audio or intermittent interruptions in tele-connections can lead to a lack of proper assessment, for instance, of radiological images.

Worse, the absence of a key consultant, oncologist or specialist would mean a lack of consensus.

Nurses are also of the opinion that teleconferencing can encourage what is called “tribalism,” with experts present in the same room having the tendency to support their group’s findings as against the dissenting opinion of a group located or participating from another (remote) site. Moreover, there is the natural preference for face-to-face communication, as against the benefits of accessing overseas experts in real-time video-conferences.

Another cause of gridlock is the lack of information such as the pending results of CT scans or pathology 12

European Urology Today

work, which can further delay a much-needed collective decision. And more significant is the lack of direct knowledge of the patient’s actual condition.

“There are patients over 70 years who are fit, into active sports and yet they couldn’t have a surgical procedure because the first specialist or referral doctor is bound, for example, by the hospital’s guideline not to offer surgical intervention for the elderly,” said Prof. Manfred Wirth, EAU Treasurer and head of the Urology Department in Dresden’s University Hospital Carl Gustav Carus (DE).

K. Byar and colleagues, in their 2016 article “Coordination of Care with a Multidisciplinary Care Team During Treatment,” described the key principles of coordination of care in a multidisciplinary team setting.

Aside from concluding the importance for teams to encourage open communication that is “…efficient, accurate and precise,” they also noted that the patient “…remains the constant member of the team.”

The last recommendation may be construed as provocative by many experts since MDT decisionmaking is a complex, highly-technical process that involves specialist information and timely intervention.

“It would be a disaster to confront the patient with these “This may run counter to the assessment of a discussions, which can only lead to raising patient urologist who has personally seen the patient and anxiety,” is a common response among doctors. This is made a thorough assessment of his actual physical condition. In this case, there is room for individualised a valid point that requires further discussion. But it cannot be denied that without taking the patient’s care. But even that may be difficult if not all in the viewpoint fully into account, a consensus decision MDT has key insights on the patient’s physical status and wishes,” Wirth said, adding that the opposite can would eventually run into hurdles. also be true with the patient “looking good on paper” In his article “Reviewing Cancer Care Team but is actually not fit to undergo further systemic Effectiveness,” (J Oncol Practice 2015 May), S. Taplin and treatment. colleagues underlined eight hallmarks of effective MDT teams. The first four, as listed below, described the Crucial role for lead expert basic characteristics of these teams: Wirth stressed the importance of the urologist taking the lead role in onco-urological diseases since the optimal treatment of these malignant conditions must • Negotiating and developing shared goals for mutually shared patients or patient populations, take into account not only co-morbidities and disease sharing unique information proactively, working progression but also complications that can affect jointly to make sense of available information other organs. He said it cannot be denied that (communication); team-based approaches can lead to better follow• Demonstrating explicit commitment to working ups. But the intervention of an organ specialist such collaboratively (cooperation); as a urologist can be more decisive since he can identify a strategy that is guideline-compliant. “There • Orchestrating explicit coordination of activities and identifying cues or triggers indicating that key are existing guidelines that urological specialists can tap into whenever a patient’s case calls for specific steps have been completed or are in progress (coordination); and, interventions,” he said.

• Developing trust and the desire to work together in the future (cohesion).

“The best suited expert or specialist in onco-urology is the urologist given the nature of the disease and his direct contact with the patient. Undoubtedly, we have Taplin then added four theoretical drivers that would help MDTs address the first four, and these are: to balance the approach with opinions of other • Belief that the team as a unit can accomplish specialists in the MDT group, but the lead expert has shared goals (collective efficacy); the pivotal task to speed up the decision-making • Shared description and understanding of the team process,” Wirth added.

characteristics (collective identity); • Developing the ability to recognise the pertinent cues of team members and use the team’s collective resources (cognition), and • Need for coaching, since 58% of people who are trained in teamwork require additional reinforcement and deliberate practice to sustain the changes in their performance.

Enhancing the role of MDT’s lead experts can certainly contribute to boosting the efficacy of a multidisciplinary approach, particularly when there are gridlocks or there is an anticipation of potential delays. Recognising these delays can be signalled through effective, direct communication, and a lead expert, such as urologists, can fulfil the function as they are well-placed in the broader scheme of onco-urological care.

Finally, there is a need to find out how MDTs function and impact on long-term outcomes, and an understanding of how lessons about teams in other settings can apply to teams in cancer care. Certainly, it would be interesting to find out the perspectives of other experts, and this article can serve as a starting point for an oncologist, urologist, pathologist or radiation oncologist to comment on.

Points for further discussion: • What are the benefits of patient involvement in MDT? • What are the links between MDT meetings and implemented decisions?

• How do the disparate perceptions among professionals (i.e. doctors and nurses, oncologists and urologists) regarding their collaboration affect their effectiveness as MDT members?

January/February 2018

SATURN Registry enrols 50th patient European Registry for Patients Undergoing Surgery for Male Stress Urinary Incontinence in five countries Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL)

Country Belgium Czech Republic Germany Netherlands Spain

(Sub) Investigator Prof. F. Van Der Aa Dr. R. Zachoval Dr. T. Hüsch/ Prof. A. Haferkamp Dr. J. Heesakkers/Dr. F. Martens Dr. E. Fernández Pascual/ Prof. J.I. Martinez-Salamanca

City Leuven Prague Mainz Nijmegen Madrid

Hospital University Hospital Leuven Thomayer Hospital University Hospital Mainz Radboud UMC Hospital Universitario Puerta De Hierro-Majadahonda

Date EC Approval 08-09-2017 12-06-2017 16-10-2017 10-10-2016 30-06-2017

# Patients recorded in eCRF 23 3 0 27 2

w.witjes@ uroweb.org

Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ uroweb.org The primary objective of the SATURN study is to evaluate the cure rate of surgical 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 are 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

or groin pain, haematuria, swelling or other and surgical variables that correlate with (in) continence or revisions for each of the device subtypes. problems). The ICIQ UI Questionnaire SF and EQ-5D-5L questionnaires will be handed over or posted out to the patients at 12 weeks after surgery Study participants and then yearly up to and including Year 5 by the A total of 500 male patients undergoing surgery for treatment of stress urinary incontinence with medical Local Consultant or Research Coordinator, if required on the prompt from the central data manager. 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. Long-term follow-up will consist of yearly visits after visit at one year post-surgery up to and including Year 5.

Pre-operative data (e.g., patient characteristics, Charlson co-morbidity index, 24-hour pad test, urodynamic results), per-operative data (e.g., details on surgery, type of prosthesis, cuff size and location, pressure of regulating balloon, presence of double cuff, type of per-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

Study update As of press time (cut-off date 3 January 2017), five centres are initiated which recorded in total 55 patients in the eCRF. This may be an underestimation of the actual number of recruited patients as not all included patients are yet recorded in the eCRF. Preparations to initiate the study in Austria (Göttlicher Heiland, Vienna), Finland (Helsinki University Central Hospital , Helsinki), France (CHU Rouen; CHU Nimes, Hôpital Universitaire Pitié-Salpêtrière, Paris), Germany (University Hospital Bonn, University Hospital Frankfurt, Asklepios Hospital West Hamburg, Ludwig-Maximilian University Münster, Diakonie Hospital Stuttgart, Lukaskrankenhaus Neuss), Italy (Humanitas Mater Domini, Milan; Sant' Andrea Hospital Rome ), The Netherlands (UMC Utrecht, UMC Maastricht), Spain (Universidad Francisco de Vitoria, Madrid; University Hospital of the Canary Islands, Tenerife) and United Kingdom (Bristol Urological Institute Bristol, CUH - Addenbrooke's Hospital Cambridge, University College London Hospitals London) are ongoing.

surveymonkey.com/r/9X9HRHP or send an email to researchfoundation@uroweb.org.

Collaborator: Boston Scientific Corporation Study team: Principal Investigator: Rizwan Hamid Assistant Professor of Urology Consultant Urological Surgeon Department of Urology, University College London Hospitals London, 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

Interested to join the SATURN Registry? Please fill in the Feasibility Questionnaire at https://www.

Call for Applications: EAU RF Unveils new Seeding Grant The EAU Research Foundation (EAU RF) is announcing a new seeding grant, with the aim of supporting highly innovative and original research by a junior investigator. The call for applications is currently open, with the deadline closing on March 2nd, 2018.

Research Foundation

EAU Research Foundation is looking for investigators from basic urology research Interested? http://eaurfbslist.uroweb.org/

EUR UROL Supplement probes novel research in Genitourinary Pathology What are the emerging molecular diagnostic techniques that allow early diagnosis of the oligometastatic state and improve patient outcomes?

Why should histopathological subtype be considered in the prognostic evaluation of patients with penile squamous cell carcinoma?

Chairman of the EAU Section of Uropathology (ESUP), Prof. Rodolfo Montironi (IT), examines the latest studies on these topics through the pathologist perspective as Guest Editor of the European Urology (Eur Urol) Supplement “Update on Genitourinary Pathology”.

The supplement is copious on innovative research such as latest novelties in WHO classifications, histological and molecular subtyping, and strategies centred on tumour-associated macrophages, to name a few.

Get your genitourinary pathology essentials.

Download your copy now: http://www.sciencedirect.com/journal/ european-urology-supplements/vol/16/issue/12

January/February 2018

Applicants are invited to submit 1-year research projects with a total budget up to €25,000. These projects should be designed to collect or strengthen preliminary data and to qualify for future external competitive funding.

Preliminary data is not required in the application. Seeding grants will be awarded in basic, translational and/or clinical research.

Funding for this Call for Application amounts to a maximum of € 50,000 in total for 2 projects. The Applicant must be an academically active researcher/clinician and member of the EAU and be 40 or younger at submission deadline. The total project period is one year. Successful projects will start on April 1st, 2018 and will end on April 1st, 2019.

Grants will be awarded on a competitive basis.

All accepted Applications will undergo a two-step selection process. The Review Panel will be composed of the members of the EAU Research Foundation and an external expert reviewer. At the first step of selection,

applications will be evaluated based on, among other things: originality, feasibility, potential to be eligible for larger-scale funding and the qualifications of the applicant.

The top 3 applicants will then be invited to a personal meeting with the Review Panel, consisting of a brief presentation of their proposal (10 minutes) and a question & answer session.

How to apply Candidates are expected to submit: • Completed application form • CV and list of publications Further details on the application, application criteria as well as all relevant forms can be found online: www.uroweb.org/eaurfseedinggrant All scientists intending to apply must notify the EAU Research Foundation Central Research Office by email (info@researchfoundation.org) no later than February 16th, 2018. The abovelisted documents must be completed and uploaded sent to the EAU RF by using the link mentioned above no later than March 2nd, 2018 at 12 noon.

European Urology Today

13

CAUREP 2018 gains momentum, spreads best practices The programme celebrates fifth successful year

By Erika De Groot

“I had the privilege of being a recipient of scholarships from the CAU and the EAU back in the Spanish writer Miguel de Cervantes once wrote, day,” stated Dr. Sanchez-Salas. “I truly enjoyed the “El que lee mucho y anda mucho, ve mucho y sabe CAUREP and EUREP educational programmes as both mucho.” (He whom reads a lot and walks a lot, sees a a trainee and a faculty member. I have seen both lot and knows a lot.) Providing learning opportunities worlds.” and quality information for and in the heart of the Hispanic urological community is the core aim of the CAUREP objectives Confederación Americana de Urologia Residents “Every year, we offer a full day of lectures presented Education Programme (CAUREP). Now on its fifth

by CAUREP’s esteemed faculty. The programme’s successful year, the programme will continue to boost objectives include sharing expertise such as EAU knowledge in the region. standards and guidelines, and enhancing knowledge on evidence-based medicine. The CAUREP topics are What is CAUREP? adapted annually on a rotational basis to cover all CAUREP is modelled after the European Urology areas in urology,” stated Dr. Palou.

Residents Education Programme (EUREP), a flagship programme of the European School of Urology (ESU) He continued, “The main messages and concepts offered to urological residents who are in their final delivered during the lectures are clear; they facilitate year. “We wanted to share the same high-level EUREP understanding and change in decision-making in experience with the Confederación Americana de daily clinical practice. The ESU is actively involved in Urología (CAU), an association that brings urologists the programme and there is participation from the from Central America, South America, Spain and EAU faculty during the Plenary Sessions. The overall Portugal together. Hence, the inception of CAUREP,” attendance is high and the general evaluation is said Dr. Joan Palou (ES), Chairman of the ESU and positive.”

Course Director.

Impressions of the previous CAUREP According to CAUREP faculty member Prof. Marcus “CAUREP 2017 will always leave a lasting Drake (GB), the programme focuses on exchanging impression on me,” said Prof. Drake. “It was an know-how and spreading best practices. “CAUREP excellent meeting; the speakers were highlyencourages new interactions and helps expand the regarded experts. The delegates were friendly and urological community. Throughout the years, we have easy to talk to. I was inspired by everyone's seen strengthening of the ties between the European commitment and determination. The highlight of Association of Urology (EAU) and the CAU, evident in any event like this is the interaction. The inquiries the CAUREP activities and the CAU sessions during and discussions after the lectures were plenty and EAU’s Annual Congresses.” impactful which are indications of good engagement and good teaching. I would love to “CAUREP is the realisation of what was once a vision see this intellectual exchange become more and of the CAU and the EAU years ago,” added Dr. Palou. more prominent in CAUREP meetings.”

What sets CAUREP apart from the rest CAUREP faculty member Dr. R. Sanchez-Salas (FR) stated, “The programme features both European and CAU faculty in a multicultural environment with a solid academic profile. The delegates receive state-of-the-art updates from the speakers and have more interaction with them. Whether the audience’s inquiries were clarifications or addressing controversies, they were discussed openly and comprehensively.”

“Language was never a barrier,” he said. “Sessions are presented in English with simultaneous Spanish translations. Also, the EAU has brilliant, Spanishspeaking lecturers who help enhance the positive impact of CAUREP on the local audience.”

According to Dr. Sanchez-Salas, “CAUREP was initially organised for CAU residents. The programme became so successful that it is no longer considered a urologist-in-training session, but a well-established programme instead. It has evolved to a not-to-be-missed programme with dedicated educational objectives. Although it is slightly different from its European counterpart EUREP, it definitively shares the same teaching interests.

Nowadays, CAUREP is recognised as a major academic support from the EAU to CAU. It remains dynamic and evidence-based.”

CAUREP faculty member, Prof. Urs Studer (CH), shared his observations from the previous CAUREP: “The programme’s main goals were met as the speakers concentrated to the most relevant issues in the field. They were well-prepared and gave comprehensive overviews within the time allotted to them. The audience attendance was excellent.

The meeting consisted of an actualised overview of issues pertinent to practising urologists. The three main topics were prostate cancer, bladder cancer and voiding disorders.”

Prof. Studer advised future speakers of the CAUREP meeting, “Avoid presenting just your own data and/or just concentrating on a urological subspecialty. Instead, give a broad scientificallybased overview on the subjects designated and stay practice-oriented.”

“Being a part of the CAUREP faculty that included Prof. Studer, Dr. Palou and Prof. Nicholas Mottet (FR) was a great privilege,” said Prof. Drake. He added, “Grab this great opportunity to attend CAUREP. Ask your questions, share your insights. The programme has a lot to offer you!”

History and the future “When we started CAUREP in 2014, it was originally a two-day programme scheduled before the CAU

advancement for the region. Allowing more time and interaction within the CAUREP agenda will benefit everyone.”

“We are putting the finishing touches on this much-awaited programme for this year’s CAUREP in Punta Cana in the Dominican Republic. You can expect a high-level programme with exemplary faculty members and speakers,” said Dr. Palou.

Prof. Studer added, “Participants of this CAUREP 2018 can look forward to contemporary and significant urological topics.”

View from the stage: Room is packed with an enthusiastic CAUREP audience

congress. Then it was streamlined into a day of teaching with four CAU faculty members and four EAU faculty members. The attendance has grown through the years; more than 500 urologists attend the programme annually!” said Dr. Palou.

“In the beginning, CAUREP was solely intended for residents and today, we all benefit from it. Whether you are an audience member or part of the faculty, the programme is an memorable, academic experience. CAUREP’s progress can only be described as a complete undeniable success,” said Dr. Sanchez-Salas. “The CAUREP of the future will possibly include more recommended readings on top of the informative slides as reading materials, and studying before the actual session takes place .

The programme aims to have more interactive sessions with clear explanations on how to differentiate between recommendations and practice in referral centres and in the community urological centres as well.”

Prof. Drake stated, “Stemming from the EUREP model and continually progressing, CAUREP is a notable

Join us this year at CAUREP 2018!

Interested in joining CAUREP? Future participants are required to become a CAU member and attend the CAU congress. For more information about the CAU, please visit www.caunet.org. To know more about other highly-informative ESU activities, check out www.uroweb.org/education/.

Mark your calendars for the 30th of October 2018 and be part of the one most anticipated programmes of the year! We shall see you in Punta Cana, Dominican Republic!

