European Urology Today October/December 2017 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology

4-5

Vol. 29 No.5 - October/December 2017

EAU18 Preview

EMUC17 in Barcelona

PCa17 Update Meeting

A glimpse of what's to come in Copenhagen

New therapies: A test to MDT goals?

Addressing gaps in clinical practice

Prof. A. Stenzl

EU politicians agree to improve Europe-wide PCa care A patient-centred, multi-professional approach with equal access for all European men is essential By Jarka Bloemberg

(EORTC), posed the question if prevention of PCa is a utopia. “There is no magic pill, because we have been “We all share a common goal: for Europeans to remain naive in the development of PCa trials. Researchers as healthy as possible for as long as possible.” That is should therefore put more energy in identifying men how EU Commissioner for Health and Food Safety, Mr. at high risk as many genes are involved in PCa.” He Vytenis Andriukaitis, started his speech during the also mentioned that the evidence for dietary changes European Prostate cancer Awareness Day (EPAD) 2017 is weak. However, the evidence of the role of exercise at the European Parliament on September 27th. is increasing. “We should have a system in place to “Better understanding and knowledge of health risks get men moving. In the European Union we currently and how to manage them are crucial. Preventing and lack a clear mechanism to actually make the controlling prostate cancer, and cancer more generally, changes”, Tombal concluded. is of key concern to the European Commission”, the Commissioner continued.

and early diagnosis are essential to prevent mortality rates rising at the same rate as incidence rates.”

In his speech he underlined the importance of raising awareness to keep a healthy lifestyle, but also to further investigate the opportunities of personalised healthcare as is recommended in the Prostate Cancer White Paper. Commissioner Andriukaitis invited all participants to share this valuable resource with the EU Health Policy Platform to ensure that it reaches all stakeholders.

“It’s not only about money”, said Tit Albreht, chair of the Joint Action Against Cancer (CanCon). More and more data is showing that the anxiety with PCa patients is a permanent reality. According to Ian Banks of the European Men’s Health Forum most men just want to go back to work after treatment. “Treatment just involves a small part of the patient’s journey”, added Lawrence Drudge-Coates of the European Association of Urology Nurses (EAUN). According to all speakers there is a great role for the non-medical professional (trained nurse or psychologist), who is closer to the patient. “Nurses are identified as pivotal role in holistic care, not just medical but also physical and psychological. We should no longer talk about a multidisciplinary team, but about a multi-professional one.”

“How can we accelerate innovation in healthcare systems?” asked Denis Horgan of the European Alliance of Personalised Medicine (EAPM). Political involvement and commitment are key in technological advancement. Traditional approaches are limited in identifying a patient at an early stage of his disease.

Next steps: standardize, investigate, personalise and big data The variation between European countries makes it difficult to standardize care. “Prostate Cancer has guidelines for clinicians in 14 different countries, but for general practitioners this is far less”, said Albreht. “We must allow the patient to be informed and address inequalities in nurses and their level of education. By standardising at EU level and by extending PCa guidelines for after care as well, we can together fine-tune these guidelines for the next Joint Action which will include prostate cancer.”

MEP Peterle added: “When the terrorists attacked Brussels last year, we were shocked to realize that even police or intelligence structures don’t share data on criminals. Patients don’t have unified cancer registries amongst Europe, some don’t even have them on a national level. The EAU and Europa Uomo are not alone in addressing these issues. You can count on us.”

Together with Europa Uomo and the European Cancer Patient Coalition (ECPC), the European Association of Urology (EAU) organised this day to discuss the recommendations of the White Paper on how to lower the risks and improve the management and care of prostate cancer, which was launched in January earlier this year. Policy makers, scientific experts, clinicians, nursing staff and patients with an interest in prostate cancer came together to contribute jointly to improve prostate cancer care in Europe. The event was chaired by two MEPs, Mrs. Marian Harkin and Mr. Alojz Peterle, both very committed to the joint mission. Mr. Peterle, a former PCa patient himself, said it all starts with awareness. Mrs. Harkin complemented him by addressing the misconception on the disease. “Prostate Cancer is not always “an old-man’s disease” and it can threaten the lives of younger men as well. Early detection is crucial and awareness campaigns at EU and national level should make men alert to take symptoms seriously.” Join forces in raising awareness The representatives of the two patient organisations, Mr. Francesco de Lorenzo of ECPC and Mr. Ken Mastris of Europa Uomo, addressed the necessity to collaborate. Mastris: “Patients alone cannot achieve this mission. We have to work together.” De Lorenzo added: “Together with the EAU and Europa Uomo we are an alliance to talk in one voice. However, the European Commission (EC) should and could do more. They should help us to create the same level of awareness as they did for breast cancer.” Mastris said that the awareness campaign should take into account the local level in raising awareness. Adjusting campaigns to language and different cultures increases the impact significantly. Also Prof. Chris Chapple, Secretary General of the EAU, stressed the need to collaborate more. “We have the expertise to advise the European Parliament and we look forward to working together to make things happen. The six recommendations of the White Paper on Prostate Cancer are the starting point for the road map to lower the risks and mortality rate of the most frequent cancer in men.” Prevention of PCa Prof. Bertrand Tombal, President of the European Organisation for Research and Treatment of Cancer

October/December 2017

Mr. V. Andriukaitis, EU Commissioner for Health and Food Safety, responds to the White Paper

According to Mrs. Lydia Makaroff, director of ECPC, patients are co-creators of their own health. “Civil society can lead promotional campaigns. Patients can support wide dissemination and advocate prevention programmes as ambassadors, but patient organisations should be sitting at the table with politicians to discuss what patients really need. By speaking in one voice, we will raise the voice of people living with prostate cancer.” To screen or not to screen? “Prostate cancer kills, so it should be screened. However, no country has a structure in place to do so”, Prof. Nicolas Mottet, chair of the Prostate Cancer Panel of the EAU Guidelines, stated. “The problem is that if we do systematic screening, a vast majority of the positive results might be insignificant PCa, but still the general principle is that an early diagnosis is more readily treatable than late diagnosis.” An important recommendation in the EAU Guidelines for urologists is that the benefits and drawbacks of early diagnosis should be discussed with a patient before an approach is decided upon. Former patient Paul Enders said that early diagnosis is a warning. If it’s positive, the decision has to be made together with the patient. A better differentiation between low and high risk prostate cancers is crucial in preventing overtreatment. The reliability of biopsy results should also be improved. Recent developments in using MRI help to better detect and characterize the tumour. Prof. Jochen Walz stated that in the future we might be able to achieve targeted treatment with less healthy tissue lost. There is a downside; MRI is costly, from 300 to 1000 euros depending on where the patient lives. “We need to invest in a proper infrastructure with qualified and experienced urologists throughout Europe”, said Walz. Equal access to care And that last part is another challenge. The countries that are most affected by PCa-related deaths, have fewer resources. “Higher income countries have a higher incidence, but their facilities increase survival rates,” said Dr. Vitaly Smelov of the International Agency for Research on Cancer (iARC) and the World Health Organization. “The incidence rate of low to middle income countries will increase further due to population growth. Education on preventive matters

Treatment: costs & psychology Luckily treatment options are expanding, but so are the costs. What are the current costs of local treatment? Prof. Dominik Berthold presented a case where the total costs of prostate cancer treatment over a period of 18 years resulted in over €300,000. He strongly recommended intensifying research into widening the spectrum of therapeutic options, but Health Technology Assessments (HTA) should be performed on all new technologies.

“Nurses are identified as pivotal role in holistic care, not just medical but also physical and psychological. We should no longer talk about a multidisciplinary team, but about a multi-professional one.” There are many opportunities for research funding, explains Mr. Jan Willem van de Loo of DG Research and Innovation (EC). “We have had 83 research projects to advance healthcare with a total budget of

€128 million. For prostate cancer there are several possibilities. The White Paper is a clear document with recommendations for innovative technologies and personalised health care, but it is complex. We need more research, but we will bring together funding from different member states for this.”

According to James N’Dow, chairman of the EAU Guidelines Office, big data can be a solution. “Imagine all experiences with the disease and all of our outcomes are centrally stored and accessible for all. Imagine the new insight we would gain! However, the current structure is so inefficient that we cannot share data. What are we protecting each other from? Our most important innovations can save lives, but we have to be willing to share it.”

“Money is not always the differentiator”, Peterle continued. “We are still lacking political will to do more together.” Prof. Hein Van Poppel, co-organiser of the EPAD on behalf of the EAU, emphasized that all parties present need support from the European Parliament, the European Commission, but most importantly from patients. “They need to voice their concerns and knock on the doors of urologists. The White Paper is the basis for this discussion, but this should also have some outcome.” Van Poppel concluded: “It all starts with awareness to prevent prostate cancer, but we as urologists want to be heard in new Joint Actions when it comes to screening as well. All parties present are willing to work with the EU to improve care in a patient-centred, multi-professional approach with equal access for all European men. Urologists and urology patients hope to be invited, so together we can save lives.”

www.eau18.org

European Urology Today

The EULIS Urolithiasis Training Curriculum FIGURES

Figure 1 – The Urolithiasis updated training curriculum outline among surgeons Standardising urolithiasis education toEULIS ensure skills http://uroweb.org/section/eulis/education-training/ Mr. Kamran Ahmed MRC Centre for Transplantation King’s College London Guy’s and St. Thomas’ NHS Foundation Trust London (GB) kamran.ahmed@ kcl.ac.uk

Prof. Dr. Kemal Sarıca Dept. of Urology Dr. Lütfi Kırdar Kartal Research and Training Hospital Istanbul (TR) saricakemal@ gmail.com Co-author: Mr. Abdullatif Aydın, London United Kingdom On behalf of the EULIS, ESU, EUREP and ESUT Educational Working Groups EULIS Educational Working Group: Domenico Veneziano, Ben Van Cleynenbreugel, Ali Serdar Gözen, Bhaskar Kumar Somani, Andreas Skolarikos, Christian Seitz, Sven Lahme, Nicola Macchione, Francesca Kum, Thomas Knoll, Juan Palou Redorta, M Shamim Khan, Prokar Dasgupta, Evangelos Liatsikos Advances in technology have resulted in minimally invasive surgery becoming the mainstay of treatment of urological disease. However, steeper learning curves in these procedures, limited training time and increasing patient expectations have created challenges in urological training.

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

European Urology Today

E-LEARNING PROCEDURAL RELATED KNOWLEDGE Modules on EAU website Completion required to advance to hands on training courses

HANDS-ON TRAINING URS / PCNL TECHNICAL SKILLS and NON-TECHNICAL SKILLS Modular training system: basic, intermediate and advanced steps Simulator model guided by classification

BASI

INTERMEDIATE

ADVANCED

BASIC SKILLS Instrument assembly, navigation, guide wire insertion, access sheath placement, basic cystoscopy and ureteroscopy VR and bench models

INTERVENTIONS Laser fragmentation, ballistics use, stone basketing, stent insertion

PROCEDURES Full procedures, handling and preventing complications, complex cases Integration of nontechnical skills +cadaveric simulation

FELLOWSHIP PERIOD SKILLS PROGRESSION and PROFESSIONAL DEVELOPMENT Supervised modular training in the operating room

CERTIFICATION Assessed video footage of trainee performance

Figure 1: The EULIS Urolithiasis training curriculum outline. http://uroweb.org/section/eulis/education-training/

Similarly, the next steps in training involve the development of EST step 2a and 2b, which are dedicated to stone fragmentation in ureteroscopy and PCNL, respectively.

the necessary skills to contribute to patient safety and The newly and recently launched ESU Non-technical wellbeing. Skills for Urological Surgeons is also a recommended With influence from the aviation and military industries, course in the curriculum for residents in urolithiasis to References supplementary training in the simulation laboratory 1. Ahmed K, Patel S, Aydin A, et al. European Association of develop essential skills for the operating room. has been suggested to enhance performance in the Urology Section of Urolithiasis (EULIS) Consensus Simulation training modules will be followed by operating room. Due to its closed-cavity nature, Statement on Simulation, Training, and Assessment in accredited cadaveric and/or wet-lab training modules endourology has been particularly suited to simulation as well as fellowships in accredited centres. Each Urolithiasis. Eur Urol Focus. 2017 Mar 31. [Epub ahead of training and an overwhelming number of simulators print] phase of the modules requires successful completion have been produced in recent years, particularly for 2. Veneziano D, Ahmed K, Van Cleynenbreugel B, et al. before moving to the next component. urolithiasis. However, recent developments in surgical Development methodology of the novel Endoscopic stone education suggest that strengths and weaknesses of treatment step 1 (EST s1) training/assessment curriculum. The EULIS Educational Group is also a major models should be identified and adopted within a J Endourol. 2017 Jul 10. [Epub ahead of print] collaborator of the SIMULATE randomised controlled curriculum, which may be much more effective for trial – the first international multicentre training. Furthermore, emphasis must also be placed study assessing the transferability of on non-technical skills training. simulation-based training to operating room performance and patient outcomes The EAU Section of Urolithiasis (EULIS) Educational (Figure 3). A European educational Working group, formed in 2015, has been working programme was held in Salzburg in July hard to develop and validate a standardised training 2016, which trained 13 residents in curriculum for urolithiasis, in association with the ureteroscopy under the umbrella of European School of Urology (ESU), EAU Section of EULIS, with many centres in Europe Uro-Technology (ESUT) and European Urology participating. Residents Education Programme (EUREP). Our group, composed of stones specialists and educationalists Much effort and research has gone into started off with a road map in Vienna in February the current curriculum development 2016. Since then, opinion surveys were circulated process in the hope of standardizing amongst EULIS specialist members to attain the urolithiasis education whereby we can standards of an ideal training curriculum and several ensure to raise and prepare the next meetings were held (n=6) to reach a consensus Figure 2: Working group and simulation evaluation generation of stone surgeons that have curriculum outline (Figure 1). As a result, the developed guidelines have been published1 and, with great collaborative work and support from the ESU, we have successfully launched the first e-learning module in urolithiasis, pertaining to ureteroscopy, which forms the initial step in training. Simulator assessment sessions were held at Guy’s Hospital, London (Figure 2), to test the range of models available for the simulation component of the curriculum. With collaboration from ESUT and EUREP, the first simulation module, the Endoscopic Stone Treatment step 1 (EST s1), was developed2 and launched. It has since been delivered as a hands-on training course during EUREP 2017, and then in the EULIS17 meeting. Participants are required to complete and pass this module before moving on to the next module of training. Developing follow-up modules Our work continues as we develop the next phase of the EULIS Urolithiasis training pathway. The team is currently preparing the next e-learning module, which will be focused on percutaneous renal surgery. EAU Section of Urolithiasis (EULIS)

Figure 3: The SIMULATE study outline and collaborating regions (Project leads: Prokar Dasgupta, Kamran Ahmed, M Shamim Khan; Coordinator & PhD candidate – Abdullatif Aydin abdullatif.aydin@kcl.ac.uk)

October/December 2017

Update from the Guidelines Office Autumn Edition 2017 Recent publications from Guidelines Panels We are very pleased to announce that several papers from Guidelines Panels have recently been accepted and will be published by European Urology in the next few months: • Oncological Outcomes of Laparoscopic Nephroureterectomy Versus Open Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: An European Association of Urology Guidelines Systematic Review (J.L. DominguezEscrig and B. Peyronnet)

• Prognostic Performance and Reproducibility of the 1973 and 2004/2016 World Health Organization Grading Classification Systems in Non–muscleinvasive Bladder Cancer: A European Association of Urology Non-muscle Invasive Bladder Cancer Guidelines Panel Systematic Review (V. Soukup) Guidelines Office Meetings Update September and October is always a busy time for all the Guideline Panels as they work to finalise their guidelines texts in advance of the deadline.

• Updated Guidelines for Metastatic Hormonesensitive Prostate Cancer: Abiraterone Acetate Combined with Castration Is Another Standard (N. Mottet) • Potential Benefit of Lymph Node Dissection During Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the European Association of Urology Guidelines Panel on Non-muscle-invasive Bladder Chronic Pelvic Pain Meeting in London Cancer (B. Peyronnet) September and October saw meetings by the panels on Male Infertility in Amsterdam, Male LUTS in Munich, Urological Trauma in Marseille, Urinary Incontinence in Florence, Chronic Pelvic Pain in London, Urolithiasis in Vienna, RCC in Copenhagen, Urinary Infections in Amsterdam, Prostate Cancer in Amsterdam and Renal Transplantation in Lisbon. By the end of the year a meeting of the MIBC panel will also have taken place in Barcelona.

Chairmen's Meeting in Budapest

presentation was given by Dr. Sara MacLennan and Mr. Phil Cornford on patient engagement plans, putting forward for discussion ways in which Guidelines Panels could involve patients in guideline development. As always, the meeting served as an opportunity for the Panel Chairs to ask questions of the Board and discuss plans for their Panels over the upcoming years.

EU politicians agree to improve Europe-wide PCa care . . . . . . . . . . . . . . . . . . 1

Dissemination on Social Media The Guidelines Panels have been using Twitter to disseminate their Guidelines in <140 character format using the hashtag #eauguidelines for almost three years now. The success of the initiative can be shown by the fact that now 5% of all the guideline-related traffic is generated by social media amounting to an additional 35,000 visitors to our webpages.

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

The most popular tweet this year with 8,942 impressions was from the NMIBC Panel:

The EULIS Urolithiasis Training Curriculum. . . 2 Update from the Guidelines Office . . . . . . . . . 3 EAU Patient Information. . . . . . . . . . . . . . . . . 3 ESUT: European Urology Forum 2017 . . . . . . . 6 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11 Ten Questions: Xavier Tillou. . . . . . . . . . . . . 12 Keeping antibiotics working is everyone's responsibility. . . . . . . . . . . . . . . . . . . . . . . . 12 EAU Research Foundation explores further collaboration . . . . . . . . . . . . . . . . . . 13 NIMBUS trial expands to other countries . . . 13 EMUC17: New therapies reinforce multidisciplinary goals. . . . . . . . . . . . . . . . . 14 ESUI17 assesses new technologies and limited resources. . . . . . . . . . . . . . . . . . 15 European Prostate Cancer Centres of Excellence. . . . . . . . . . . . . . . . . . . . . . . . . 15

And the following, after having appeared online earlier in the year, were recently published in the November 2017 print edition of European Urology: • What are the Benefits and Harms of Ureteroscopy Compared with Shock-wave Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review

Guidelines Office

The Dissemination Committee, led by Prof. Dr. Maria Ribal, are excited about the continuing progress this project has made and have a number of plans for expanding the presence of the EAU Guidelines on The Guidelines Panel Chairs met with the Guidelines social media, including the development of two Office Board in October, in Budapest. This highly infographics per Guideline Panel and greater use of productive meeting, chaired by Prof. Dr. James N’Dow, Instagram and Facebook. The group are also looking served as an opportunity to discuss Guidelines activities at developing the use of video clips to promote the for 2019 and beyond. Amongst other things, a activities of the Guidelines Panels. Urolithiasis Panel Meeting in Vienna

Providing unbiased facts amid diverse sources can be a challenge

t.bach@asklepios.com Most patients have the tendency to search online information about their diseases or surgical procedures. This has resulted in the increase of so-called “unbiased” patient information, which is ironically often provided by interest groups. EAU Patient information (PI) aims to change that by providing patients with impartial and reliable information. PI continues to render information from the EAU Guidelines into patient-centred language. It is a growing programme of the EAU and the only source of patient information that is evidence-based. PI offers easy-to-read text, animated videos on certain procedures, and translations in 18 languages to guarantee clarity and comprehension. Research on PI Understandability is the most important factor of high-quality patient information; a factor evaluated by the team of Dr. Patrick Betschart and Dr. Valentin Zumstein of Kantonsspital St.Gallen on the readability of PI’s web-based patient education material (PEM). October/December 2017

They analysed each topic from the PI website (patients.uroweb.org) in detail using well-established readability tools. In their research paper “Readability assessment of online patient education materials provided by the European Association of Urology 1”, they concluded: “The EAU provides carefully worked out online patient information for 17 urological disorders. Information is available as a basic and a more extensive in-depth version for most of the topics and illustrations and glossaries which contribute to an improved comprehensibility. Compared to similar analyses, EAU-PEM show improved readability. Nevertheless, simplification of readability of certain chapters might be helpful to facilitate better patient understanding.” #patientinformation

CEM17: Regional collaboration leads to gains in urology. . . . . . . . . . . . . . . . . . . . 22 ERUS17: Robotic Section attracts young and experienced. . . . . . . . . . . . . . . . . . . . . . 23

EAU Patient Information Prof. Dr. Thorsten Bach Chairman EAU Patient Information Group Asklepios Klinik Harburg Hamburg (DE)

ESU section: ESU participates in SMA meeting in Belgrade. . . . . . . . . . . . . . . . . . . . . . . . . . 16 Huge attendance at ESU Course in Northern Cyprus. . . . . . . . . . . . . . . . . . . . . . 16 ESU Course Tunis tackles management small renal masses. . . . . . . . . . . . . . . . . . . . 16 European-Basic Laparoscopic Urological Skills (E-BLUS). . . . . . . . . . . . . . . . . . . . . . . 17 ESU visits urologists who can’t always travel to Europe . . . . . . . . . . . . . . . . . . . . . . 19 EUREP17: Designed for optimal knowledge-exchange. . . . . . . . . . . . . . . 20-21

Although the authors identified action points to improve readability in some parts of PI, e.g. complex topics such as “neurourological disorders”, they stated that the improved readability of PI information is superior as compared to recent AUA patient information, and evaluated using well-established scoring systems. EAU Patient Information will continue to provide patients the best possible insight in their disease and the latest developments in evidence-based treatments. Reference 1. Betschart P, et al. Readability assessment of online patient education materials provided by the European Association of Urology. Int Urol Nephrol 2017 Sep 13 p1695.

EULIS17 examines latest advances in urolithiasis. . . . . . . . . . . . . . . . . . . . . . . . 24 PCa17: Update meeting exposes gaps in clinical practice. . . . . . . . . . . . . . . . . . . . . 25 ESFFU: Why do urologists need to master nocturia management?. . . . . . . . . . . . . . . . . 26 A memorable EUSP fellowship. . . . . . . . . . . 27 EBU section: EBU Certification Programmes. . . . . . . . . . . 28 Third term Certification for Urology Department Donauspital. . . . . . . . . . . . . . . . 28 EBU re-certifies Urology Department in Croatia. . . . . . . . . . . . . . . . . . . . . . . . . . . 28 EBU Certified Residency Training Programmes, Sub-Specialty and Host Centres . . . . . . . . . . 29 ELUTS17: Inaugural EAU meeting focuses on LUTS. . . . . . . . . . . . . . . . . . . . . . 31 YUO section: A successful 2nd Spanish Residents Day. . . . GeSRU presents full programme at DGU 2017 Congress. . . . . . . . . . . . . . . . . . . . Get involved in a BURST collaborative study. . YAU: Current status of scrotal varicocele and renal cancer. . . . . . . . . . . . . . . . . . . . . .

32 32 33 33

Urology Week. . . . . . . . . . . . . . . . . . . . . . . . 34 Free time well spent in London during EAU17 . . . . . . . . . . . . . . . . . . . . . . . . 35 ESUT: Temporary implantable nitinol device (TIND) . . . . . . . . . . . . . . . . . . . . . . . . 36 ESUR17 boosts exchange among researchers, urologists. . . . . . . . . . . . . . . . . 37 Obituary John Wickham . . . . . . . . . . . . . . . . 38 EAUN section: European Parliament meeting examines PCa White Paper. . . . . . . . . . . . . . . . . . . . . . 39

European Urology Today

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

Scientific Programme: Balanced, high-quality content From precision medicine to future prospects in urology Organising a five-day congress with a Scientific Programme that addresses the extensive scope of international urology can be daunting. Not for Prof. Arnulf Stenzl, Chair of the EAU Scientific Congress Committee and his team who Prof. Arnulf Stenzl had brainstormed and planned for a seamless series of balanced, high-quality sessions that focus on into the most current -if not controversy-riddentopics in modern urology.

“We have invited international speakers whose research, opinions and expertise are among the best“ “Every year is a challenge since we have to present in five days not only a broad range of topics we also have to make sure that we examine the most pertinent issues. We have invited international speakers whose research, opinions and expertise are among the best, and to assemble such a group is always a real challenge,” said Stenzl. Compact, but comprehensive With seven Plenary and 19 Thematic Sessions, the core Scientific Programme of EAU18 is a compact but comprehensive update on major urology topics. Emphasis is given on bladder and prostate cancer management with two plenary sessions. Plenary Session 2 is the Nightmare Session on Bladder Cancer Management which follows the format in London where three expert clinicians are crossexamined by a lawyer for possible clinical lapses. On the other hand, prostate cancer management dilemmas will be the focus of Plenary Session 3 with case presentations that delve into oligometastatic disease, genomic screening and imaging-based biopsy, among other issues. Precision Medicine is highlighted on Plenary Session 5 with case presentations and expert lectures that cover prostate and bladder cancer diagnostics. Also on the agenda are Hot Topics & Advances in Andrology (Plenary Session 1), Contemporary Storage LUTS Management (Session 4), Preventing Urological Disease: Future prospects (Plenary Session 6), and Stones for Plenary Session 7 which is held on the last congress day. Thematic Sessions: Highlights “I personally look forward to Semi-Live surgical sessions. Next year we have again the popular semi-live sessions where presenters bring their videos on which they comment on-stage and share insights from their own experience,” Stenzl said. “It’s different because these semi-live sessions focus on the technique itself with live documentation, discussions and live critique. And world-renowned discussants participate by giving their critique on the techniques shown on video.” From the 19 Thematic Sessions, two Semi-Live meetings are in the agenda, namely Thematic Sessions 6 and 14. Thematic Session 6 presents

Semi-Live Surgery Sessions at EAU18 techniques on robotic extended lymph node dissection for prostate and bladder cancer, robotic salvage radical prostatectomy and laparoscopic adrenalectomy. Pelvic Floor Surgery will be shown in Thematic Session 14 with international surgeons demonstrating innovative techniques in recurrent stress urinary incontinence (SUI) such as secondary sling and robotic burch procedures, and artificial sphincter in female patients.

“Semi-live sessions focus on the technique itself with live documentation, discussions and live critique” New to the Thematic Sessions is Transgender Healthcare (Thematic Session 19) which will provide a thorough primer for the urologist with state-of-the-art lectures on psychological evaluation, gender-affirming endocrine treatment, vaginoplasty techniques, penile implants and penile transplantation. “There is a wealth of topics up for discussion and complemented with update lectures in the Thematic Sessions such as the Overview of Fusion-Biopsy Devices (Thematic Session 8), with renowned experts giving state-of-the-art lectures,” added Stenzl. Underactive bladder, bladder cancer in the elderly, testis cancer, developments in imaging, end-stage renal disease and kidney transplantation, paediatric urology, challenges in upper urinary tract, and complicated urinary stone disease, are among the few issues to be covered in the Thematic Sessions. Abstracts review: A difficult task Aside from the challenge of presenting a solid and complete Scientific Programme, Stenzl noted the dedication of abstract reviewers.

“Every year we receive thousands of abstract submissions from all over the world and the numbers are increasing. Our reviewers judge them anonymous and have to make difficult choices and provide the opportunity to the most innovative, interesting and insightful studies. It’s a difficult task and we have to be objective as much as possible,” said Stenzl. With the tough review process the challenge for researchers is to submit their best work. The top-rated studies will be acknowledged by 6 awards in 2 categories, Oncology and Non-Oncology. International, specialised and skills-focused EAU18 also fulfils three main core goals— international, specialised and skills-focused. As in previous congresses, the Urology Beyond Europe Programme is a day-long joint meetings of the EAU together with national and regional associations which probes into shared clinical dilemmas and challenges. From Central Asia, Africa to the Middle East, international urology groups are well-represented in around 12 separate meetings.

“Our reviewers have to make difficult choices and provide the opportunity to the most innovative, interesting and insightful studies” Meanwhile, the EAU Section Meetings are expected to organise 10 meetings that individually examine current issues in various specialties. One of the longest in the programme is the nearly seven-hour Live Surgery session with a series of live procedures transmitted from a local host or expert centre, with the EAU Section of Uro-Technology as lead organiser.

To participants who aim to refine or acquire new surgical skills and education, the European School of Urology (ESU) has organised more than 50 courses, hands-on training courses and related workshops scheduled over three days. With his myriad tasks to mount Europe’s biggest scientific congress in urology, Stenzl said his team has stepped up to the rigors of planning. Asked what he considers the biggest challenge, Stenzl replied. “That would be to get the participation of the best speakers and to find exciting topics. We have to do that a year before and to identify the topics that will be interesting or actual in the years to come and that will define future issues— that’s not easy.”

Important dates Congress days 16-20 March 2018 Exhibition days 17-19 March 2018 Early Fee deadline 15 January 2018 Late Fee deadline 12 February 2018

Check out the programme ove

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rview at

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European Urology Today

October/December 2017

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

Visit Copenhagen during EAU18 A memorable cultural and scientific experience EAU Adjunct Secretary General and proud Dane, Prof. Jens Sønksen (DK), shares his views on Copenhagen as host city to EAU18, what he loves about the Danish capital and Hygge.

Must-see places “Copenhagen may be an old city but it has kept pace with developments through the years,” said Prof. Sønksen. “It’s vibrant and exciting. Copenhagen is a wonderful mix of historic charm coupled with modern convenience and the renowned Scandinavian design.”

Prof. Jens Sønksen

“I look forward to showcasing Denmark to friends and colleagues from around the world. I want to welcome them with open arms and have them enjoy a few days of what we, Danes, enjoy on a daily basis,” said Prof. Sønksen. “Knowledge exchange with colleagues is a central part of any major international medical meeting and Copenhagen has excellent infrastructure and

Tivoli Gardens amenities to host such a monumental event like EAU18. Not a lot of people know that. It’s time for them to discover what Copenhagen can offer,” he stated.

Here are Prof. Sønksen’s highly-recommended places to see: • Tivoli Gardens Tivoli Gardens (also known as Tivoli) is a pleasure garden and the second-oldest operating amusement park in the world. “You can spend an entire day at Tivoli and still not see the park in its entirety.” •

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Amalienborg Palace Amalienborg Palace is home to the Danish Royal Family and a definite must-see! Every day at noon, you can watch the changing of the guards.

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The Little Mermaid Den Lille Havfrue, also known as The Little Mermaid, is one of his favourite stops. “Don’t be disappointed with the size of the statue! It’s beautiful but it’s really small.”

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Kronborg Castle

Kronborg Castle A UNESCO World Heritage Site, Kronborg Castle is Denmark’s most famous castle immortalised by William Shakespeare in his play Hamlet back in the 1600s.

Nyhavn and Strøget “I would have to say that my top recommendations are Nyhavn and Strøget. There are plenty of places for dining, sight-seeing and shopping in these areas.”

The Little Mermaid The happiest people in the world Another good reason to be in Copenhagen is the Danes’ outlook on life. “Surveys show that Denmark generally tops the list as the happiest country in the world. The feeling of Hygge is the reason why. It’s a very Scandinavian concept which depicts the feeling of cosiness, content and happiness,” said Prof. Sønksen. “The Danish people have a way of embracing the concept of Hygge in the midst of daily challenges. We step back and embrace nature, the bond with our families and the company of friends in a way that these things are not only cherished, but savoured. This way, we cultivate the feeling of safety and togetherness with others and the world we live in,“ he concluded.

Could you be the first EAU Guidelines Cup champion? Do you consider yourself an EAU-Guidelines expert? Do you know which recommendations are best for which urological conditions? Dr. Juan Luis Vásquez (DK), Chairman of the European Society of Residents in Urology (ESRU), invites you to show off your skills at the first-ever EAU Guidelines Cup set to take place at EAU18 in Copenhagen, Denmark. What is the EAU Guidelines Cup? “The EAU Guidelines Cup is a new competition intended for residents and young urologists which will determine who knows the EAU Guidelines the best,” said Dr. Vásquez. “There will be a total of three rounds. The first and second preliminary rounds will be online. Leading participants from the first round will qualify for the second round. Then the top three participants from the second round will compete during the live finale on YUORDay18 on 17 March 2018.” How to participate “There are no requirements other than your enthusiasm and your Guidelines know-how,” said Dr. Vásquez. Stay tuned via the EAU’s Twitter account for more information on where to sign up. Let the games begin! During the finale, there will be two parallel competitions. The three finalists will be competing for the title of the Guidelines Cup champion on stage. To answer and score points, they will have to press the red buzzer. Prizes to win The third-place winner will receive full one-year

October/December 2017

access to over 60,000 items of a quality scientific content via UROsource. The prize for second place is the four-volume set of Campbell-Walsh Urology (11th edition). This series features 22 new chapters with an increased focus on robotic surgery and image-guided diagnostics. Easy online access to 130 video clips is also included. “The champion of the EAU Guidelines Cup will have the privilege to choose from a selection of comprehensive masterclasses organised by the European School of Urology (ESU),” said Dr. Vásquez. The masterclasses include the following: • ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction • ESU-ESFFU Masterclass on Female and Functional Reconstructive Urology • ESU-ESUT Masterclass on Lasers in Urology • ESU-ESOU Masterclass on Non-MuscleInvasive Bladder Cancer • ESU-Weill Cornell Masterclass in General urology • ESU-ESUT Masterclass on Urolithiasis The audience will compete anonymously just as it was during a traditional Campbell’s Quiz. Each audience member will have a voting pad. The one with the highest score will win a one-year subscription to UROsource, the largest knowledge base in the field of urology. Dr. Vásquez encourages you to participate, “You could be the first-ever EAU Guidelines Cup champion. Join now and show us what you got!”

Win a masterclass of your choice

About YUORDay18 YUORDay18 comprises of activities tailored to residents’ educational needs. Vital information on surgical tips and tricks, and the role of lymphadenectomy for urological cancers will be offered to the participants. A new feature this year is the “Challenging the EAU Guidelines” session. YUORDay18 is organised by the EAU Young Urologists Office (YUO) and the ESRU.

eau18.org/guidelines_cup

European Urology Today

European Urology Forum 2017 Highlights from the Expert Meeting on diagnosing localised PCa Dr. Iason Kyriazis University of Patras Patras (GR)

jkyriazis@gmail.com

mpMRI and MRI fusion biopsies. In accordance with Table 1: Comparison of main features of different devices for MRI-TRUS-fusion biopsy of the prostate Table 1: Comparison of main features of different devices for MRI-TRUS-fusion biopsy of the prostate AUA guidelines, MRI guided biopsy sampling is insufficient without standard TRUS given the Device Integration of 3D acquisition Technique of Planning of Needle guidance Ultrasound biopsy biopsy multifocal nature of PCa and the low sensitivity of mpMRI especially for low-grade tumours. Mark Koelis Ultrasound integrated 3D scanner with automated Transrectal Virtual biopsy Hand-held Trinity as console (Samsung) movement of piezo-electric optional TRUS-probe Emberton (UK) concluded that in expert hands visually crystal within the probe held directed biopsies are absolutely fine and conventional in position by hand prostate biopsy is still a valid option for prostate Ascendus Ultrasound integrated Longitudinal movement of Transrectal No pre-planning Hand-held cancer diagnosis. as console (Hitachi) TRUS probe by hand TRUS-probe

Promising advantages of novel ultrasound-based technologies Tilmann Loch (DE) reviewed the role of TRUS in the Prof. Jens Rassweiler diagnosis of prostate cancer focusing on innovative University of and new ultrasound-based techniques employing Heidelberg, Medical various novel technologies such as enhanced Clinic Heilbronn grey-scale analysis using neuronal networks Dept. of Urology (C-TRUS), elastography, contrast enhancement and Heilbronn (DE) fusion with other radiology imaging data. Hannes Cash (DE) demonstrated a sensor-based fusion biopsy using a high-end ultrasound platform with integrated jens.rassweiler@ fusion system. Promising advantages of highslk-kliniken.de frequency probes (10-20 MHz) are its high-resolution imaging while limitations are still the operatorCo-Authors: Jochen Walz, Maurizio Brausi, Joan Palou, dependent character of the approach. Evangelos Liatsikos Biomarkers for PCa: Are we ready to use them? The EAU Section of Uro-Technology (ESUT), in Manfred Wirth (DE) addressed the current role of collaboration with the EAU Sections of Oncological biomarkers in prostate cancer diagnosis and Urology (ESOU), Urological Imaging (ESUI) and screening. A wide availability of biomarkers can be Uropathology (ESUP) organised an expert meeting on used for both diagnostic and prognostic purposes. the management of locally confined prostate cancer Given that more than 2,000 genes are differentially (PCa) during the European Urology Forum held early expressed between PCa and BPH tissues, novel long this year in Davos, Switzerland. non-coding RNAs I in the urine have been identified to have high diagnostic specificity and sensitivity. Still, The meeting acknowledged the rapidly growing further documentation of their value is necessary scientific evidence regarding localised PCa and the before it can affect our everyday practice. W. need to understand more about the management Lernhardt (DE) focused on the role of Raman micro options currently available. The highlights of this spectroscopy as an additional tool for prostate biopsy exciting meeting on the diagnosis and management to enhance the diagnostic accuracy by analysing of prostate cancer are summarised in this article. Raman spectra in the stromal tissue adjacent to the prostate cancer. Implication of MRI on PCa detection and staging Alberto Briganti (IT) questioned whether staging of "Based on this, the EAU Section prostate cancer with multi-parametric magnetic resonance imaging (mpMRI) is a real benefit or waste Office and European School of of money. Briganti said MRI staging is the best Urology (ESU) are preparing imaging modality available for local staging but urologists should be aware of the high rate of false dedicated courses on the negative results especially in low volume centres. interpretation of MRI results Whether MRI staging should be recommended to all intermediate and high-risk men is still controversial in especially for urologists..." the literature, and more mature data should be expected in the near future for a definite answer. Choline and PSMA PET in the initial staging of PCa In the same context, Jochen Walz (FR) focused on the Stephano Fanti (IT) reviewed the role of choline and PSMA-PET in the initial staging of PCa. Current limitations of MRI staging: A negative MRI is no literature is characterised by low level of evidence, warrantor for absence of significant prostate cancer which uniformly documents a moderate to high and to make prostate MRI work better we need specificity but a low sensitivity for these techniques in expertise and better standardisation of MRI data assessment. Based on this, the EAU Section Office and the detection of lymph node metastases and, as a result, the approach should be reserved only for European School of Urology (ESU) are preparing dedicated courses on the interpretation of MRI results selective cases. especially for urologists. Role of active surveillance Active Surveillance (AS) has become an important MRI-based prostatic biopsy: Real tool or a tale? strategy in the treatment of patients with prostate Lars BudĂ¤us (DE) described the available technical approaches, which could bring the MRI information to cancer. Jonas Hugosson (SE) questioned whether we know the long-term risks of this strategy. the tip of prostate biopsy needle (Figure 1). It was concluded that cognitive MRI based biopsy is superior According to Hugosson, we still lack studies with to the conventional TRUS biopsy. Whether machine guidance for MRI-fusion biopsy further increases its performance is still a matter of debate. Novel technologies can enhance the applicability of MRI imaging in prostate biopsy and currently more than 10 systems offer solutions for fusion biopsy. The urologists who were involved in the clinical introduction of the different systems presented function and advantages of each of these systems, including Koelis Trinity, Ascendus, BiopSee, Biojet, Artemis, MIM Symphony, and Biobot. Finally, Marcel Fiedler presented a comparison of the devices focusing on equipment (type of console, ultrasound devices, stepper / arm, type of fusion technology, robot- assistance), the mode of biopsy (transrectal, perineal), actuation of biopsy device, and the workflow when using the device. He concluded that actually there is no ideal fusion biopsy system and the choice depends on costs and preferences of the surgeon (Table 1).

European Urology Today

Ultrasound integrated as console (B&K)

Manual linear stepper

Perineal or transrectal

Preplanning of all needles

Biojet

Compatible with all Manual linear stepper devices (using arm and stepper)

Perineal or transrectal

No pre-planning Stationary grid TRUS-probe held by arm

Artemis

Compatible with all devices (using semi-robotic arm)

Manual rotating stepper

Perineal or transrectal

Preplanning of all needles

Semi-robotic arm or hand-held TRUS probe

IS robot (Biobot)

Ultrasound (B&K) separate with robotic arm

Automated linear stepper, Perineal via TRUS probe in plastic sheath two incisions inserted manually

Preplanning of all needles

Robotic guidance pipe

sufficient follow-up data to define the long-term risks of AS. Current practice is not optimal in defining patients suitable for AS and in identifying the timing for switching to active treatment. Many are treated too early and many are treated too late. Caroline Moore (UK) presented data on mpMRI as imaging modality during AS. MRI should be used at baseline to assess suitability for prostate preservation and guide additional targeted biopsies in case of discordance between MRI and TRUS biopsy. MRI should be repeated at different time intervals depending on risk category (presence of lesion on MRI or not) and the PRECISE guidelines should be always used for reporting (respectively PIRAD-score version 2). The ideal follow-up scheme during active surveillance is still a matter of debate and several on-going prospective trials on the subject are expected to reinforce our knowledge in the future. Mark Colombel (FR) summarised current evidence on the subject and concluded that reclassification should be based on biopsies only and time intervals for repeat biopsy can be limited to first one-year evaluation, three and five years. Multi-parametric MRI should be included in the evaluation protocol to exclude the presence of significant prostatic cancer. Target biopsies onto suspected zones and reduce these to limit the number of necessary prostate biopsies during follow-up. Nevertheless, Axel Heidenreich pointed out, when challenging EAU Guidelines, that there are no well-defined criteria to convert from AS to radical therapy.

Stationary grid

future as modern equipment can provide precise treatment planning and real-time monitoring allowing very accurate treatment focus. However, only for vascular-targeted photodynamic therapy (VTP) using TOOKADTM soluble a phase 3-study comparing VTP against active surveillance has been published, demonstrating significant reduction of progression (28% vs. 58%) resulting in less conversions to radical therapy (6% vs. 29%). E. Barret (FR) reviewed current standards of follow-up protocols after focal treatment of prostate cancer. According to the presenter, a multi-criteria evaluation is required including PSA levels, mpMRI imaging, targeted biopsies on the treated zone using MRI-TRUS fusion techniques and validated questionnaires to access functional outcomes. Treatment failure should be defined as the persistence of carcinoma in the treated area based on the targeted post-treatment biopsies.

Current evidence on gold standard radical treatment options The meeting concluded with a critical review of outcomes of the gold standard radical treatment options. Manfred Wirth (DE) defended open retropubic prostatectomy and Evangelos Liatsikos (GR) discussed laparoscopic radical prostatectomy, saying that according to current EAU guidelines these approaches can deliver optimum oncological and functional outcomes to patients. Bernardo Rocco (IT) critically reviewed the outcomes of the literature that fail to clearly document any major superiority for robotic-assisted radical prostatectomy over open approach. He presented data on the long-lasting learning curve of robotic technique that is required to provide optimum functional results to Role of focal therapy the patient. He also presented on-going randomised Jens Rassweiler (DE) and Roman Ganzer (DE) reviewed the results of on-going clinical trials on focal trials on the subject which are expected to provide clearer evidence within the next few years. therapy for prostate cancer including high-intensity ultrasound treatments, vascular-targeted photodynamic therapy, electroporation, brachytherapy Finally, Thomas Wiegel (DE) presented the state-ofand cryo-therapy. Most of these treatments appear to the-art on radiotherapy for prostate cancer. Modern radio-therapeutic equipment using intensity be oncologically effective with great potential in the modulated and image-guided techniques are the new standards which deliver superior oncological outcomes with minimum morbidity to prostate cancer patients.

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Meanwhile, Bob Djavan (AT) questioned whether conventional prostate biopsy has any role in the era of EAU Section of Uro-Technology (ESUT)

BiopSee

www.eu.acme.org Fig. 1: Alternatives of MRI-TRUS-Fusion biopsy of the prostate

October/December 2017

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

Oliver.Hakenberg@ med.uni-rostock.de

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

Case study No. 53 This 25-year-old man was referred by an office urologist because of left flank pain, weight loss of 5 kg over the last two months and night sweats. Ultrasound showed a hydronephrotic left kidney, urinalysis was normal. A CT scan confirmed left hydronephrosis and showed a large retroperitoneal tumour (Figures 1 and 2). Clinical examination and ultrasound of both testes were normal. Serum markers were AFP 44.000 IU/l, β-HCG 10 IU/l, PLAP 480 mU/l and LDH 717 U/l. Bilateral testicular biopsy was normal on the right

side and showed testicular intraepithelial neoplasia on the left side.

Discussion points: 1. What is the likely diagnosis? 2. Are further investigations needed? 3. What treatment is advisable? Three main differential diagnoses need to be considered when a retroperitoneal mass is observed in a young male patient: sarcoma, lymphoma or germ cell tumours. A retroperitoneal mass accompanied by elevated AFP and ß-HCG is pathognomonic for a non-seminomatous germ cell tumour (NSGCT). Probably it is of a primary extragonadal origin as both testes are clinically normal and only a testicular intraepithelial neoplasia is diagnosed in the unnecessary testicular biopsy. Because of the highly elevated AFP of 25.000 IU/l the tumour is classified as a clinical stage III poor prognosis NSGCT following the IGCCCG criteria. The clinical diagnosis based on imaging and blood based tumour markers is absolutely sufficient to treat this patient. Any histological work-up as performed here by testicular biopsy is not required and does only delay potentially curative treatment.

Figure 1

Figure 2

Pre-treatment diagnostics should include either thoraco-abdominal CT scan or MRI. Additionally, tumour markers (AFP, ß-HCG, LDH) before start of treatment should be determined. Regarding the highly elevated AFP levels and the high-tumour burden in this patient, staging should include brain scan and bone scan as well. However, staging examinations must not delay the initial systemic treatment either. In patients suffering from a poor risk clinical stage III NSGCT, treatment of choice is chemotherapy (normally 4 cycles of BEP (bleomycin, etoposide and cisplatin), alternatively four cycles of VIP (etoposide, ifosfamide and cisplatin) in patients with contraindications for bleomycin) followed by resection of tumour residuals. In patients with a high tumour burden (risk of tumour lysis syndrome) or in reduced general condition (e.g. dyspnoea due to lung metastases) induction therapy may be required before start of regular systemic treatment. Regarding the multifaceted problems which may arise during therapy (e.g. inadequate marker decline requiring treatment intensification), these patients should be treated at a centre of expertise. In this individual case, ureteral stenting or percutaneous nephrostomy should be performed prior to systemic therapy to optimize renal function allowing optimal dosing of chemotherapeutic agents.

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

Case Study No. 53 continued The testicular biopsy performed did indeed cause some confusion and as a result of that, a percutaneous biopsy of the retroperitoneal tumour was done. The pathology assessment reported “mostly necrotic tissue of an undifferentiated carcinoma, some cells positive for AFP and PLAP, in view of largely elevated serum AFP this most likely represents a malignant germ cell tumour, most likely embryonal carcinoma and yolk sac tumour”. The patient then underwent four courses of BEP chemotherapy (bleomycin, etoposide and cisplatin) which were reasonably well-tolerated and led to an almost complete marker response (AFP 43 IU/l, β-HCG < 0,1 IU/l). We then undertook post-chemo RPLND with complete tumour resection which necessitated the insertion of an aortic prosthesis and left nephrectomy. The final pathology report was “large and completely necrotic extragonadal germ cell tumour plus 11 interaortocaval lymph nodes without evidence of malignancy, segmental abdominal aorta with mucoid media degeneration, moderate chronic pyelonephritis of the left kidney.” The recovery was uneventful and the patient is alive and recurrence-free five years later.

Figure 1

Figure 2

Discussion points: 1. Are further investigations needed? 2. Is further treatment advisable?

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

It is with great enthusiasm that we officially launch European Urology Oncology as a new sister journal to European Urology and the first official publication of the EAU fully devoted to the study of genitourinary malignancies.

will be peer-reviewed by a panel of experts before being considered for publication. Original articles can be directly submitted to the journal via this link: https://ees.elsevier.com/euonco

Our journal aims to deliver high quality research while pursuing the goal of a multi-disciplinary approach. Urology, Medical Oncology, Radiation Therapy, Imaging, Pathology and Basic Research working together with the same final aim: to improve patient care.

In addition, selected manuscripts initially considered for publication in European Urology will be given the opportunity to be published in European Urology Oncology after completion of a fast and thorough peer-review process.

The journal will include original articles, opinion piece editorials and invited reviews covering clinical, basic and translational research and it will be published six times a year in electronic format. All submitted manuscripts

We sincerely hope you can contribute and help us to make our Journal great! Editor-in-Chief: Alberto Briganti Associate Editors: Laurence Albiges, Gianluca Giannarini, Ashish Kamat and Paul Nguyen.

Introducing the newest member of our family of journals, European Urology Oncology. October/December 2017

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 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. What is the likely diagnosis? 2. Are further investigations needed? 3. What treatment is advisable?

Commentary on: Clinical Challenges – Case No. 53 Comments by Dr. Günter Niegisch Düsseldorf (DE)

Case study No. 54

EUROPEAN UROLOGY ONCOLOGY European Urology Today

Key articles from international medical journals Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

Increasing prevalence of multidrug resistancetuberculosis of the Beijing genotype in Iran and Pakistan The Beijing genotype is a distinct genetic lineage of Mycobacterium tuberculosis, which is distributed worldwide, and may cause large outbreaks of multidrug resistance-tuberculosis (MDR-TB). The distribution of such strains in the Eastern Mediterranean region (EMR) is unclear, and clarifying the data was the purpose of this study, apart from the presence of Beijing TB in Iran. The authors searched published literature from CINAHL Cochrane Library, Current Contents, Database of Abstracts of Reviews of Effects (DARE), ProQuest Google Scholar PubMed, PsycINFO, Thomson Reuters, (SID), and Medical Library (MedLib) to detect relevant studies from the year 2000 to July 2015 with the following keywords: M. tuberculosis, Beijing genotype, EMR, and drug resistance. Random-effect models were used to estimate the proportion of Beijing strains in STATA 14. Heterogeneity was investigated by subgroup analysis and meta-regression.

The Beijing family was most prevalent in Iran and Pakistan and a strong relationship with drug resistance was reported in these countries The meta-prevalence of Beijing strains was 4% (CI 95% = 3–5). The prevalence was different based on types of detection techniques (spoligotyping = 4% vs. other techniques = 6%; p = 0.003). The prevalence increased from 2% before the year 2000 to 4% after year 2000 (p = 0.004). The Beijing family was most prevalent in Iran and Pakistan and a strong relationship with drug resistance was reported in these countries. Additional studies of drug-resistant TB distribution among Beijing strains in EMR countries are needed, as well as a time-trend analysis of the Beijing strain infection in the region.

blaCTX-M genes. Antibiotic susceptibility testing was performed for fosfomycin and other antibiotic comparators. For the isolates considered nonsusceptible to fosfomycin by disk diffusion, the minimum inhibitory concentration (MIC) was determined.

antibiotic to which the infecting pathogen was susceptible or a second-line if a first-line could not be used or (2) patient without UTI: not to prescribe an antibiotic. UTI was defined by typical symptoms and significant growth in a reference urine culture performed at one of two external laboratories.

This study showed that fosfomycin had a numerically higher susceptibility rate than the other antibiotics against the ESBLproducing isolates of the most common Enterobacteriaceae

Secondary outcomes were clinical cure on day five according to a seven-day symptom diary and microbiological cure on day 14. Logistic regression models taking into account clustering within practices were used for analysis.