Prof. Mottet talks about Focal Therapy for prostate cancer

www.esubpo18.org

3rd ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction 4-5 May 2018, Heilbronn, Germany An application has been made to the EACCME® for CME accreditation of this event

Meet the ESU faculty: Dr. J. Palou, Prof. N. Mottet, Prof. U. Studer, Prof. M. Drake

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European Urology Today

January/February 2018

ESUfocaltherapy17 takes on novel focal therapy management Masterclass focuses on accurate patient selection, personalised treatment Dr. Eric Barret Institut Mutualiste Montsouris Dept. of Urology Paris (FR)

Masterclass on Focal Therapy for Localised Prostate Cancer (ESUfocaltherapy17). Held in December 2017 in Paris, the two-day Masterclass focused on Focal Therapy (FT) modalities, evaluation methods and new treatment strategies.

eric.barret@imm.fr

Importance of mp-MRI One of the essential topics of the Masterclass was multiparametric MRI (mp-MRI) and its significance in patient selection to ensure the success of FT. mp-MRI is an accurate imaging technique for prostate cancer (PCa) detection and staging and allows the use of images as targets for needle biopsies1.

Stimulating presentations, informative live surgeries and hands-on training, with clinical cases were some of the highlights of the 2nd ESU-ESUT-ESUI

A targeted biopsy can be performed as an in-bore MRI-targeted biopsy, cognitive fusion or an MRI/Ultrasound (US) software fusion biopsy. The combination of mp-MRI with targeted fusion biopsy sampling enables urologists to better localise the index lesion. Relative to a standard biopsy, the combination also makes significant increase in cancerdetection rate possible.

With this end in mind, different MRI/ ultrasound (US) image fusion platforms allow transrectal or transperineal biopsies. These platforms are used to guide focal treatments and improve targeting of lesions during a biopsy.

Fig. 1: MRI-US Fusion-Guided Focal HIFU: a transrectal approach Focal One® device (EDAP-TMS)

Several companies have developed specific devices that allow MRI-US fusion systems to be used for focal treatments. Their goal is to enhance accuracy in the application of energy to the tissue. This technique has already been applied transrectally with high-intensity focused ultrasound (see Figure 1).

With the recent development of the transperineal approach, MRI/US systems can be used for treatments with several energy sources like cryotherapy (see Figure 2) or brachytherapy. In fact, these are suitable for any treatment that necessitates needle placement within the prostatic parenchyma.

Future FT technologies Novel therapeutic transperineal options such as vascular targeted photodynamic therapy (VTP) and Irreversible Electroporation (IRE) will be available in the near future. These new approaches are particularly interesting because of their limited thermal effect.

A phase 3 study has recently shown that VTP is a safe and effective treatment for low-risk, localised PCa. The Fig. 2: MRI-US Fusion-Guided Focal Cryotherapy: a transperineal approach. Artemis® device approach is an improvement on active surveillance as VTP reduces the rate of histological the accurate targeting of the tissue set for destruction, progression2. The authors concluded that it may even irrespective of the energy used. allow more men to opt for a tissue-preserving approach and defer or avoid radical therapy References altogether.

1. Ahmed H. et al: Diagnostic accuracy of multi-parametric Although the IRE is still being evaluated, the first published studies have shown the safety of the technique and promising cancer control results; several clinical trials are already in progress allowing patient inclusion.

www.esuurolithiasis18.org

It is important to emphasise that the success of FT depends on the correct evaluation of the cancer and

2nd ESU-ESUT Masterclass on Urolithiasis 22-23 June 2018, Patras, Greece

ESUfocaltherapy17 testimonials An application has been made to the EACCME® for CME accreditation of this event

Found below are collated testaments from various participants of the recent FT Masterclass.

Participant highlights “My overall impression is positive. The information offered was easy to understand and accessible. I especially liked the multidisciplinary approach when the MRI specialist and the morphologists shared their views. The cordial vibe of the masterclass encouraged good, open communication,” said Dr. Dmitry Enikeev (RU).

“The Masterclass provided a good review of the novelties in FT through discussions of various concepts and criteria exchange among experts.

As a result, the Masterclass became an exemplary learning tool for participants,” stated Dr. Cristina Redondo (ES).

“I appreciate the comprehensive lectures on FT management and the collaboration among urologists, pathologists, and radiologists. The live surgeries were impressive and helpful to urologists like me who don’t practice it yet in their hospitals,” said Dr. Matteo Manfredi (IT).

“For me, the main highlight of the Masterclass was the optimisation of PCa treatment while reducing major complications,” stated Dr. Amir Arbab (IR). “The programme as a whole, the delivery of contemporary FT updates and overall learning atmosphere were excellent.”

January/February 2018

MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet 2017; 389:815-822.

2. Azzouzi A.R. et al: 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. Lancet Oncol. 2017;18:181-191.

Customised treatment “Focal therapy is the future in the treatment of PCa. Technological advances and multidisciplinary interaction between urologists, radiologists and pathologists will allow better understanding of patients’ needs, personalisation and optimisation of treatments,” said Dr. Redondo.

“Undoubtedly, the key to good FT is accurate patient selection,” stated Dr. Manfredi.

“To personalise FT à la carte, experts at the Masterclass reported a novel concept: selection of an energy modality based on its limitations, complication profile and intraprostatic cancer location. Additionally, they underlined the importance of mp-MRI and imaging-target biopsies to make cancer diagnosis more precise and to increase quality of the cores delivered to anatomopathologists.”

He added “I highly recommend attending the Masterclass. I had big expectations from the start and I can honestly say, all of them were met.”

“To future participants – novice and experienced surgeons – I say to them, this Masterclass is definitely worth their time!” concluded Dr. Enikeev.

European Urology Today

15

Teaching activities 2018

www.esusalzburg18.org

European School of Urology March 16-20

May 4-5

33rd Annual EAU Congress, Copenhagen (GB) 3rd ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction, Heilbronn (DE) ESU course on Bladder cancer at the 5th Baltic Meeting in conjunction with the EAU, Riga (LV)

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June 8-9 13 13 15 22-23

July 1-7

EAU Update on Bladder cancer (BCa18), Munich (DE) ESU course on Erectile dysfunction and infertility at the national congress of the Polish Urological Association, Katowice (PL) ESU course at the national congress of the Spanish Association of Urology, Gijon (ES) ESU course on Advances in male urinary symptoms (LUTS) at the national congress of the Ukrainian Urological Association, Kiev (UA) 2nd ESU-ESUT Masterclass on Urolithiasis, Patras (GR)

ESU - Weill Cornell Masterclass in General urology 1-7 July 2018, Salzburg, Austria An application has been made to the EACCME® for CME accreditation of this event

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

Augustus 31-5 Sept

16th European Urology Residents Education Programme (EUREP), Prague (CZ)

September 5

11-14 14-15 14 or 15 28

October

4 13 27

30

ESU-ERUS courses at the 16th Meeting of the EAU Robotic Urology Section (ERUS), Marseille (FR) Hands-on training skills programme on Laparoscopy and Endourology, Caceres (ES) 2nd EAU Update on Prostate cancer (PCa18), Milan (IT) ESU course on Urolithiasis at the national congress of the Russian Society of Urology, Krasnoyarsk (RU) ESU course at the national congress of the Armenian Urological Society, Yerevan (AM) ESU course at the 25th Meeting of the EAU Section of Urological Research (ESUR), Athens (GR) ESU course at the national congress of the Hellenic Urological Association, Athens (GR) ESU course on Update on prostate and bladder cancer at the national congress of the Turkish Association of Urology, tbd (CY) 5th Confederación Americana de Urologia Residents Education Programme (CAUREP), Punta Cana (DO)

November 8-11

22-23

ESU courses at the 10th European Multidisciplinary Meeting in Urological Cancers (EMUC), Amsterdam (NL) 5th ESU-ESUT Masterclass on Lasers in urology, Barcelona (ES)

December 13-14

3rd ESU-ESUT Masterclass on Focal therapy for localised prostate cancer, Paris (FR)

Preliminary ESU programme in Copenhagen ESU Courses Adrenals • Adrenals for urologists Andrology • Office management of male sexual dysfunction • The infertile couple – Urological aspects Female urology • Prolapse management and female pelvic floor problems • Advanced vaginal reconstruction General urology • How to proceed with a haematuria • Ultrasound in urology • Update renal, bladder and prostate cancer guidelines 2018. What is changed?

• What has changed in the non-oncology guidelines • Practical aspects of cancer pathology for urologists. The 2018 WHO novelties • How to write introduction and methods • How to write results and discussion 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

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#EAU18

European Urology Today

Neurogenic and non-neurogenic voiding dysfunction • Chronic pelvic pain in men and women • Urological management of patients with neurological diseases • Lower urinary tract dysfunction and urodynamics Paediatric urology • Paediatric urology for the adult urologist 1.

Congenital problems of the urinary tract: Obstruction and reflux and longterm outcome • Paediatric urology for the adult urologist 2.

Congenital disorders of the external genitalia, DSD and longterm outcome Penis/testis • Testicular cancer • Penile diseases Prostate cancer • Robot-assisted laparoscopic prostatectomy • Retropubic radical prostatectomy – Tips, tricks and pitfalls • Focal treatment in prostate cancer • Prostate cancer imaging: When and how to use it • Prostate cancer screening and active surveillance – where are we now?

• Prostate biopsy – tips and tricks • Metastatic prostate cancer • Oligometastatic prostate cancer • Prostate cancer update: How to optimise the everyday management of your patients Renal tumours • Robot renal surgery • Small renal masses: From concepts to tips and tricks in daily management • Advanced course on laparoscopic renal surgery • Surgery for renal cancer beyond minimally invasive approaches : Opportunities and limits

ESU Hands-on Training Courses Stones • Percutaneous nephrolithotripsy (PCNL) • Update on stone disease • Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips and tricks, indications Trauma • Urinary tract and genital trauma Urethral strictures • Advanced course on urethral stricture surgery Urological surgery • Surgical anatomy • Laparoscopy for beginners • Advanced course on upper tract laparoscopy: Kidney, UPJ, ureter and stones • Basic penile scrotal surgery and first steps in endourology • Prosthetic surgery in urology • Lymphadenectomy in urological malignancies Urothelial tumours • Practical management of non-muscle invasive bladder cancer • New perspectives in the management of upper tract tumours • 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.eau18.org

Robotic surgery • ESU/ERUS HOT in Robotic surgery intro course 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 • ESU/ESUT/ESUI HOT in MRI reading for urologists in the diagnosis and management of prostate cancer Functional urology • ESU/ESFFU HOT in OnabotulinumtoxinA administration for OAB • ESU/ESFFU HOT in Sacral neuromodulation 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 Endoscopic stone treatment Communication • ESU HOT in Non-technical skills in surgery • ESU HOT in Sharpening your presentation skills to improve your career

January/February 2018

Highlights of the ESU Masterclass on Lasers in Urology Expert masterclass offers practical techniques and valuable insights difficulties and complications. Furthermore, semi live/ pre-recorded surgeries were presented, describing in a step-by-step manner each procedure.

Dr. Alberto Breda Chair of the ESUT Laparoscopy group Chief of Uro-Oncology Division and Kidney Transplant Unit at Fundació Puigvert Dept. of Urology Barcelona (ES) albbred@hotmail.com

Fig. 2: A. Dr. Alberto Breda performing an en bloc bladder tumor resection with thulium laser. B: Macroscopic evaluation of the specimen; C, D: Confocal laser endomicroscopy (Cellvizio®) evaluation of the specimen on bench

provided a succint explanation of confocal laser Dr. Angelo Territo endomicroscopy (Cellvizio®) in distinguishing Uro-Oncology low-grade vs. high-grade urothelial tumor. In Division and Kidney particular, Dr. Breda demonstrated the advantages of Pre-recorded surgeries were shown and live surgeries Transplant Unit Thulium laser in bladder tumor resection and the were performed to provide a realistic and complete Dept. of Urology Cellvizio evaluation both in-vivo (during the spectrum of clinical laser applications.

Fundació Puigvert procedure) and ex-vivo (bench table), as shown in Barcelona (ES) Figure 2.

The first day focused on the use of current laser systems such as the holmium laser, the 532-nm laser, The second day course was dedicated to the laser KTP-80W, HPS-120 and XPS-180, diode and thulium treatment of BPH. Lectures on several techniques laser. Expert lectures were given by Oliver Traxer, were presented by experts such as Drs. Gomez Fernando Gomez Sancha, Thomas Knoll, Andreas Sancha, Gross, Scoffone and Ponce de Leon, reporting The fourth edition of the ESU Masterclass on Lasers in Gross, describing the various technique and different clinical experiences in an interesting round procedural details. Live surgery sessions included a Urology took place on 23 to 24 November 2017 at table on this topic (Figure 3). Furthermore, live flexible ureteroscopy (Olympus) with laser lithotripsy Fundació Puigvert in Barcelona (ES), in collaboration surgeries on prostate enucleation were done. Prostate (Olympus) of a lower pole 2 cm stone performed by with EAU Section of Uro-Technology (ESUT). laser enucleations using holmium laser, green light Prof. Traxer; a mini-PCNL (Karl Storz) for 2 cm pelvic and thulium were respectively performed by Drs. The masterclass is organised by Alberto Breda, stone done by Dr. Knoll and Dr. Angerri; a 12 mm Scoffone, Gomez Sancha, and Gross (Figures 4 – 5).

Evangelos Liatsikos and Joan Palou. The two-day lower pole stone treated by Dr. Emiliani with flexible ureteroscopy (Rocamed). course aims to provide a detailed description of all On both days, tips and tricks were given to optimise laser applications in urology, including the treatment In the afternoon, Prof. Traxer presented the state-ofthe laser treatment efficacy and to manage surgical of benign prostatic obstruction, bladder and upper the-art lecture on the endourological management of bladder and upper tract urothelial cancer using lasers and in the live surgery, he showed how to treat uretero-intestinal stricture endourologically with an anterograde approach. Dr. Breda performed a live procedure on bladder Fig. 1: Dr. Alberto Breda and Dr. Joan Palou introducing the tumor resection with Fig. 3: Experts panelist discussing on “Laser for BPH”. From left: Dr. Gomez Sancha, Dr. Gross, 4th ESU-ESUT masterclass on “Lasers in Urology” Thulium laser, and Dr. Scoffone, Dr. Ponce De Leon tract urothelial carcinoma, renal stones and urinary tract strictures.

More than 40 participants from all over Europe attended this masterclass. Thanks to the interactive discussions, the participants learned the basic concepts of laser applications and several treatment options, including the right patient selection for each approach.

We hope to see you for another comprehensive masterclass at Fundació Puigvert in Barcelona, on 22 to 23 November 2018. Special thanks to the sponsors COOK Medical, Karl Storz, Lisa Laser, Lumenis, Olympus, Rocamed, Quanta System, and Boston Scientific.

Fig. 4: Holmium laser prostate enucleation performed by Dr. Cesare Scoffone

Fig. 5. Dr. Fernando Gomez Sancha showing the use of the Green light laser for BPH

Best practices in laser technology at ESUlasers17 A joint report on the Masterclass dedicated to lasers in urology

By Erika De Groot What was the secret to the success of the recent 4th ESU-ESUT Masterclass on Lasers in Urology (ESUlasers17)? What was its pinnacle? In this report, participants Dr. Volodymyr Chernylovskyi (UA), Dr. Giovanni Grimaldi (IT), Dr. Matteo Ferrari (CH) share their experience and impressions of the wellattended Masterclass held late last year in Barcelona, Spain.

Personal highlights “The Masterclass had plenty to offer with its live surgeries and educational sessions,” said Dr. Ferrari.

“I was impressed with the live surgery performed by Dr. Jose Maria Gaya Sopena (ES). It was the en bloc resection of bladder cancer using the Thulium laser which delivered more benefits than the traditional bipolar technique in disease staging, and was applicable to lesions at any bladder level.

Additionally, the tips and tricks provided during the live retrograde intrarenal surgery (RIRS) will help maximise safety and efficacy of the RIRS.”

“The high point of the Masterclass for me were the live surgeries of Prof. Thomas Knoll (DE) and Prof. Olivier Traxer (FR),” said Dr. Chernylovskyi. “Prof. Knoll’s Mini-PCNL + holmium laser for renal stone taught me multiple approaches. When Prof. Traxer demonstrated RIRS + holmium laser for lower pole stone, I’ve learned its advantages (no injuries and no scars) and disadvantages (prolonged operation time).”

Expectations met “The Masterclass offered a critical and thorough evaluation of the right source of energy for various pathologies which included management of benign prostatic obstruction (BPO), bladder and upper tract tumours, urinary tract stenosis and stone diseases,” stated Dr. Grimaldi. According to him, the goal to provide deeper understanding of existing and potential urological applications of laser technology was achieved. The Masterclass has provided a comprehensive overview of characteristics and operating mechanism of diverse laser types.

Dr. Ferrari also mentioned the lecture Lasers for BPO: Different techniques for different prostates by Dr. Fernando Gomez (ES). “It provided excellent synthesis of up-to-date evidence, the fundamentals of correct technique indications and the optimal use of various lasers.”

“As a urologist aspiring to gain more knowledge in laser surgery, I decided to sign up for this intensive Masterclass. I felt that it was important for me to learn directly from eminent experts in the field as laser technology is increasingly used in the endourological treatment of different pathologies,” explained Dr. Ferrari. “In the end, my initial expectations have been fully met.”