The susceptibility rate to fosfomycin remained almost steady (90–100%) over a 12-year period, although it fluctuated vis-à-vis ciprofloxacin (0–54%), trimethoprim/sulfamethoxazole (9.1–31.7%), and nitrofurantoin (41.7–100%). Of all the antibiotics tested, fosfomycin was the most active antimicrobial agent (97%) against the ESBL-positive isolates. Fosfomycin maintained higher activity against ESBL-Escherichia coli than against ESBLKlebsiella pneumoniae. Only 11 (3%) isolates were not susceptible to fosfomycin according to disk diffusion and they had MICs greater than 1,024 mg/ ml. All of the fosfomycin-nonsusceptible isolates were positive for the blaCTX-M gene (100%), while five (45.4%) and three (27.3%) of the isolates harbored the blaTEM and blaSHV genes, respectively. This study showed that fosfomycin had a numerically higher susceptibility rate than the other antibiotics against the ESBL-producing isolates of the most common Enterobacteriaceae. Given its low resistance rate and oral administration, fosfomycin may be deemed a promising antibiotic for the treatment of urinary tract infections caused by ESBL-producing Enterobacteriaceae.

Source: The Activity of Fosfomycin Against Extended-Spectrum Beta-Lactamase-Producing Isolates of Enterobacteriaceae Recovered from Urinary Tract Infections: A Single-Center Study Over a Period of 12 Years. Aris Parisa, Boroumand Mohammad Ali, Rahbar Mohammad, and Douraghi Masoumeh. Microbial Drug Resistance. October 2017, ahead of print. https://doi.org/10.1089/mdr.2017.0097

Negative effects of point-ofcare (POC) susceptibility testing on antibiotics prescription for patients with uncomplicated UTI in general practice

Source: Mycobacterium tuberculosis of the Beijing genotype in Iran and the WHO Eastern Mediterranean Region: A meta-analysis. Hoffner The objective of this randomised controlled trial was to investigate the effect of adding point-of-care (POC) Sven, Sahebi Leyla, Ansarin Khalil, Sabour susceptibility testing to POC culture on appropriate Siamak, and Mohajeri Parviz. Microbial Drug Resistance. October 2017, ahead of print. https://doi.org/10.1089/mdr.2017.0160

Study shows effectiveness of fosfomycin against extendedspectrum beta-lactamaseproducing isolates of Enterobacteriaceae Despite global efforts to tackle resistance in extendedspectrum beta-lactamase (ESBL)-producing isolates via old antibiotics, there are limited data on the efficacy of fosfomycin—an old oral antibiotic—against Enterobacteriaceae in the Middle East. The purpose of this study was to evaluate the in vitro activity of fosfomycin against urinary ESBL-producing isolates of Enterobacteriaceae. Between 2004 and 2015, 363 isolates of ESBLproducing Enterobacteriaceae were recovered from high-risk patients suffering from cardiac disorders and were subjected to polymerase chain reaction using specific primers for the blaTEM, blaSHV, and Key articles

use of antibiotics as well as clinical and microbiological cure for patients with suspected uncomplicated urinary tract infection (UTI) in general practice. Included patients were women with suspected uncomplicated UTI, elderly patients above 65, patients with recurrent UTI and patients with diabetes. The sample size calculation predicted 600 patients were needed. Flexicult SSI-Urinary Kit was used for POC culture and susceptibility testing and ID Flexicult was used for POC culture only.

The authors concluded that adding POC susceptibility testing to POC culture did not improve antibiotic prescribing for patients with suspected uncomplicated UTI in general practice The primary outcome was appropriate antibiotic prescribing on the day after consultation defined as either (1) patient with UTI: to prescribe a first-line

Twenty general practices recruited 191 patients for culture and susceptibility testing and 172 for culture only. 63% of the patients had UTI and 12% of these were resistant to the most commonly used antibiotic, pivmecillinam. Patients randomised to culture only received significantly more appropriate treatment (OR: 1.44 (95% CI 1.03 to 1.99), p = 0.03). There was no significant difference in clinical or microbiological cure.

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

Cycling and male sexual and urinary function The aim of this study was to explore the relation between cycling and urinary and sexual function in a large, multinational sample of men.

Cyclists were recruited to complete a survey through Facebook advertisements and outreach to sporting clubs. Swimmers and runners were recruited as a The authors concluded that adding POC susceptibility comparison group. Cyclists were categorised into low and high-intensity cyclists. Participants were queried testing to POC culture did not improve antibiotic prescribing for patients with suspected uncomplicated using validated questionnaires, including the Sexual Health Inventory for Men (SHIM), International UTI in general practice. Susceptibility testing should be reserved for patients at high risk of resistance and Prostate Symptom Score (I-PSS), and National Institute of Health Chronic Prostatitis Symptom Index complications. (NIH-CPSI), in addition to questions about urinary Source: Effect of point-of-care susceptibility tract infections (UTIs), urethral strictures, genital testing in general practice on appropriate numbness, and saddle sores.

prescription of antibiotics for patients with uncomplicated urinary tract infection: a diagnostic randomised controlled trial. Holm A, Cordoba G, Møller Sørensen T, Rem Jessen L, Frimodt-Møller N, Siersma V, Bjerrum L. BMJ Open. 2017 Oct 16; 7(10):e018028

Of 5,488 complete survey responses, 3,932 (72%) were included in this analysis. In a multivariate analysis, swimmers/runners had a lower mean SHIM score compared to low and high-intensity cyclists (19.5 vs. 19.9, p = 0.02 and 20.7, p < 0.001), respectively. No significant differences were found in I-PSS, NIH-CPSI scores, and UTI history.

Outcomes atypical Hemolytic Uremic Syndrome after kidney …cyclists had no worse sexual or transplantation treated with urinary functions than swimmers/ eculizumab runners, but cyclists were more The monoclonal antibody ecolizumab has recently prone to urethral strictures been introduced as a new and effective treatment for the atypical haemolytic uremic syndrome (aHUS). This study assessed the efficacy and safety of eculizumab in a cohort of kidney transplant patients suffering from aHUS.

Effective treatment of renal transplant patients with the monoclonal antibody ecolizumab A series of patients treated with eculizumab after transplantation were assessed and subdivided into those treated therapeutically (aHUS onset after transplantation) and prophylactically (patients with a history of aHUS undergoing kidney transplantation). There were five patients treated therapeutically use and two with prophylactic eculizumab treatment. In the five therapeutic cases, there was improvement of the thrombotic microangiopathy within 48 hours of starting eculizumab and there was no recurrence within an average follow-up of 21 months with continuous eculizumab treatment (minimum of 6 and maximum of 42 months). One patient died at 6 months, due to Aspergillus infection. Of the two cases treated prophylactically, one had relapsing thrombotic microangiopathy after four months while the other remained asymptomatic with 16 months of follow-up (both with continuous treatment). Little is known about the use of eculizumab in transplant patients. This series, although small, showed that the drug is effective with improvement of the microangiopathy parameters. Prophylactic treatment needs to be assessed further as dosing and treatment duration are completely undetermined and the treatment is fairly expensive.

Source: Long-term outcomes of the atypical Hemolytic Uremic Syndrome after kidney transplantation treated with eculizumab as first choice. De Andrade LGM, Contti MM, Nga HS, Bravin AM, Takase HM, Viero RM, da Silva TN, Chagas KN, Palma LMP. PLoS One, 12(11), 2017: e0188155. doi: 10.1371/journal. pone.0188155. eCollection

Cyclists had statistically higher odds of urethral strictures compared to swimmers/runners (Odds Ratio (OR) 2.5, p = 0.042). Standing more than 20% of the time while cycling significantly reduced the odds of genital numbness (OR 0.4, p = 0.006). Adjusting the handlebar higher or even with the saddle had lower odds of genital numbness and saddle sores (OR 0.8, p = 0.005, and OR 0.6, p < 0.001), respectively. The authors concluded that cyclists had no worse sexual or urinary functions than swimmers/runners, but cyclists were more prone to urethral strictures. Increased time standing while cycling, and higher handlebar height were associated with lower odds of genital sores and numbness.

Source: Cycling and male sexual and urinary function: Results from a large, multinational, cross-sectional study. Awad MA, Gaither TW, Murphy GP, Chumnarnsongkhroh T, Metzler I, Sanford T, Sutcliffe S, Eisenberg ML, Carroll PR, Osterberg EC, Breyer BN J Urol. 2017 Oct 12. pii: S0022-5347(17)77722-1. doi: 10.1016/j.juro.2017.10.017

Treatment options and predictive factors for recurrence and cancer-specific mortality in bladder cancer after renal transplantation Bladder cancer (BC) in an immunosuppressed and often comorbid renal transplant population can be a clinical challenge. This study analysed bladder cancer treatment after renal transplant (RT) in a study with multi-centre data collection. The authors collected and retrospectively analysed the data of 88 patients with BC after RT from a total of 10,000 renal transplantations from 10 European centres. Diagnosis of BC occurred at a median of 73 months after RT. 71 patients (81.6%) had non-muscle invasive bladder cancer, 29 (40.8%) received adjuvant treatment

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

tebj@medisin.uio.no (6 BCG, 20 mitomycin). In univariate analysis, patients with BCG had a lower recurrence rate (p < 0.044). On multivariate analysis, switching immunosuppression to an mTOR inhibitor signiﬁcantly reduced the risk of recurrence (HR 0.24, 95% CI: 0.053-0.997, p < 0.05). 26 patients (29.8%) underwent radical cystectomy, none of whom had major complications. Cancerspecific mortality was 13.8%, overall mortality 32.2% with a median follow-up of 126 months.

mTOR inhibitors reduce the recurrence rate in NMIBC in renal transplant patients Treatment of bladder cancer in renal transplant patients follows the same rules as usual. The use of BCG and mTOR inhibitors for immunosuppression are important factors for reducing the recurrence rate of NMIBC in transplant patients.

Source: Treatment options and predictive factors for recurrence and cancer-specific mortality in bladder cancer after renal transplantation: A multi-institutional analysis. Rodriguez Faba O, Palou J, Vila Reyes H, Guirado L, Palazzetti A, Gontero P, Vigués F, Garcia-Olaverri J, Fernández Gómez JM, Olsburg J, Terrone C, Figueiredo A, Burgos J, Lledó E, Breda A. Actas Urol Esp. 2017 pii: S0210-4806(17)30176-6. doi: 10.1016/j.acuro.2017.05.007. [Epub ahead of print]

Sexual dysfunction and enlargement of seminal vesicles in sexually active men treated for BPH with alpha blockers The aim of this study was to evaluate sexual dysfunction and enlargement of seminal vesicles in sexually active male who were treated by α1-blockers for benign prostatic hyperplasia and its possible clinical application. The authors conducted a prospective cohort study from January 2015 to December 2016. They enrolled sexually active men above the age of 40 years having moderate to severe lower urinary tract symptoms. Patients with a history of prostate surgery, suspicious DRE findings, serum PSA > 4 ng/dl, history of medication with anticholinergic /cholinergic /diuretic agents were excluded. Patients were divided into group A, group B and group C based on the prescription of silodosin 8 mg, tamsulosin 0.4 mg or alfuzosin 10 mg orally once for LUTS and followed at four weeks and 12 weeks.

…alpha blockers as silodosin, tamsulosin and alfuzosin are safe and effective tools for improving LUTS and quality of life

A total of 109 potent men were randomised to HBO2T or control. Forty-three (43) men in the air group and 40 in HBO2T completed the 18-month follow-up. No statistically significant differences were observed between the two groups on any outcome measure.

…larger studies involving more diverse comorbidities and different HBO2T regimens are needed to better evaluate the usefulness of HBO2T for PR after radical prostatectomy

October/December 2017

g.ploussard@ gmail.com

recurrence was noted between both arms. Potential factors explaining this significant difference could be the traumatic manipulation of gland during the neuro-vascular dissection in RARP. Urologists performing RARP may also expand indications of This study showed no difference in erectile recovery in nerve preservation due to the vision magnification, men treated with HBO2T versus placebo. The authors exposing patient selected on not stringent criteria to an increased risk of positive margins. Interestingly, in stated that larger studies involving more diverse high-risk cases, this link was inverted with a higher comorbidities and different HBO2T regimens are needed to better evaluate the usefulness of HBO2T for risk of margins in open RP cases suggesting that the tactile feedback was not an oncologic advantage in PR after radical prostatectomy. cases of none organ-confined disease. The main limitations of this study were the lack of ClinicalTrials.gov registration number NCT00906269. randomisation, the absence of integration of Source: A double-blind, randomized trial on the confounding factors (hospital volume, surgeon experience) that could introduce interpretation biases. efficacy and safety of hyperbaric oxygenation

therapy in the preservation of erectile function after radical protastectomy. Chiles KA, Staff I, Johnson-Arbor K, Champagne A, McLaughlin T, Graydon RJ J Urol. 2017 Oct 12. pii: S0022-5347(17)77720-8. doi: 10.1016/j.juro.2017.10.016

Source: Erectile Function and Oncologic Outcomes Following Open Retropubic and Robot-assisted Radical Prostatectomy: Results from the LAParoscopic Prostatectomy Robot Open Trial. Sooriakumaran et al. Eur Urol 2017 doi: 10.1016/j.eururo.2017.08.015.

The mean age was 54.8 years (41- 68 years). At 12 weeks of treatment, silodosin, tamsulosin and alfuzosin had significant improvement in total IPSS and QOL score (p < 0.001). Baseline erectile function score was 26.4, 27.6 and 28.1 and baseline overall satisfaction (IIEF-OS) was 7.1, 8.3 and 8.6 among group A, B and C respectively. After 12 weeks of α1-blockers, IIEF-EF score was 24.0, 24.7 and 26.2 and IIEF-OS was 6.4, 7.8 and 7.9. All three groups demonstrated statistically significant enlargement of seminal vesicles after 12 weeks' treatment, most significant in group A patients (7.65 to 14.11 cc, p < 0.001).

Robotic versus open radical prostatectomy: Results from a Cardiovascular risk under androgen deprivation therapy: large, prospective Swedish Does the type of suppression cohort really matter?

The LAPPRO (LAParoscopic Prostatectomy Robot Open) study is a large, prospective non-randomised trial consisting of a prospective data collection of Swedish patients undergoing a radical prostatectomy Impact of donor and recipient (RP). No randomisation was done but the human cytomegalovirus status characteristics of the public health system in Sweden The authors concluded that alpha blockers as make possible that all patients within a specific on kidney transplantation silodosin, tamsulosin and alfuzosin are safe and geographical area are operated on at one hospital. effective tools for improving LUTS and quality of life. The surgical approach depends on the procedure Loss of seminal emission with α-blockers appears the used in this regional hospital. With this the authors Human cytomegalovirus (CMV) is an important cause of seminal vesicles enlargement. The exact pathogen affecting the outcome of renal argued that randomisation was replaced by place of mechanism of these findings needs further clinical residence and this provided a high validity of this transplantation. Since both recipient and donor may and experimental research. prospective trial. A prior LAPPRO study had reported be CMV positive, CMV reinfection is possible after significantly better erectile function outcomes at 12 transplantation. However, little is known about how CMV transmitted from an infected donor to an infected Source: A prospective study to evaluate sexual months for the robotic approach, but with a tiny dysfunction and enlargement of seminal vesicles absolute difference. recipient modulates the recipient's already in sexually active men treated for benign suppressed immune system. prostatic hyperplasia by alpha blockers. Sokhal Overall, 2,545 patients who underwent radical AK, Sankhwar S, Goel A, Singh K, Kumar M, prostatectomy were followed prospectively from The authors followed 52 kidney transplant recipients Purkait B, Saini DK. September 2008 to November 2011, in 14 centres. Out for up to two years with regular measurements of T, B, and natural killer lymphocytes as well as naïve and Urology. 2017 Aug 28. pii: S0090-4295(17)30887-7. doi: of these 14 centres, seven used robotic assistance and seven open RP. The cohort consisted of 1,792 patients memory T-subsets, CD28 expression, relative telomere 10.1016/j.urology.2017.08.025 who had undergone a RARP and 753 open RP. This length, CMV-specific lymphocytes and serum represented for around half the annual case-load in cytokines. Patients were also monitored for CMV Sweden during the same period. Two-thirds of men viremia and other infections. Efficacy and safety of were pre-operatively potent. Baseline characteristics hyperbaric oxygenation were quite comparable between both groups. A CMV-positive organ donation leads technique was more likely performed therapy in preserving erectile nerve-sparing in RARP cases than open RP (84.0% versus 68.2%), to an exhaustion of the immune regardless of the pre-operative risk group. In the postresponsiveness in organ recipients function after radical operative course, patients in the open RP group used prostatectomy more frequently invasive erectile than RARP patients The most important observation from this study was at all time points. The aim of this study was to evaluate the efficacy and that CMV-specific lymphocytes expand vastly in safety of hyperbaric oxygenation therapy (HBO2T) in CMV-infected recipients with transplants from Urologists performing RARP may the preservation of erectile function (EF) as part of CMV-positive donors compared to recipients with kidneys from CMV-negative donors. Despite this, higher penile rehabilitation (PR) after robot-assisted bilateral also expand indications of nerve nerve sparing radical prostatectomy for prostate rates of CMV viremia were found in infected recipients preservation due to the vision cancer. with organs from CMV-positive donors. Immune deterioration in these patients was expressed as an magnification, exposing patient A prospective, randomised double-blind study was increased number of CD28-negative T-lymphocytes, selected on not stringent criteria to conducted. Men (40-65 years old) who underwent inverted CD4/CD8 index and shortened telomeres, robot-assisted bilateral nerve sparing radical again most marked in CMV-infected recipients an increased risk of positive margins prostatectomy were randomised 1:1 to either the transplanted from CMV-positive donors. The authors conclude that CMV alters the immune system in kidney control or treatment group. Participants were transplant recipients and promotes an exhaustion of the exposed to either air (control) or 100% oxygen Post-operative erectile function recovery was better (treatment) in hyperbaric conditions. The primary immune responsiveness, most markedly in CMVafter RARP in low- and intermediate-risk patients, at outcome was EF at 18 months as measured by the positive recipients with CMV-positive organs. all time points. Conversely, the recovery was higher in International Index of EF (IIEF). Secondary outcomes the open RP group when analysing only high-risk were 12-month urinary symptoms, and 18-month Source: Impact of donor and recipient human prostate cancer patients two years after the surgery. sexual-, urinary-, bowel- and hormonal-related cytomegalovirus status on kidney symptoms as measured by the Expanded Prostate transplantation. Zielinski M, Tarasewicz A, The second endpoint was the surgical margin status. Index Composite-26 (EPIC-26). Adverse events and Zielinska H, Jankowska M, Moszkowska G, In pT2 tumours, the positive surgical margin rate was long-term cancer outcomes were monitored. Primary Debska-Slizien A, Rutkowski B, Trzonkowski P. 7% higher in the RARP compared with the open RP and secondary outcomes for the two groups were Int Immunol. 2017, doi: 10.1093/intimm/dxx062. [Epub group (17% versus 10.2%). In pT3 disease, this rate compared using independent group t-tests, Wilcoxon ahead of print] was 15% higher in open RP cohort (48.1% versus Ranked Sum tests and chi-square tests of proportion. 33.3%). No difference in terms of biochemical Key articles

Dr. Guillaume Ploussard Section editor Toulouse (FR)

Emerging evidence suggests that androgen deprivation therapy (ADT) during prostate cancer treatment is correlated with a higher risk of cardiovascular events (acute myocardial infarction, ischemic stroke), occurring even during the initial course of deprivation. Several publications have suggested that the type of androgen suppression (medical versus surgical castration, GnRH agonist or antagonist) could influence the risk of cardiovascular events under treatment. Bilateral orchiectomy could be at lower risk of cardiovascular events compared with medical androgen deprivation therapy. This difference has been highlighted in a large, retrospective, populationbased analysis from the SEER database of cancer registries. However, contradictory findings have been reported among series and no prospective randomised trial has yet been published to draw any strong conclusion. In the present study, the authors reviewed the data from the Taiwan National Health Insurance Research Database, from 14,715 patients with prostate cancer diagnosed from January 1, 1997, through December 31, 2011. Androgen suppression was obtained by bilateral orchiectomy or GnRH agonist (aGnRH). Interestingly, almost one-quarter of patients underwent surgery with the following distrbution: 3,578 patients treated by bilateral orchiectomy and 11,137 patients under aLHRH. Only patients who underwent bilateral orchiectomy or GnRHa alone were included in this study.

This present study did not close the debate and provide a definitive conclusion Duration of aGnRH exposure was estimated by calculating the total number of one-month-equivalent doses. The duration of ADT exposure was stratified on the basis of the duration of aGnRH use or interval after bilateral orchiectomy with an 18-month cut-off. Cardiovascular death was defined according to the criteria of the Standardized Definitions for End Point Events in Cardiovascular Trials. At baseline, the mean age of the patients was 75.4 years and patients treated with aGnRH were slightly younger. Patients treated with orchiectomy had a lower number of distant metastases. There were no statistically differences between groups after propensity weighting. The rate of oral anti-androgen use was also similar between the two groups

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Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ hotmail.com (approximately 70%). The distribution of castration type changed over time. After 2005, the rate of aGnRH use increased gradually whereas the use of orchiectomy decreased progressively. The risk of cardiovascular ischemic events was similar between the two groups after propensity score weighing and after accounting for all-cause death as the competing risk, during the study period. Nevertheless, cox regression analysis showed that the risk of cardiovascular ischemic events was significantly 1.4-fold higher in the orchiectomy group than in the aGnRH group during the first 18 months of follow-up after ADT initiation. Hazard ratio was 1.40 (95% CI 1.04 to 1.88). The risk was similar between groups after 18 months of follow-up. This risk was predominantly marked in patients > 65 years old, who had hypertension or a previous history of cardiovascular events. The large, contemporary, nationwide study has compared the cardiovascular safety of androgen suppression types. Results showed a higher risk of events in the orchiectomy group and are contradictory with those reported from the SEER database analysis. However, in the present, a Cox regression analysis was used as statistical method (rather than a competing risk model), and population cohorts were more homogeneous, leading to less comparisons biases. Moreover, the rate of patients receiving orchiectomy was substantially higher reinforcing the power of statistical analysis. Unfortunately, the use of LHRH antagonist was not assessed. This present study did not close the debate and provide a definitive conclusion. However, these findings help us to reassure the patient. In this homogenous population-based cohort, the use of aGnRH clearly did not increase the cardiovascular risk compared with bilateral orchiectomy.

23,000 patients undergoing radical nephrectomy during a span of 13 years (2003 – 2015).

centres or in the case of challenging cases where the risk of scope damage may be considered high.

…trends of robotically-assisted radical nephrectomies in United States were reviewed and related costs were compared with the laparoscopic approach

More recently, some German authors have reviewed their cohort of renal stone patients (n = 423) treated with disposable reusable fURS from 2013 to 2016 for diagnostic (24%) or therapeutic (76%) purposes; results and costs, including repairs during the observation period, were compared with the cost of single-use digital fURS -the Lithovue (reported as 1000 Euros).

The first important data is that while robotic radical nephrectomy accounted for only 1.5 % of the cases in 2003, 12 years later it overcome laparoscopic approaches at 27%, with the remaining cases (nearly 46%) treated with open surgery.

In line with data from literature, mean life span of the reusable scopes was 14.4 procedures before repair.

After adjusting statistical analysis for risk factors, no benefits of robotic approach were shown against the laparoscopic one: in particular, operative time and costs were significantly higher with the former, though no difference were found in terms of complications and blood transfusion. The authors argued that increased number of robotic radical nephrectomy could be due to maintaining a sufficient volume of procedures to justify the purchase and maintenance costs of the robotic systems. They have also hypothesised that a larger number of challenging partial robotic nephrectomies could have carried the risk (and rate) of a higher number of converted radical nephrectomy: however, this latter theory is difficult to demonstrate and it may account for a very small number of cases.

Source: Risk of Cardiovascular Ischemic Events After Surgical Castration and GonadotropinJAMA. 2017 Oct 24;318(16):1561-1568. doi: 10.1001/ Releasing Hormone Agonist Therapy for Prostate jama.2017.14586. Cancer: A Nationwide Cohort Study. Dong-Yi Chen, et al. J Clin Oncol 2017 https://doi.org/10.1200/ JCO.2016.71.4204

Robotic surgery? Yes, but not for everything Robotic surgery has replaced open and laparoscopic approaches in several urological procedures: Wherever facilities are available, radical prostatectomy and partial nephrectomy are mostly performed robotically because of the appealing technique to patients, surgeons’ comfort, and advantages in performing significant steps of the procedures with more precision. With health providers more and more concerned about budget restrictions, all new or expensive technologies need evaluation within the context of cost-effectiveness and no longer on surgeons’ preference. The use of robotically-assisted surgery has also been extended to other urological procedures even though no clear advantages have been demonstrated. An example is the case of radical nephrectomy: while for a partial nephrectomy the higher ability provided by the robot to perform a suture of resection bed and renorraphy of parenchyma are clearly facilitated by the assistance of a robot, in a radical nephrectomy, generally, there are no surgical steps where the precision of the machine can make any difference. In a recent paper published in JAMA, trends of robotically-assisted radical nephrectomies in United States were reviewed and related costs were compared with the laparoscopic approach. The authors had full access to the database of a US health provider, capturing 20% of population from 700 hospitals; they reviewed data of more than Key articles

Disposable flexible ureteroscopes: A new tool to reduce or increase costs? Flexible ureteroscopy in the last decade has gained wide popularity across the world for the treatment of upper urinary tract stones. However, cost of the procedures has been a limiting factor regardless significant efforts from manufacturers: for example, the introduction of digital scopes, though increasing the visibility, has not improved durability of the devices. The latter is mostly related to the surgeon’s skills, and the centre’s volume and expertise, including ability in processing the devices. Fragility of instruments has a significant impact in terms of high expenses associated with repairs; moreover, a repaired device may not always perform and last as a new one, increasing the risk of an even more reduced life-span of the refurbished scopes.

Disposable single-use flexible ureteroscopes (fURS) have been introduced in an attempt to reduce costs and keeping optimal scopes conditions for every procedure

philip.cornford@ rlbuht.nhs.uk

Both UCLA Prostate Cancer Index and EPIC-26 Short Form were used over time and common subsets questions were analysed to compare quality of life As expected, most of the damages occurred during evolution during the study period. Of the 341 men complex cases: multiple, large and lower pole stones included, 221 (65%) received radical prostatectomy, 25 (especially with steep pelvic-infundibular angle) were (7.3%) received radiotherapy, and 32 (9.4%) received factors most associated to breaking of the working low-dose brachytherapy. Conservative management channel due to laser misfiring or use of other tools, as by AS or watchful waiting was the initial treatment for well as to breaking of the shaft due to the excessive or 63 men (18%). lengthy torque and bending. According to the cost analysis, their reusable fURS programme accounted for an overall average of 500 Euros per procedure, which was nearly half the cost of a Lithovue scope unit. Interestingly, the authors have noted that if they had used single-use Lithovue’s during the most challenging procedures, they would have saved the equivalent of the cost of 70 procedures with the disposable scope.

Regardless of several limitations of the paper, authors have been able to provide additional evidence that disposable scopes may deserve to become an integrated part of the armamentarium of a highIn an era where costs of health provisions has increased dramatically, costs and sustainability of new volume centre but not a complete substitute. technology need careful analysis; unfortunately, competition among institutions in countries were the Still, single-use fURS programme may be costeffective in the context of low-volume centres because health system is not public may provide distorted messages regarding the benefits of new technologies of the optimal performance of the devices at each procedure, the relatively less dependency on the even though these are not evidence-based. surgeon’s skills and the lack of need for cleaning processes and dedicated personals. These investigations, such as the one published in However, more robust data are required. JAMA, are very important since it can provide an appropriate picture of the real impact of the latest Source: surgical tools for patients and community.

Source: Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015. Jeong IG, Khandwala YS, Kim JH, Han DH, Li S, Wang Y, Chang SL, Chung BI.

Mr. Philip Cornford Section editor Liverpool (GB)

1) The Economic Implications of a Reusable Flexible Digital Ureteroscope: A Cost-Benefit Analysis. Martin CJ, McAdams SB, AbdulMuhsin H, et al.

Interestingly, radical treatments were not significantly associated with long-term adverse impacts on sexual health and urinary bother After a 10-year follow-up and after adjustment for baseline scores and risk factors, patients who chose AS had higher levels of distress and hyper-arousal than patients who received radiotherapy techniques. After adjustment for domain-specific baseline quality of life scores, patients who were treated by active surveillance had better urinary incontinence scores than patients who received radical prostatectomy, and improved bowel bother scores than patients receiving radiotherapy. However, no difference was reported for the remaining six psychological and four heathrelated quality of life domains. Globally, long-term psychological and heath-related quality of life outcomes were similar between the conservative management and active treatment groups. The only significant difference favouring radical treatments was noted in the distress and hyper-arousal levels. Thus, in line with previous studies and systematic reviews, conservative management is not associated with major adverse impacts on psychological well being, as anxiety or depression.

J Urol. 2017 Mar;197(3 Pt 1):730-735.

2) Retrospective cost analysis of a single-center reusable flexible ureterorenoscopy (fURS) program: a comparative cost simulation of disposable fURS as an alternative. Ozimek T, Schneider MH, Hupe MC, Wiessmeyer JR, Cordes J, Chlosta PL, Merseburger AS, Kramer MW. J Endourol. 2017 Oct 26. doi: 10.1089/end.2017.0427. [Epub ahead of print]

Active surveillance in prostate cancer: Long-term impact on quality-of-life Active surveillance entails a strategy by which selected men are managed expectantly with the intention to apply potentially curative treatment in case of progression signs. Several studies have suggested that active surveillance (AS) for low-risk disease provides 10-year cancer-specific survival rates similar to those achieved with curative strategies. One of the goal of AS and watchful waiting is to preserve quality of life by avoiding adverse effects of radical treatments. However, few studies have reported long-term results of quality of life and psychological effects in AS patients. Anxiety has often been highlighted as a major barrier for continuing surveillance. In the present study, the authors used the findings from the Prostate Cancer Care and Outcome Study (PCOS). The PCOS is an Australian population-wide longitudinal cohort study, with a primary objective of evaluating the impact of various treatments on quality of life after the diagnosis of prostate cancer. Overall, 1,874 men were recruited between 2000 and 2002 in New South Wales, and interviewed at baseline and at one, two, three, and five-year after diagnosis.

A former study by Martin et al. showed that reusable fURS were more cost-effective than single-use scopes (LithovueTM) in the context, though, of a high volume centre.

For this prolonged analysis, men were eligible if they had completed a baseline and 10-year follow-up survey and had low-risk localised disease at diagnosis. Finally, 341 patients were included (response rate 59%).

Since then, some authors have suggested a more cost-effective use of disposable fURS in low-volume

Several validated psychological instruments have been assessed as well as quality if life measurements.

Interestingly, radical treatments were not significantly associated with long-term adverse impacts on sexual health and urinary bother. Nevertheless, the small differences observed here could influence the initial therapy choice. So, despite the limitations of this series, these findings may help the physician improve patient counselling and guide treatment decisionmaking.

Source: Long-term Psychological and Qualityof-life Effects of Active Surveillance and Watchful Waiting After Diagnosis of Low-risk Localised Prostate Cancer. Egger et al. Eur Urol 2017, http://dx.doi.org/10.1016/j. eururo.2017.08.013

Renal access for percutaneous nephrolithotomy: Urologists do better Percutaneous nephrolithotomy (PCNL) has been experiencing a new revival in recent years: the introduction of new techniques – such as the supine approach- and of new technologies – for example, micro/ultra-mini/super-mini PCNL- have changed dogmas which have remained unchallenged for many years. One of the last to remain, at least in some countries, was the prerogative of interventional radiologists to carry out the renal access (RA). Especially in the Anglo-Saxon regions, the RA has been traditionally performed by radiologists considering the high volume of nephrostomies these professionals are accustomed to perform in daily practice. However, trends in the rest of the world have been quickly changing in this regard: as reflected in the outcomes from the Clinical Research Office of the Endourological Society (CROES), more than 90% of the 5,803 patients included in CROES database undertook a PCNL with RA performed by urologists.

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A recent paper in United States has investigated the potential effects of RA during PCNL performed by interventional radiologists versus urologists. By using a database from a health provider, authors could analyse outcomes from > 40,000 patients undergoing PCNL from 2003 to 2015 in the US; by using the coding system, they could control patients’ demographics and comorbidities, complications, length of hospital stay (LOS) and direct hospital costs. They found that urologists obtaining the RA on their own accounted for only 17% of the cases; on the other hand, this latter subgroup of patients experienced lower 90-day complication rates (5 vs. 8.3 %; p < 0.001) and lower rate of prolonged (i.e. ≥ 4 days) hospital stay (22.5 vs. 42.1%; p < 0.001). Similar results were confirmed at multivariate analysis for RA performed by urologist was associated with a significant lower rate of complications (OR: 0.70), LOS (OR: 0.67) and hospital costs (OR: 0.65).

RA performed by urologist was associated with a significant lower rate of complications (OR: 0.70), LOS (OR: 0.67) and hospital costs (OR: 0.65) However, study design could not control for confounding factors, such as RA jointly performed by urologists and radiologists in the same session. Moreover, authors did not have access to follow-up data to assess stone-free rates and, consequently, they could not know the amount of extra costs for new admissions and ancillary procedures if no stone-free conditions were achieved. Overall, this study further confirmed the impression that RA performed by urologists can be at least as safe as the access obtained by interventional radiologists, with the advantages for the patients to have the procedure performed in one stage and for the health providers to reduce costs.

Sources 1) The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. de la Rosette J, Assimos D, Desai M, Gutierrez J, Lingeman J, Scarpa R, Tefekli A; CROES PCNL Study Group. J Endourol. 2011 Jan;25(1):11-7.

2) The Effect of Physician Specialty Obtaining Access for Percutaneous Nephrolithotomy on Perioperative Costs and Outcomes. Speed JM, Wang Y, Leow JJ, Bhojani N, Trinh QD, Chang SL, Korets R. J Endourol. 2017 Oct 4. doi: 10.1089/end.2017.0441. [Epub ahead of print].

KEYNOTE-052: Multicentre, phase 2 study First-line cisplatin-based combination chemotherapy improves survival in patients with advanced urothelial cancer. However, more than half of all patients are unable to receive it because of renal dysfunction, or other comorbidities. Carboplatin-based regimes are used as an alternative but are recognised as inferior. Gemcitabine plus carboplatin, the most common drug regimen for cisplatin-ineligible patients, is associated with a nine-month median overall survival and a 21% treatment discontinuation frequency because of toxic effects. Indeed about 50% of patients with advanced urothelial cancer do not receive any chemotherapy because of concerns with toxic effects, underscoring the need for effective and tolerable first-line treatments that can be given broadly in this population Pembrolizumab is an anti-PD-1 antibody with antitumour activity in multiple tumour types and drugs targeting the PD-1 pathway have been effective in the treatment of recurrent advanced urothelial cancer. Indeed, in the phase 3 KEYNOTE-045 trial second-line pembrolizumab improved overall survival compared with chemotherapy in patients with advanced urothelial cancer. This study evaluates the activity of the drug as first-line treatment in patients ineligible for cisplatin-based treatment. 374 patients were enrolled in 91 academic centres across 20 countries. 370 patients received intravenous Key articles

October/December 2017

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pembrolizumab 200 mg every three weeks given until confirmed disease progression or intolerable toxic effects were observed. Cross-sectional imaging initially nine weeks after commencement of the drug and then every six weeks for the first year and every 12 weeks in the second year assessed tumour response.

This data suggests that PD-1 inhibition may have a role in the management of advanced urothelial carcinomas although data on overall survival is still missing The primary endpoint was objective response (the proportion of patients who achieved complete or partial response) in all patients and by PD-L1 expression status according to the RECIST, as assessed by independent central review. PD-L1 expression was assessed in tumour and inflammatory cells from tumour biopsies provided at study entry. Activity and safety were analysed in all patients who received at least one dose of pembrolizumab (all-patients-treated population). 89 (24%, 95% CI 20–29) of 370 patients had a centrally assessed objective response, and as of September 1, 2016 (data cutoff), 74 (83%) of 89 responses were ongoing. Median follow-up was five months (IQR 3·0–8·6). A PD-L1-expression cut-off of 10% was associated with a higher frequency of response to pembrolizumab; 42 (38%, 95% CI 29–48) of 110 patients with a combined positive score of 10% or more had a centrally assessed objective response. The most common grade 3 or 4 treatment-related adverse events were fatigue (eight [2%] of 370 patients), alkaline phosphatase increase (five [1%]), colitis, and muscle weakness (both four [1%]). 36 (10%) of 370 patients had a serious treatment-related adverse event. 17 (5%) of 370 patients died from non-treatment-related adverse events associated with death, and one patient died from treatment-related adverse events (myositis in addition to grade 3 thyroiditis, grade 3 hepatitis, grade 3 pneumonia, and grade 4 myocarditis).

follow-up data. Biopsy Gleason scores were then used to stratify the cohort into the five corresponding GGs, including GG 1 (909 men; 36.2%), GG 2 (813 men; 32.4%), GG 3 (398 men; 15.9%), GG 4 (279 men; 11.1%), and GG 5 (110 men; 4.4%).

with docetaxel alone (5.4 months vs 2.8 months; hazard ratio [HR] 0.389, 95% CI 0.235–0.643; p=0.0002). This study presented the progression-free survival data from a randomized phase 3 trial in a similar population.

Kaplan-Meier estimates were then graphed by GG for each endpoint, including biochemical recurrence BCR, secondary therapy, CRPC, metastatic disease, prostate cancer specific mortality (PCSM), and all-cause mortality (ACM). Differences in progression to the various endpoints were tested using the log-rank test. Cox proportional hazards models were used to test the associations between GG and each outcome. Models were adjusted for clinical covariates. To account for changing of Gleason grading over time and the lack of centralized pathology review and the year of surgery and surgical centre were also included as covariates.

These finding are relevant because ramucirumab is the first-in-class agent to show efficacy in urothelial cancer, although follow-up is short and overall survival data are not yet available

The median follow-up was 60 months (interquartile range, 33-90 months). Higher GG was associated with higher clinical stage, older age, more recent surgery, and surgical centre (p < 0.001) as well as increased biochemical recurrence, secondary therapy, castration-resistant prostate cancer, metastases, and prostate cancer-specific mortality (all p < 0.001). There were no significant interactions with race in predicting measured outcomes. Analysing outcomes from an equal-access health system confirmed the GG classification predicted long-term outcome after radical prostatectomy. This highlights the divergent biologic behaviour within D’Amico “intermediate-risk” disease. In addition it has important clinical implications when counselling men with GG 2 about active surveillance.

A five-tier system was introduced to simplify the risk stratification of patients with prostate cancer in which Gleason score is separated into the following groups ≤ 6, 3+4, 4+3, 8 and 9+. Originally validated using PSA recurrence this paper tested the validity of the groups in predicting multiple long-term oncological endpoints in the Shared Equal Access Research (SEARCH) database, which consists of patients from six Veterans Affairs hospitals in the USA.

Analysing outcomes from an equalaccess health system confirmed the GG classification predicted long-term outcome after radical prostatectomy Data from men who underwent primary radical prostatectomy between 2005 and 2015 were included. From a total of 2,628 cases during the study period, 2,509 were identified who had available biopsy Gleason scores, covariate clinical data, and long-term

Progression-free survival was prolonged significantly in patients allocated ramucirumab plus docetaxel versus placebo plus docetaxel (median 4·07 months [95% CI 2·96–4·47] vs 2·76 months [2·60–2·96]; HR 0·757, 95% CI 0·607–0·943; p = 0·0118). An objective response was achieved by 53 (24·5%, 95% CI 18·8–30·3) of 216 patients allocated ramucirumab and 31 (14·0%, 9·4–18·6) of 221 assigned placebo.

Source: Validation of the 2015 prostate cancer grade groups for predicting long-term oncologic outcomes in a shared equal-access health The most frequently reported treatment emergent system. Schulman AA, Howard LE, Tay KJ, et al. adverse events, regardless of causality, in either Cancer. 2017; 123:4122-9.

New second-line options in metastatic urothelial carcinoma

This data suggests that PD-1 inhibition may have a role Platinum-based combination chemotherapy is in the management of advanced urothelial carcinomas standard front-line treatment for patients with although data on overall survival is still missing. advanced or metastatic urothelial carcinoma. Despite objective responses of 40-70% the duration of Source: First-line pembrolizumab in cisplatinresponse is limited and on-progression prognosis is ineligible patients with locally advanced and poor. Immune-checkpoint inhibitors targeting the unresectable or metastatic urothelial cancer programmed cell death 1 protein (PD-1) and its ligand (KEYNOTE-052): a multicentre, single arm, (PD-1L) appear to have clinical activity in a subset of phase 2 study. Balar AV, Castellano D, O’Donnell patients; however, there is a clear need for other PH et al. targets and treatments. Lancet Oncol. 2017; http://dx.doi.org/10.1016/ S1470Vascular endothelial growth factor receptors (VEGFRs) 2045(17)30616-2 and their ligands are important mediators of tumour angiogenesis and contribute to the pathogenesis and of urothelial carcinoma. Ramucirumab is Prostate Cancer Grade Groups progression an IgG1 monoclonal antibody that binds to the are they predictive? extracellular domain of VEGFR-2, competing with VEGFA, VEGFC, and VEGFD. Although there have been major pathologic revisions since it was first published in the 1970s, Gleason grading remains central to contemporary clinical staging. However, a developing understanding of biological behaviour has led to the development of an updated prognostic grade group (GG).

530 patients who had progressed during or after platinum-based chemotherapy, were randomized (1:1) to receive intravenous docetaxel 75 mg/m2 plus either intravenous ramucirumab 10 mg/kg or matching placebo on day 1 of repeating 21-day cycles, until disease progression. Previous treatment with one immune-checkpoint inhibitor was permitted. The primary endpoint was investigator-assessed progression-free survival, analysed by intention to treat in the first 437 randomised patients. Patients with untreated brain metastasis or thromboembolic event six months before randomization were excluded.

In a randomised phase 2 study in patients with platinum-refractory advanced or metastatic urothelial carcinoma, ramucirumab plus docetaxel significantly improved median progression-free survival compared

treatment group (any grade) were fatigue, alopecia, diarrhea, decreased appetite, and nausea. These events occurred predominantly at grade 1–2 severity. The frequency of grade 3 or worse adverse events was similar for patients allocated ramucirumab and placebo (156 [60%] of 258 vs. 163 [62%] of 265 had an adverse event), with no unexpected toxic effects. Sepsis was the most common adverse event leading to death on treatment (four [2%] vs. none [0%]). One fatal event of neutropenic sepsis was reported in a patient allocated ramucirumab. These finding are relevant because ramucirumab is the first-in-class agent to show efficacy in urothelial cancer, although follow-up is short and overall survival data are not yet available. While we wait for these data, results of the CALGB 90601 trial may be of interest. In that study, bevacizumab is being tested with chemotherapy in first-line treatment for urothelial cancer. Hopefully, in a situation similar to that reported with colorectal cancer, ramucirumab might improve outcomes after previous bevacizumab

Source: Ramucirumab plus docetaxel versus placebo plus docetaxel in patients with locally advanced or metastatic urothelial carcinoma after platinum-based therapy (RANGE): a randomised, double-blind, phase 3 trial. Petrylak DP, de Wit R, Chi KN, et al. Lancet. 2017; http://dx.doi.org/10.1016/S01406736(17)32365-6.

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

European Urology Today

• What do you think is the biggest challenge in urology? That would be patient-tailored or personalised treatment depending on the disease. • If you were not a urologist, what would you be? I planned to be an aircraft engineer but then I had an accident when I was 16 years old, and the doctor who took care of me was so nice that I was inspired to become a surgeon. • What is your most important piece of advice for doctors just starting out? Young doctors have to take the initiative to learn new things. Being independent is important and if they are curious they can learn from the people they meet during the course of their career. Widening their perspective by travelling or further education is also important. • What is the most rewarding aspect of being a doctor? To have the satisfaction that you have done well at the end of the day, and that you have offered cure to the patient and have made the right decisions. • What is your advice to other physicians on how to avoid burnout? I learned to wisely manage my time and spend time with my family. My wife is a surgeon too so it’s important for me to spend time with my family and my daughter, which can reduce the stress from work. • If you could change something in the healthcare system, what would it be? That’s a tough and tricky question, especially the healthcare we have in France now (Pauses). It’s important to have a balance between administrators and medical professionals. The big challenge would be to restore the control of doctors since administrators today have more influence. • What´s the last wonderful book you have read? ‘Dune’ by Frank Herbert, a science fiction novel and an amazing book with a universe that is completely different from ours. Reading it was a great escape. • What’s the last thing that surprised you? I follow social media and there you could see the ugliest and most beautiful traits of humanity at the same time. It surprises me to see beautiful creations such as music, pictures and films. But at the same time there is also ugliness. There is extreme contrast. • What’s your favourite hour in a day and why? End of the day, just before going to bed. I work late and when I come home my wife and daughter are already sleeping and I would give them the last kiss. It makes me glad to know they’re safe and we’re a family. It’s my favourite moment.

TEN QUESTIONS Interview: Joel Vega Photography: Edwin Van Wijk

Age: 40 Specialty: Uro-oncology, Renal transplantation City: Caen (FR) Current Posts: EAU17 Congress, René Küss Prize, Winner of Best Paper on Transplantation Urology; Dept. of Urology and Transplantation, CHU de Caen, France

• What do you most often wish you could say to patients, but didn’t? The conversation one has with a patient is very difficult because if you explain all the potential complications it can be very stressful for them. I try to explain a little but not everything. I wish to tell them everything but you have to be flexible because not all patients are ready to hear the bad news.

XAVIER TILLOU

Keeping antibiotics working is everyone's responsibility Antimicrobial stewardship is crucial to ensure prudent use of antibiotics Dr. Andrea Ammon ECDC Director European Centre for Disease Prevention and Control (ECDC) Solna (SE) eaad@ ecdc.europa.eu For decades, antibiotics have been our primary weapon to treat bacterial infections. Today, we face one of the biggest challenges of our times: we are having difficulties curing infections caused by bacteria, which were once susceptible to the action of antibiotics, because they have become resistant to these medicines. The situation is even more complex, since only few new antibiotics have been discovered and marketed in recent years. The emergence of multidrug-resistant bacteria, as well as of bacteria resistant to last-line antibiotics, is a major problem especially in hospitals and other healthcare settings. European Centre for Disease Prevention and Control (ECDC) data on antibiotic resistance and antibiotic consumption, which are released every year in November, show that antibiotic resistance continues to increase for most bacteria and antibiotics under surveillance. Nevertheless, the progress and success of some European Union (EU) Member States in tackling this problem are encouraging, and are an indication that there is still time to turn the tide of antimicrobial resistance and ensure that antibiotics will remain effective in the future. A point prevalence survey coordinated by ECDC in 2011-2012 showed that, overall, 59% of patients in European urology wards received at least one antimicrobial agent on a given day1. This high 12

European Urology Today

proportion of patients exposed to antimicrobials – one of the highest among all specialties in participating European hospitals – highlights the responsibility of urologists to take a key role in antibiotic stewardship and to implement interventions to reduce unnecessary antibiotic use. In a Dutch urology ward, case audits to reassess antibiotic use after 48 hours reduced antibiotic consumption and length of stay, and also had a positive direct return on investment2,3, thus showing that antibiotic stewardship interventions in urology can be successful and cost-effective.

"A point prevalence survey coordinated by ECDC in 2011-2012 showed that, overall, 59% of patients in European urology wards received at least one antimicrobial agent on a given day 1." Since 2008, the ECDC has coordinated the European Antibiotic Awareness Day (EAAD), a European health initiative. EAAD provides a platform for the development and support of national campaigns in Europe, to raise awareness about antibiotic resistance and advocate a more prudent use of antibiotics. EAAD is marked every year on 18 November, with campaigns and activities undertaken by national governments and professional organisations with an interest in antibiotics and antimicrobial resistance.

pharmacists, nurses as well as veterinarians and farmers, have an additional responsibility to use antibiotics wisely. With the #KeepAntibioticsWorking social media initiative, ECDC is asking policymakers, governmental institutions, professional and patient organisations, as well as health professionals and the general public to show the actions that they are taking to address the problem of antibiotic resistance. Anyone can take part by sharing messages, pictures or videos during the week 13-19 November 2017 on different social media channels, using the hashtag #KeepAntibioticsWorking. Finally, in 2017, the European Commission published EU guidelines for the prudent use of antimicrobials in human medicine and ECDC released evidence-based key messages for professionals in hospitals and other healthcare settings that are available from the EAAD website4. The EU guidelines and the key messages have been translated and are available in all EU official languages. Joint action can lead to concrete results in the fight against antibiotic resistance. ECDC is committed to continue its efforts, together with EU Member States, health professionals and the EU institutions, to keep antibiotics working. For further information please visit: https://antibiotic.ecdc.europa.eu @EAAD_EU

EAAD.EU

van Gemert-Pijnen LE, et al. Automatic day-2 intervention by a multidisciplinary antimicrobial stewardship-team leads to multiple positive effects. Front Microbiol. 2015;6:546. 3. Dik JW, Hendrix R, Friedrich AW, Luttjeboer J, Panday PN, Wilting KR, et al. Cost-minimization model of a multidisciplinary antibiotic stewardship team based on a successful implementation on a urology ward of an academic hospital. PLoS One. 2015;10(5):e0126106. 4. European Commission. Commission notice EU Guidelines for the prudent use of antimicrobials in human health. 2017. http://eur-lex.europa.eu/ legal-content/EN/TXT/?uri=uriserv:OJ.C_. 2017.212.01.0001.01.ENG&toc=OJ:C:2017:212:TOC 5. European Centre for Disease Prevention and Control. European Antibiotic Awareness Day: Key messages for professionals in hospitals and other healthcare settings. 2017. https://antibiotic.ecdc.europa.eu/en/get-informed/ key-messages/key-messages-professionals-hospitalsand-other-healthcare-settings-0

EUROPEAN ANTIBIOTIC AWARENESS DAY A EUROPEAN HEALTH INITIATIVE

EAAD_EU

References This year, ECDC is launching a social media initiative called #KeepAntibioticsWorking, which aims at highlighting that everyone has a role in ensuring that these medicines remain effective. Individuals, as potential users of antibiotics when facing bacterial infections, need to know how to use these medicines prudently. Healthcare professionals such as urologists and other medical doctors,

1. European Centre for Disease Prevention and Control (ECDC). Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals 2011-2012. Stockholm: ECDC, 2013. https://ecdc. europa.eu/sites/portal/files/media/en/publications/ Publications/healthcare-associated-infectionsantimicrobial-use-PPS.pdf 2. Dik JW, Hendrix R, Lo-Ten-Foe JR, Wilting KR, Panday PN,

October/December 2017

EAU Research Foundation explores further collaboration Plugging gaps in the Guidelines, encouraging new research and working with ESUR By Loek Keizer The EAU Research Foundation has had new leadership since EAU17 in London, earlier this year. The existing board members retired to advisory roles within the EAU RF and new members came in under the leadership of Prof. Anders Bjartell, the new chairman. “So far, it’s been going well,” Bjartell begins. “It’s a big challenge but we’ve already had three board meetings since London. The new board members are coming with new initiatives and plans for new registries and prospective studies, particularly in areas of bladder and prostate cancer.” Prof. Bjartell is joined on the board by Dr. Wim Witjes (Arnhem, NL), Dr. Hashim Ahmed (London, GB), Dr. Andrea Necchi (Milan, IT), Prof. Guido Jenster (Rotterdam, NL), Dr. Shahrokh Shariat (Vienna, AT) and Prof. Bart Kiemeney (Nijmegen, NL). Bjartell: “I’m particularly pleased with the composition of the new EAU RF Board. Together, we cover most aspects of urological research, like epidemiology, basic science and different urological malignancies. The board members also have great experience with multi-centre studies. The previous board members now support us with their expertise when we need them.” Identifying knowledge gaps One of the primary tasks that the EAU RF is taking on is identifying and then filling in gaps in current urological knowledge. To this end, it works closely with the Guidelines Office. Prof. Bjartell explains: “I have already had a productive and pleasant meeting with [EAU Guidelines Chair Prof.] James

N’Dow. We understand how much we need each other when it comes to improving healthcare within urology. The Guidelines Office panels have been asked to work to identify the most urgent questions and ‘gaps’ in the current knowledge, where we can benefit from new studies and registries. If these gaps can be identified by the Guidelines Office, we can have a discussion about what studies and registries we can initiate. Our new initiatives will serve the expansion of our knowledge in urology, it won’t just be research for its own sake. I feel this is one of the most important things we have to put effort into.”

supported. The results will determine the potential and long-term feasibility of the research.