For Dr. Grimaldi, it was the debates that piqued his interest the most. “I hold the speakers’ expertise in high regard; from their capabilities to the content of their lectures. The exchange of opinions, the brainstorming and debates between the speakers and the audience were thought-provoking.”

Final assessment According to Dr. Chernylovskyi, the Masterclass had a friendly atmosphere conducive to learning. “It was well-organised. The open discussions were the best way to jumpstart the days and to keep the exchange of ideas going. Rephrasing Hamlet’s famous line,

January/February 2018

‘To attend or not to attend the Masterclass’, I definitely recommend participating!”

“Live surgeries can capture the pitfalls of procedures and illustrate how to deal with them properly,” said Dr. Grimaldi. “Participating in this Masterclass gave me the chance to ask the experts in person; encouraged me to try new and different approaches; and enabled me to deliberate with others to help improve existing techniques.” He added that the semi-live surgeries were useful in showing a more schematic division of surgical times and best ways to proceed.

Dr. Ferrari stated that although the Masterclass was extensive, it was conducted in an open and informal

environment which facilitated interaction and learning. “I appreciated that the live surgeries were explained in detail: usage of instruments, surgical manoeuvres, basic elements and the most advanced tips. It was incredibly helpful that the audience can pose their questions during the procedures. I was also impressed by the complexity of the live surgeries that stimulated discussions regarding anterograde ureteroscopy for the diagnosis and treatment of uretero-intestinal stenosis.”

“I would like to thank the faculty, the European School of Urology (ESU), and the EAU Section of Uro-Technology (ESUT) for making the two-day Masterclass highly-productive and truly educational,” concluded Dr. Ferrari.

ESUlasers17 faculty members

European Urology Today

17

EUREP18 16th European Urology Residents Education Programme 31 August-5 September 2018, Prague, Czech Republic

www.eurep18.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, 30 August 2018 Departure date: Wednesday, 5 September 2018 after the modules end at 12.30.

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 2018

Registration information

Module 1 Urological cancer

Important dates Online registration opens on 8 January 2018.

The selection process will be made after the close of registration on 1 May 2018. 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 2018. 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 18

European Urology Today

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

A. De La Taille (FR), Chair

A. Briganti (IT)

S. Joniau (BE)

T. Steuber (DE)

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 16th EUREP course we strongly recommend that you visit www.eurep18.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 16th EUREP course please go to www.eurep18.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

H. Abol-Enein (EG) B. Burgu (TR)

Y.F. Rawashdeh (DK) F. Wagenlehner (DE)

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 January/February 2018

When do we need urodynamics for female SUI? UDS: A valuable diagnostic tool that gives vital information Dr. Riyad Al Mousa Consultant NeuroUrologist/ Urologist King Fahad Specialist Hospital Dammam (KSA) riyad100@ hotmail.com

Prof. Hashim Hashim Consultant Urological Surgeon & Honorary Professor Director of the Urodynamics Unit, Bristol Urological Institute Bristol (UK) h.hashim@gmail.com Stress Urinary Incontinence (SUI) is defined as the involuntary loss of urine during physical exertion, effort, coughing or sneezing in the absence of a detrusor contraction1.

SUI can occur either on its own or in combination with urgency urinary incontinence (UUI) and then it is called mixed urinary incontinence (MUI). Urinary incontinence, although not life-threatening, can have serious effects on quality of life and negatively impact physical, social, financial and psychological wellbeing of patients and their families2-4. Up to 55% of women in Europe are affected by urinary incontinence at some point in their life5. SUI can affect about 85% of women with UI6.

The basic assessment of female patients with SUI includes a focused history and physical examination, objective demonstration of SUI, for example, during coughing, urinalysis, uroflowmetry and post-void residual7,8. Despite the vital role of invasive urodynamics (filling cystometry and pressure/flow studies) as a diagnostic test for the assessment and management of incontinent patients, its role in the management of female patients with pure SUI has been and continues to be heavily debated. This article will address the need of urodynamic (UDS) for female SUI. UDS indications in SUI The underlying philosophy of performing urodynamics is that it should only be done if it is going to change the management of a patient.

Therefore, in the context of SUI, it is mainly indicated after failure of conservative and medical therapy and prior to invasive surgical procedures for SUI. One way of thinking about UI and UDS is to divide UI into complicated and uncomplicated types.

Uncomplicated SUI therefore refers to those patients with pure SUI, with no other associated lower urinary tract symptoms (LUTS), that is diagnosed based on a clinical evaluation. Complicated UI is defined by the International Continence Society (ICS) as urinary incontinence associated with pain, haematuria, neurological conditions, recurrent urinary tract infection (UTI), suspected voiding dysfunction, significant pelvic organ prolapse, previous incontinence surgery, pelvic irradiation or surgery and/or suspected fistula9-11.

UDS in women suffering with pure SUI. It is also invasive, expensive, time consuming, symptoms are not always reproducible, not universally available and may not affect the outcomes of surgery. Complications include infections (3% - 9%) and very rarely haematuria and urethral injury18-20.

A multicentre, randomized, non-inferiority (VALUE) trial involving 630 women (315 per group) with uncomplicated, demonstrable SUI were divided into two groups: one group underwent office based evaluation only, while the second group underwent invasive UDS assessment. The conclusion was that pre-operative office evaluation alone was not inferior to evaluation with urodynamic testing for outcomes at one year (76.9% and 77.2%) and therefore UDS was not required in the evaluation of these patients21.

Another multicentre cohort study with a noninferiority randomized controlled (VUSIS) design was conducted in 30 Dutch hospitals to assess the value of UDS before SUI surgery. The conclusion was that an immediate sling operation is not inferior to individually tailored treatment based on UDS in uncomplicated SUI. This supported the opinion that UDS is not necessary in uncomplicated SUI patients22.

A systematic review and meta-analysis concluded that UDS doesn’t have any add-on value in women with isolated SUI or stress-predominant MUI with normal bladder capacity and post-void residual (PVR)23.

"In a secondary analysis of the VALUE study, urodynamic studies changed the results of office evaluation in 56.8% of cases..."

On the other hand, there are several studies which looked at the benefits of UDS in patients with pure SUI. This is supported by the fact that the “bladder is an unreliable witness,” and symptoms do not always predict the cause of the incontinence.

Hashim et al, found a better correlation in results between OAB symptoms and the urodynamic diagnosis of detrusor overactivity (DO) in men than in women; 69% of men and 44% of women with urgency (OAB dry) had DO, while 90% of men and 58% of women with urgency and urgency urinary incontinence (OAB wet) had DO and 87% of women with UUI had symptoms of SUI24 and pure SUI represented a minority among SUI suffering patients. Therefore, doing UDS will help make a more accurate diagnosis and might alter the management and therefore outcome25.

Wang et al. in a study of 79 patients with SUI, concluded that women with normal pressure flow studies (PFS) preoperatively were more likely to have a better pad test result and better quality of life as compared to those who had abnormal PFS with Qmax <15ml/sec and pdetQmax > 20cmH2O26.

Miller et al. in their study of 98 women who underwent sling surgery for SUI without evidence of DO concluded that woman who void with a weak or absent detrusor contraction are most likely to have urinary retention post-operatively27.

Alperin et al. found that 56% of patients with pdet > 15cmH2O during filling developed de novo urgency Current guidelines recommend the use of UDS prior to incontinence compared to only 21% in patients with SUI surgery in the following complicated conditions12-17 pdet <15cmH2O. This result was extracted from the final analysis of 92 female patients who underwent (Tables 1 and 2). sling surgery without subjective evidence of de-novo DO28. Thus, UDS can be used in the counselling of • Patients with neurologic conditions; patients.

• Patients who had previous anti-incontinence surgery; Digesu et al. assessed the value of UDS in 3,428 • Patients who had radical pelvic surgery, urethral women with pure SUI. Only 8.9% were classified as surgery or gynaecologic surgery; having pure SUI .They concluded that UDS provides • Patients with voiding dysfunction (obstructed useful information in the assessment of women with flow, urgency incontinence or suspected history of pure SUI, because almost 20% of them underactive bladder); might not need surgery as the first-line invasive • Patients with a history of pelvic radiation; and treatment29.

• Patients with significant pelvic organ prolapse.

Do we need UDS prior to surgery in an index patient with uncomplicated pure SUI? This is the main debated question. Those who believe that UDS has no role in pure SUI have based their opinion on data from multicentre studies and systemic reviews that showed there was no benefit from doing EAU Section of Female and Functional Urology

January/February 2018

Uncomplicated SUI A large retrospective multicentre single national study from Italy investigated the prevalence of uncomplicated SUI cases that underwent UDS in six centres. Only 36% of those patients were classified as uncomplicated SUI which represented a minority in their study and planned surgery was cancelled or modified in 19% due to UDS findings. They concluded that the role of UDS in complicated cases is

Table 1: EAU 2017 guidelines on UI in adults (UDS recommendation)

Recommendations

(NB: Concerning only neurologically intact adults with urinary incontinence) Clinicians carrying out urodynamics in patients with urinary incontinence should: • ensure that the test replicates the patient’s symptoms; • interpret results in the context of the clinical problem; • check recordings for quality control; • remember there may be physiological variability within the same individual.

C

Advise patients that the results of urodynamics may be useful in discussing treatment options, although there is limited evidence that performing urodynamics will predict the outcome of treatment for uncomplicated urinary incontinence.

C

Do not routinely carry out urodynamics when offering treatment for uncomplicated urinary Incontinence.

B

Perform urodynamics if the findings may change the choice of invasive treatment.

B

Urodynamic practitioners should adhere to standards defined by the International Continence Society.

C

F.C. Burkhard, J.L.H.R. Bosch, F. Cruz, et al. EAU guidelines on UI in adults.2017: 17.

Table 2: Urodynamic Studies in Adults: AUA/SUFU Guideline

Recommendations

(NB: Concerning only neurologically intact adults with urinary incontinence) Clinicians who are making the diagnosis of urodynamic stress incontinence should assess urethral function.

Poorer urethral function as predicated by lower cough leak point pressure (VLPP/ALPP) tends to predict less optimal outcomes with some types of therapy. Some clinicians may use this information about urethral function to guide surgical treatment decisions.

C

Surgeons considering invasive therapy in patients with SUI should assess PVR urine volume.

D

Clinicians may perform multichannel UDS in patients with both symptoms and physical findings of SUI who are considering invasive, potentially morbid, or irreversible treatments.

C

In women with high-grade POP but without the symptom of SUI, clinicians should perform stress testing with reduction of the prolapse. Multichannel UDS with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated LUTS.

C

Winters JC, Dmochowski RR, Goldman HB, et al. Urodynamic Studies in Adults: AUA/SUFU Guideline.

J Urol 2012; 188:2464-2472.

mandatory and unchallenged while the role of UDS in uncomplicated SUI is useful as a diagnostic tool that might alter the management plan30.

In the UK, the NICE guidelines recommend that UDS are not mandatory in a small group of women with pure clinical stress incontinence based on history and clinical examination. The small group was about 5% of cases in whom 25% had a UDS diagnosis other than pure SUI. Also, in that same document, NICE concluded that women with a maximum urethral closure pressure of less than 20cmH2O i.e. intrinsic sphincter deficiency, do badly with transvaginal tapes and colposuspension7,31. It is therefore very obvious from this that the distinction between intrinsic sphincter deficiency and urethral hypermobility as a mechanism for stress urinary incontinence is important as it can alter the choice of treatment that is offered to women. This is very important in the current climate where meshes are being scrutinized for their safety. Therefore before embarking on major surgery such as colposuspension or autologous pubovaginal slings, it is important to know exactly the pathophysiology and cause of the leakage to offer appropriate counselling to women.

In a secondary analysis of the VALUE study above, urodynamic studies changed the results of office evaluation in 56.8% of cases by increasing the diagnosis of voiding dysfunction (2.2% to 11.9%), cancelling the surgery in 1.4%, changing the incontinence procedure in 4.4% and modifying the mid-urethral sling tension in 6.8%32.

A valuable diagnostic tool UDS remains to be a valuable diagnostic tool that provides vital information to both the surgeon and the patient after failure of initial non-invasive therapy. It is indicated in complicated cases prior to SUI surgery. In the minority of patients, with pure SUI, the use of UDS continues to be debatable; however, the authors still believe that it will add value to the diagnosis of storage and voiding symptoms and management of such patients.

UDS however may not affect the outcome of surgery but it is important to remember that UDS is a diagnostic test, and not an outcomes measure, analogous to an electrocardiogram (ECG) used in patients with chest pain or an X-ray in patients with fractures. UDS would allow a more detailed pathophysiological explanation of UI and therefore allows the surgeon to offer the most appropriate treatments and the patient to make an informed choice about the type of surgery they wish to have.

This all depends on the test being performed to the highest standards according to the ICS good urodynamic practice guidelines and appropriate interpretation of the results33.

References 1. Luber KM. The definition, prevalence, and risk factors for stress urinary incontinence. Rev Urol 2004;6(Suppl 3):S3–9.

2. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:167-178.

3. Brown WJ, Miller YD. Too wet to exercise? Leaking urine as a barrier to physical activity in women J Sci Med Sport 2001;4:373–8.

4. Fultz NH, Burgio K, Diokno AC, et al. Burden of stress urinary incontinence for community-dwelling women.

Am J Obstet Gynecol 2003;189:1275–82.

5. Stuck AE, Elkuch P, Dapp U, et al.Feasability and yield of a self-adminstered questionnaire for health risk appraisal in older people in three European countries.

Age Aging 2002;31:463–7.

6. Giarenis I, Cardozo L. What is the value of urodynamic studies before stress incontinence surgery? BJOG 2013;120:130–132.

7. Urinary incontinence: The management of urinary incontinence in women. NICE clinical guideline 171 (2013). http://www.nice.org.uk/guidance/cg171/ evidence/cg171-urinary-incontinence-in women-fullguideline 8. Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary incontinence does this woman have? JAMA 2008;299:1446–56.

9. Blaivas JG, Appell RA, Fantl JA, et al. Definition and classification of urinary incontinence: recommendations of the Urodynamic Society. Neurourol Urodyn 1997;16:149–51.

10. Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L, Chapple C, 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.

11. Sandvik H, Hunskaar S, Vanvik A, et al. Diagnostic classification of female urinary incontinence: an epidemiological survey corrected for validity. J Clin Epidemiol. 1995;48:339-343.

12. Weber AM, Walters MD. Cost-effectiveness of urodynamic testing before surgery for women with pelvic organ prolapse and stress urinary incontinence. Am J Obstet Gynecol 2000;183:1338–47.

13. Cornella JI, Margrina JF. An algorithm for the management of urinary stress incontinence. Int Urogynecol J 1996;7:221–6.

14. Holtedahl K, Verelst M, Schiefloe A, et al. Usefulness of urodynamic examination in female urinary incontinence.

Scand J Urol Nephrol 2000;34:169–74.

15. Diokno AC, Dimaculangan RR, Lim EU, et al. Office base criteria for predicting type II stress incontinence without further evaluation studies. J Urol 1999;161:1263–7.

Continued on page 20

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ESUT Brainstorming Meeting in Barcelona New plans to further boost ESUT’s long-term strategies Dr. Jan-Thorsten Klein Universitätsklinikum Ulm Dept. of Urology & Pediatric Urology Ulm (DE)

implementable projects. The working groups not only reported their achievements but also discussed how to effectively implement plans.

jan-thorsten.klein@ uniklinik-ulm.de

What does it mean to be a member of the ESUT? The query on what an ESUT membership entails emphasised active and consistent production for scientific publications. The rationale is that it gives a member the unique opportunity to collaborate with well-known experts and produce a body of scientific work on pertinent topics. It also provides the member the acquisition of knowledge on recent developments and easier access to new technology.

Following the invitation of EAU Section of UroTechnology (ESUT) Chairman Evangelos Liatsikos, ESUT members met in Barcelona last November to discuss new ideas, concepts and plans that will further boost the activities of the society.

The ESUT consists of six working groups, namely: Laparoscopy and New Technology Group; Ablative Group; Lower Tract Group, Research Group, Training Group and the Endourology Group. Each group has its own chair who is also a board member.

One of the ESUT’s major activities is to organise the biannual ESUT Congress including live surgeries which show the newest technologies. The upcoming ESUT Congress will take place in Modena, Italy, and will cover a wide range of new technological developments in urology. Another major activity is the organisation of the very well-attended full-day live surgery at the Annual EAU Meeting.

The ESUT also coordinates multiple worldwide training activities in collaboration with the European School of Urology (ESU) including the masterclasses on different topics like BPO, lasers, and stones, among others. Another area that is progressively evolving is research and publication activities undertaken by the various ESUT working groups, particularly the Research and Endourology groups which are actively pursuing their own initiatives.

To further clarify the role of the ESUT within the bigger EAU Section Office, the topics listed below were among the issues discussed during the meeting:

Identifying and implementing new ideas The professional link to engineers and the industry are crucial to develop concepts, identify new ideas, and design devices that support or improve current surgical procedures. One crucial step is on how to link up various areas of expertise. For instance, the collaboration of the ESUT with Engineering Societies is a major step, although it is just the beginning of an anticipated closer team work among various disciplines.

Future of live surgeries A topic that was intensively discussed was how to transform the live surgery concept into a modern congress-adapted form. There is no question that a transformation has to take place and different ideas were brought to the table. A major drawback in live surgery concerns legal requirements and the fact that

regulatory framework of live surgery procedures vary from country to country.