Further collaboration In addition to working with the Guidelines Office and Scholarship Programme, the EAU Research Foundation is looking to other natural allies within the EAU. Prof. Bjartell, himself a former chairman of the EAU Section for Urological Research (ESUR) acknowledges their common goals and potential for shared meetings.

We need young colleagues to work on these studies and registries, and one way we Prof. Anders Bjartell have been achieving this so far is through these traditional “One of our board members, Guido Jenster was scholarships,” Bjartell explains. also involved with ESUR in the past. Recently we have been considering closer collaboration, “Another approach for us to fill research gaps is to starting in the coming year. We have drawn up a offer what we call ‘seeding grants’ from the Research plan to collaborate with the Research Section Some gaps have already been identified: “One is Foundation itself. We will be announcing a budget for when they have their annual meeting in the alternative treatments of prostate cancer. Besides new research initiatives. If you have a new idea, it autumn of 2018. We can contribute to their surgery and radiation therapy, we have different kinds may be a high-risk project. One way to find out if it’s scientific programme.” of focal therapy. These options have not always been something really good is to start working on it with a described in prospective, high-quality studies. There seeding grant. If results are promising, it can be “The same goes for the Young Academic Urologists is an urgent need for more studies in focal therapies expanded to a larger study.” (YAU). The Research Foundation will get a slot in their for prostate cancer, and to collect real world data. programme at the Annual EAU Congress. In general, That could be in the form of registries. We also aim to “It’s a way to get the first results in quickly and we would like to achieve more interaction with the compare different methods and patient-reported examine whether it is a feasible long-term project. YAU, as we have similar target audiences and we can outcome measurements, PROMS. That’s certainly Not all ideas have promise, or work out how you offer scholarships to young urologists.” another gap in our current knowledge and indeed our expect, there is no telling in advance. We think this guidelines for urologists.” strategy will pay off.” The upcoming Annual EAU Congress offers more opportunities for the EAU Research Foundation to There is a range of topics that have potential for new advertise its goals and drum up interest for its “With a close collaboration with the EAU Guidelines research. “We have had a lot of discussion on the projects. Bjartell: “We are looking ahead to EAU18 in office and other sections, the Research Foundation Copenhagen. In addition to our participation in the will contribute to improve healthcare for our patients.” surgical methods in urology, and projects related to new drugs. These are often initiated by YAU Session, we are contributing to different poster Scholarship opportunities pharmaceutical companies, because it’s really sessions, and also to a research news session where The EAU RF is also exploring an increase in the expensive to set up trials like that. There is a need for new initiatives in clinical trials are being presented by research scholarships that are currently being offered more studies on surgical methods. The use of new companies and other organisations. This session is an through the European Urology Scholarship medical devices, matters like focal therapy. This is an opportunity to highlight new research, showcase the Programme (EUSP). Through a so-called “seeding area in which we should also identify new projects to prospective studies that we have in collaboration with grant”, short-term, exploratory projects can be be started.” industry.”

NIMBUS trial expands to other countries Firm commitment to start up in Spain, Belgium, Portugal and Italy By Dr. Wim Witjes and Dr. Raymond Schipper The NIMBUS trial assesses whether a reduced number of Bacillus Calmette-Guerin (BCG) instillations is not inferior to standard number and dose intravesical BCG treatment in patients with high grade non-muscle invasive bladder cancer (NMIBC). Intravesical instillation of BCG is a widely accepted strategy to prevent recurrence of non-muscle invasive bladder cancer. The most accepted treatment schedule is induction of BCG: weeks 1 through 6 plus maintenance (weeks 1,2,3) at months 3, 6 and 12, but it is unknown how many administrations are really necessary. Scientific evidence supports the hypothesis that after an initial sensitisation to BCG antigens has occurred, the number of instillations can be reduced for a proper anamnestic immune response resulting in similar clinical efficacy and potentially less side-effects and costs. The NIMBUS study is a multicentre prospective, randomised, parallel group, not blinded, trial to compare the efficacy and safety of two different adjuvant treatment schedules: 1) Induction cycle BCG-full dose; weeks 1 through 6 plus maintenance cycles at months 3, 6 and 12 (wks. 1,2,3); total 15 full dose BCG instillations 2) Induction cycle BCG-full dose (reduced frequency); weeks 1,2, and 6 plus maintenance cycles at months 3, 6 and 12 (wks. 1,3); total nine full dose BCG instillations.

Hospitalier, Lyon Sud; CHU Hôpital Charles-Nicolle, Rouen; CHU La Pitié-Salpêtrière, Paris) have been initiated of which the site Hôpital Edouard Herriot, Lyon (Prof. Marc Colombel ) recruited seven patients. In Belgium, the following sites have submitted the study to the regulatory authorities in October 2017: AZ Groeninge, Kortrijk; AZ Maria Middelares, Gent; Jessa Ziekenhuis, Hasselt; AZ Sint-Jan Oostende-Brugge. Spain will participate with 10 sites: Hospital Universitario La Paz, Madrid; Valdecilla Hospital, Santander: Hospital Central Asturias, Asturias, Fundacio Puigvert, Barcelona; Araba University Hospital , Vitoria-Gasteiz; Complejo Hospitalario de Navarra, Pamplona; Hospital Universitario de Canarias, Tenerife; Instituto Valenciano de Oncología, Valencia; Hospital Universitario Salamanca, Salamanca. Hospital Virgen de la Macarena, Sevilla. Approval in Spain expected in December 2017. Preparations to initiate the study in Italy (Vita Salute San Raffaele University, Milan; Sapienza Università, Roma) and Portugal (Centro Hospitalar de Vila Nova de Gaia, Espinho; Centro Hospitalar, Cova de Beira; Centro Hospitalar, Baixo Vouga; Hospital Senhora, Oliviera de Guimarães) are ongoing. Start-up in Finland (Finnbladder study group) is currently under investigation.

EAU Research Foundation

October/December 2017

Amendment protocol • The recommendations to perform a second Transurethral Resection (TUR) of the bladder in the diagnosis of bladder cancer are changed in the 2017 EAU guidelines. It is now recommended to perform a second TUR in case of a pT1 HG tumour in the initial resection and not for pTa HG/ G3 tumours as was recommended in the EAU guidelines of 2016.

described in the current version of the protocol how to practice adequate contraception and to continue such precautions during the study treatment period. Text has been adapted in some sections of the protocol and in the patient information to further clarify the study procedures for female patients of childbearing potential (i.e. to take appropriate precautions to avoid pregnancy and which procedures to follow for those who become pregnant during the study treatment phase).

NIMBUS study presented at EAU17 An update of the NIMBUS study was presented at the Steering Committee meeting, European Investigator meeting, Independent Data Monitoring Committee (IDMC) meeting and the EAU Research Foundation Special Session, coinciding with the 32nd Annual EAU Congress (24-28 March, 2017) in London, UK. The Steering Committee decided, after taking into account the advice of the IDMC and the report of the

• The presence of pregnancy is an exclusion criterion in the current protocol. It is not clearly

Table 1: Monthly and Overall inclusion

In May 2017, the study has been approved in France. Four sites (Hôpital Edouard Herriot, Lyon; Centre

Investigator Meeting, to fine-tune the protocol in a way that study timelines and study procedures are adapted according to the current EAU guidelines, daily urological practices and availability of BCG.

National Coordinators • Germany: Marc-Oliver Grimm • The Netherlands: Toine Van Der Heijden In the amended protocol it is the investigator’s • France: Marc Colombel discretion whether to perform a Re-TUR • Spain: Luis Martinez-Piñeiro (or-Re-Re-TUR) in case of a pTa HG tumour in the • Belgium: TBD initial resection (or Re-TUR), provided muscle was • Italy: Francesco Montorsi present and reported in the specimen and there • Portugal: Pedro Costa was a complete macroscopic resection of all of • Czech Republic: Marko Babjuk the papillary tumour(s) at the initial resection (or • Turkey: Levent Türkeri Re-TUR). Are you interested to participate in the NIMBUS study? • The persistent worldwide BCG shortage and Please contact: delays in obtaining approvals of national and/or local regulatory authorities has hampered the EAU RF Central Research Office start-up of new countries/sites and accrual of the PO Box 30016, 6803 AA Arnhem, The Netherlands, NIMBUS trial. Therefore, the recruitment period Email: researchfoundation@uroweb.org was extended from four to six years. Phone: +31 (0) 26 38 90 677

The primary endpoint for inferiority analysis is time-to-first-recurrence. The secondary objectives are to identify if number and grade of recurrent tumours, rate of progression to a higher stage (T2 or higher) of the disease and safety, specifically the presence of treatment related toxicity > grade 2 differ between the two study arms. Study status (cut-off date 31 October, 2017) Germany: 36 centres are initiated in Germany of which 24 sites randomised, in total, 113 patients. In the Netherlands 13 sites are initiated of which 10 centres randomized in total 67 patients.

Fig. 1: Flow chart for eligibility patients with CIS only, Ta and T1 tumours in TUR

To find out more about the EAU RF and its ongoing projects, please visit www.uroweb.org/research European Urology Today

EMUC17: New therapies reinforce multidisciplinary goals Balancing gains of novel treatments with patient’s quality of life, still a challenge By Joel Vega True to its goal of pursuing multidisciplinary collaboration, the recent 9th European Multidisciplinary Meeting on Urological Cancers (EMUC17) urged onco-urological experts and professionals to focus on informed, evidence-based treatment while keeping an eye on the evolving, diverse developments triggered by new research and drug technologies.

Nicolas Mottet (FR) gave the concluding opinion when he said that although normal MRI results avoid biopsy and complications, high costs are involved. He said decision-making must be evidence-based, and reiterated guidelines compliance which recommends the use of a risk calculator or an additional serum or urine-based test (e.g. PHI, 4Kscore or PCA3) or imaging for asymptomatic men with a PSA between 2-10 ng/ml, before performing a prostate biopsy.

This was the recurring message to the nearly 1,160 participants, coming from around 70 countries, who attended the three-day EMUC17 in Barcelona last November 17 to 19. Not only did the latest EMUC edition tackle key issues and current controversies in prostate, kidney, bladder, penile and testis cancers, it also provided the day before a compact and complementary pre-event programme with two meetings: the 6th Meeting of the EAU Section on Urological Imaging (ESUI17) and the EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP). Also held on the same day was the closed-door EAU Prostate Cancer Centre Consensus Meeting (EPCCCM) whose deliberations were later described in summary by European Association of Urology (EAU) Treasurer and Communications Head Prof. Manfred Wirth (See Full Story on Page 15).

Focal therapy For the debate question “Will Level 1 Evidence influence our practice in focal therapy?”, urologist Mark Emberton (GB) presented pro arguments, while radiation oncologist Alberto Bossi (FR) opposed. “Focal therapy has emerged as a new class of therapy which now commands legitimacy,” said Emberton. Not only is there patient acceptance and less harms but he added that “focal therapy has forced an order of precision in terms of risk stratification that was previously missing.”

At the EMUC, Prof. Thomas Powles (GB) of the European Society for Medical Oncology (ESMO), Prof. Peter Hoskin of the European SocieTy for Radiotherapy & Oncology (ESTRO) and Prof. Hein Van Poppel of the EAU welcomed the participants as they all underlined the necessity of working together amidst the fastevolving changes in technology, drug and clinical researches. Van Poppel took note of EMUC’s growth as an annual multi-professional event, Powles stressed its role to effectively engage cancer experts, while Hoskins underlined EMUC’s task to disseminate best practices and new insights.

To resolve the impasse between the conflicting viewpoints, Arnauld Villers (FR) pointed out there is agreement on FT ‘failures’ such as ablation, targeting and patient selection failure. He discussed follow-up treatments for residual cancer and whether these are suitable for AS or focal therapy. “There is agreement on multi-focality, and FT should be targeted to the index lesion…Multi-focal cancer should not preclude focal therapy,” Villers said.

The first-day opening plenary session tackled prostate cancer (PCa) management with the first segment focusing on detection and treatment of clinically significant PCa, followed by the influence of Level 1 evidence on focal therapy, and lectures related to treating primary PCa, with the ProtecT study as the central topic. Immunotherapy in urological cancers was the agenda in the second segment, particularly prostate, bladder and kidney cancers with lectures by medical oncologists Silke Gillessen (CH), Andrea Necchi (IT) and Tom Powles. Pre-biopsy MRI Urologist Hashim Ahmed (GB) and radiologist Harriet Thoeny (CH) teamed up to argue for MRI before biopsy as against the contrary views of Olivier Rouvière (FR) and urologist Jochen Walz (FR). “With the introduction of MR/TRUS-fusion-guided targeted biopsies, there has been a higher detection rate of clinically significant prostate cancer compared to the higher detection rate of insignificant PCa by random TRUS biopsy,” said Thoeny who stressed that image quality has to be excellent. “The dedication and experience of the radiologists and urologists is absolutely mandatory,” she added. “Looking at MRIs is like predicting the weather. No one remembers the huge numbers of times, we get it right. Everyone remembers the big misses….everyone forgets how bad it was before MRI,” Ahmed said in support of MRI. Rouvière remained unconvinced although he gave a more nuanced comment when he noted that MRI is indeed recommended in the repeat biopsy setting, but not in biopsy-naïve patients where there are conflicting results. Walz sustained the critique on MRI as he noted that the quality of mpMRI outside of expert centres “… is too poor to recommend routine use.” “Standardisation, certification and quality assurance are necessary before any recommendation can be given,” said Walz.

Nearly 1,160 participants gather in Barcelona for EMUC17

European Urology Today

Bossi insisted alternatives to “whole organ” therapy must have the ability to reliably identify suitable candidates, provide acceptable morbidity and improve QoL outcomes. He noted that salvage robot-assisted radical prostatectomy (RARP) after focal therapy (FT) failure “is feasible with acceptable complication rates.”

Educational sessions on testis and bladder cancers took up the remainder of the day with experts providing lectures on the management of metastatic and residual diseases, bladder preservation, lymph node dissection, and pathology issues.

Dr. Tobias Nordström (3rd from left) wins the Best Oral Presentation. (From left) Session chairs Profs. Barbara Jereczek-Fossa, Susanne Osanto and Hein Van Poppel present the award in Barcelona

Junker on biomarkers: “There are validated biomarkers in independent cohorts; signatures are used…but we have several tasks such as performing prospective trials, standardised sampling and we have to take into account that we should have standard techniques.”

Concepts in metastatic PCa are in a flux and the last-day plenary session highlighted this with four lectures by radiation oncologist Nicholas James (GB), radiologist Uwe Haberkorn (DE), urologist Derya Tilki (DE), radiologist Frédéric Lecouvet (BE), and urologist Simon Brewster (GB) leading the case discussions.

Ost on local ablation: “Metastasis-directed therapy (MDT) is an option in oligometastatic RCC, especially for solitary lesions and non-symptomatic patients. Surgery has more complications and if histology is warranted choose surgery. There are still open questions such as MDT only, or MDT followed by standard of care (SOC) or SOC followed by MDT in non-progressors.”

James said the sequence of therapy in CRPC needs to be individualised. “There is not one size fits all,” he said, noting that upfront therapy with abiraterone and docetaxel, improves survival and patterns of care. Lecouvet discussed impact on QoL and harmonisation of standards. “Symptoms and PSA are sufficient monitoring tools in most mCNPC,” said Lecouvet referring to the APCC 2017 recommendations in metastatic prostate disease.

Selection criteria in PCa for active surveillance Following a summary report by Gillessen on the highlights of the Advanced Prostate Cancer Consensus Conference (APCCC2017), Prof. Jonathan Epstein (US) gave a succinct overview update lecture on the selection criteria and definition of reclassification for prostate cancer on active surveillance. His lecture demonstrated the impact of pathological findings and how it can affect treatment decision-making, such as disqualifying a patient for active surveillance or reinforcing the need for watchful waiting to avoid overtreatment.

On distinguishing between very low and low-risk disease, he said cancer extent on biopsy and PSA density at diagnosis are directly associated with grade reclassification during surveillance (Loeb et al. J Urology 2013), there is a two-fold higher risk of surgically confirmed non-organ confined cancer and Oligometastatic kidney cancer Chaired by Vincent Khoo (GB), Van Poppel, Powles and Gleason pattern 4 in men with low risk versus very low risk disease (Tosolan et al. J. Urol 2013), and there Ferran Algaba (ES), best practices and difficulties in managing oligometastatic kidney cancer were taken up is a two-fold higher risk of metastatic disease, prostate cancer death, and treatment failure with with Axel Bex (NL) who discussed optimal timing for cytoreductive nephrectomy (CN), Umberto Capitanio (IT) surveillance for low-risk versus very low risk disease (Godtman el, Eur Urol 2016). on advances of adjuvant therapy, Kerstin Junker (DE) giving an overview on potential biomarkers for Another relevant issue he noted is the problem with the decision-making and Piet Ost (BE) examining the role Gleason system with regards scale. of local ablation in delaying systemic therapy. Below are selected key messages from their lectures: “Six is the lowest grade reported although the scale Bex on CN: “Patients with oligometastatic disease (with goes from 2-10,” he said. “Thus, patients are told they have a Gleason score of 6 out of 10, and logically but the primary tumour in place) should undergo CN and incorrectly think that they have a tumour in the middle be carefully observed after surgery. Data of the only of the grade spectrum, contributing to the fear of currently available randomised study showed those cancer.”’ requiring systemic therapy with VEGFR-TKI should be offered deferred CN. Deferred CN approach appears to select out patients with inherent resistance to systemic Epstein: “Urologists need to reassure and educate patients when told they have Gleason score 6 cancer. At therapy. This confirms previous findings from singlethe same time there is the need to modify how arm phase 11 studies.” pathologists report cancer grade to more accurately Capitanio on adjuvant therapy: “Based on available reflect their behaviour.” data, adjuvant therapy is affected by significant toxicity and there is no Drug repurposing and evolving concepts in benefit for the majority of metastatic PCa high-risk M0-RCC Gauthier Bouche (BE) discussed the potential of drug patients. However, a repurposing and the opportunities in uro-oncology. non-negligible “Drug repurposing gives you freedom to look for new proportion of high–risk therapeutic options…it can be innovative and patients (pN1) harbour scientifically rewarding,” he said as he pointed out the early systemic drugs which are off-patent require no reformulation dissemination with very although there are “challenges ahead.” poor survival prognosis. In this specific scenario, adjuvant therapy might show the highest ratio between clinical benefit and costs (toxicity).” Closing session with (from left) Profs. H. Van Poppel (EAU), J. Oldenburg (ESMO) and P. Hoskin (ESTRO)

Tilki said there is no Level 1 evidence with respect to managing the primary tumour in mPCa. “All conclusions to date are gathered from observational data or retrospective institutional studies,” she said. She also noted that men undergoing surgery are more likely to be fit and have a lower burden of metastatic disease. “Or they have robust disease responses with systemic therapy and would have probably done well without local treatment.”

“Urologists need to reassure and educate patients when told they have Gleason score 6 cancer. At the same time there is the need to modify how pathologists report cancer grade to more accurately reflect their behaviour.” EC and scientific initiatives Xavier Prats Monné (ES), Director General for Health and Food Safety, gave the European Commission Lecture in which he stressed the importance of collaborative efforts such as the European Reference Networks and international meetings like the EMUC. He also described the obstacles in policy-making and how scientific advances are affected when unified action is needed from across sectors, disciplines and even national boundaries. He forwarded a frank and realistic assessment when he said that “the beauty of scientific progress is often slowed down by the difficulty of creating policies despite the evidence.” “Tribal thinking,” according to him is an obstacle and creates resistance to forward-looking, European-wide collaboration. At the same time, he noted that despite these hurdles, initiatives should be pursued and challenged the audience to continue with their work in scientific collaboration, which he described as “crucial work” that is often left unrecognised. EMUC17 concluded with the summary take-home messages and the closing remarks of the organisers led by Van Poppel for the EAU, Hoskin for ESTRO and Jan Oldenburg (NO) for ESMO. Amsterdam will be the venue for the 10th edition in 2018.

16-19 November 2017 Barcelona, Spain October/December 2017

ESUI17 assesses new technologies and limited resources Evaluating the efficacy on patients and cost-effectiveness By Erika De Groot

of missing evidence. He advised to concentrate on patients with sVNH (symptomatic non-visible haematuria) and on older patients over 50 years of age with aVNH (asymptomatic non-visible haematuria) instead.

The recently concluded 6th EAU Section of Urological Imaging (ESUI17) offered several sessions on the impact of MRI technology on the diagnostics of urological cancers. New technologies were evaluated whether these provide true benefit for patients and how to implement them in a cost-effective way.

Dr. Christof Kastner (GB) discussed the advantages of transperineal approach: lower infection and sepsis rate; access to anterior lesions; and more stable fusion with less distortion through movement. Additionally, he stated the benefits of a transrectal approach: less resources required; and possible advantage in accessing posterior lesions.

According to Dr. Maarten De Rooij (NL), allocation of limited healthcare resources should be optimised in prostate cancer diagnosis. Decision analytic model for identification of risks, costs and potential benefits of new diagnostic interventions should be considered. In the point and counterpoint debate on the costeffectiveness of MRI before primary biopsy, Prof. Nicolas Mottet (FR) contended that it is not costeffective as the quality of the radiologist remains the main issue. Prof. H.U. Ahmed (GB) argued that MRI pre-biopsy reduces the number of biopsies and insignificant cancers found, and improves detection of significant cancers. “The use of new biomarkers and/or risk calculators will improve prostate cancer diagnostics,” said Prof. Tobias Nordström (SE). “Both new biomarkers, as well as, improved imaging add value independently.” Prof. Monique Roobol (NL) advised to risk stratify before (repeating the) MRI. According to her, “Risk stratification is key as this could prevent a lot of men from (further) unnecessary testing and (immediate) re-testing.”

For abstracts, webcasts and posters of ESUI17 and EMUC17, please visit the Resource Centre via http://rc.emuc2017.org/. (Left to right) Prof. T. Loch and ESUI Chairman Prof. G. Salomon

cases. “Software allows us to generate precise 3D models improving our surgical strategy and PN outcomes.” In his other lecture, he stated that the MAP (Mayo Adhesive Probability Score) score is the better tool to predict adherent perinephric fat tissue and that the latter can influence operative time and blood loss during PN. Prof. Alessandro Volpe (IT) said that active surveillance is a reasonable option in elderly and comorbid patients with limited life expectancy and increased perioperative risk. He added that long-term results of well-designed prospective studies have the potential to better define the best active surveillance for small renal tumours.

Prof. Jochen Walz (FR) said “Before we can draw clear conclusions for the general population, we need realistic cost-effectiveness analysis that do take into account what is currently available in the general population.”

Prof. Nina Wagener (DE) stated that texture analysis (TA) is a challenging quantitative imaging biomarker and it provides an objective assessment of tumour heterogeneity.

According to Prof. Vincenzo Ficarra (IT), an AngioCT scan should be strongly considered in the surgical planning of Partial Nephrectomy (PN) for difficult

Prof. Steven Joniau (BE) said that "PN remains the gold standard treatment but ablation is growing in importance. There is a higher risk of local recurrence

or repeat ablation." He added that overall survival rate and cancer specific survival is comparable to PN but less (minor) complications, shorter hospital stays, and less pain. "In imaging of prostate cancer, positron emission tomography–computed tomography (better known as PET-CT or PET/CT) has almost no role in the diagnosis; limited role in staging and only for selected patients; while PET/CT with new tracers (such as PSMA) has absolutely a major role in biochemical recurrence," said Dr. Stefano Fanti (IT). According to Dr. Fanti, who spoke on behalf of Prof. Roberto Delgado Bolton, 18F-FDG remains the gold standard for imaging of glycolytic tumours with regard to renal cancer. He said that new PET radiotracers for functional imaging are currently Riveting discussions piqued the audience’s interest under investigation which will explore alternative metabolic pathways for growth as markers of hypoxia, proliferation and/or angiogenesis.

16 November 2017 Barcelona, Spain

Prof. Marek Babjuk (CZ) said that diagnostic algorithm in patients with microhaematuria is not clear because

European Prostate Cancer Centres of Excellence Optimal prostate cancer care in Europe to enter new phase By Joel Vega A new phase for optimal prostate cancer care will be introduced across Europe with the European Prostate Cancer Centres of Excellence, which will offer a network of highly specialised centres that can effectively respond to the need for holistic care in prostate cancer treatment and management. The initiative, led by the European Association of Urology (EAU), begun early in 2017 and involved cancer experts and representatives from various sectors and institutions including patient and nursing groups. With the first consensus meeting by its members held last November 16 in Barcelona, Spain, the formative step was taken to bring the project closer to implementation. “There are PCa expert centres in Europe but we need to link them up to create a more responsive and streamlined network which efficiently responds to modern demands in clinical, research and educational

developments. This initiative is unique in the sense that we aim to bring to another level the gains already made by these centres, and further improve the way we manage prostate cancer,” said Prof. Manfred Wirth (DE), EAU Treasurer and Head of Communications, who opened the EAU Prostate Cancer Centre Consensus Meeting (EPCCCM) in Barcelona. Serving as EPCCCM co-chairs were Professors Hein Van Poppel (BE), EAU Adjunct Secretary General for Education, Peter Albers (DE) President of the German Cancer Society, and Dr. Nicola Fossati (IT). “The need to develop this network has been always there, but we needed to first identify the core goals, refine the basic mechanisms, and carefully go through the standards that will define the network,” added Wirth. He also expressed appreciation for the work of the task force members in the consensus meeting who play key roles in realising the project’s objectives. Reiterating Wirth’s message, Albers noted that unifying centres of high expertise in prostate cancer will benefit both physicians and patients due to streamlined collaboration, not only among different institutions but also various medical disciplines and stakeholders engaged in prostate cancer care. The initiative involved institutions such as the European School of Oncology (ESO), the European Society for Medical Oncology (ESMO), the European Society for Therapeutic Radiation Oncology (ESTRO), the European Organization for Research and Treatment of Cancer, Genito-Urinary Cancer Group (EORTC GU CG), and Europa Uomo (EUomo). There are also representations from the European Board of Urology (EBU), International Psycho-Oncology Society (IPOS), and the International Agency for Research on Cancer-World Health Organization (IARC-WHO).

Prof. M. Brausi makes a comment during the discussions

October/December 2017

The second step (Research) consisted of the accreditation of the institution as a “European Prostate Cancer Research Centre,” with requires internal monitoring of research outcomes. A data-manager has the central role for data collection from patients diagnosed and treated with prostate cancer. The scientific activity, in terms of number of publications per year and impact factor of the peer-reviewed journals, also defines the score of this step.

Input were received and come from the various EAU Section Offices such as the EAU Guideline Office (EAUGO), the EAU Section of Oncological Urology (ESOU), the EAU Section of Uro-Pathology (ESUP), and

Prof. Manfred Wirth chairs the consensus meeting in Barcelona

the EAU Section of Urological Research (ESUR), making the initiative one of the most multi-level projects spearheaded by the EAU.

“There are PCa expert centres in Europe but we need to link them up to create a more responsive and streamlined network which efficiently responds to modern demands in clinical, research and educational developments.”

The third qualifying step consisted of the accreditation of the institution as a “European Prostate Cancer Educational Centre,” which involves offering young specialists in PCa fellowships focused on prostate cancer. The consensus meeting also discussed other requirements and proposed both short and long-term strategic goals for the network that will further set quality standards for the centres of excellence. “This initiative is not only crucial for cancer experts and professionals to improve their treatment standards but also further boost the existing collaborative efforts among prostate cancer experts. With the direct input of medical and patient groups, we can go a long way by further enhancing current standards and to achieve a higher level of quality in prostate cancer care,” said Wirth.

Formative mechanisms During the EMUC’s first plenary session, Wirth gave a summary of the formative mechanisms that were reviewed by the consensus meeting participants. They identified and defined three steps such as Clinical, Research and Education. The first step consisted of the accreditation of the institution as a “European Prostate Cancer Clinical Centre,” using five criteria which are: core team, multi-disciplinary approach, diagnostic pathway, therapeutic pathway, and general criteria.

Task force members represent various disciplines and institutions

European Urology Today

ESU participates in SMA meeting in Belgrade Course on stones attracts young Serbian urologists Prof. Dragoslav Basic Director, Clinic of Urology President, Urological Section of Serbian Medical Association Nis (SRB) basicdr@gmail.com The 1st National Congress of the Urological Section of Serbian Medical Association (SMA) and Regional Joint Meeting with ESU Course took place last September 28 to 30 in Belgrade. The meeting was organised by the Urological Section of SMA, Serbian Academy of Sciences and Arts, with more than 300 participants from Serbia, Bosnia and Herzegovina, Bulgaria, Macedonia, Croatia, Greece, Slovenia, Austria, and Germany. The Scientific Programme included six plenary sessions which covered the topics BPH/LUTS, penis and urethra, bladder, prostate and kidney cancers and urolithiasis,

and four abstract sessions on renal cell carcinoma (RCC), female urology/urolithiasis, urothelial/prostate cancer) and the ESU Course on urolithiasis. There were four sponsored symposia.

excellent and offered participants and guests an opportunity to relax and meet friends.

Developments in urolithiasis An ESU Course on “Recent developments in diagnosis Eminent lecturers presented 47 outstanding lectures, and surgical treatment of urolithiasis” was led by Dr. and it was a marvellous opportunity for the congress Guido Giusti (IT) and Dr. Thomas Taily (BE). The course participants to share their experiences and knowledge was well-attended by many residents and junior by taking part in several dynamic interactive urologists. The ESU staff provided support and discussions. Several veteran urologists also inspired assistance, and their enthusiasm contributed to the us with their enthusiastic participation during the success of the meeting. The participants appreciated scientific debates. The social programme was the quality of the scientific content, and the practical insights shared by the outstanding lecturers during the interactive discussions. Also noteworthy was the participation of young urologists, Dr. Mirko Jovanovic (Military Medical Academy, Belgrade), Dr. Vladimir Radojevic (Bel Medic Hospital, Belgrade), and Dr. Kremena Petkova (Military Medical Academy, Sofia), who all presented excellent case reports.

Opening plenary session of SMA's National Congress

Since the congress took place during the Urology Week 2017, the Urological Section of Serbian Medical Association organised several activities to promote urology. During that week, these activities were promoted on TV, radio and by print media.

Prof. Novak Milovic receives the SMA Award from academician Hadzi Djokic

Participants included well-known Serbian and visiting urologists. There were also live TV broadcasts during the congress. The urologists of the Urological Section were also available for free online consultations, and free phone consultations were also offered by urologists from Hospital Bel Medic. Definitely, our activities during Urology Week 2017 helped raised public interest on urology in Serbia, and have contributed to efforts in raising awareness on the importance of urological healthcare and its impact on quality of life.

Huge attendance at ESU Course in Northern Cyprus 26th National Congress of Turkish Association of Urology hosts uro-oncology course Assoc. Prof. Dr. Gokhan Atis General Secretary 26th National Congress Turkish Association of Urology Istanbul (TR) gokhanatis@ hotmail.com The European School of Urology (ESU) organised last October 12 to 15 a course on uro-oncology during the 26th National Congress of Turkish Association of Urology held in Kyrenia, Northern Cyprus. Organised by the Turkish Academia of Urology under the chairmanship of Prof. Ates Kadioglu, the meeting attracted around 1,000 urologists. The ESU course took place on the second day of the congress with EAU Adjunct Secretary General for Education Prof.

Hendrik van Poppel (BE) as course chairman, with G. Ahlgren (SE) and A. Necchi (IT) as faculty members.

meta-analysis, but randomised trials do not show a difference.

The course presented updates on prostate, bladder and kidney cancers. On PCa management, Prof. Van Poppel gave a lecture titled “Advanced prostate cancer and/or oligometastatic disease: radical surgery?’’ Ahlgren discussed the EAU guidelines recommendations on prostate cancer and provided the latest developments.

The ESU course concluded with interactive case discussions with the participation of local faculty, namely Derya Balbay, Ozdal Dillioglugil, During the bladder cancer session, A. Necchi spoke on Bulent Akduman and ‘’Changing the instillations paradigm in non-muscle Ugur Boylu who invasive bladder cancer’’ and also examined the role of presented uroimaging in invasive bladder cancer. Regarding kidney oncological cases. The cancer, Ahlgren gave a lecture presenting the following Q&A forum EAU Adjunct Secr. Gen. for Education Prof. H. Van Poppel chairs the ESU course arguments for and against radical and partial prompted enthusiastic nephrectomies. In his concluding remarks he said feedback, questions and partial nephrectomy (PN) is safe and with a low risk comments from the audience. for local recurrence, but carries with it the risk of the ESU faculty for their valuable support. more postoperative complications. Moreover, PN We are honoured to host the ESU course in our The course was not only well-attended but also saves kidney function and have less mortality in congress and we are grateful to Prof. Van Poppel and very well appreciated by the Turkish urologists.

ESU Course Tunis tackles management small renal masses Participants examine key issues in treating SRMs Dr. Amin Bouker Dept. of Urology Clinique Taoufik Tunis (TN)

Europe. He then gave a comprehensive lecture on EAU Guideline recommendations on localised renal cancer discussing the incidence, WHO classification and disease management, among other topics.

aminbouker@ gmail.com

In his third lecture, Van Moorselaar gave a compact and succinct lecture on the indications for open, laparoscopic and robotic surgeries for renal tumours going through topics such as assessment of lymph nodes and metastases, surgical margins after partial nephrectomy (PN), and indications for PN. In his concluding remarks, Moorselaar noted that partial nephrectomy is recommended in T1a tumours.

Under the auspices of the Tunisian Association of Urology (TAU), the European School of Urology (ESU) held on October 12 a half-day course on the diagnosis and treatment of small renal masses (SRMs) during the annual national congress of the TAU in Hammamet, Tunisia.

European Urology Today

Meanwhile, Klatte lectured on diagnostics in SRMs and alternative therapies for localised renal tumours. He discussed the role of imaging, cystic lesions, the impact of MRI, and renal mass biopsy (RMB), among other issues. “RMB is a useful, safe and accurate clinical tool with inherent limitations,” Klatte said adding that “…RMB should take place more than “never” and less than “always”. The course concluded with the MCQ Quiz, take-home messages and practical cases.

Professors Jeroen Van Moorselaar (NL) and Tobias Klatte (UK) led the course which took up the EAU Guidelines recommendations on localised renal carcinoma, diagnostics in SRMs, assessment of open, laparoscopic and robotic surgical options, and alternative therapies for localised renal tumours. Van Moorselaar opened the course with an overview on the activities of the ESU including the various educational initiatives and projects in and beyond

“Whenever feasible do a partial nephrectomy in T1b tumours. Moreover, partial nephrectomy can be performed, either with an open, pure laparoscopic or robot-assisted approach, based on surgeon’s expertise and skills,” he said. He gave practical tips and said that every minute counts when clamping the renal hilum.

ESU course faculty members

We are delighted to have the support and participation of the ESU since this course will help local urologists to apply practical insights and expand their treatment options for this lethal disease. For the social programme we had a very interesting tour of the old districts Hammamet and Nabeul and a relaxing dinner at a seafood restaurant. The Tunisian Association of Urology expressed its appreciation for this comprehensive course and the

Course participants were given a comprehensive update on the management of SRMs

number of participants was not only remarkable but also the quality of discussions and feedback from both faculty and attendees. We hope to organise more of these courses in future meetings and thank the ESU for its continued support and collaboration! October/December 2017

European-Basic Laparoscopic Urological Skills (E-BLUS) Singapore Urological Association, ESU-ESUT collaborate in laparoscopy training Dr. Ho Yee Tiong Organising Chairman E-BLUS Pre-Congress Workshop Singapore

Dr. Yung Kung Tan Scientific Co-Chairman Urofair2017 Singapore

Uro-Technology (ESUT) Chairman Evangelos Liatsikos of the University of Patras (GR). The program included a modification to the standard E-BLUS Workshop with ‘warm-up’ lectures by both professors. They spoke on the principles, tips and tricks, as well as complications of laparoscopy, and their knowledge and enthusiasm for surgical education inspired the local faculty and workshop participants. What was clear to all was the passion of the lecturers for teaching laparoscopic urology which was shown during the dry lab workshop. The Hands-on Training (HOT) session in the dry lab followed video demonstrations of the four E-BLUS exercises, namely peg transfer, cutting a circle, needle guidance and laparoscopic suturing. We were thankful that the task training models for the exercises were brought over personally to Singapore by Prof. Gözen himself! Participants at the first E-BLUS Workshop in Singapore

Following the meetings between the 2016 Urological Association of Asia organising chairman Prof. Man Kay Li and Prof. Jens Rassweiler of the EAU to improve training collaboration, the first EBLUS pre-congress workshop was held at the Singapore Urological Association (SUA) Annual scientific meeting which is also known as the Urofair 2017.

At the HOT session, Profs Gözen and Liatsikos were assisted by local faculty from different hospitals in Singapore – namely, Drs. Wei Jin Chua, Molly Eng, Fang Jann Lee, Valarie Gan, Keng Siang Png and Yee Mun Lee. The workshop was abuzz with activity as the participants work studiously under the watchful eyes of the faculty for them to complete the exercises with minimal errors and within the required time limits. After almost four hours of training, all the participants practised a wide repertoire of skill

sets with tips given by the faculty. With persistent and regular practice, the acquired knowledge and skills from the HOT workshop would enable them to take the actual examination and perform laparoscopic surgery. Besides the E-BLUS tasks, an additional three stations were also set up with ERBE energy stations to enable the participants to try advanced bipolar energy laparoscopic dissection.

At the end of the pre-congress workshop, friendships were formed between the faculty and participants. These bonds were further strengthened over the following two days of the Urofair conference. This was clearly the beginning of a long-term collaboration between the ESUT/EAU and SUA to facilitate the training and standardisation of laparoscopic skills in Singapore and the region. Average feedback scores based on post-workshop questionnaires were more than 4.5 out of 5 for all the lectures and the hands-on tasks. These successful, collaborative moves are greatly supported by the current SUA President, Prof. Edmund Chiong, who has set up a SUA Educational Office to promote training. Last but not least, such an educational collaboration would not have been possible without pivotal industry support provided by Karl Storz. Future E-BLUS workshops in the region can no doubt count on their continued support!

Held last 20 April 2017 at the Academia, Singapore General Hospital, the workshop aimed to provide laparoscopy training to residents and urologists. There were 26 registrants from Singapore and other countries including Australia, Malaysia, Bangladesh, Pakistan and Vietnam who signed up for the oversubscribed course. The expert faculty included Professors Ali Gözen of the SLK-Kliniken Urology Department in Heilbronn (DE) and EAU Section of

www.esuurolithiasis18.org

www.esusalzburg18.org

2nd ESU-ESUT Masterclass on Urolithiasis

ESU - Weill Cornell Masterclass in General urology

22-23 June 2018, Patras, Greece An application has been made to the EACCME® for CME accreditation of this event

1-7 July 2018, Salzburg, Austria An application has been made to the EACCME® for CME accreditation of this event

October/December 2017

European Urology Today

Education Online Improve your skills: e-learning at your own convenience

New E-course on Urolithiasis:

Introduction to upper urinary tract endoscopy for stones Various Guidelines E-Courses (6 CME credits) Prostate Cancer, Renal Cell Carcinoma & Urolithiasis

Improve your surgical skills with top notch videos of urological procedures performed by the best surgeons in the world

Overactive bladder: mechanisms & management

(1 CME credit)

Non-Muscle Invasive Bladder Cancer

• Easy navigating by organ, procedure and/or technique • Step by step explanation in videos of 1-2 minutes

(CME 2 credits)

Metastatic Prostate Cancer (4 CME credits)

• Compare different techniques and different surgeons • Connect, share and learn with colleagues

www.surgeryinmotion-school.org

Overactive bladder: onabotulinumtoxinA as treatment (2 CME credits)

Risk profile-oriented management of BPE/LUTS uroweb.org/education

Surgery in Motion School is a collaboration of

Are you considering to join the next Masterclass BPO? These are the comments of some participants of the 2017 Masterclass on BPO:

www.esubpo18.org

3rd ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction

Dr. Petros Sountoulides, Greece

4-5 May 2018, Heilbronn, Germany An application has been made to the EACCME® for CME accreditation of this event

"I really enjoyed the ESUT Masterclass on the surgical treatment for BPH for more than one reason. The course offered an exhaustive overview of all available surgical procedures from small to very large BPH and was supported by very didactic live cases. We all had the chance to refresh our knowledge on routine procedures such as TURP and had the opportunity to discuss pros and cons of each procedure with the experts panel. I really favoured the theoretical session on day 2 on prostate surgery, as details such as catheter use and small tips and tricks are very valuable. Knowing this could bail you out in a difficult scenario." Dr. Alexandru Lordache, Romania “It was a very interesting meeting and I am sure that all information provided will increase the quality of my patient care and also my skills and professional expertise. I think all of us had good time in Heilbronn most of all due to our host Prof. Jens Rassweiler. “ Dr. Zhivko Siromahov, Bulgaria “The masterclass was really useful for me. I think that SLK Kliniken is a perfect venue for the Masterclass. These kind of events are wonderful places to go to for young urologists like me. We can meet each other and we can learn a lot. The lectors and the operators are really good teachers. Their presentations were great!” Dr. Aleksandar Spasic, Serbia “During this masterclass I was able to resolve some doubts that I had regarding some endourological procedures and the effect of what I learned on my daily practice will also be a lot stronger because this meeting was really organised at an expert level and it discussed the technologies that are the future of Urology. And then there was the beautiful town and great hospitality. Thank you!”

European Urology Today

October/December 2017

ESU visits urologists who can’t always travel to Europe Report on the 6th European School of Urology Masterclass in Tashkent, Uzbekistan Dr. Bekhzod Ayubov Consulting urologist Republican Specialized Center of Urology Tashkent (UZ) bekzod.ayubov@ gmail.com Since 2007, it has become a good tradition every other year to invite professors from the European Association of Urology (EAU) to Uzbekistan. There, they share the latest news and innovations on urology with their Uzbek colleagues by organising European School of Urology (ESU) courses on different topics. Each time, the topics are chosen in accordance with the host’s preference. This is a good idea, because each country knows where its weaknesses lie and this makes it possible to improve this concrete area. We planned our ESU courses on 6 November, but we asked our visiting faculty to stay in Uzbekistan two days longer so that we could organise further surgical demonstrations in central and regional hospitals. We also organised extra lectures not only for urologists,

An instructive partial nephrectomy procedure

The ESU courses were organised by the EAU and the Scientific Society of Urology of Uzbekistan (NOUU). Within the framework of the planned visit, the faculty conducted the masterclass laparoscopic operations at the Republican Specialized Center for Urology (RSCU) and the RSCU branch in Khorezm, as well as delivered lectures at the Tashkent Medical Academy (TMA), at the TMA branch in Khorezm and in Samarkand Medical Institute. Extra lectures On the early morning of 4 November, our distinguished guests Prof. Antonio Alcaraz (Barcelona, ES) and Dr. Giovannalberto Pini (Milan, IT) arrived in Tashkent, Uzbekistan and within an hour they were in the operating room of the CCU for performing the laparoscopic partial nephrectomy for a 27-year-old patient, with a cT1bN0M0 kidney tumour. The operation was performed successfully with explanation of details and tips and tricks along the way. After finishing the operation Prof. Alcaraz gave the lecture “Why should you become a urologist?” at the Tashkent Medical Academy for students, undergraduates and young doctors, followed by a Q&A. More than 100 people participated in this outstanding lecture and we enjoyed the teaching skills of a master surgeon. Later that evening, the guest professors travelled to the Khorezm and Samarkand regions to continue their education and show new high-tech interventions in urological practice. Also on 5 November, in the Khorezm region after short sightseeing of ancient Khiva, we went to the Urgench branch of the Medical Academy, where Prof. Alcaraz gave a lecture on the theme of innovations in urology. This topic provoked intense interest in the audience and raised a lot of questions from young specialists. More than 250 students, residents and young specialists of the Khorezm region participated in this event.

Teaching activities 2018 European School of Urology January 27 27

ESU course on Kidney cancer at the occasion of the 15th meeting of the EAU Section of Oncological Urology (ESOU), Amsterdam (NL) ESU/ESUT/ESUI Hands-on Training in MRI reading for urologists in the diagnosis and management of prostate cancer, Amsterdam (NL)

February 1-2

1st ESU-ESOU Masterclass on Non muscle invasive bladder cancer, Prague (CZ)

March 16-20 33rd Annual EAU Congress, Copenhagen (GB)

May 4-5

“The current role of laparoscopy in urological practice” was followed by a Q&A and was attended by more than 120 students and residents. That evening, the guests returned to Tashkent.

but also for students and young doctors of the Medical Academy and in regional medical institutions.

3rd ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction, Heilbronn (DE)

Expert panel for the ESU masterclass in Tashkent

At the end of the meeting the director of the Urgench branch of the Medical Academy Prof. R.Y. Ruzibaev honoured the Prof. Alcaraz with an Honorary Professorship of the Urgench branch of Medical Academy. After the lecture, on the same day, two high-tech master class operations were performed at the Khorezm branch of the Center of Urology under the supervision of Prof. Alcaraz: retroperitoneoscopic ureterolithotomy and laparoscopic ureterolithotomy. On the same day our other guest, Dr. Pini gave a lecture in the Samarkand Medical Institution. His talk,

ESU courses On November 6, we held full-day ESU courses for the urologists of Uzbekistan. During the day, six high-level lectures were given by Profs. Alcaraz and Pini (now joined by Prof. Roman Ganzer (Pasewalk, DE)) with interactive discussions of interesting cases from practice. The seminar was accompanied with subsequent explanations of the details of each procedures, as well of a lot of questions from the audience. More than 250 delegates-urologists from Tashkent and the regions participated in and enjoyed the meeting. This event once again proved the necessity of holding such kind of sessions to improve the knowledge and skills of local urologists, who cannot always travel to Europe for the latest scientific information. On behalf of the Scientific Society of Urologists of Uzbekistan, we express our gratitude and appreciation to EAU and the board of ESU and specifically to Profs. Alcaraz and Ganzer, Dr. Pini and the secretaries of the EAU offices who assisted in the organising of the courses.

ESU Masterclass faculty join their hosts for a souvenir photo

www.esunmibc18.org

1st ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer 1-2 February 2018 Prague, Czech Republic An application has been made to the EACCME® for CME accreditation of this event

June 15

ESU course on Advances in male urinary symptoms (LUTS) at the national congress of the Ukrainian Urological Association, Kiev (UA) 22-23 2nd ESU-ESUT Masterclass on Urolithiasis, Patras (GR)

July 1-7

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

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) ESU course on Urolithiasis at the national congress of the Russian Society of Urology, Krasnoyarsk (RU)

November 8-11

ESU courses at the 10th European Multidisciplinary Meeting in Urological Cancers (EMUC), Amsterdam (NL)

Contact: esu@uroweb.org

October/December 2017

European Urology Today

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

EUREP17: Designed for optimal knowledge-exchange A compact yet comprehensive curriculum EUREP, the European Urology Residents Education Programme is the definitive course for final-year urological residents. A flagship programme of the European School of Urology (ESU), EUREP has offered young and eager minds with a quintessential, high-level programme

since its inception in 2003. Held annually in Prague, Czech Republic, EUREP has five required modules which are presented during the six-day course by a distinguished European faculty.

videos and test-your knowledge sessions.

As EUREP’s popularity grows, so does the need for additional tutors to guide the next generation of EUREP also provides residents the opportunity to young urologists. Read on and know more on what it hone their skills in laparoscopy, ureteroscopy and takes to be a EUREP tutor. Also on these pages of transurethral resection. The hands-on training courses European Urology Today, a collection of testimonials, The mornings are reserved for state-of-the-art lectures are an essential part of the programme offered at anecdotes and impressions of residents who have and discussions, while afternoons are dedicated to attended the recent EUREP17. various levels of expertise.

Do you have what it takes to be a EUREP tutor? Search is on for the next mentors and you could be one of them Four esteemed EUREP tutors share their teaching sections to apply for the highly-regarded tutor role.” experiences and their visions for the programme. Read on to find out more on what it takes to guide the HOT Coordinator of the ESU, Dr. Ben Van Cleynenbreugel (BE), said “Prospective tutors can next generation of young, promising urologists. come to us through different pathways. They can be young but qualified urologists in training who What makes a good tutor? “Being an EUREP tutor is a privilege, but it requires demonstrated promising skills and eagerness to learn during the HOT sessions. Or they can come highlymore than enthusiasm. You have to have excellent recommended by expert urologists. These selected surgical skills to effectively demonstrate and explain manoeuvres in detail. You need to stay current with tutors then go on to the ‘Training the Trainer’ programme to further hone and improve their training curriculums and simulators used,” said Dr. teaching skills. This project was initiated with the help Domenico Veneziano (IT), Hands-on-Training (HOT) of Dr. Shekhar Biyani (GB), in close collaboration with coordinator of EUREP. ESUT and EULIS.” “A good tutor listens well to the residents he/she Added value in tutoring trains. With an open mind regarding his/her own According to Dr. Veneziano, EUREP tutors have a method of performing a procedure, a good tutor conducive network to collectively develop new inspires and encourages residents to develop their solutions and training protocols. He added, “Another own method based on evidence, experience and critical self-reflection,” said Dr. Stefan Haensel (NL). benefit of being a tutor is that every time you teach someone, you also learn something new because you’ve explored other perspectives.” Selection process How are EUREP tutors selected? Prof. Dr. Ali Serdar “Guiding the residents is a rewarding role. It’s Gözen (DE) stated that the candidates must have a exhilarating and satisfying to know I’ve contributed to surgical background, previous experience as a trainer, and scientific orientation as the ESU Training & Research the future of urology,” said Prof. Dr. Gözen. Board makes the final selection based on these criteria. The tutor experience “Every day, the tutors spend up to four hours straight Dr. Veneziano added, “The initial selection is carried in the training room. They do their best to deliver the out by the EAU Section of Uro-Technology (ESUT), EAU Section of Urolithiasis (EULIS), and the ESU through the same level of high-quality content and performance in every single session,” stated Dr. Veneziano. training group. Interested parties should contact these

At the beginning of each HOT session, the tutors sets expectations and states the learning objectives. Dr. Van Cleynenbreugel stated, “He/She explains the exercises and adapts them to the resident’s level whenever possible. The tutor gives the residents tips and tricks, and assists them if they experience difficulties. At the end of the training, the tutor assesses the residents. Were the participant’s expectations met? What was good or bad during the HOT session? What can be improved?” Dr. Haensel described what happens during a HOT session on transurethral resection: “In between the theoretical sessions of the EUREP-course, the residents are offered a 50-minute individual session with a tutor. Four fully-equipped, state-of-the-art operation sets are used for the transurethral resection training. The prostate model used is made of engineered tissue which mimics the anatomy and tissue properties a normal prostate adenoma.” HOT training beyond Europe Prof. Dr. Gözen said that urologists from outside Europe can benefit from the HOT sessions. “They will have the opportunity to undergo the European training programme in Basic Laparoscopic Urological Skills (E-BLUS) and receive the E-BLUS certificate, the most-valued certificate on basic laparoscopy.” He stated, “There is an increase in the number of urological associations, course organisers, and individual urologists who contact us. They want to be

included in the European Association of Urology, learn and benefit from our training and membership programmes. We respond to every call and email, and propose tailored training programmes for each one.” EUREP as a whole “We have the passion for the hands-on training and this propels us forward. We have excellent, standardised and verified training programmes. EUREP is our kitchen where we use ingredients such as feedback and measurable results to produce, apply and optimise our content and performance,” said Prof. Dr. Gözen. According to Dr. Veneziano, “The EUREP HOT faculty is not only made of great surgeons, but a group of friends. Right after the programme ends, we already look forward to seeing each other the following year.” “It is inspiring to have the opportunity to work with many young residents who are eager to learn operative techniques and who think out-of-the-box. Sharing this wonderful experience to more than 20 tutors experts from all across Europe, leads to a greater professional network and lifelong friendships. I’m very grateful to the ESU for granting me the honour of being a tutor,” said Dr. Haensel. Interested in being a EUREP tutor? Contact Ms. Lotte Kraaijeveld (l.kraaijeveld@uroweb. org) or Mr. Ton Brouwers (t.brouwers@uroweb.org) for more information.