Another sub-topic was the live transmission of cases.

It was noted that cases will be done by the surgeons in their home hospitals with a team and environment that they are already familiar with. This will definitely lower the pressure on the surgeon during the procedure and side-step forensic aspects. For optimal live surgery sessions, complementary semi-live cases will be presented by the surgeons at the congress site, which means that more resources can be allotted to transmission technologies. Moreover, the live surgery will provide a more comfortable environment for the surgeon while reducing potential legal issues.

Future of hands-on training sessions (HOT) The ESUT will continue to provide training concepts and experts as part of the society’s core activities. HOT activities will mainly focus on masterclass courses that offer intensive, structured training. Short-term training courses during section meetings that failed to attract the sufficient number of participants will be suspended, although a feasibility assessment will be conducted by the training team. Furthermore, training activities will expanded beyond European borders.

ESUT Day of Endourology Another interesting topic taken up was the ESUT Day of Endourology. This event features a 24-hour live transmission from different institutes all over the world. Participating institutions stream their procedures directly into the web, and which are made available via an access key. The surgeries will cover various endourology topics which show a range of techniques. This is a plan that the whole ESUT team is working on for possible implementation within this year.

The ESUT also conferred the working groups the essential or corresponding capacity to successfully achieve their plans. Moreover, during the brainstorming meeting, new perspectives and approaches were encouraged by the leadership for the members to come up with fresh and EAU Section of Uro-Technology (ESUT)

Continued from page 19

16. Thompson PK, Duff DS, Thayer PS. Stress incontinence in women under 50: does urodynamics improve surgical outcome? Int Urogynecol 2000;11:285–9.

17. Jha S, Toozs-Hobson P, Parsons M, Gull F. Does preoperative urodynamics change the management of prolapse? Journal of Obstetrics & Gynaecology. 2008; 28(3):320–2. [PubMed: 18569478] 18. J Putran, B Sanderson. Incidence Of Urinary Tract Infection After Urodynamic Study:Are Prophylactic Antibiotics Necessary? The Internet Journal of Gynecology and Obstetrics. 2005:6.1.

19. Baker KR, Drutz HP, Barnes MD. Effectiveness of antibiotic prophylaxis in preventing bacteriuria after multichannel urodynamic investigations: a blind, randomized study in 124 female patients. Am J Obstet Gynecol 1991; 165:679-81.

20. Payne SR, Timoney AG, McKenning ST, et al.Microbiological look at urodynamic studies. Lancet.

1988; 12:1123-6.

21. Nager CW, Brubaker L, Litman HJ, et al. A randomized trial of urodynamic testing before stress- incontinence surgery. N Engl J Med. 2012;366:1987–1997.

22. van Leijsen SA, Kluivers KB, Mol BW, et al.Protocol for the value of urodynamics prior to stress incontinence surgery (VUSIS) study: a multicentre randomized controlled trial to assess the cost effectiveness of urodynamics in women with symptoms of stress urinary incontinence in whom surgical treatment is considered.

BMC Womens Health. 2009; 9:22. [PubMed: 19622153] 23. Rachaneni S, Latthe P. Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis. BJOG. 2015;122:8–16.

24. Hashim H and Abrams P. Is the Bladder a Reliable Witness for Predicting Detrusor Overactivity?J Urol.2006; 175: 191-195.

25. Zimmern P, Litman H, Nager C, et al. Pre-operative

20

European Urology Today

The ESUT Board and Working Group Members met in Barcelona last November

urodynamics in women with stress urinary incontinence increases physician confidence, but does not improve outcomes. Neurourol Urodyn. 2014;33:302–306.

26. Wang AC, Chen MC. The correlation between preoperative voiding mechanism and surgical outcome of the tension-free vaginal tape procedure, with reference to quality of life. BJU Int. 2003 Apr; 91(6):502–6.

[PubMed: 12656903] 27. Miller EA, Amundsen CL, Toh KL, Flynn BJ, Webster GD. Preoperative urodynamic evaluation may predict voiding dysfunction in women undergoing pubovaginal sling. J Urol. 2003 Jun; 169(6):2234–7.

[PubMed: 12771757] 28. Alperin M, Abrahams-Gessel S, Wakamatsu MM. Development of de novo urge incontinence in women post sling: the role of preoperative urodynamics in assessing the risk. Neurourol Urodyn. 2008; 27(5):407–11.

[PubMed: 17985373] 29. Digesu GA, Hendricken C, Fernando R, et al. Do women with pure stress urinary Incontinence need urodynamics?

Urology.2009;74:278-81.

30. Maurizio Serati, Luca Topazio, Giorgio Bogani, et al.

Urodynamics Useless Before Surgery For Female Stress Urinary Incontinence: Are You Sure? Results From A Multicentre Single Nation Database. Neurourology and Urodynamics. 2016; 35:809–812.

31. Agur W, Housami F,Drake M, et al. Could the National Institute for Health and Clinical Excellence guidelines on urodynamics in urinary incontinence put some women at risk of a bad outcome from stress incontinence surgery?

BJU Int.2008; 103:635–639.

32. Sirls LT, Richter HE, Litman HJ et al. The effect of urodynamic testing on clinical diagnosis, treatment plan and outcomes in women undergoing stress urinary incontinence surgery. J Urol. 2013; 189(1):204-9.

33. Rosier P, Schaefer W, Lose G, et al. International Continence Society Good Urodynamic Practices and Terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure-flow study. Neurourol Urodyn. 2017; 36(5):1243-1260.

Power of collaboration The ESUT gives all members the unique possibility of generating and sharing data while collaborating with a top expert group. This leads to publications with good patient numbers and a coverage of different topics of the ESUT groups. With the creation of the Research Group, this process started

Prof. Liatsikos leads the brainstorm session on new ideas for the future

successfully and is continuously evolving (seven articles in the last two years).

Set up of social media With communication channels rapidly changing, a homepage on the Web is no longer sufficient. To catch up, the ESUT created a Twitter account and a Facebook community page. These media are open to all urologists with a shared passion for new technologies in urology. You will find the pages via these links: https://twitter.com/eauesut https://de-de.facebook.com/EAUESUT/ A necessary step The ESUT Brainstorming meeting was a necessary step to further define the strategy and future activities of the ESUT, one of the biggest sections of the EAU. Furthermore, the meeting enabled ESUT members to successfully prepare for the upcoming ESUT18-IAE Congress in Modena, Italy, to be held from 24 to 26 May this year.

To fulfil its core mission, the ESUT believes in the synergies of various groups for it to identify and provide to the urological community the latest developments in urotechnology. With this long-term strategy and attendant commitment, it is an honour to be an ESUT member as we are given the chance to contribute in achieving this central goal.

Apply for your EAU membership online!

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!

January/February 2018

Manila congress tackles latest trends in urology ESUT collaborates with PUA in laparoscopic training Dr. Juvido Agatep Jr. East Avenue Medical Center Quezon City (RP)

juvido_urology@ yahoo.com.ph With the theme “East Meets West: Moving Towards the Same Direction in Urology”, the Philippine Urological Association (PUA) held its 60th Annual Convention in conjunction with the 3rd Clinical Congress of the Federation of ASEAN Urological Associations (FAUA).

The congress, held from November 28 to December 2 in Mandaluyong City, Metro Manila, was preceded by pre-congress workshops offered during a two-day period. On the first workshop day, the 2nd EAU Section of Uro-Technology (ESUT) workshops were held in CASSTI- Medical City, including the Masterclass in Retroperitoneoscopic Surgery and an E-BLUS course.

Associate Professor Prof. Ali Serdar Gözen (DE), chairman of the ESUT training group and the main guest speaker, lectured on instructional E-BLUS course and porcine as a training model in Laparoscopic Urologic Surgery. The E-BLUS course is a laparoscopic hands-on training using the pelvic trainer, as recommended by the European School of Urology. The course included training exercises such as peg transfer, cutting a circle, needle guidance, and single knot tying. The author demonstrated a retroperitoneoscopic nephrectomy on an anesthetized live hog.

EAU Section of Uro-Technology (ESUT)

Sixty participants attended the whole-day programme including consultants and residents in urology. They showed enthusiasm in performing both the pelvic training exercises and retroperitoneoscopic nephrectomy in live pig models.

This activity, highlighting laparoscopic surgery in the retroperitoneum, was led by Prof. Gözen with assistance from Dr. Samuel Yrastorza, Dr. Jonathan Noble, and the author who are all fellows of Klinikum Heilbronn and trained under mentorship of Prof. med Jens Rassweiler.

Live ESUT surgeries On Day 2., two ESUT live surgeries were performed by Prof. Jens Rassweiler, chairman of the EAU Section Office, and Prof. Evangelos Liatsikos, chairman of the EAU Section of Urotechnology (ESUT) at the Urology Center of the Philippines in Quezon City, Manila.

Liatsikos lectured on “Achieving Excellence in PCNL”.

Another live surgical demonstration was held with a patient who had a staghorn calculi in the inferior pole. In the afternoon session, Prof. Rassweiler lectured on extraperitoneal laparoscopic radical prostatectomy- using the ‘Heilbronn Technique,’ followed by a live surgery which demonstrated a procedure for a 72-year-old male with stage A prostate cancer. The live surgical demonstrations were interactive, with direct commentaries from Profs.

Rassweiler and Liatsikos who explained the

Many laparoscopic training exercises in live pig models were performed on several stations

Elspeth M. MacDougall, Dr. Peter Lim, Dr. Murali Sundram and Dr. Paksi Satyagraha, as well as equally competent local speakers. All the lectures attracted a high number of attendance and the ensuing discussions were enthusiastic with critical views from both speakers and audience members.

New EAU members from PUA take the official oath on the bylaws of the EAU

procedures. They also responded to questions from the audience which numbered to almost a hundred.

The five-day event was capped off with a night of music, the highlight of which was when Prof.

Rassweiler joined a live band, sang, and displayed excellent guitar skills. He definitely rocked everyone’s night away. With a finale that was high on emotions, we hope for a similar success in the forthcoming collaboration and continuing partnership of the EAU, PUA, and the Federation of ASEAN Urological Associations.

Day 3 was the opening PUA’s 60th annual convention with a grand yet solemn ceremony that included a march of the official flags of the Philippines and PUA, officers of the society, followed by past PUA presidents, fellows, and members. Dr. Ponciano M. Bernardo Jr., considered one of the prominent Philippine pioneering urologists, gave the Domingo Antonio Memorial Lecture titled, “Pearls and Secrets of Urologic Practice” which held the attention of the audience.

With their vast contribution in the training of Filipino urologists in Minimally Invasive Urology and active support of PUA-ESUT activities, Prof. Jens Rassweiler and Prof. Ali Gözen were conferred and inducted as honorary PUA members. A mass induction ceremony of more than a hundred Filipino urologists was also held and which marked their membership to the European Association of Urology. The ceremony reflects the strong ties between the EAU and the PUA, which will be more evident in their future collaborations.

Throughout the congress several lectures on pertinent and timely topics were delivered by renowned international speakers such as Prof. Jens Rassweiler, Prof. Evangelos Liatsikos, Dr. Ralph Clayman, Dr.

Unveiling of Dr. Domingo Antonio Memorial Lecture

The pre-congress E-BLUS training was held in CASSTIMedical City

Penile cancer: What’s new?

Penile cancer management has improved but survival in advanced cases remains poor Mr. Ben Ayres St George’s University Hospital Dept. of Urology London (UK)

benjamin.ayres@ stgeorges.nhs.uk

Mr. Nick Watkin St George’s University Hospital Dept. of Urology London (UK)

urethral squamous cell cancer2. Such techniques preserve penile appearance and function to a greater degree, although time will tell if this is at the expense of increased local recurrence. Early oncological results are encouraging and local recurrence has limited impact on overall survival.

in addition to grade and lymphovascular invasion as before. The change in nodal staging is pN2 now requires three or more unilateral nodes to be involved, previously it was two or more. Bilateral inguinal nodal involvement is still pN2 and extra capsular spread or pelvic node involvement remains pN3.

Inguinal sentinel lymph node sampling has significantly reduced the morbidity of inguinal nodal staging, with low levels of false negative results in large European centres. Tracer evolution continues, and recent results from a new hybrid radioactive and fluorescent tracer showed significantly better sentinel node detection when compared to blue dye3. SPECT-CT scans have also been introduced in many nuclear medicine departments. These produce 3D images of sentinel node position, which should aid the surgeon in locating them. These techniques in improving sentinel node detection will hopefully reduce the already low false negative rate.

The EUROCARE-5 study reported no improvement in penile cancer survival in Europe between 1999 and 20074. However, data from one region in the UK, has reported around a 10% improvement in five-year cancer specific survival to 85% following centralisation5. There was no improvement in one-year cancer specific survival at around 90%.

This highlights the need for new ways to treat advanced penile cancer and share expertise across Europe and worldwide, to improve patient care and outcomes. New initiatives are focusing on both these areas.

nick.watkin@nhs.net Others have tried to reduce the morbidity of groin surgery by using minimally invasive surgical There have been many advances in penile cancer over techniques; both standard and robotic-assisted the last two decades; in particular the development endoscopic approaches have been reported. Early of penile preserving surgery and inguinal sentinel results show a comparable number of lymph nodes lymph node sampling. Both these techniques have excised compared to open surgery but fewer significantly reduced the morbidity of treatment for wound-related complications and some have many but not all patients. Big challenges remain in reported lower rates of lymphoedema. More robust the management of advanced disease, not only with studies are required to assess the impact of survival but also in reducing the impact of minimally-invasive surgery on lymphoedema and lymphoedema. patient quality of life.

Glansectomy with skin graft reconstruction is now well established for managing penile tumours confined to the corpus spongiosum of the glans or glanular urethra. Recent advances in penile preserving surgery have resulted in closer margins, with 1 mm being sufficient for cancer clearance and a low recurrence rate (2%)1. Glans resurfacing is used in some centres for superficial, hyperkeratotic T1 tumours and distal urethrectomy with buccal graft reconstruction has also been described in the management of small distal January/February 2018

TNM 8 classification Pathological staging of penile cancer changed in January 2018 with the release of the TNM 8 classification. Tumours invading the corpus cavernosum are now pT3 instead of pT2. Tumours invading the urethra are no longer pT3. If the urethra is involved this should be stated but it no longer changes the T category. Corpus spongiosum glans tumours remain pT2. The presence (pT1b) or absence (pT1a) of perineural invasion has been added to the T1 category

"eUROGEN is an exciting new initiative. It facilitates a multidisciplinary approach, with experts from across Europe discussing complex cases, such as penile cancer, ..."

InPACT is a randomised phase III International Rare Cancers Initiative study, assessing whether there is a role for neoadjuvant chemotherapy or chemoradiotherapy in managing men with inguinal node involvement. It is also studying whether prophylactic pelvic lymph node dissection, for micrometastatic disease, improves survival compared to prophylactic chemoradiotherapy to the pelvic nodes. eUROGEN is an exciting new initiative. It is a European Reference Network, whose aim is equitable access to the best care in Europe for rare uro-genital

diseases and complex conditions. It facilitates a multidisciplinary approach, with experts from across Europe discussing complex cases, such as penile cancer, on a secure on-line platform and providing recommendations for the patient and their doctor. It is up and running and any physician can submit cases for review and advice. Collaboration, research and educational events are also key elements of this initiative.

Penile cancer management has come a long way from the days of partial or complete amputation and morbid groin dissections for all. Survival in advanced penile cancer remains poor and new treatments and regimens are desperately needed.

Some countries have approached this rare cancer by centralising services, such as in the UK and Scandinavia. A multidisciplinary approach and sharing knowledge and advances in penile preserving surgery and inguinal node management are critical in such a rare disease. The EAU guidelines and new initiatives, such as eUROGEN should significantly drive this forward.

References 1. Sri D, Sujenthiran A, Lam W et al. The significance of close surgical margins in organ sparing surgery for penile squamous cell cancer. Eur Urol Suppl 2017;16:e1237 2. Kulkarni M, Sahu M, Coscione A et al. Substitution urethroplasty for treatment of distal urethral carcinoma and carcinoma in situ. J Urol 2015;193:e117 3. Brouwer OR, van den Berg NS, Matheron HM et al. A hybrid radioactive and fluorescent tracer for sentinel node biopsy in penile carcinoma as a potential replacement for blue dye. Eur Urol 2014;65:600-9.

4. Trama A, Foschi R, Larranaga N et al. Survival of male genital cancers (prostate, testis and penis) in Europe 1999-2007: Results from the EUROCARE-5 study. Eur J Cancer 2015;51:2206-2216.

5. Ayres BE, Hounsome L, Alnajjar H et al. Has centralisation of penile cancer services in the United Kingdom improved survival? Eur Urol Suppl 2014;13:e50.

European Urology Today

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Introducing the newest member of our family of journals, European Urology Oncology.

We’re bringing together multiple disciplines — including urology, medical oncology and radiation oncology—to achieve one goal, to advance research in urological oncology. Join our community of authors and reviewers collaborating for the benefit of patients in every corner of the world.

If you’ve got practice changing, groundbreaking research in urological oncology we hope to hear from you.