EUREP17 boosts training in the Philippines High-level programme makes its way to Southeast Asia By Dr. Samuel Yrazstorza (PH) Secretary, Philippine Urological Association My colleague Dr. Juvido Agatep, Jr. (PH) and I arrived in the beautiful Dr. Samuel city of Prague to attend the 15th European Urology Residents Yrazstorza Education Programme (EUREP17), an annual gathering of senior residents for a six-day review in urology. We felt fortunate to have been invited to the programme which was made possible through the efforts of Prof. Dr. Jens Rassweiler (DE) and Prof. Dr. Ali

European Urology Today

Serdar Gözen (DE). We were there to observe the format of the hands-on training workshops so that we may get ideas and replicate it back home. The comprehensive and intensive review and training exceeded our expectations. The whole experience spurred great ideas and plans for urological training in the Philippines. The 360 EUREP17 participants were divided into five groups. Five varying modules were scheduled each day. These modules focused on topics on urologic cancers; male voiding LUTS (lower urinary tract symptoms); andrology, stones and upper tract endourology; paediatric urology, trauma and infection; and functional urology. Each module had

four faculty members; world-renowned experts who discussed the basics as well as clinical cases. The lectures were stimulating, informative and engaging. It was far better than any international lectures we have attended.

We admired at how the HOT sessions were carried out efficiently, and the availability of training tools. We hope that these could be done for our residents and practicing urologists back home as well. Someday, this might become a reality.

There were 24 stations dedicated to the HOT sessions on basic and intermediate laparoscopy skills, rigid and flexible ureteroscopy, and transurethral resection of the prostate. Coordinator of the HOT sessions, Dr. Domenico Veneziano (IT) and the rest of the faculty demonstrated concepts, actual trainings, and practical exams. They also discussed future goals and the advent of better 3D models for skills training which they observed as better than computer simulations.

Access to training programs and lack of collaboration may be the remaining hurdles to overcome in my country. But attending EUREP proves otherwise; opening a clearer and more concrete path on what the next steps will be. Being there and witnessing the programme has motivated us even more as we aspire for further optimisation of urological training in the Philippines through a closer collaboration with the EAU.

October/December 2017

Comprehensive urology training in just six days Challenging residents and enhancing their know-how By Dr. Diederick Duijvesz (NL) Canisius Wilhelmina Hospital Nijmegen This year was my chance to participate at the 15th edition of Dr. Diederick EUREP. I already knew that this Duijvesz course is a must-attend for urological residents who are in their final year. Previous attendees told me that the programme was going to be challenging – plenty of information to absorb in a relatively short time. Fortunately, the well-organised programme provided an environment conducive to learning. We all arrived on Thursday, August 31st and it seemed that everybody went to bed quite early to have a fresh start in the morning. The next day, all 360 residents were welcomed by Dr. Joan Palou who gave an overview of previous editions and the objectives of EUREP17. We were also asked to come up with a clever

name with an abbreviation for the programme. Although names from previous editions were really funny, we felt like we could come up with a better one. Each day, we had interesting presentations and discussions with leading experts. In six days, we addressed almost all urological topics such as oncology, Lower Urinary Tract Symptoms/neurogenic bladder, urinary tract infections, paediatric urology, trauma and andrology. It was a lot to process but the discussions were informative and useful. There were a lot of Hands-on-Training (HOT) facilities which were handled by enthusiastic trainers. The residents were given the opportunity to train their skills in transurethral resection of the prostate/ bladder, cystoscopy/ureteroscopy (URS) and laparoscopy (basic and intermediate). I chose to do the URS and the intermediate laparoscopy training. The trainers gave good advice and helped improve my skills.

The models used were good representations of real patients. Aside from the Basic Laparoscopy Skills (E-BLUS) exam, there was the EST-1 exam (Endoscopic Stone Treatment step 1) as well. In my opinion, these exams are useful in acquiring skills before starting with specific surgical techniques. On Sunday, the European Society of Residents in Urology (ESRU) held their annual fall meeting which I attended as ESRU Secretary. During this meeting, we had great discussions with the National Communication Officers from most European countries on varying topics such as the Resident Surveys, UROsource for residents, and the Residents Day during EAU 2018. Local issues from each country were addressed and discussed, and new plans have been made to improve the position of urology residents within Europe. After the meeting, we went to a barbecue and karaoke at Letenský Chateau. This EUREP tradition is

Essential learning, building connections New insights gained during EUREP17 By Dr. Nikola Fösel, Dr. Lauri Lalu, Dr. Inari Kalalahti, and Dr. Heli Sammaltupa (FI) A small country with only 5.5 million inhabitants and some 200 urologists, Finland had a quite large representation at EUREP this year: three residents from Helsinki and one from Oulu. Two more residents have applied albeit not selected, reflects high interest in the programme. So what makes EUREP attractive? EUREP is one of the most intensive programmes for residents covering numerous urological topics in just six days. It is based on the EAU Guidelines and prepares residents for examinations by the European Board of Urology, as well as, national examinations. A total of 360 residents from and beyond Europe met up for jam-packed programme, a special feature that makes EUREP unique.

professional experience. Prof. Morgan Rouprêt once said, “Not knowing the Guidelines will make a bad urologist, but relying on the Guidelines alone will also make a bad urologist.” The Finnish team arrived in Prague on Wednesday, 31 of August. Even though we did not all know each other and work in different parts of the country, we “met” each other via social media before EUREP17. We created the WhatsApp group EUREPFinns to stay in touch during the programme.

Being in the last year of our residency, all of us have attended EAU meetings and are familiar with the EAU Guidelines and the European Urology journal as many of us are active researchers. It was an honour to meet our heroes who talked us through the The Finnish team (from left to right): I. Kalalahti, Guidelines and offered us insights acquired from H. Sammaltupa, L. Lalu and N. Fösel

EUREP made it easy for us to meet residents from other countries. We soon discovered that the average Finnish resident is a little different from many other residents; three of us are female with a mean age of 34.7 years, 1.75 children and 0.5 horses. We also discovered differences in the structures of the various residency programmes. In Finland, urologists are, first and foremost, surgeons who undergo the same common trunk training as every other surgical specialty for a minimum of 18 months. Only after completion of the common trunk in a peripheral hospital will the resident complete their residency in a university hospital learning the ins and outs of urology. But we also discovered our similarities with the rest of the residents. We all struggle with the same worries about our careers and our futures, how to become better surgeons and which subspecialty to choose as there are plenty of great options in urology. All of us are enthusiastic about urology and dedicated to better patient care. These are what connect us. And as it was said in the closing words of the programme, we are now all part of the EUREP family.

South African representation at EUREP17 An exciting and stimulating experience By Dr. Nico Lourens (ZA) University of Pretoria

The congress covers all aspects of Onco-urology, Functional Urology, Paediatric Urology and Urogynaecology in six days which usually lasted until Having heard from colleagues who 18:00 almost daily. Residents were encouraged to ask previously attended EUREP, Dr. questions and give their opinions. Clinical cases were Laurie Blake (University of Pretoria), used to illustrate real-life situations, and often an Dr. Nico Lourens Dr. Kalli Spencer (University of the unsuspecting resident was jolted back after a long Witwatersrand) and myself decided night of discussing urology, when he or she was to apply to participate at EUREP17. We were delighted asked what the solution was for a specific case. when our applications were accepted. Our recent visit to Prague, Czech Republic for the resident programme There were many, various opportunities for was an exciting and stimulating experience. learning and amicable discussions among delegates from different countries with regard to With the long flight already behind us, we were keen experience, future plans and preparations for the upcoming exams. to stimulate our minds with EUREP17’s interactive courses and also to explore the historic city we have never been to. A central part of EUREP17 was the Hands-on Training (HOT) sessions, such as the laparoscopy and ureteroscopic lithotripsy sessions, that each EUREP 2017 brings together some of the most respected minds in urology from all over the world. resident could apply for and partake in. The

October/December 2017

an informal and fun way to meet other residents. That evening was a great social activity held mid-week. EUREP may be intensive and challenging but the programme is an excellent way to update your knowledge and work on your skills, including social skills! I highly recommend residents to apply for next year’s programme. EUREP is definitely a must-attend!

The enthusiastic ESRU team

Liked what you’ve read? Interested in EUREP 2018? If you are interested in applying for EUREP 2018 (31 August - 5 September 2018) please be aware of the following: EUREP is only for residents in their last year of training. We have a strict selection procedure therefore keep in mind the selection criteria. • Last year resident • EAU junior member • Accrue CME credits by completing MCQ’s in European Urology • First-come first served • English skills • Geographic spread • You can only participate one time in EUREP Please be aware that we only have limited places for non-Europeans Important dates • Dec 2017 – Website will open • 8 Jan – Registration opens All registrations should be accompanied by a copy of your passport and proof of status. • 1 May 2018 registration closes

good-natured competition evident among the participants encouraged excellence and was also a source of fun. One of the highlights of EUREP17 was the customary karaoke event held on Sunday at the beautiful Letenské Sady park with a panoramic view of Prague. There was a wonderful festive atmosphere. All the participants sang along to well-known songs from all over the world. The stars of the show were certainly the HOT tutors who surprised and impressed everyone with not only their singing abilities, but also with their dancing skills. It was challenging for many residents and faculty members to attend the early Monday morning sessions after having enjoyed themselves so much the previous evening. Nonetheless, the classes were full of red-eyed but attentive participants.

Approximately 15 June you will be informed if you have been selected or not. Still have questions? Please email us at eurep@ uroweb.org

It was with great sadness that the resident programme ended on Wednesday afternoon. Many contact cards were exchanged with the hope that the reunion will not be too distant, and that collaboration, hopefully soon as qualified urologists, will continue in the near future, perhaps in Copenhagen in March 2018. To all organisers and faculty members of EUREP17, thank you for what was certainly a memorable and wonderful learning opportunity.

European Urology Today

CEM17: Regional collaboration leads to gains in urology Plzenˇ hosts longest-running urology meeting in Central Europe By Joel Vega With over 700 registered participants, Plzen in Czech Republic hosted the two-day 17th Central European Meeting (CEM17) with both young and veteran urologists from at least eight countries attending the longest-running regional urology event co-organised by the European Association of Urology (EAU). CEM17 was held in conjunction with the 63rd Conference of the Czech Urological Society (CUS) with Professors Milan Hora and Marko Babjuk as Conference President and Scientific Programme Chairman, respectively. “The developments in urology in our region are not only a positive sign but also an inspiration for us to work and collaborate together. CEM as an annual event serves to unite urologists in the region and to show what has been achieved by many opinion leaders and promising urologists here,” said Hora during the opening plenary session held last October 19. Joining the local organisers were Prof. Francesco Montorsi (IT), EAU Adjunct Secretary General for Science and Prof. Jens Sønksen (DK), EAU Adjunct Secretary for Clinical Practice.

Laparoscopy training with Prof. A. Gözen (left)

“We are glad to see the growth of urology in Central Europe and this current format of the CEM is proof of the dynamic work and collaboration among local and international urologists,” said Montorsi. Babjuk, on the other hand, said the growth of urology in Central European deserves the full support from international organisations like the EAU since young urologists can benefit a lot from training, expertise and continuing medical education. Eight countries are part of the Central European region which has an estimated total of around 4,045 urologists and 990 residents, with Poland and the Czech Republic having the biggest numbers (a combined total of 2,823 urologists including residents). Other countries such as Austria and Romania account for 443 and 400 urologists, respectively, with Croatia, Hungary, Slovakia and Slovenia having smaller numbers. Issues in urological malignancies The opening plenary session highlighted urological malignancies with lectures by speakers A. Leminski (PL), Prof. Montorsi, A. Abdel-Karim (EG), M. Stanik (CZ), L. Dusek (CZ) and O. Hes (CZ) on bladder, prostate and renal tumours. Leminski, winner of last year’s Young Urologist Competition, examined the role of minimally invasive radical cystectomy. “The literature data on minimally invasive radical cystectomy seem mature enough to recommend it as an alternative for selected muscle invasive bladder cancer patients qualified for radical treatment,” he said. But he noted that high initial stage or bulky tumours with extensive nodal involvement should probably still be managed with open radical cystectomy. Montorsi discussed prostate cancer (PCa) management such as tailoring the surgical approach based on pre-operative clinical characteristics, improving post-operative results and urinary continence recovery after radical prostatectomy, and managing erectile or functional problems. Prof. Aly Abdel-Karim shared insights on laparoscopic repair of female genito-urinary fistulas as he said conservative treatment often does not provide cure. “This remains a challenge to the surgeon and operative failure represents a burden, both for the patient and surgeon,” he said. 22

European Urology Today

made of silicon which can be used by doctors to practise laparoscopy. The total costs of the DIY model amounted to only about 80 euro cents. “Surgical simulation tools can easily be created and our model is realistic, easy to make, cheap and feasible,” Sarlós said. He eventually won the competition’s first prize (See List of Winners), impressing the jury with his innovative approach.

Stanik discussed surgery in managing locally advanced and regionally metastatic bladder cancer, and looked into the role of lymph node dissection, neoadjuvant chemotherapy, and future prospects in imaging, molecular classification and emerging therapies. “Muscle-invasive bladder cancer is frequently a systemic disease at the time of diagnosis and deserves combined local and systemic treatments,” said Stanik. Patients with locally advanced and node-positive tumours, according to Stanik, “should not be neglected as many of them are still potentially curable.” Bio-statistician Ladislav Dusek (CZ) presented the incidence and survival rates of onco-urology patients in Czech Republic and said 2015 figures showed 7,049 new PCa patients, which accounts for 8.2% of all new cancer cases. Pathologist Prof. Ondrej Hes (CZ) discussed the WHO 2016 updated report on lethal renal tumours such as tubulocystic renal cell carcinoma (RCC), acquired cystic disease-associated RCC, and hereditary leiomyomatosis RCC. Management of lethal RCC patients depends on genetic tests and disease progression. “In some patients, checking family history is recommended and in cases of mutation, a close follow-up of the patient is needed,” said Hes. A well-attended live surgery featured procedures to treat urolithiases including techniques such as Percutaneous NephroLithotomy (PCNL), staged retrograde flexible ureteroscopy (FURS) and endoscopic combined intrarenal surgery (ECIRS), which was transmitted from the Ceské Budejovice Hospital and performed by surgeons A. Petrík (CZ), and T. Ürge (CZ). Follow-up sessions focused on research career opportunities and the role of scientific urological journals in education with lectures by Profs. S. Shariat (AT) and T. Drewa (PL). Shariat stressed the importance of consistent output particularly in the publication of quality research, while Drewa cited the contributions of quality journals as an educational tool. Afternoon sessions included lectures on reconstructive and paediatric urology such as urethroplasty for urethral stricture and hypospadias repair with speakers O. Dolejšová (CZ) and M. Skrzypczyk (PL). Prof. Maurizio Brausi (IT) gave the European School of Urology (ESU) Lecture on the diagnosis and management of complications after radical cystectomy (RC) such as intra-operative complications, tromboembolic events, urinary infections, post-operative surgical complications, and long-term problems. He discussed the benefits of minimally invasive techniques such as small incisions, cosmetic gains, less pain or functional impairment and fewer wound-related problems.

"Host country Czech Republic and Romania dominated the poster presentations not only in terms of submissions but also in the six available awards..." Regarding risk and predictive factors, Brausi mentioned the incidence of tumour seeding in laparoscopic and robot-assisted surgery, recurrence pattern issues and offered some tips and tricks in open RC. “I recommend surgeons to perform a simple operation and pay the maximum attention to blood loss by using clips. And use the simplest diversion you are used to. Do not try many diversions since you will have the maximum complications from each of them,” he said. Prof. Sønksen delivered the second EAU Lecture and tackled urological procedures in treating male infertility such as varicocelectomy, vaso-vasostomy, vaso-epididymostomy and Transurethral Resection of the Ejaculatory Ducts or TURED. “Couples without any other reasons of documented infertility than clinical varicocele in combination with impaired semen quality should be offered fertility treatment,” said Sonksen. He said vaso-vasostomy is indicated for men who had

Opening plenary session at CEM17

vasectomy within the last eight years and with a gynaecologically healthy partner not older than 35 years. Regarding TURED, he noted the significant gains seen in semen parameters and ejaculation patterns. Young Urologist Competition The Young Urologist Competition opened the second day with candidates tackling a wide range of topics. Alexandru Dick (RO) discussed the incidence and management of lichen sclerosus, and said proper diagnosis helps prevent disease progression to lethal penile cancer. He looked into medical, surgical and oncologic approaches including two and one-stage urethroplasties and their benefits and drawbacks.

Michal Skrzypczy (PL) compared the various surgical tools used in managing male incontinence. He said further long-term studies are needed to assess current procedures and head-tohead RTCs are necessary for evaluation. Meanwhile, Jirí Stejskal (CZ) looked into the role of mpMRI/TRUS fusion in the current PCa diagnostic algorithm. Ján Švihra Jr. (SK) took up health-related quality of life in PCa patients using a questionnaire-based survey, and described not only the challenges in questionnaire translation but also the objective evaluation that follows. Milena Taskovska (SI) described her team’s work in laparoscopic living donor nephrectomy, including donor recruitment and down to the surgical approaches and challenges such as vascular control, kidney extraction and managing donor complications.

Doris Hebenstreit (AT) presented her experience on long-term outcomes of paediatric renal transplantation in boys with posterior urethral valves (PUV). She reported good results in PUV patients compared with a control group after renal transplants. “Cystostomy is a favourable pre-transplant intervention and bladder dysfunction does not have a major impact on graft survival,” she said. Ivan Pezelj (HR) tackled a cost -benefit analysis of mpMRI-guided biopsies in Croatia and discussed the use of PIRADS and how it impacts on TRUS biopsy. “Initially, prostate mpMRI represents a significant cost in prostate cancer diagnostics. But benefit is attained by avoiding unnecessary biopsies,” said Pezelj.

Best poster presentations Host country Czech Republic and Romania dominated the poster presentations not only in terms of submissions but also in the six available awards given by Olympus and Berlin Chemie in two categories, Oncology and Non-Oncology. First prize Bogdan Sandu and his team from Bucharest won the Berlin Chemie Award for Oncology with their study on genetic biomarkers, while Petr Macek and colleagues collected the Olympus Award first prize in NonOncology for modifications in laparoscopic ureteroneostomy (See List of Winners).

Donát Péter Sarlós (HU) reported his new partial nephrectomy training model. In do-it-yourself (DIY) fashion, Sarlos recreated a tumour kidney model

CEM 17

19-20 October 2017 ˇ Czech Republic Plzen,

Innovative research and fresh insights Young Urologist Competition 1st Prize: D.P. Sarlós (HU) - New partial nephrectomy training model available to everyone 2nd Prize: I. Pezelj (HR) - Cost -benefit analysis of the introduction of mpMRI guided biopsies in Croatia 3rd Prize: D. Hebenstreit (AT) - Long-term outcome of pediatric renal transplantation in boys with posterior urethral valves Best Poster Presentations Olympus Award (Non-Oncology) 1st Prize: P. Macek et al. (CZ) - Modifications of laparoscopic ureteroneostomy 2nd Prize: C. Gingu et al. (RO) - Orthoplasty, an important part of the hypospadias cripple repair

Olympus Award First Prize Winner for Best Poster (Non-Oncology) Dr. P. Macek (right) receives his prize from Prof. Marko Babjuk

3rd Prize: G. Varga et al. (CZ) - Evaluation of urological infections in patients with multiple sclerosis – a prospective study Berlin Chemie Award (Oncology) 1st Prize: B. Sandu et al. (RO) - Genetic biomarkers related with prostate cancer: New perspectives 2nd Prize: Š. Nykodymova et al. (CZ) - Our experience with laparo-endoscopic single-site surgery (LESS) nephrectomy in clinical practice 3rd Prize: I. Minarik et al. (CZ) - Does MRI-TRUS fusion increase the detection rate of prostate cancer in primary biopsy setting in patients with PSA ≤20ng/ml?

Dr. Bogdan Sandu (2nd from left) won the first prize Berlin Chemie Oncology Award for Best Poster Presentation. Awarding the prize were (From L to R) Profs. M. Babjuk, Milan Hora and Michiel Sedelaar

October/December 2017

ERUS17: Robotic Section attracts young and experienced Close to a thousand participants in three-day robotic urology meeting in Bruges By Loek Keizer The fourteenth meeting of the EAU Robotic Urology Section in Bruges, Belgium represented an informal 10th anniversary: a return to Belgium where the first meeting of an independent ERUS took place. The scope and scale of the meeting was a clear sign that robotic urology has grown to an important pillar within urology. ERUS Chairman and, on this occasion, also local organiser Prof. Alex Mottrie (Aalst, BE) was pleased with the attendance and the quality of the diverse programme on offer. “To be honest, I’m very happy and proud. We’ve offered high-quality science and surgeons.” On the character of the meeting and robotic urology in a wider sense: “We can see that robotic surgery is maturing. This is reflected in the motto of the meeting: ‘experts of today versus the rising stars of tomorrow’. We have been able to bring new talented surgeons into our scientific programme and that proves that they are doing great.”

ways in which robotic surgical techniques are being applied to paediatric urology. She shared her experiences in a talk that set out some of the particularities associated with treating children with robots designed for adults. “So far, not many centres are using robotic surgical systems with child patients, perhaps four or five in Europe. There is a lot of improvisation involved, as it’s not easy to use full-size robots designed for adults on much smaller children,” Spinoit explained. “But I think children deserve minimally invasive technology, so that’s why we apply it anyway.”

The multitude of (planned) systems that were then presented each had unique selling points, some focusing on affordability, some on a mobile form factor, miniaturisation and almost all trying to offer surgeons a complete, multifunctional package. Human and even animal trials were still far off in The difficulties mainly involve the consequences of the most cases, with some robots first being presented in child patients’ smaller and more fragile physique. 2014 and still not available. Rather than simply being “smaller adults”, the child’s body (and organs) is still developing. There is a danger of collapsed lungs when too much insufflation pressure is applied, and the non-standard way of placing trocars, unique to every child. The newer Xi system table is not suitable for children due to its size, so urologists have to (re-)acquaint themselves with a three-armed system and much smaller cavities to operate in. So far, there is not much support from manufacturers to customize systems or approaches for use on children, so paediatric urologists like Dr. Spinoit are blazing the trail. The major paediatric procedures that lend themselves to ‘robotisation’ are pyeloplasty or other procedures that involve a lot of suturing.

Live surgery was broadcast simultaneously from three operating theatres

“The specialty is around 15 years old, so it’s only natural that there are new stars coming in. At ERUS meetings, we give visibility to all surgeons. We want to be a section that gathers all of those who are interested in robotics, it should not be a club for established big names. When I say that robotic urology is maturing, I also mean that robotic surgery is getting standardised and better because it is becoming more reproducible than it used to be.” ERUS17 was organised in conjunction with the EAU Young Academic Urologists Meeting, the Junior ERUS-YAU meeting, an extended ERUS-EAUN Robotic Urology Nursing Meeting, courses by the European School of Urology, Hands-on Training and a technical exhibition. Altogether, nearly 1,000 participants descended on Bruges on 24-27 September, making this one of the largest urology meetings in Europe. Live Surgery On the first day, Prof. Mottrie welcomed the delegates in the Bruges Concert Hall from behind his console in Aalst, pointing out the use of three operating theatres simultaneously, which allow a record-breaking sixteen cases to be squeezed into six sessions. “With this year’s programme, we’re pushing the boundaries a little bit. In earlier editions of the ERUS meeting, we went for easier indications. Now we have seen quite difficult cases, including preoperated patients, very difficultly located kidney cancers, and a wonderful example of an extended radical prostatectomy, with an extended lymphadenectomy done by Prof. Briganti.”

“As surgeons, we are in expectation of several features in future robotic systems,” Tyritzis started, listing tissue recognition/haptic feedback, augmented reality/ image guidance, a smaller footprint, affordability and automation. “The new systems need to be as good as the DaVinci systems that we have, or better, and offer new features in order to become widely adopted.”