Submit your paper today: http://ees.elsevier.com/euonco

http://europeanurology.com/euoncology

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European Urology Today

January/February 2018

17th Congress of Russian Society of Urology Congress marks 110th anniversary of Russian urology Prof. Igor Korneyev Saint Petersburg State Pavlov Medical University Dept. of Urology Petersburg (RU )

urology in line with European standards. Having endorsed the EAU Guidelines, the RSU annually released clinical recommendations in urology strategically important for Russian healthcare. RSU actively collaborated with young urologists, providing them with opportunities for professional growth at the beginning of their career.

iakorneyev@ yandex.ru Moscow hosted last November 8 to 10 the 17th Congress of Russian Society of Urology (RSU), which also marked the 110th anniversary of the RSU.

Since 2013, the RSU Congresses was organised with close cooperation from the EAU and key opinion leaders from the EAU participated in RSU congresses every year. The annual congresses also featured ESU courses, masterclasses and hands-on training, state-of-the-art lectures and the latest updates on controversial topics in urology.

The congress looked back at the society’s achievements in the last five years and conducted new elections for the RSU chairman, Board and Presidium. The congress’ comprehensive scientific programme was organised with the collaboration of the EAU and the European School of Urology.

Alyaev re-elected as RSU chair The General Assembly re-elected Prof. Yuri Alyayev as RSU chair. Alyayev is the corresponding member of the Russian Academy of Sciences and Head of the Department of Urology of the First Sechenov Moscow State Medical University.

The first congress day was scheduled for the elections.

RSU Chairman Prof. Yuri Alyayev’s accounting report preceded the General Assembly which highlighted the society’s significant achievements from 2013-2017, a period in which the RSU’s membership doubled.

He thanked the delegates for their trust and underlined the RSU’s tasks for the next five years: "We have a lot of work to be done including certification and accreditation of urologists, implementation of distance learning, improvement of post-graduate education of urologists and much more. I am more than confident that there will be issues that require collective actions and immediate solutions," he said.

Today the RSU has more than 4,700 medical professionals including urologists, residents and medical students. RSU has also initiated educational gatherings across the country, tackling major issues in International Relations Office

The RSU Congress opening was highlighted by the Award Ceremony with urologists from various cities and medical centres awarded for their excellence and service to the society. The EAU Secretary

EUSP-EULIS offer new scholarships

Prof. Chris Chapple receives an Honorary Membership of the RSU from Prof. Yuri Alyayev

General Prof. Chris Chapple received an Honorary Membership in the RSU.

The ESU course focused in urological complications and Profs. Chapple, Van Der Aa, Ignacio Moncada, and Dr. Henk Van Der Poel Key topics included complications and errors in lectured on complications after surgery for female urological practice, troubleshooting following incontinence, male urethral strictures, BPH and erectile dysfunction surgery. Interactive case endoscopic and laparoscopic surgeries, lasers, cell technology, robot-assisted surgery and others. Despite discussions followed the lectures with the the fact that modern technology makes diagnosis presentations done by Russian urologists. more precise and treatment becomes more effective and safe, new methods can lead to new With the ESU courses aimed to prompt scientific discussion, Prof. Chapple noted the continuing complications, posing their own challenges. collaboration between the EAU and RSU. “We are "Complications we face today are quite different from happy to share knowledge we have and learn from those reported earlier. Patients may believe high-tech our Russian colleagues. Close collaboration new operations can guarantee full recovery and lead between the EAU and RSU is key in making this happen,” he said. to less complications. But it is our responsibility to ensure the prevention and treatment of complications, as we are the professionals directly responsible for More than 2,200 urologists from Russia and the quality of care,” said Prof. Dmitry Pushkar. abroad participated in the congress, which held a corresponding member of the Russian Academy of number of practical sessions, symposia and Sciences and Head of the Department of Urology discussions, all presented in a friendly and open atmosphere.

Moscow State Medical and Dental University.

New scholarships in endourology Prof. Vincenzo Mirone Chair EUSP Naples (IT)

mirone@unina.it The European Urological Scholarship Programme (EUSP) and the EAU Section of Urolithiasis (EULIS) have launched the new EULIS Endourology Scholarship Programme.

Besides specialty scholarship collaborations in fertility medicine, robotic surgery and kidney transplantation, this newly launched scholarship programme is intended for residents and young urologists interested in improving their skills and furthering their experience in endourological urinary stone management procedures, specifically Percutaneous nephrolithotomy (PNL) and ureteroscopic management of urinary tract stones (URS).

The EULIS aims to encourage, support and train scholarship winners in all aspects of endourology training. The scholarships will be offered at five European Centres of Excellence in endourology, specially chosen by the EULIS board. The fellowship programme will consist of full training in PNL/URS procedures with close supervision and guidance by EULIS members who will mentor the fellows closely to ensure continuity and high quality and successful completion of the three-month training period.

The young endourologist scholar will take part in all rounds, scheduled scientific meetings and case discussion sessions held in the endourology department of their host institute and participate in relevant ureteroscopic and percutaneous stone removal procedures performed together with local staff.

European Urological Scholarship Programme Office

January/February 2018

The scholarship runs for three months during which a working plan will be developed with the visiting fellows to ensure that the educational and training aims of the programme are successfully met in a practical, step-by-step manner. The fellow will join the local endourology team and be instructed in all procedures along with fellow staff urologists.

At the end of each month, the attendant young endourologist will undergo a quick assessment exam by the hosting team to determine the degree of knowledge obtained and training acquired in both medical and surgical aspects. Upon completion of the programme formal certification will be given attesting to the satisfactory completion of the programme.

Applications for the EULIS Endourology Scholarship Programme are now open on the EAU website at: http://uroweb.org/section/eulis/education/ with a May 1, 2018 deadline.

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 2018!

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

EUSP @ Annual EAU Congress 2018 in Copenhagen: This year the EUSP will once again be holding its session during YUORDay which is scheduled for Saturday the 17th of March 2018 from 11:00 - 11:45 hrs.

Below is the preliminary programme: Moderators:

V.G. Mirone, Naples (IT) J.P.M. Sedelaar, Nijmegen (NL)

11:00 - 11:10 hrs.: “The EUSP Programme;

does it deserve your attention”?

M.J. Ribal, Barcelona (ES) 11:10 - 11:20 hrs.: EUSP Scholars’ achievements

J.A. Schalken, Nijmegen (NL) 11:20 - 11:30 hrs.: Emerging Partnerships with EUSP

V.G. Mirone, Naples (IT) 11:30 - 11:40 hrs.: Announcement of award for the

Best Scholar Award Winner 11:40 - 11:45 hrs.: Question & Answer Session

Provide sustainable patency.

Resonance

®

M E TA L L I C U R E T E R A L S T E N T

MEDICAL

© COOK 01/2017 URO-D32084-EN-F

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The EAU History Office in Copenhagen EAU18 brings scientific sessions, exhibition and new publications

By Loek Keizer The History Office of the EAU can be counted on to use each Annual EAU Congress to highlight some interesting topics from the host nation’s urological history. As EAU18 is taking place in Copenhagen, look forward to historical tales from Danish (and Scandinavian) urology in the shape of lectures from local speakers, instruments and memorabilia related to the region’s history and the usual selection of highlights from the history of our field.

196 beautiful black and white illustrations and 9 coloured reproductions, a complete overview on the History of Urological Surgery and Urology from its origins to the beginning of the 20th century.

For more information on Ernest Desnos and the inaugural winner of the prize, be sure to read the upcoming 25th Anniversary Edition of De Historia Urologiae Europaeae, which will also be launched in Copenhagen and made available to members shortly after. Artefacts related to Desnos will also be on display in the Historical Exhibition, in addition to special items from the history of urology in Scandinavia.

"The prize bears the name of Dr. Ernest Desnos (1852-1925), as a tribute to this pioneering French urologist who was also an eminent historian of Urology"

Ernest Desnos, (1852-1925), who gave his name to the EAU’s newest Award

However his most significant contribution was in the field of the History of Urology. Therefore his ‘magnum opus’ is the first book on the History of Urology ever.

This book was published in 1914 as “Histoire de l’Urologie” (History of Urology, Paris. Doin éditeur, 1914). The large volume presents, in 294 pages with

At the 33rd Annual EAU Congress, EAU18 in Copenhagen, EAU members can look forward to a new publication by Dr. Johan Mattelaer. For this relief, much thanks! explores the depiction of urination in art, both classical and contemporary. It is a beautifully illustrated coffee table book that celebrates our field and offers unique insights. The book can be picked up at the EAU Booth in the Exhibition, with the appropriate entitlement and on a first come, first served basis.

Sessions Delegates can look forward to two scientific sessions covering the history of urology, both on Friday, March 16th. In the morning, a three-hour special session will feature topics like the development of urology as an independent specialty in Denmark, biographies of pioneers Hans Henrik Holm and Tage Hald, and an exploration of the Scandinavian Association of Urology.

Beyond the Scandinavian Angle, the session will give attention to the Desnos Prize and its inaugural winner, the presentation of Dr. Mattelaer’s latest Congress gift For this relief, much thanks: Peeing in Art, and, in honour of the 100 years since the end of the First World War, British urologists during the Great War.

The Desnos Prize For the first time, the EAU History Office will be honouring a person who has significantly contributed to the field of the history of urology. The winner of the Poster Session 14, later that afternoon features Ernes Desnos Prize will be honoured at the the Opening fourteen extremely diverse presentations on topics Ceremony, along with the other award winners. from the fabled history of our field.

The prize bears the name of Dr. Ernest Desnos (18521925), as a tribute to this pioneering French urologist who was also an eminent historian of Urology and who wrote the first book devoted solely to the history of urology. Not least of Desnos’ accomplishments are co-founding the AFU and later the SIU, as well as treating Emperor Napoleon III for a bladder stone in 1873 and major pioneering work on prostate brachytherapy.

For this relief, much thanks!

Peeing in art

History Office Programme in Copenhagen • EAU History Office Specialty Session: Danish Contributions to Urology and more Friday, 16 March 9:15 - 12:15 Orange Area, Room 2 (Level 0) • Poster Session 14: History of Urology Friday, 16 March 14:15 - 15:45 Blue Area, Room 2 (Level 0) • Historical Exhibition Saturday, Sunday, Monday (until 15:30) EAU Booth, H69, Exhibition

NGage®: Reach for the original.

NGage Nitinol Stone Extractor

MEDICAL

© COOK 01/2017 URO-D32084-EN-F

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.

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European Urology Today

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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.

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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, Z. Zotter, zotter.zsuzsanna@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.

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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 2018

Movember's PCa Active Surveillance initiative (GAP3) Paving the path to global AS consensus guidelines and implementation

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

c.h.bangma@ erasmusmc.nl

Prof. Monique Roobol Dept. of Urology Erasmus MC Rotterdam Rotterdam (NL) m.roobol@ erasmusmc.nl Active Surveillance (AS) has become a preferred alternative option to active treatment for men with low risk prostate cancer. AS reduces the risk of over-treatment and associated side effects - such as incontinence, sexual and bowel dysfunction significantly affecting the quality of life.

However, AS has not yet reached its full potential yet. Many AS protocols have been reported in literature but there is little consensus on which protocol is most effective. Clearly, there is a need for a worldwide consensus regarding the optimal criteria and protocols for AS which would allow clinicians and patients to have greater confidence in the decision to either delay or proceed with active treatment.

Movember Foundation’s innovative global approach, the GAP3 consortium The Movember Foundation is a global charity that invests in initiatives that deepen the worldwide knowledge of prostate cancer such as the Global Action Plan (GAP). There are seven GAP projects of which the GAP3 project focuses on Active Surveillance for low risk prostate cancer.

Launched in August 2014, GAP3 has united as many as 25 institutions, hospitals and research centres across the globe (Figure 1)1. Each of these 25 centres contributed AS cohort data that was combined into the largest central AS database. By analyses of this unique data set, GAP3 aims to identify the optimal criteria for selection, monitoring and switching to active treatment. The primary objective of the GAP3 initiative is to create global consensus on the selection and monitoring of men with low risk prostate cancer and to bring this knowledge to physicians and most importantly the patients. This will ultimately improve confidence in AS as

3. Getting insight into existing guidelines The increasing popularity of AS as a management option, resulted in publication of a range of clinical guidelines. Recently within GAP3, Bruinsma et al. reviewed 16 guidelines for AS originating from USA, Canada, Singapore, New Zealand Australia, UK and six European countries 4.

The guidelines vary on eligibility criteria for AS, follow-up protocol and definitions for disease reclassification. The predominant eligibility criteria used for inclusion are: pre-treatment clinical stage T1c or T2 tumours, serum PSA < 10 ng/ml and biopsy Gleason score of 6 or less.

Other less reported criteria are a maximum of one or two tumour-positive biopsy core(s) and/ or a maximum of 50% of cancer per core.

Patient characteristics such as age, life

Fig. 1: Centres participating in the Prostate Cancer Active Surveillance (GAP3) initiative

January/February 2018

1.0 0.8 0.6 Probability 0

5

10

15

20

Time (years)

Fig. 2 Discontinuation of Active Surveillance over time (n = 14,033) Protocol based progression= clinical and pathological progression, clinical progression, other PSA kinetics, pathological progression, PSA progression (PSADT< 3 yrs.), or radiological progression

2. Bringing clarity in nomenclature Semantic heterogeneity exists in AS literature and guidelines. For instance AS and watchful waiting (WW) are inconsistently used and frequently interchanged while they refer to very different observational approaches. To overcome this semantic heterogeneity in AS literature and guidelines, the GAP-3 consortium decided to bring clarity to the nomenclature of AS . For this, a panel of leading prostate cancer specialists in the field of AS was convened. A modified Delphi consensus procedure including a three-round sequence of online questionnaires and a face-to-face consensus meeting was used. Of a total of 61 terms used within the context of AS, ten terms were unanimously discarded as being unnecessary. Consensus definitions were formulated for the remaining 51 terms.

Agreement ranged from 75-100% with full agreement for 24 terms3. The Movember Gap-3 consortium encourages all stakeholders to conform to this terminology since it will support multidisciplinary communication, reduce the extent of variations in clinical practice and as such aid in clinical decision-making.

| 58%| 39%| 23%| Still on AS | 23%| 30%| 36%| Progression | 11%| 16%| 20%| Unknown | 5%| 5%| 6%| Patient/Doctor choice | 1%| 3%| 3%| Watchful Waiting | 2%| 7%| 12%| Died

0.4

Current achievements 1. Joining forces, creating a unique database One of the first milestones within the GAP3 initiative was constructing the largest centralised prostate cancer AS database to date. Patient data from 25 established AS cohorts worldwide has been combined within one central database. First, the clinical investigators agreed on the codebook of the GAP3 database, which consists of four sections: period before diagnosis, inclusion, follow-up, and end of Active Surveillance. At time of inclusion, the consortium is interested in recording patient characteristics and tumour characteristics. During follow-up, information is gathered on e.g. PSA, PSA kinetics (PSADT, PSAV), T-stage by DRE, biopsy characteristics, Quality of Life and MRI. At the end of Active Surveillance, reasons for stopping, type of metastasis, type of treatment and cause of death are recorded. The database currently comprises clinical, marker-related and imaging data on more than 15,000 patients. Figure 2 shows the probability over time for discontinuation of AS and the reason for stopping. A descriptive publication outlining the data on inclusion and follow-up during AS within this unique global AS database is recently published 2.

GAP3 consortium database (5800 AS patients) 6. PASS-RC estimates the probability of reclassification on a surveillance biopsy and preliminary data shows that it discriminates reasonably well between patients with and without reclassification on biopsy. However, recalibration to the local setting is required before implementation.

0.2

j.helleman@ erasmusmc.nl

treatment strategy of men with low risk prostate cancer and extend the implementation into daily clinical practice across the globe.

0.0

Dr. Jozien Helleman Dept. of Urology, Erasmus MC Rotterdam Rotterdam (NL)

expectancy, comorbidities and general health condition, were recommended as eligibility criteria in most of the guidelines but were not often well-defined.

Twelve guidelines provide recommendations on how to monitor patients on AS. Most of these 12 guidelines recommend serial serum PSA measurements (interval mostly between 3-6 months), digital rectal examinations (interval ranging between 3-12 months) and surveillance biopsies to assess tumour progression.

Criteria for switching to active treatment were less often reported with none included in seven of the guidelines. Only re-biospy Gleason score and PSA doubling time < 3 years were more commonly mentioned triggers for switching to active treatment.

The overview shows that there is little consensus on criteria used for inclusion, monitoring and switching to active treatment and many questions remain on what are the most optimal criteria.

4. We started analyses!

Now that we have created this dataset we can fully focus on addressing the unanswered questions such as which intermediate-risk patients are candidates for surveillance, what is the most efficient way to follow patients longitudinally, can individual risk stratification reduce the burden of follow-up?

Multiple data analyses of this unique global data set are currently ongoing focussing on the different topics including: •

•

• Risk analyses, how well do we predict true-low risk prostate cancer Preliminary data shows that currently used selection criteria for AS within the 25 cohorts leads to acceptable rates of disease reclassification at one and four years 7.

Stronger predictors, possibly genomic markers, will be needed to further improve the identification of true low risk among the current candidates for AS. • Adherence to current guidelines, what is happening in daily clinical practice?

Adherence to local guidelines was assessed for the 25 AS cohorts 8. First analysis shows good-to-excellent adherence to inclusion criteria in about 75% of the cohorts, and weak – fair adherence for 25% of the cohorts. Overall adherence to biopsy schedules varied from good-to-poor at start of AS, and were poor at the end of follow-up (Figure 3).

This illustrates that just drafting another set of guidelines will not be enough. To be able to implement knowledge into daily clinical practice, we on one hand have to reinforce our confidence in the validity of the guideline, and on the other hand need involvement of patients and decision aids such as the Movember programme TrueNTH. The TrueNTH programme informs men how to enhance quality of life, on treatment options, gives life style advice and provides aiding tools (https://us.truenth.org/).

The GAP-3 database is alive, updating and augmenting Movember has recently allocated additional funding to maintain the database and update the clinical data annually. Current follow up time is limited, therefore sustaining the database to prolong follow-up time is imperative and will dramatically increase its value for AS research. Furthermore, we especially focus on including more MRI, quality of life and genomic data. By combining data from separate smaller cohorts, we aim to assess the value of MRI with respect to lesion definition and changes over time and the use of genomic markers and quality of life in the decision to pursue AS rather than active treatment.

Providing clarity and increasing confidence In summary, analyses of worldwide AS data brought Quality control together in the Movember GAP3 database will provide We performed a centralised pathology review clarity and a solid basis for AS guidelines regarding of 5-10% randomly selected biopsy specimen inclusion criteria, surveillance schedules and from 15 of the GAP3 centres. Preliminary results intervention thresholds. This project will allow confirm consistent biopsy quality and grading clinicians and patients to have greater confidence in across the different centres, enabling the decision to either delay or proceed with active comprehensive data analyses 5. treatment based on the most up-to-date data and clinical guidelines available.

The GAP3 database, a perfect tool for validation The global AS data within the GAP3 database The references of this article are available from provides a perfect tool to validate previously the EUT Editorial Office. Please send an e-mail to: published studies. The Canary Prostate Active EUT@uroweb.org with reference to the article Surveillance Study Risk Calculator (PASS-RC) “Movember's PCa Active Surveillance initiative” has been validated using six cohorts within the by Dr. Helleman, Jan/Feb. issue 2018.

Fig. 3: Adherence to repeat biopsy schedules during AS for the six largest cohorts within GAP3.

Adherence: a biopsy 3 months before or after the protocol indicated; Earlier: a biopsy > 3months before the protocol indicated; Later: a biopsy > 3months after the protocol indicated; No biopsy: no biopsy taken at the time as indicated in the protocol

European Urology Today

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New Clinical Patient Management System goes live for ERNs Healthcare providers share expertise for rare urogenital diseases and complex conditions Michelle Battye EAU EU Policy Coordinator and eUROGEN Manager Sheffield (UK)

michelle.battye@ sth.nhs.uk The European Reference Network (ERNs) for rare urogenital diseases and complex conditions has been established by the EU as a framework to facilitate multidisciplinary team work between professionals.

This will provide internet based access to specialist input from centres of particular expertise in different countries for these conditions allowing them to share their knowledge and expertise.

The last 12 months has been a busy period for eUROGEN, the European Reference Network (ERN) for rare urogenital diseases and complex conditions in Urology. This programme was approved by the European Commission in March 2017, along with 23 other ERNs. eUROGEN encompasses 29 healthcare providers in 11 Member States. These centres will collaborate in a network to provide expert advice on diagnosis and management of patients with rare urogenital or very complex conditions. eUROGEN is structured into three Workstreams, each with a dedicated lead. Workstream 1: rare congential urogenital anomalies is led by Prof. Wout Feitz, of Radboudumc in Nijmegen (NL); Workstream 2 complex urogenital conditions requiring highly specialised surgery, led by Prof. Margit Fisch, Universitätsklinikum Hamburg-Eppendorf (DE) and Workstream 3: rare urogenital tumours, led by Mr. Vijay Sangar, The Christie NHS Foundation Trust (UK). eUROGEN is led by Prof. Chris Chapple (UK), with support from the EAU Central Office and we have

been working hard to implement the new Clinical Patient Management System (CPMS) which is the web-based clinical software application where healthcare providers from all over the EU can work together virtually across national borders to diagnose and recommend treatments for patients with rare, low prevalence and complex diseases in Europe. Using CPMS, our eUROGEN healthcare providers can set up ‘virtual’ advisory panels of medical specialists across different disciplines and discuss cases in real time.

We are delighted to announce that eUROGEN held its first panel case consultation to pilot the electronic system; discussing a complex case and involving Sheffield Teaching Hospitals Foundation Trust (the Coordinator of the ERN), Radboud University Medical Centre, Universitätsklinikum Hamburg-Eppendorf and Katholieke Universiteit Leuven. The case presented was an adult woman with a urethral diverticulum and urinary incontinence. Symptomatic female urethral diverticula are an uncommon clinical problem with an incidence of 18 per 1 million population per year. This makes it difficult for an individual surgeon to accumulate the required expertise on this particular condition, especially if he/she is practising in an EU country with a smaller population. Using the CPMS we were able to conduct a virtual consultation meeting with the experts in the field and review all the patient information including the videourodynamic study and the magnetic resonance images. All the experts were impressed with how CPMS worked and with the quality of the medical imaging in particular. The consensus view of the clinicians involved was that “using CPMS is a step change in collaboration at a European level between healthcare providers. We will be able to provide expert advice, more quickly delivering better care for our patients and reducing the need for them to travel.”

One of the objectives of eUROGEN is to transfer knowledge between countries thereby sharing expertise and experience. Therefore it will be fascinating to utilise a feature of the CPMS designed

to help us make this a reality in 2018. Clinicians from countries where a patient lives and who has a rare or complex urogenital condition that cannot easily be managed or treated at national level can contact eUROGEN and ask if we can review this case. If agreed, the treating clinician can be issued with a guest login to CPMS and they can upload the relevant medical information. eUROGEN can then hold a panel case consultation with the appropriate experts from within our network who can then give advice to the treating clinician. All of this can be done without the patient having to travel. Please contact Michelle Battye, Manager of eUROGEN if you have a case that you would like to consider referring to eUROGEN (michelle.battye@sth.nhs.uk).

This year, eUROGEN will be working to allow the more widespread use of CPMS across the whole network. We hope our collaboration will intensify and go beyond providing virtual expert clinical advice on diagnosis or treatment options. eUROGEN will also be working on developing new clinical guidelines where none currently exist, training and the sharing of knowledge, especially in countries with smaller populations.

rare diseases and complex conditions involves the whole spectrum from congenital anomalies to lifelong care and complex functional and rare urogenital tumours. Patient care and interaction, clinical guidelines, training and education and research activities are interacting for the improvement of the care for your patients.

Presentations will be given by the European Commission and the perspective of patients will also be an important topic for this session. Speakers from each of the three workstreams will also be present: Hypospadias registries and clinical implications (Workstream 1) F. Van Der Toorn, Rotterdam; Complex functional urology research knowledge gaps and solutions (Workstream 2) and Clinical aspects and ERN impact on penile tumour care improvement (Workstream 3), M. Albersen, Leuven.

The second eUROGEN annual meeting will take place 11-12 June in Noordwijk (NL) at the venue of the EAU National Societies meeting with detailed consultation with the European National Societies over the ensuing meeting with them. We really look forward to an exciting and productive event.

Special session EAU18 There will also be a special session devoted to the European Reference Networks and eUROGEN in particular on Sunday 18 March 15.45 – 18.00 and we would be delighted to see interested parties. The ERN eUROGEN session will update you on the recent largest health care innovation in Europe involving 30 million patients with rare or complex conditions. This programme on urogenital

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

paul.meria@ sls.aphp.fr

Oxford Textbook of Urological Surgery Urology is a wide specialty including medical and surgical aspects of various diseases affecting the genitourinary tract. This textbook belongs to a series of specialty-specific textbooks, intended for trainees nearing the end of their course. More than 150 worldwide experts have contributed to this work which aims to provide the reader with an exhaustive survey of urology.

All aspects of inflammation and related diseases were reviewed in the first section, including various chapters dealing with acute and chronic infectious diseases.

Urolithiasis was considered in the succeeding section and the authors focused on the medical and surgical treatments applicable to stone formers.

Functional urology and trauma were addressed in two dedicated parts before the authors presented two leading sections dedicated to BPH and oncology. All genitourinary cancers were covered, with focus on prostate cancer, including recent advances in diagnosis and treatment.

Erectile dysfunction and infertility were addressed in the andrology section which was followed by a section dedicated to pediatric urology. An original Book reviews

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European Urology Today

REGISTRATION OPEN part focused on “renal function” and addressed various aspects of kidney diseases, before considering urological aspects of dialysis and transplantation.

The last part of the work was dedicated to imaging techniques in urology, including various aspects of radiation protection.

With this exhaustive work the authors achieved their objective, since they assembled an amount of practical information useful for trainees and certified urologists. Nevertheless, we hope for more illustrations in future editions.

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

: F.C. Hamdy, I. Eardley : 9780199659579 : available : Sep. 2017 : Oxford University Press : First : 1200 : 500 figures : Hardback : € 253 : https://global.oup.com

cuameeting.org

January/February 2018

The 3rd Urology Simulation Boot Camp 5-Day course to boost baseline surgical skills Table: Urology Simulation Boot Camp Modules

Dr. Giacomo Pirola University of Modena and Reggio Emilia Dept. of Urology Modena (IT)

Module 1 2 3 4 5 6 7 8

gmo.pirola@ gmail.com

Dr. Joana Do Carmo Silva Charles University 2nd Faculty of Medicine Dept. of Urology Prague (CZ)

Skills Scrotal examination, fixation, priapism, troubleshooting with catheters Bowel anastomosis, ureteric reimplantation, stoma formation, ileal conduit Basic laparoscopic skills (EBLUS), access, ports, use of harmonic TURP, TURBT, Instruments (handling and assembly), bladder washout Emergency urology scenario (Non-technical skills) Setting up for urodynamics, TVT, TOT, pelvic examination, urethral bulking agent Simulated wardround (Non-technical skills) Cystoscopy and stent, rigid and flexible ureteroscopy

Organised by Mr. Shekhar Biyani and Mr. Sunjay Jain in collaboration with The British Association of Urological Surgeons (BAUS), the course follows the United Kingdom ST3 Urology Curriculum from the Higher Specialty Training Syllabus. The participants were mostly ST2/ST3 trainees from the United Kingdom; a total of 48 participants. The faculty comprised 80 experienced consultants from all over the country, experts in their own areas.

joana.carmo.s@ gmail.com Changes in health care across the globe have had a profound impact on the number of hands-on surgical training opportunities that are available to residents.

During five days, 30 hours of technical skills simulation training in cystoscopy, ureteroscopy, TURP, TURBT, TVT, Botox, Scrotal Surgery, Bowel

The transition from core surgical trainee to first-year (ST3) urological registrar (resident) can be a time for significant stress and insecurity. In the UK, a 5-day course has been introduced to help new urology trainees to achieve baseline competence in knowledge and skills and improve their confidence level. It comprises of eight modules (Table) and is mapped to the ST3 (first year urology resident) curriculum with an emphasis on one-to-one hands-on training. For further information watch the video about the course at https://www.youtube.com/watch?v=lhf0jEXJkE&t=164s or Follow @UrologyBootCamp

Anastomosis and Laparoscopy were provided with one-to-one hands-on training.

Moreover, the course included 10 hours of nontechnical training skills in the form of simulated scenarios using state-of-the-art technology, followed by interactive structured debriefing sessions. The simulation consisted of emergency situations using actors, mannequins and the Sim man and urology ward round, including decision-making, breaking bad news, task delegation and prioritisation. The course was divided in eight different modules and the participants were divided in small groups (up to six people per group), rotating between each module. At the end of the course, a skill assessment was performed to document the trainees’ improvements.

Approaching the end of the course a lovely dinner with the Urology Boot camp faculty ensued. We exchanged ideas, shared practices and enjoyed the Yorkshire hospitality.

This course is unique in its design, as the trainee is able to practice on both virtual reality simulators (i.e. ureteroscopy / laparoscopic skills) as well as wet lab models (TURP, TURBT / scrotal surgery / bowel anastomosis and ureteral reimplantation). The teaching staff was highly qualified and fully available to discuss with trainees and guide them in improving their technical skills in a one-to-one fashion.

The third edition of the “Urology Simulation Boot Camp” took place in Leeds (UK) from 10 to 14 October at St James’s University Hospital.

Furthermore, this was an opportunity to face the UK teaching system and to improve both technical and theoretical knowledge in urology. Every course participant was enthusiastic of this experience and we personally recommend it to all residents, as the opportunity to have a high level and focused tutoring is not always possible. We want to thank Mr. Biyani, Mr. Jain and all the BAUS faculty for their commitment, kindness, availability and competence.

Simulation of a boari flap (A), familiarisation with endoscopic instruments (B), learning to fill up an Ellik evacuator (C), flexible ureteroscopy (D).

Rainer Engel, MD, FACS

Competent urologist, dedicated curator and excellent historian 1933 - 2018

Rainer Engel, a very good friend and an active expert of the History Office of the EAU passed away on 6th January 2018.

Born the third of nine children near Cologne, Germany in 1933, his early years were heavily influenced by World War II: bombings, ruins and marching troops. He went to medical school at the Rheinische Friedrich Wilhelm Universität in Bonn, which at that time was the provisional capital of Germany.

After his exams he travelled through the US for 6 months and decided to live in this country. He married Dorothy, a young nurse, and after two years both went back to the United States. In 1970 Rainer finished his urology residency at Johns Hopkins in Baltimore and became chief resident.

William W. Scott, MD, was his professor throughout his residency. He practised at both Johns Hopkins and Union Memorial and also

January/February 2018

Greater Baltimore Medical Center and Baltimore City Hospital and joined the AUA in 1976.

In 1993 he was officially approved by the AUA as curator of the Didusch Museum but continued to teach at Johns Hopkins. At the same time he coordinated and organised the museum, prepared and executed exhibits on the history of urology and travelled around the world gathering artefacts for the Didusch collection. Dorothy, his wonderful wife, shared his plans and worked with him to make the museum great and one of the most interesting medical museums in the world.

The AUA awarded him the William P. Didusch Art and History Award in 1996 and honorary membership to the AUA in 2006. Both Rainer and Dorothy were honoured by the AUA Board with an appreciation award in 2004 for their work in rebuilding the museum at the new AUA Headquarters.

During all these years he did not lose his contacts in Europe, and as he spoke fluent German he had also many contacts with the museum and archives of the German Urological Association (DGU) first in Düren, later in Düsseldorf.

During his annual trip to Europe he would from 1996 have contact with and attend the meetings of the starting Historical Committee of the EAU (today History Office). He officially became an expert of this EAU Committee in 1999. He attended all of the annual meetings of his European friends interested in the history and the development of urology. He was the ideal connection between the AUA and EAU urological historical offices and contributed a lot in our collaboration.

His first publication in the De Historia Urologiae Europaeae was in Volume 8: “Europe’s Influence on American Urology in the 19th century” (2001).

In November 2008, he organised the 4th International Congress on the History of Urology at the Didusch Museum in Linthicum, Maryland, USA, which was one of the most exciting and interesting meetings on the history of Urology.

Rainer Engel was fervent and ardent in his job as a curator, he was a very competent urologist and an excellent historian. He brought people from both sides of the Atlantic Ocean together in their common urological history. He was also an excellent speaker and an organiser with a very warm heart. He was really a very good friend. We will miss him.

Johan Mattelaer, Dirk Schultheiss and Philip Van Kerrebroeck On behalf of the EAU History Office

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Young Urologists/Residents Corner Residents Around the Globe New column series to present resident’s experience and insights on training Dr. Zsuzsanna Zotter Section editor EUT Hungarian Defense Forces, Medical Center Dept. of Urology and Andrology Budapest (HU)

less the same, the systems behind the process are very much different. Thus, it is always interesting to get acquainted with other nations’ educational structures and compare it with your own.

Later in the course of my residency, which I thought is a much more limited field of my studies and is similar to others, I realised that there is a significant variance, even within Europe, not only in the duration of the zotter.zsuzsanna@ different programmes, but also in the curriculum. gmail.com These differences may arise from the dissimilarities of the healthcare system, as well as from distinct When as a student I met other medical students from traditions and also from which level (nationwide, all over the world during scholarships and exchange regional, hospital) the programme is organised. The schedules are also affected if the national associations programmes, it fascinated me that although in actively take part in, or, even more, organise it. And in the long run the degree that we earn is more or

certain countries there is no special urology training; residents acquire the necessary knowledge by joining the surgery programme, or any international exchange schemes.

I believe that by familiarising with other training programmes, we can learn a lot from and about each other. What I have learned from overseas colleagues is that there is a uniquely significant part in the training that would help the resident become an even better urologist. I am sure that if we recognise these small variations, we can better understand each other and can get new ideas about our training. These variations are also reflected in my country. I am proud that the Hungarian Society of Urology organises a three-day programme, four times a year, which supplements

resident training. In these short courses we discuss the different areas and guidelines of the profession.

Unfortunately, it is impossible to gather personal experiences of the different programmes everywhere.

Thus, the ESRU thought that one prominent resident from every country should present in an article series their country’s resident training plan. This way everybody can get an insight of other programmes.

With the Residents Around the Globe article series, we aim to get the residents closer to their colleagues, while learning from each other.

We hope that everyone will read the articles with the same excitement and joy, as we are looking forward to reading them in every issue.

Urology Training Around the Globe Focus on Argentina Dr. Diego Santillán Dept. of Urology Hospital Italiano de Buenos Aires Buenos Aires (AR)

diego.santillan@ hospitalitaliano.org.ar Argentina is a vast and beautiful country, full of incredible landscapes from North to South.

Its outstanding glaciers, majestic waterfalls and blue lakes attract thousands of tourists every year.

However, visitors will see a different scenario when they visit our hospitals, which could make them realise how seriously inequity affects our healthcare system. Argentina is not a poor country, but wealth distribution is unequal which led to severe consequences in many fields. Urology residency programmes are also affected. Why? The answer is simple. Despite the lack of official statistics, it is a known fact that urology residents get different training depending in which hospital they are doing their training.

In this article, I will try to briefly describe how one gets a position as a urology resident in Argentina. I will also describe the main differences between being a resident in a private hospital as against a public one. I will also mention specific requirements needed to achieve a urology diploma. Finally, I will present some ideas that might help improve our residency programme system.

To get a position as a urology resident in Argentina, a medical doctor has to sit for a multiple choice exam.

The higher your score is, the better your chances to select a hospital for training. For public hospitals the exam is the only requirement needed. In private hospitals, the best scorers also have to go through a personal interview, plus a review of the candidate’s CV. Table 1 lists the other differences between public and private hospitals.

It is worth highlighting that in public hospitals surgeries like anatrophic nephrolithotomy, ureterolithotomy and Millin´s operation are still routinely performed due to the lack of endourology instruments. In my view, however, medical activity without technological support is as challenging as it is admirable. Creativity and dexterity replace high technology in the public operating rooms. Meanwhile, laparoscopic surgeries are almost exclusively performed in private hospitals for similar reasons. Though widely adopted in developed countries, robotic surgery is only done in three private hospitals in Argentina, after a public hospital failed in its attempt to acquire one.

Hopefully, if modern technological equipment become more affordable in the near future, minimally invasive surgery will be accessible in more hospitals.

The length of each residency programme depends basically on the selected hospital. Typically, it takes four to five years to complete a programme. Every resident must train for at least six to 12 months at a General Surgery (GS) Department before entering Urology. Only a few hospitals demand completing a full GS residency programme.

Urología. After completion of a residency programme, written and oral exams are obligatory before one gets certification as a urologist. Other specific requirements depend on the association that supervises each hospital. Except for a few hospitals, surgical skills are not usually evaluated. Neither practical exams nor simulation exercises are implemented. Despite the fact that all hospitals are regulated by one of the abovementioned associations, hospitals do not have similar infrastructures, volume of surgical procedures or patient numbers. Hence, a resident’s training experience is not even and relies much on the hospital that was chosen and on personal motivation.

In my opinion, a single national urology residency programme, including a national board exam with unified symmetrical criteria to evaluate residents before certification would be a great tool towards achieving a more balanced urology education, nationwide. Another option is to follow the French or Australian systems in which residency programmes

consist of semestral rotations in different hospitals. In this way, residents can take the best from each institution. In a survey performed in 2013 by Coelho R., Longo E. et al, 93% of 64 residents from 19 institutions would prefer a unique national residency programme and 95% opted for rotations in different hospitals.

Similar to a pilot’s checklists which is done before a flight, evaluating a resident’s surgical skills before actual operation on real patients is necessary.

Adopting an electronic portfolio (like Medbook which is used in many European countries) in which surgeries are recorded with subsequent trainers’ evaluations, using 3D printed models to simulate open surgeries or virtual reality devices and pelvic trainers for laparoscopic surgeries are examples of methods that could be implemented to properly perform an evaluation. Several Simulation Centers for laparoscopic surgery are also being planned to fill the gap, but it will take some years until they expand throughout the whole country.

Appendix:

LOCATION REQUIREMENTS TO APPLY

PUBLIC HOSPITALS SMALL AND MAIN CITIES MULTIPLE CHOICE EXAM

LENGTH SUPPORT MAIN PRACTICES DEDICATION

LESS BUDGET OPEN SURGERIES PART-TIME**

PRIVATE HOSPITALS ONLY IN MAIN CITIES MULTIPLE CHOICE EXAM* +INTERVIEW + CV 4-5 YEARS MORE TECHNOLOGY MINIMALLY INVASIVE PROCEDURES FULL-TIME

In Argentina, there are two organisations that officially Table 1: Differences between public and private hospitals in Argentina certify medical doctors as urologists: the Sociedad * Each private hospital has a different multiple choice exam Argentina de Urología and the Federación Argentina de ** At noon, residents leave hospital and often assist staff urologists in their private practice

Using Social Media in healthcare campaigns The #urologyweek experience

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Dr. Juan Gómez Rivas ESRU Chairman Elect RAEU Chairman YUO Board Member ESUT-YAU Associate Member Madrid (ES) @JGomezRivas Co-author: Jarka Bloemberg The ability to access and disseminate information through Social Media (SoMe) is changing societal activities. Within the health branch, there is potential for interaction to enable individuals to interact with others who have similar concerns about health risks or in areas where health care is wanted.

Urology Week is a campaign of the European Association of Urology (EAU) which aims to raise

awareness regarding the importance of urological care and its relation to patients’ quality of life. We aimed to access the impact of SoMe on urology healthcare campaigns using the #urologyweek experience.

We accessed the data with the official hashtag “#urologyweek”, which was created and registered for the campaign, on the website Symplur, used to measure activity on Twitter. The official days of this event from 2015-2017 were taken into account. The following measurements were collected: number of participants, number of tweets, tweets per participant, tweets per hour and impressions. We also analysed data on Thunderclap, a ‘crowd speaking’ online platform used to amplify the campaign in 2017 and the official webpage (www.urologyweek.org).

The total number of participants during the threeyear period analysed was 937, increasing from 74 in 2015 to 614 in 2017. Participants included urological associations, patients associations, urology and other healthcare influencers, pharmaceutical industries, journals, and others. Total number of tweets was

2,016, going from 195 to 1,126 from years 2015 to 2017.

The “impressions” is a measure of the impact and scope of the campaign and rose from 401,105 to 3,232,000. The tweets per hour and tweets per participants remained stable during the study period.

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January/February 2018

#uro

EAU Update on Bladder Cancer

8-9 June 2018 Munich, Germany

EAU onco-urology series

Early fee registration deadline: 8 March 2018

BCa18: Shifting landscape prompts new approaches EAU Update on Bladder Cancer offers strategic insights for optimal management With new genetic research, drug development and fresh insights in immunology, rapid changes are unfolding in the diagnosis and management of urothelial tumours, a tall challenge that prompts onco-urological specialists to adjust their approach for new and optimal management strategies.

To address this challenge and offer an educational event that critically looks into various and novel ways of diagnosis and treatment, the EAU Update on Bladder Cancer presents a unique two-day update meeting on 8 and 9 June in Munich, Germany.

“We are witnessing many novel developments in diagnosis and treatment that impacts on current guidelines and practices. How do we optimize our management within the context of current standards while keeping in mind the possibilities offered by new medical therapies? How does systemic treatment impact on more radical options such as surgery? Balancing these pathways and making a timely, insightful decision is a challenge,” says Prof.

Hein van Poppel, member of the Steering Committee together with Profs. Francesco Montorsi and Manfred Wirth.

“There are new opportunities in both locally advanced and metastatic disease. Identifying these potential drug therapies and taking them into careful consideration for the right patient (after careful selection) and at the right time can help improve

quality of life or even impact survival prospects,” said Montorsi. He said the European Association of Urology (EAU) and the European Society for Medical Oncology (ESMO) has collaborated to pool their expertise and resources for an expert-led update. Recent trials have made inroads in bladder cancer outcomes realized through immuno-oncology approaches. “There is, therefore, the urgent need to further deploy multidisciplinary care not only in muscle-invasive bladder cancer but also in non-muscle invasive bladder cancer,” noted Van Poppel.

A compact and fully interactive meeting, BCa18 goes straight into the core topics and treatment dilemmas of metastatic and high-risk bladder disease. It will explore and identify key issues with Day 1 divided into two parts. The first session “High risk non-muscle invasive bladder cancer: From guidelines to future approaches” will go through EAU and ESMO Guidelines on non-muscle invasive bladder cancer (NMIBC), and pinpoint the gaps between guideline recommendations and actual clinical practice. Surgical and systemic approaches in muscle invasive and advanced bladder cancer, meanwhile, will be the focus of the second session.

A fully interactive case discussion segment will link the two sessions with participants breaking out into three groups for a more detailed, one-on-one discussions with the expert faculty. Aside from questions posed by participants, direct voting regarding treatment decisions will enable both faculty and participants to identify insights on best practices, multidisciplinary considerations and drug sequencing, which help refine clinical practice. To-the-point commentary and evidence-based medicine will characterize the active exchange between the expert panel and participants.

Forward-looking management strategies Day 2 will look into forward-looking treatment options and clinical opportunities with the first session taking up “What is new in bladder cancer classification and treatment?” and the second examining postoperative management of surgical patients. As in Day 1, and following three update lectures, the breakout groups will go into detailed discussions.

Each faculty group will consists of two experts examining topics such as indications and patient selection in palliative cystectomy, management of metastatic bladder cancer, and dealing with histological variants in bladder cancer.

Post-operative management issues will examine enhanced recovery after radical cystectomy (ERAS) and immunonutrition in bladder cancer patients. In the case discussions, issues up for discussion are optimising peri- and post-operative management and managing complications in radical cystectomy, and selection and optimal treatment in bladder sparing for muscle invasive bladder cancer (MIBC).

Organisers are aware of the need for cancer specialists from various disciplines to update and refine their practices in the wake of new or anticipated outcomes.

“Ongoing trials are coming up with fresh insights and how to employ or integrate new knowledge and translate them into bedside practice for effective patient management are the main goals of this update meeting,” said Van Poppel, as he added that it is a unique opportunity for two frontline medical organizations to harness the expertise of their members.

For registration information and programme overview, visit the meeting website at: www.bca18.org

ESUT18-IEA Early registration deadline: 1 March 2018

6th Meeting of the EAU Sectionof Uro-Technology in conjunction with the Italian Endourology Association (IEA) 24-26 May 2018, Modena, Italy

Live Surgery

Come to Modena and see live surgery from across the globe The EAU Section of Uro-Technology (ESUT) is set to host its sixth meeting in Modena, Italy this coming spring, together with the Italian Endourological Association (IEA). On May 24-26, 2018 delegates can expect a complete update on the technology that (endo-)urologists will be using in the coming years in the treatment of their patients.

ESUT Chairman Prof. Liatsikos emphasized the wide-ranging nature of the scientific programme, as well as the great diversity in its most important component: the live surgery sessions. Rather than inviting the surgeons to perform their surgery Prof. E. Liatsikos in Modena or in nearby cities, live Chairman-elect surgery will be broadcast from places as far away from the audience as South Korea, China, India and Brazil.

Topics “We are preparing to give delegates a technological update on the entire spectrum of endourology,” Prof. Liatsikos summarized. “Treatment of upper and lower urinary tract stones, laparoscopic and robotassisted procedures like radical prostatectomies, nephrectomies and cystectomies.”

“We have updated the programme from our last meeting (ESUT16 in Athens) to reflect and showcase

the latest developments and technical breakthroughs.

We’ve seen improvements in scopes and imaging techniques, as well as new manufacturers entering the market. ESUT18-IEA is a platform for all of Europe’s endourologists to get acquainted with the latest technology, and we offer some of the world’s best surgeons to demonstrate technique as much as technology.”

Collaboration with the IEA ESUT18-IEA is a collaborative meeting, the first of its kind for the Uro-Technology Section. “One of the core aims of ESUT is to establish good relations with all of Europe’s endourologic societies. By joining forces in this way, we provide members of other (national) societies with the access to international colleagues, companies and crucially, technologies.”

“We’ve not formally worked with the IEA before, but some of them are also our members. We’ve been in close contact in the organization of this meeting, and this marks our first official collaboration.” The collaboration will be expressed in the scientific

programme by featuring many Italian presenters and a large local audience, all taking part in the Englishlanguage programme.

Innovations in Live Surgery Live surgery is an integral part of the scientific programme, taking place on all three days across six sessions. Some of these sessions feature as many as three live procedures. Pre-recorded case presentations, edited to ten minutes each will be interspersed throughout the live programme to keep the level of education (and interaction) high for the audience.

Liatsikos: “Our live surgery is coming from across the globe, including stone surgery from India, robotic procedures from South Korea and laparoscopic procedures from China and Brazil. Uniquely, this will give participants insights into how surgery is performed at these institutions, by surgeons in their native environment.”

This marks a change from the more usual approach for live surgery, where ‘guest surgeons’ are flown in to perform at local surgical theatres in the vicinity of the congress venue, often with local surgical teams.

This international dimension to the live surgery will give extra flavor and new insights for the delegates at ESUT18-IEA.

For registration information and programme overview, visit the meeting website at: www.esut18.org

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www.baltic18.org

www.eulisursworkshop.org

EULIS-URS Workshop

BALTIC18

10-12 May 2018, Madrid, Spain La Paz University Hospital, Urology Department

5th Baltic Meeting in conjunction with the EAU 25-26 May 2018, Riga, Latvia An application has been made to the EACCME® for CME accreditation of this event

Call for Abstracts Deadline 1 April 2018

www.erus18.org

ERUS18 15th Meeting of the EAU Robotic Urology Section

2nd EAU Update on Prostate Cancer

Optimising clinical pathways with robotic surgery

14 -15 September 2018 Milan, Italy

5-7 September 2018, Marseille, France

www.pca18.org

In conjunction with: Junior ERUS-YAU Meeting European School of Urology (ESU) Courses ESU/ERUS Hands-on Training in Robotic Surgery

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www.esur18.org

www.cem18.org

ESUR18

CEM18

25th Meeting of the EAU Section of Urological Research

EAU 18th Central European Meeting (CEM) in conjunction with the national congress of the Romanian Association of Urology

4-6 October 2018, Athens, Greece

11-12 October 2018, Cluj Napoca, Romania An application has been made to the EACCME® for CME accreditation of this event

www.esui18.org

www.eulis19.org

ESUI18

EULIS19

7th Meeting of the EAU Section of Urological Imaging

5th Meeting of the EAU Section of Urolithiasis

8 November 2018 Amsterdam, The Netherlands

Fall 2019, Milan, Italy

In conjunction with the 10th European Multidisciplinary Congress on Urological Cancers

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

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

Getting it right: Indications for modern urological imaging

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Focus gives you...

Insight

With high-quality, high-impact primary research articles

Research through a new lens 32

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January/February 2018

Abstract submission deadline 1 July 2018 8-11 November 2018 Amsterdam, The Netherlands

Implementing multidisciplinary strategies in genito-urinary cancers 10th European Multidisciplinary Congress on Urological Cancers In conjunction with the • 7th Meeting of the EAU Section of Urological Imaging (ESUI) • EAU Prostate Cancer Consensus meeting on Active Surveillance (EPCCAS) • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) • European School of Urology (ESU) • EAU Young Academic Urologists Meeting (YAU)

www.emuc18.org January/February 2018

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ERUS-EAUN Robotics Meeting Refreshing insights from a comprehensive programme Simon John Borg Practice Nurse, Urology Mater Dei Hospital (MT) Head of Technology and Health Planning Technoline (MT) s.borg@eaun.org Robotic surgery is, by far, one of the best and most advanced examples of combined competencies, forged together in theatre and moving forward as an effective team. It has pushed the boundaries of what was thought to be the known limit, just over a decade or so ago, to new heights and more is yet to come. Theatre nurses are intrinsic members of any effective robotic surgery team, thus their training and contribution to robotic surgery best practice, should not be underestimated.

As soon as ERUS— many months before the set date for the Bruges event— invited EAUN to put together a nursing meeting, work started immediately. No stone was left unturned by Linda Söderkvist (roboticexperienced nurse and EAUN Board Member) and Jane Petersson (RNFA, Denmark) who worked very hard to invite excellent speakers to address a wide range of salient topics. Also noteworthy was the undivided support from ERUS especially from Prof.

Mottrie and Dr. Van Der Poel, who were instrumental for the success of the event.

Dezita Taylor (UK) gave an interesting presentation about human factors, and the importance of team training and efficiency in the OR Around 100 nurses attended the robotic nurses' programme in Bruges

Jane Petersson and Hilde Cammu (OR Nurse, Belgium) gave the welcome remarks and a quick outline of the programme, followed by my presentation, “Introduction to EAUN – now more than ever”. I highlighted the importance of coming together, getting organised, and moving forward in a concurred pathway to build upon what has been achieved. The EAUN is an ideal and well-placed platform from where all involved can contribute to a better harmonised evidence-based educational pathway.

Dezita Taylor (Lecturer in OR practice, Birmingham City University) quickly followed with her presentation titled “Human Factors in Robotic Surgery, team training and OR efficiency,” which was a welcoming, nononsense wake-up call on robotic surgery from a nursing point of view. She aptly took the audience through what, from a nursing perspective, can and will go wrong when one ventures into robotic surgery without the necessary training and coherent team build-up. Robotics is not something that one mentions on a Friday and wheel in theatre a DaVinci on a Monday. This has happened in the past, possibly still does with not so pleasant outcomes. Most of what she outlined must have rang home with many in the audience and yes, we are not alone in some predicaments, and yet there are solutions out there.

system and competence build-up, both clinical and academic. She also advocated the need for a structured and EU-wide defined robotic nursing training, not an easy task but an achievable one at that.

On a similar note but from a different take, was Jane Petersson’s presentation titled “Training and education to become RNFA”. Again, the need for a clear and structured robotic nursing training regime was covered extensively in this presentation with an outline of her work towards achieving it. The importance of a structured and mentored “hands-on approach” was well-described with practical examples of what has been achieved in her practice.

Around 100 nurses attended the robotic nurses' programme in Bruges

After a quick coffee break, again it was Dezita Taylor’s turn for another easy-to-relate to, eye-opening presentation, titled “Avoiding complications in Robotic Surgery”. This time round, she focused on standard operating procedures applicable to avoiding complications. Simple measures yet so effective, based on a rich experience build-up and careful analytic approach on what went wrong, why and control measures to avoid it.

The next presentation by Veronica Ramirez (OR nurse, MSc. Karolinska University Hospital Sweden) focused on a very specific yet very important topiccomplication avoidance. Her presentation titled “Position-related extremity symptoms after roboticassisted laparoscopic cystectomy” was built upon her evidence-based study focusing on this subject. With far reaching complications, if not well prepared for, she took us into an evidence-based approach, built upon data collected on the subject. The choice for the correct type of consumable system, plus patient positioning needs are part and parcel of what is required for the desired intervention outcome, thus avoiding long-lasting painful complications.

Insightful presentations The day progressed with presentations from a non-nursing background, starting off with a two-part presentation by Prof. Erdem Canda (Ankara University Hospital, Turkey). Session one was titled “Port placement for robotic assisted radical prostatectomy & radical cystectomy; know your anatomy and how to avoid external and internal conflicts”. It was well presented, making constant references to actual complications and how to best avoid them by proper assessment and well-placed entry ports. The second part, was as interesting and well presented as the first, this time titled “Managing rectal injuries during robotic assisted surgery; what to do when things go wrong”. Again, this was backed up by extensive visual and pictorial references of situations one wouldn’t like to encounter, but inevitably will in the course of such interventions and how to rectify the situation.

For the first and only time during this day, we had a very valid presentation from a “non-surgical” point of view. It was Dr. Geert Vandenbroucke (OLV Hospital, Belgium) who gave us a valuable insight on what theatre nurses seem to take for granted, with his presentation titled “Anaesthesia for patients undergoing robotic surgery – what all OR nurses and RNFA’s should know”. This presentation clearly underlined the fact that there are less visible aspects of robotic surgery but of which all team members must know due to their severity and implication to our patients.

Luc Bols (Intuitive) demonstrates new Xi features

HOT training in small groups at the venue in Bruges

Another presentation followed that also focused on complication awareness and problem-solving.

Dr. Victor Corona Montes (Mexico City, Mexico) discussed “Complications during robotic assisted urology surgery. What to do when something goes wrong” which followed the same high-level presentation seen during the day. Experienced clinical complications were well presented, with situations that any experienced robotic surgery team may be exposed to but will quickly react to if well trained. The need for a thorough drill regime for such situations was an important take home message to all present that day.

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discussed “How to ensure patient ethics and patient safety during Live Surgery – what are the EAU standards”. We were invited to look into the ethics of live surgery broadcast with a burning question – “Are we being educated or entertained?”. For the first time for many in the audience, the procedure to follow for an ethically conducted live surgery, was well covered and aptly explained.

After the lunch break, the afternoon session kicked off with Dr. Markus Aly (Karolinska University Hospital, Sweden) and his presentation “Radical prostatectomy: Which patients do we meet in the OR/ Latest research on the topic of PSA and diagnosing with fusion biopsies, factors deciding whether the patients will undergo surgery or have optional treatment. Handling postoperative complications”. The title actually says it all and it took the theatre nursing community into areas that they seldom are involved in, but nevertheless, need to understand and appreciate.

It gave the audience an insight on what is the current and accepted norm and what may the next steps be as deciding factors for best treatment options.

Up next was Dr. Rafael Sanchez-Salas (Institute Mutualiste Montsouris, France) with “Bladder Cancer: Diagnosis and treatment. Factors deciding ilieal conduit or neobladder. Challenging case. Quality of life after surgery”. This was also an interesting presentation, excellently described and well presented with interesting insights going beyond that to which robotic surgery nurses would be directly involved in.

After a quick coffee break, Dr. Frederiek d’Hondt and OR Nurse Hilde Cammu (OLV hospital Belgium)

Challenging cases Last but not least Mr. Ben Challacombe (Guy’s Hospital, UK) presented his “Kidney cancer: Diagnosis and Treatment. Focus on partial nephrectomy, challenging cases and surgical case”. This last presentation was also evidently well received by the audience, with well-placed visual references to difficult situations, what was done to overcome them and practical advice.

This year’s ERUS-EAUN Robotic Nursing meeting had also a hands-on side to it. Again, with support of Prof.

Mottrie, we had something special to offer to our nursing participants – a visit to ORSI Institute. We all hear about it but few of us ever get the opportunity to visit. Due to the large request, we were divided into groups. Half of the visit was dedicated to an introduction on difference between consumables used in the latest DaVinci models as opposed to the older generation with special reference to the de-docking technique. The second part was downstairs with the actual DaVinci systems where we had the opportunity to try out what we had been briefed on before. The newest hardware instalment from DaVinci was more intuitive, with respect to many aspects of the previous machine, and also offers more options and ease of user interface.

Another well received hands on session was from STAN Institute, again not possible without ERUS support. It covered the importance of communication skills that basically mimic those used in aviation between control towers and aviators. Simulation experience was also a great eye opener on how difficult it is to control such hardware. This becomes very evident in situations where one team member has a 3D view of the work area yet needs to interact with the rest who are looking at a 2D image without the benefit of depth perception.

One excellent presentation was followed by another one, this time from Kate Furbur (Specialist OR Nurse, American Hospital of Paris). Her presentation, “Standardizing a European curriculum for nurses working with robotic surgery, a reality or a utopia?” was an apt subject to follow the previous one. Kate build her argument on better robotic nursing training based on her personal journey on the subject.

Starting off some years back, from a less ideal situation where little training was available, she described her experience and pathway to a structured European Association of Urology Nurses

26-27 September 2017 Bruges, Belgium

Harold Omana (UK) demonstrates OR instruments at the ORSI Academy in Melle (BE)

From the post meeting feedback received, we can say that all the hard work paid back in dividends in the way of high-quality take-home new knowledge and greater appreciation of what it takes to be efficient, safe and competent in this ever-demanding sphere of high-end urology surgery.

January/February 2018

3rd ESUN Course ”Bladder Cancer in Depth” Amsterdam hosts comprehensive course on Bladder Cancer care Bente Thoft Jensen, RN, PhD Chair, EAUN Bladder Cancer SIG Group Aarhus (DK)

benjense@ skejby.rm.dk Organised by the European School of Urology Nursing (ESUN) and the EAUN’s Bladder Cancer SIG Group, the 3rd ESUN Course “Bladder Cancer in Depth” was held in Amsterdam, The Netherlands, from October 27 to 28 last year.

Educational grants from sponsors involved in the treatment and care for bladder cancer patients made it possible for the first time to invite 50 urological nurses from around the world to participate in this spectacular ESUN event. Like in previous courses, the

After sharing experiences and local challenges, each group works on a plan to implement the knowledge gained European Association of Urology Nurses

The programme covered the following sections: • Module 1: Principles of treatment of non-muscle invasive bladder cancer - K. Hendricksen, Amsterdam (NL) • Module 2: Principles of treatment of muscle-invasive and metastatic bladder cancer - R.P. Meijer, Utrecht (NL) • Module 3a: Neoadjuvant chemotherapy and chemoradiotherapy - R.P. Meijer, Utrecht (NL) • Module 3b: Immunotherapy - H. Pappot, Copenhagen (DK) • Module 4: Intravesical therapy - Moderator: S. Vahr Lauridsen, Copenhagen (DK) • Patient safety issues - K. Chatterton, London (GB) • Nurse safety issues - W.M. De Blok, Utrecht (NL) • Everything you always wanted to know about BC but did not have the opportunity to ask • Module 5: Patient’s perspective and unmet needs in bladder cancer - C. Paterson, Dundee (GB) • Module 6: Group work Part 1: Connect with nurses from your country and prepare questions • Module 7: Adherence to treatment - H. Pappot, Copenhagen (DK) • Module 8: Clinical health promotion in relation to bladder cancer - B.T. Jensen, Aarhus (DK) & S. Vahr Lauridsen, Copenhagen (DK) • Module 9: Nursing role from haematuria to cancer - K. Chatterton, London (GB) • Module 10: Group work Part 2: Discuss items to teach back home, create a programme with teacher, make a financial plan, present the plan

only requirement to apply for an ESUN course is to motivate your application.

quality improvement and how to approach implementation aspects at their local hospitals.

Despite growing public awareness, bladder cancer care is still an area in urological nursing which deserves attention through education and knowledge of the actual growing body of evidence. The core of bladder cancer care is complex and requests from members and congress attendees during recent years inspired us to offer the “Bladder Cancer in Depth” course. A multi-professional faculty provided the attendees with excellent presentations on the basics and recent evidence in bladder cancer care.

This dynamic part of the course was very interesting for the organisers and will be an integral part in future ESUN courses. The best project design was awarded

The faculty prioritised interactive sessions to provide attendees the chance to network, share experiences and explore the possibilities of upgrading the quality of care in their own institutions. The round-table discussions were intense and each group (based on geographical area) provided concrete suggestions for

Discussing how to upgrade the quality of care back home

The organisers, Willem De Blok, Bente Thoft Jensen and Susanne Vahr pose before the course

with a small prize. It was difficult to pick the very best work or proposal but the Irish group came up with a short and realistic project that convinced the organisers of the potential for immediate implementation and benefit for the patient. We look forward to the report from the Irish group! Also noteworthy was the synergistic effect of seeing dedicated and enthusiastic nurses in a roundtable discussion, examining best care and challenging their own practice.

The learning outcome of the course and the projects for improving standard of care was impressive, and was only made possible with the contributions of the interactive participants and highly motivated speakers. Thank you to all attendees and speakers who chose to spend a weekend with us. We hope to repeat the success next year.

Ideas for future ESUN courses from members are welcome and please note that ESUN courses are accredited with 8 points by Accreditatiebureau Verpleegkundig Specialisten Register (Accrediting agency of the Specialist Nurses Register in The Netherlands) and the Accreditatiebureau Kwaliteitsregister V&VN Register Zorgprofessionals (also in the Netherlands).

EAUN-EUSC Workshop on ERAS protocols after cystectomy Nurses share practical insights on ERAS protocols Susanne Vahr, RN, PhD Chair Elect EAUN University Hospital of Copenhagen Rigshospitalet Copenhagen (DK) susanne.vahr.lauridsen@ regionh.dk

This year the 6th Emirates International Urological Conference (EUSC) in Abu Dhabi in November 2017 was held in in conjunction with the World Congress on Videourology & Advances in Clinical Urology. It was the third time that the EAUN had the pleasure to participate in the conference with a nurses’ workshop.

The conference was attended by about 800 participants with the nurses’ workshop attracting 50 nurses.

Knowing that more than 60% of the patients undergoing radical cystectomy experience complications, the surgical stress response is a problem. ERAS protocols aim to minimize the physiologic and psychological stress effects during and after surgery.

During the last decade there is a growing awareness regarding the importance of nursing interventions in ERAS. Thus, the workshop aimed to present the rationale of ERAS protocols, as well as the key principles for involving the patient in lifestyle changes and self-care. Looking at nursing interventions, information and assessment of the patient are the most important factors, preoperatively. At preadmission the first risk assessment should be made already in the out-patient clinic and include nutrition, physical activity, smoking, alcohol and education on how lifestyle habits influence surgical outcome.

The lectures also presented the EAUN recommendations for urostomy and neobladder management as well as the principles of surgical wound care. Pre-operative stoma education has

Radical cystectomy is a complex procedure involving lymphadenectomy, cystectomy and harvesting bowel tissues to use in a urinary diversion. More than 60% of the patients undergoing radical cystectomy experience at least one complication within the first three months post-operatively and following Enhanced Recovery After Surgery (ERAS) protocols might improve postoperative outcomes. In 1997 the first paper from Henrik Kehlet described the impact of the surgical stress response to organ dysfunction and how the stress response could be minimised. The surgical stress response is induced by surgery and is a complex response with an increase in catabolic hormones and a reduction in anabolic hormones, hyper-metabolism and altered carbohydrate and protein homeostasis. All these responses enhance the risk of complications.

European Association of Urology Nurses

January/February 2018

Demonstration of how to assess the patient using the Urostomy Education Scale

been shown to significantly reduce “delayed discharge” due to better patient self-care. One of the sessions in the workshop introduced the Urostomy Education Scale which is a validated and evidence-based tool to document patients' level of stoma self-care skills.

As shown in this photo there was a great interest on how to assess the patient using the Urostomy Education Scale. The introduction to the materials used during the workshop such as catheters and urostomy bags was done by Coloplast and Wellspect HealthCare representatives.

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 Introduction to the catheter material

European Urology Today

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EAUN18: Hub for urology nurses participation International meeting to spur on more cooperation The growing involvement of nurses is the focal point of the upcoming 19th International Meeting of the European Association of Urology Nurses (EAUN18) in Copenhagen, Denmark. “EAUN18 is THE congress of urology nurses. It is fully dedicated to them. And I see it as an annual ‘family meeting’ as we belong to one big family of urology nurses,” said Ms. Corinne Tillier, Chair of the Scientific Programme Committee.

Registration is open online until 26 February 2018 Registration in Copenhagen opens 13 March 2018

New updates Since the previous EAUN Congress, the scientific committee has delivered significant changes with an extra focus on the urology nurses’ practice and concerns, and to increase interaction during sessions.

The international meeting will also continue to address and fulfil the current and future needs of urology nurses and patients. “Our goals as nurses include optimisation of our daily clinical practice; further enhancement of our knowledge and skills through new evidence-based practice; and prioritisation of patients’ needs. For example with the sessions on “Men’s health” and the ESU course on “Immunotherapy” EAUN18 would help us accomplish that,” stated Tillier.

“At EAUN18 in March, participants can look forward to more innovative sessions, new developments in treatment and technologies. They can still enjoy the congress staples such as the popular and wellattended sessions of the Guidelines, difficult cases, and poster sessions,” stated Ms. Tillier.

Urgent and controversial issues Two of the most notable sessions at EAUN18 are “Thematic Session 9: Complementary or alternative medicine in urology”, and “Specialty Session 3: Creating OUR Nursing Urology Curriculum – at the ‘no fairy-tale café”.

She added, “We have listened to the nurses’ suggestions regarding themes and sessions. The national societies were very helpful, too. Based on their feedback, we have included two Thematic Sessions from the special interest groups (SIG): SIG continence and SIG bladder cancer. They selected the “Management of chronic bladder problems” and “The evolution and management of BCG” as the theme of their sessions. This way, we can satisfy what they have hoped to see at an international nurses’ meeting.”

Nurses see an increased use of Complementary or alternative medicine (CAM) among their patients.

“About 75% of cancer patients don’t inform their doctors about their CAM use but can talk openly to us nurses about it. CAM use could have serious consequences as some herbal remedies or vitamins interact with certain medications. This is exactly why we need to address the CAM use and acquire more information to deal with the issue.”

Core objectives EAUN18 encourages nurses to actively participate.

“Regardless of which country we come from, we can learn a lot from each other,” said Ms. Tillier. “Through

in conjunction with

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an exchange of ideas and examination of current programmes and practices at EAUN18, we can merge the best of what we know and this will benefit everyone in the end.”

EAUN Scientific Congress Office Member and lecturer, Mr. Jerome Marley, said that currently there is no existing curriculum for nurses that can provide structure to meet their future needs. He equates the needed curriculum to a map that “highlights the

Stefano Terzoni, Chair EAUN

Corinne Tillier, Chair SCO

key content for urology nursing that can be used by individual countries to guide local education; enhance the role of urology nurses; and fulfil the specific needs of each country.”

He mentioned four key questions to deliberate whether the creation of such a curriculum is necessary and why or why not; delivery of the curriculum in a way that it is applicable and fitting to various practices in different countries; if collaboration is necessary and if so, who should collaborate; and how should the finalised curriculum be used. Based on these questions the views of the delegates will be heard and noted, since the development of the curriculum, a cooperation of the EAUN, BAUN, the Ulster University, and individual urology nurses, needs to be supported by the whole European urology nursing community.

Interested to know more about EAUN18?

Please visit the official website at www.eaun18.org for more information on its Scientific Programme, industry sessions, the must-attend courses organised by the European School of Urology, and much more.

Join us in Copenhagen!

www.eaun18.org January/February 2018