“I’m sure that paediatric robotic surgery has the potential to be practised across Europe, and I certainly hope it will soon. The dynamic is similar to how robotic surgery was a new development some twenty years ago and it took some time to convince people. Nowadays it’s widespread and popular. Paediatric robotic surgery is only a few years behind ‘regular’ robotic surgery.” Prof. Mottrie was impressed with the talk. “Robotic urology for children is quite a rare indication, but it’s becoming more known and renowned. I feel it’s important for ERUS to push these rare indications into the urological specialty. Paediatric urology is also being practised by paediatric non-urological surgeons, but I believe that we as EAU must keep these indications in our specialty.” “We have several working groups within ERUS, one of them being paediatric urology. They have started organising the first hands-on courses in the world on this subspecialty. Dr. Spinoit is doing a great job, and with great success.” Looking to the future… Fitting for the aforementioned motto of ERUS17, the 7th Junior ERUS – Young Academic Urologists meeting asked about this upcoming generation: “Will they be using new robotic systems? Will they be ‘technology freaks’? And will they become super-specialised organ surgeons?” Dr. Alessandro Larcher (Milan, IT) presented the plans for an ERUS curriculum for robotic partial nephrectomy, based on the successful programme for radical prostatectomy. After weeks of VR, dry and wet lab training, followed by console training and scoring each phase, surgeons can master the procedure before operating on patients. This can compensate for the relatively low volume of the robotic partial nephrectomy, which is on average 60 per centre per year for the 15 most high-volume centres for this procedure.

Several forms of hands-on training were available, in this case for teams of OR nurses

Beyond surgical systems, technology has a lot to offer the future urologists. Dr. Ruben De Groote (Aalst, BE) presented a selection of recent or upcoming technological breakthroughs, including the 3D-printing of soft tissue models in order to rehearse operations, software tools like Alexa and Watson that simplify organisational duties and help surgeons make informed choices.

Some of the biggest names in robotic surgery discussed cases

with the assistance of the Firefly visual guiding system. Dr. Geert De Naeyer (Aalst, BE), chairman of the YAU Robotic Urology Working Group and Chairman of the Junior ERUS-YAU Meeting at ERUS17 was pleased with how the programme unfolded: “We had a perfect Junior-ERUS meeting, with very interesting topics, and practical advice for young urologists. Particularly the interactive case discussions on the management of complications drew a lot of comments from the audience.” “This year, the live surgery was streamed through the internet rather than satellite transmission. We were a little apprehensive about this, but it went well and it has potential. Moderation was a little different. Due to the 30 second lag, we used [mobile instant messaging platform] WhatsApp to get in touch with the surgical team, rather than simply speaking directly. This made interaction a little more complex.” “Achilles did a great job on a difficult case, clamping two of the three arteries. It looked perfect as he was finishing up and the session ended.”

The morning session ended with a live surgery demonstration by Dr. Achilles Ploumidis (Athens, GR), who performed a rather unusual partial nephrectomy

26-27 September 2017 Bruges, Belgium

www.erus18.org

ERUS18 15th Meeting of the EAU Robotic Urology Section

Robotic Live Surgery

Optimising clinical pathways with robotic surgery

5-7 September 2018, Marseille, France In conjunction with: Junior ERUS-YAU Meeting European School of Urology (ESU) Courses ESU/ERUS Hands-on Training in Robotic Surgery

· · ·

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

“As we are progressing as a subspecialty, our role is changing. In the beginning our role was instructing robotically naïve surgeons on basic technique. Now the majority of the auditorium is filled with robotic surgeons and we want to teach them how to push their boundaries.” A sign of the maturation of robotic surgery can be found in the special session for the Surgery in Motion School, which examined a great variety of approaches for surgical procedures. The School in question (surgeryinmotion-school.org) is an online platform that collects videos of the foremost surgeons and sorts Discussion at the Junior ERUS-YAU Meeting them according to organ, procedure and technique. Beyond an online presence, the platform can be used as a resource for ERUS courses and discussions. The 80 delegates present that morning were then treated to an extensive overview of the robotic systems Potential for paediatric surgery that are currently in development, some just around A further indication of the maturing of robotic urology the corner and others better treated with caution. Dr. is its expansion into new areas of medicine. On the Stavros Tyritzis (Athens, GR) pointed out the explosive morning of the 26th, Dr. Anne-Françoise Spinoit’s growth of the sector, going from $3.2 billion in 2014 to (Ghent, BE) state-of-the-art lecture concerned the a projected $20 billion a mere six years later. October/December 2017

European Urology Today

EULIS17 examines latest advances in urolithiasis From live surgeries to personalised therapy, EULIS looks into new treatment options By Erika de Groot The 4th biennial meeting of the EAU Section of Urolithiasis (EULIS17) brought new, exciting developments on the management of stone disease. EULIS Chairman Prof. Dr. Kemal Sarica (TR) and local organiser Prof. Dr. Christian Seitz (AT) welcomed 400 participants to the Austrian capital. This article provides a recap of the meeting’s highlights. Live surgeries One of the main highlights that made EULIS17 a must-attend event was the live surgeries streamed from two locations: Pforzheim (DE) and Vienna (AT). The use of modern instruments and disposables were demonstrated, in combination with new and significant research developments. On Thursday, 5 October, Prof. Dr. Sven Lahme (DE) performed a mini PNL (percutaneous nephrolithotomy) staghorn, followed by Dr. Thomas Hermann (DE) who carried out two surgeries: RIRS (Retrograde intrarenal surgery) with LithoVue™ and Super mini PCNL. Prof. Dr. Thomas Knoll (DE) concluded Day 1 with an RIRS. Day 2 of the live surgeries commenced with an RIRS robotic procedure by Prof. Dr. Jens Rassweiler (DE), followed by a PNL conventional prone by Prof. Evangelos Liatsikos (GR) and an RIRS complex stone by Prof. Dr. Olivier Traxer (FR). Prof. Palle Jörn Sloth Osther (DK) and Dr. Cesare Marco Scoffone (IT) performed ECIRS (Endoscopic Combined Intrarenal Surgery) supine and for the last live surgery for EULIS17, a Super mini PNL by Prof. Guohua Zeng (CN).

In his lecture, Prof. William Robertson (GB) concluded: “Inhibitors of crystallisation appear to have little or no effect on the nucleation of calcium salts at the high levels of supersaturation necessary for nucleation at short-time intervals (about four minutes).” FlexibleURS Regarding surgical options, Prof. Martin Schoenthaler (DE) said doctors should accurately weigh the indications for surgery as large lower pole stones may not be a preferred target for flexible ureterorenoscopy (URS). Dr. Christian Türk (AT) said that URS, including flexible URS, are first choice for larger ureteric stones and are adequate alternatives for smaller renal stones. According to Dr. Bogdan Geavlete (RO), there are “10 golden rules” to be followed when performing ureteroscopy: right patient selection; correct pre-operative diagnosis; adequate instruments (high level centres); accurate surgical technique; correct ureteral orifice negotiation and the use of safety guide wires in difficult cases; low irrigation pressure; gentle movements of instruments; always “see what you treat”; and always stop the procedure when inadequate conditions or complications appear. New PNL standards The most important factor in selecting a prone or supine approach is the experience of the surgical team, according to Prof. Andreas Skolarikos (GR). Prof. Guohua Zeng (CN) stated that Super-Mini Percutaneous Nephrolithotomy “solves all drawbacks of Mini-Perc” as it helps achieve a high stone-free rate, high-total tubeless or tubeless rate, short hospital stays, and fewer complications with no blood transfusions necessary. Prof. Liatsikos (GR) said Standard Percutaneous Nephrolithotomy (PCNL) should be regarded as the gold standard treatment option for large renal calculi as it combines acceptable morbidity with excellent stone-free rates. In his lecture, Prof. Dr. Sarica recommended that a modified Clavien classification should be established to monitor PNL outcomes following validation in prospective studies.

Always a full house during the live surgeries

Special considerations in endourology Dr. Noor Buchholz (DE) said that patients with cardiovascular stents and heart valves constitute a unique risk group. He advised that input from a specialist(s) should always be sought.

Mr. Bhaskar Somani (GB) stated that there is an Stone disease updates overall rise in treatment for stones in solitary kidney. Prof. Peter Alken (DE) cited a study which showed that It has been shown that URS is associated with a lower only 2.7% of registered urological studies were risk of major complications, and PCNL for large stones dedicated to urolithiasis. “What should be the next In shows a higher risk of complications. terms of research? Biopsies from the renal papilla,” Alken said. “We should also study biomineralization.” Prof. Athanasios Papatsoris (GR) cited findings from "Review on diagnosis and management of urolithiasis in According to Prof. Dr. Walter Ludwig Strohmaier (DE), pregnancy: an ESUT practical guide for urologists” compared to calcium oxalate urolithiasis, papillary which stated that urolithiasis during pregnancy needs calcifications uric acid urolithiasis is less important in careful multidisciplinary management to achieve a the pathway of stone formation. good outcome for both the mother and the foetus. Advanced ureteroscopy should aim at complete removal of fragments or creation of “micron-size debris” stated Asst. Prof. Martin Schoenthaler (DE). He added that novel technologies for removal of fragments are possible solutions.

URS/RIRS updates According to Prof. Dr. Jens Rassweiler (DE), the use of Holmium-laser for stone disintegration has improved. This allows dusting and fine-fragmentation thus reducing the amount of fragments to be extracted.

Meanwhile, Prof. Hammad Ather (PK) discussed how PROMIS pain measures are responsive to the phase of care during symptomatic stone events.

Dr. Alberto Breda (ES) stated that formalizing the technical approach is fundamental in optimizing the efficiency of holmium laser lithotripsy of renal calculi.

Prof. Dr. Christian Seitz (AT) said: “Meta-analyses based on small, single centre trials should be interpreted with caution; and hypotheses should be generated for more reliable randomized controlled trials rather than providing the best possible evidence.”

On personalised endourology, according to Mr. Kamran Ahmed (GB) the ideal endourology simulator does not exist. He emphasised that a combination of various bench top models should be used to achieve the “ideal simulation experience”.

Understanding stone formation According to Dr. Jan Halbritter (DE), CaOx-lithiasis is the most common of renal stones and a few monogenic forms may be underestimated in prevalence, notably in adults. Dr. Pietro Manuel Ferraro (IT) stated that macromolecules in stone matrix and urine might play a role in CaOx stone formation. 24

European Urology Today

In his lecture Mr. Samih Al-Hayek (GB) mentioned the rapid improvement of technology with an array of different instruments and that treatment of stones should be individualised according to patient, who should also be involved in decision-making. On metabolism Dr. Florian Kurtz (DE) advised that patients should maintain a generous fluid intake, allowing for a 24-hour urine volume > 2.5 liters.

It is possible to reduce new stone formation through lifestyle advice, whether general or based on screening, according to Prof. Dirk Kok (NL). He added that coaching greatly enhances success and could be streamlined by also focusing on recurrent stone formers, using self-analysis tools and using e-health and mobile-health technologies. Infectious complications “Treat symptomatic and special risk groups preemptively,” said Dr. Andreas Bourdoumis (GR). He said that as part of the prevention regimen, there should be complete stone clearance and antibiotic prophylaxis guided by stone culture and microbiologist guidance. Meanwhile, Dr. Panagiotis Kallidonis (GR) said that drug-eluting stents (DESs) have a high potential to reduce the incidence of infectious complications of ureteral stents. Shock Wave Lithotripsy (SWL) In his lecture on SWL, Dr. Tzevat Tefik (GR) recommended the following: a CT scan seems to be an unavoidable imaging modality in patient counsel for stone treatment; use a Smart CT software to predict the fragmentation Shock Wave Lithotripsy (SWL); and patients with renal stones require repeated studies (cumulative radiation burden should be kept in mind when deciding upon the appropriate imaging method). Asst. Prof. Andreas Neisius (DE) said that with little prior knowledge on the biological effects of shock waves on human tissues, the design of the firstgeneration HM3 lithotripter offers numerous benefits. Stone physiology Dr. Alberto Trinchieri (IT) stated that the prevalence of uric acid stones should be evaluated by combining general stone prevalence and uric acid frequency; and that climate is a major determinant of the epidemiology of uric acid stones.

EULIS17

5-7 October 2017 Vienna, Austria

According to Prof. Dr. Sarica, the incidence of kidney stones in children is increasing. Hypocitraturia, hypercalciuria and hyperoxaluria are the most commonly observed underlying metabolic causes. Dr. Ahmet Yaser Müslümanoglu (TR) said there is nearly a five-fold increase in paediatric stone disease incidence and children are more vulnerable to ionizing radiation than adults. “Minimally invasive techniques, which includes SWL, PCNL, RIRS methods and conservative medical expulsive therapy in children is as safe and effective as in adult patients,” said Müslümanoglu. “Children with urinary stone should be given complete metabolic evaluation.” Asst. Prof. Emrah Yuruk (TR) concluded that radiation should be avoided as much as possible during procedures. He added that miniaturization of the tract may help decrease complication rates, particularly bleeding; and that the balance between tract size and success rate should be considered. EULIS/ERA-EDTA joint session During the joint session of EULIS and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) , Dr. Pietro Manuel Ferraro (IT) stated that epidemiology data was consistent in showing the risk of chronic kidney disease/end-stage renal disease is twice as high for stone formers. According to Prof. Robert Unwin (GB), low calcium diet or loss of carbonic anhydrase II plus saponification (short or blind loop, pancreatic insufficiency, malabsorption, bile salts) lead to increased absorption (enteric hyperoxaluria). HOT courses

Dr. Shabbir Moochhala (GB) said that the main cause of idiopathic hypercalciuria is reduced renal reabsorption of calcium (distal tubule). Prof. Dr. Roswitha Siener (DE) enumerated potential risk factors of idiopathic and secondary hyperoxaluria such as high dietary oxalate intake; intestinal hyperabsorption of oxalate; low dietary intake of calcium and magnesium; n-6 / n-3 fatty acid intake; and lack of colonization with Oxalobacter formigenes. According to Prof. Dr. Walter Ludwig Strohmaier (DE), plaques and plugs play the key role in the formation of idiopathic calcium oxalate stones. He also mentioned that cellular injury by several mechanisms (e.g. oxidative stress) initiate CaP (calcium phosphate) deposition in the papilla. Mr. Simon Choong (GB) said more than a hundred chemical components were identified in stones and more than a hundred different aetiologies may be involved in stone formation.

Participants test their skills during EST s1 course

The Hands-on Training (HOT) course “Endoscopic Stone Treatment step 1 (EST s1)” of the EULIS17 programme was designed to boost the proficiency skills of participants in the treatment of urinary stones with endoscopic techniques.

The course consisted of basic HOT courses carried out under the guidance of experienced tutors; a set of four dry lab exercises developed and validated by the On paediatric stone therapy European School of Urology training group in Dr. Florian Kurtz (DE) presented the lecture of Dr. Michael Straub (DE) which concluded that age matters collaboration with the EAU Section of Uro-Technology with regards SWL, as results in children are still better and EULIS; the EST s1 examination and certification; and the online theoretical course. than in adults; but age is irrelevant in endourology.

Abstract Winners

EULIS17

5-7 October 2017 Vienna, Austria

Dr. Marcos Cepeda (ES) and his team collected the Clinical Research Award for their work “Ultrasound and miniperc for a safe access to the upper calyx in supine position: Our experience”. Dr. Amelia Pietropaolo (IT), and colleagues, were granted the Best Paper from Literature Award for their research “Role of simulation in ‘Urolithiasis intervention (URS and PCNL) as reflected by the publication trend over the last 2 decades”. Dr. Halbritter (centre) receives the Basic Research Award

Three prizes for clinical and research work and the best paper in literature were awarded during the meeting. Dr. Jan Halbritter (DE), and colleagues, received the Basic Research Award.

Get all EULIS17 resources Gain access to EULIS17 presentations, recordings of the live surgeries, abstracts and more via UROsource, the single largest knowledge base available today in urology. Visit www.uroweb.org/ urosource/ for more information.

October/December 2017

PCa17: Update meeting exposes gaps in clinical practice Vienna hosts first update series in onco-urology By Joel Vega With the long list of meetings and educational courses organised by professional organisations one is prompted to ask what the added value is of yet another meeting. The EAU Update on Prostate Cancer (PCa17) held in Vienna from September 15 to 16 gathered more than 300 participants (including faculty and exhibitors), and the diverse background, experience and motivations of those who attended reflected why a meeting with a different format can still deliver specific learning goals. “PCa17 is not just another update meeting but serves the goal to measure the depth and reach of knowledge of the participants regarding prostate cancer management. This is unique in the sense that participants interact with the faculty in a direct and comprehensive way,” said European School of Urology (ESU) Chair Prof. Joan Palou (ES) and meeting co-chairman Prof. Manfred Wirth (DE). Palou also thanked Profs. S. Joniau, A. Meserburger, N. Mottet and A. Briganti for their excellent collaboration in the Scientific Programme. Unlike in meetings where the emphasis is on didactic learning, PCa17 slightly turned the tables around by challenging participants to re-examine their comprehension and actual use of recommended guideline protocols vis-à-vis emerging or prospective diagnostic and treatment procedures. In two days, four update sessions preceded the breakout group and case discussions with the agenda topics covering Diagnosis & Staging (Session 1), Local Treatment (Session 2), Systemic Treatment (Session 3) and Future Perspectives (Session 4). With a 40-member faculty, the 270 participants were split into four groups. Using digital voting, two faculty members presented carefully selected real-life cases for discussions as basis in assessing the knowledge of participants regarding guidelines and to prompt practical problem-solving decisions.

(SE). Following their lectures, participants went into case discussions for the rest of morning with supplementary and informative talks by the moderating faculty covering topics such as patient selection for biopsy, use of imaging after prostate biopsy and active surveillance issues, among others. The voting responses of participants yielded insights varying from conservative treatment decisions to the more modern, and technology-oriented surgical and medical therapies. The faculty often noted that some answers reflected current or actual practices that are not in line with guideline recommendations.

Selected Key Messages • “Screening can save lives, and the PSA test is very useful as an initial risk stratification tool,” M. Roobol on PCa screening

PCa17 Opening plenary session

treatment of castration-resistant prostate cancer, bone Dr. James Mensah, a young urologists from Ghana, for health-related issues in advanced PCa, managing side instance, said that in Session 1 which tackled best effects of systemic treatment, salvage local treatment, practices in diagnosing and staging PCa, he consider radiotherapy, management of urinary incontinence it a challenge to diagnose the cancer which would kill and erectile dysfunction, and technical aspects of the patient and predict the biological behaviour of the open and robotic radical prostatectomy. tumour. In the last session, Prof. M. Wirth gave an update on “There are discussions on tumour volume in risk biomarker use and prospects in genome research. assessments. Average prostate sizes in black are “The future of medicine lies in comprehensive bigger than whites, so the sensitivity of biopsy is approaches for marker selection and evaluation such lower in my environment. When we take lower as artificial intelligence, neuronal networks, and tumour volumes there is a risk that we may miss the machine learning,” said Wirth as he reiterated that cancer or under-sample it. I realize that we shouldn’t validation is necessary. “There are numerous just adapt Western guidelines but instead specifically promising biomarkers but independent, prospective look at the evidence behind these guidelines, and see validation is needed,” he said whilst noting that the if it applies to us,” Mensah said (See Sidebar Story). future of PCa biomarkers hinges on single-cell analysis, liquid biopsies, and “omics” which at Future perspectives several levels are made feasible due to cost reduction With two sessions focused on local and systemic for high-throughput analysis and new analytical treatments, participants went through a approaches. comprehensive update review on topics such as Prof. Nicolas Mottet (FR), chair of the EAU Guidelines Working Group on prostate cancer, threw a challenge to participants when he said that although the guidelines should not be taken as having the last word or is “not the Holy Book” and cannot cover every single clinical situation, he urged participants to master the guidelines. He said he was taken aback to learn that some responses in the voting included practices that are no longer “standard” and yet are apparently performed as routine practices.

In the first plenary session on diagnosis and staging, prostate cancer screening was discussed by M. Roobol (NL), do’s and don’ts in diagnosis by H. Van Der Poel (NL), patient-tailored staging by N. Tunariu (GB), and Participants use digital voting systems during the case active surveillance timing and strategies by J. Stranne discussions

“Know the guidelines like a pro so you can break them like an artist…Guidelines will only have added value if we use them,” Mottet said.

• “We can expect several developments in the field of biomarkers and there are promising biomarkers for PCa at all molecular levels such as in proteomics, transcriptomics and genomics,” M. Wirth on future biomarkers • “Current PET tracers are an improvement and there clearly remains a need for more sensitive and specific tracers.” J. Walz on future functional imaging • “Some oligo-metastatic cancers progress slowly and can be a separate entity. Local therapy (RP and RT) seem safe and reduce the need of palliative treatment. M. Brausi on treating oligometastatic PCa • “One challenge to holistic care is the lack of integration in treatment and care and organized patient support groups. What we need are correct costs/efficacy and to deal with complementary, integrative medicine.” L. Denis on patient-centred care • “Our therapies should be complementary not mutually exclusive. Depending on disease severity, the range extends from active surveillance, focal therapy to whole gland treatment.” M. Emberton on future of local therapy

15-16 September 2017 Vienna, Austria

Learning goals and expectations Dr. Stefan Czarniecki (PL), Resident Urologist My expectations This update meeting reminded me of the EUREP format with the rotating faculty which allows engagement and better learning. I expect to have updates about recent developments on very specific areas of PCa management. For office urologists like me an immersive review like this is valuable. A challenging issue in PCa diagnosis (Session 1) There are ongoing discussions on the role of MRI, pre-biopsy, the expanding role of PSMA and other markers, PET imaging, the role of molecular and genetic biomarkers in primary and secondary biopsy decisions are among the topics. What I observe is that guidelines are more conservative than clinical practice. The interactive voting has demonstrated that the audience is adopting prostate MRI earlier than guidelines recommended use despite good quality evidence. Key message I picked up (Session 1) We really do not know what the role of molecular, genetic and imaging biomarkers is in prostate biopsy decision. We have entered a new field of options and we’re learning which ones to choose.

Dr. John Ochai (GB), Senior Urologist My expectations I am a co-member of the MDT oncology meeting in my hospital and most of the issues we confront every week are about prostate cancer. Many of our elderly patients have prostate cancer and the issues we face every day are being addressed in this meeting such as biopsy, active surveillance and watchful waiting. I come to this conference to get an update and learn new things. A challenging issue in PCa local treatment A high PSA doesn’t mean one has prostate cancer. One high PSA is not reliable as Prof. Hamdy has said since it may go down again. One has to combine it with clinical examination such as DRE, and probably imaging which will guide you whether you have to do a biopsy or not. Key message I picked up (Session 2) The risk calculator is very important, although it’s something that I don’t use too much. But I think every GP should have a risk calculator to minimize unnecessary referrals. We have patients who are 90 years old with a PSA of 9.7 or even less, whose risk wasn’t even calculated.

Dr. Bela Koves (HU), Mid-career Urologist My expectations Systemic treatment will be covered and based on yesterday’s sessions this is a good format with small, very interactive discussions. I am very interested in two topics: combined and systemic hormonal treatment for hormone-sensitive prostate cancer patients. The other one is prostate-targeted treatment in oligometastatic patients. Key challenge in systemic treatment (Session 3) We have many new agents we can use and urologists need to be updated regarding the treatment, and which sequel and indications to use as guide because our options have become complicated in recent years. Today, we have some options to give treatment even in cases of oligometastatic patients that are still experimental. But I’m very interested what I can find. Key message I picked up (Session 3) That we have to wait for the ongoing results to be able to choose between abiraterone and docetaxel added to hormone therapy in hormone-sensitive patients, so that we can see which is more effective. The second message is correct timing and sequence for mCRPC patients is the key. We have to follow the literature and be regularly updated.

Value of guidelines is in using them “Know the guidelines like a pro so you can break them like an artist… Guidelines will only have added value if we use them.” - Prof. N. Mottet October/December 2017

Dr. Mieke van Hemelrijck (UK), Epidemiologist My expectations To get a complete overview of where we are now in prostate cancer management in a very efficient time setting because it’s only two days and it covers the whole spectrum of prostate cancer care. My expectations were met because I have a research team who work on a variety of prostate cancer studies both quantitative and qualitative. It’s good to get an overview of where the different sub-sections are in prostate cancer research. I took photos of some of the slides and sent my notes straight away to the team, so all of them got something from me over the last two days. A challenging issue in PCa biomarkers The declining costs in genomic testing as mentioned in the lectures. I think the breakthrough lies in multi-disciplinary collaboration among wet lab scientists, statisticians, mathematicians and epidemiologists. As an epidemiologist, I am interested in the need to work with mathematicians and develop new techniques to handle all these data which can lead to personalized medicine. Key message I picked up (Session 4) In essence the medical community is appreciating and understanding now that there is a need to work with mathematicians, statisticians and epidemiologists and for us to develop new techniques. It is interesting to see that urologists, for instance, are moving beyond the more standard techniques, and that they’re accepting the need for multi-disciplinary research and really working on new analytical methods.

European Urology Today

Why do urologists need to master nocturia management? Flawed understanding of nocturia can lead to incorrect management Dr. Markos Karavitakis Athinaiki Clinic Dept. of Urology Athens (GR)

markoskaravitakis@ yahoo.gr

Prof. Marcus Drake Bristol Urological Institute Southmead Hospital Bristol Dept. of Urology Bristol (UK) Marcus.Drake@ nbt.nhs.uk

metabolic disturbances. A meta-analysis conducted by Table 1: Summary treatment recommendations of the EAU Fan and colleagues found that nocturia was Guidelines panel on non-neurogenic Male LUTS 2017 associated with a 22% increase of all-cause LE mortality5. Treatment should aim to address underlying causative factors, which may be behavioural, 4 Accurate assessment of nocturia should be initiated systemic condition(s), sleep disorders, lower urinary tract dysfunction, or a combination of factors with a careful history and physical examination, Lifestyle changes to reduce nocturnal urine volume and episodes of nocturia, and improve sleep 3 which should not be limited only to the urinary tract quality should be discussed with the patient but should consider all body systems that could Desmopressin may be prescribed to decrease nocturia in men under the age of 65. Screening for 1a influence urine output. Appropriate clinical hyponatremia must be undertaken at baseline, during dose titration and during treatment. assessment and management requires a beyond1b 3 urology approach . A dogmatic perspective of nocturia α-1 adrenergic antagonists may be offered to men with nocturia associated with lower urinary tract symptoms as a lower urinary tract symptom and consequently Anti-muscarinic drugs may be offered to men with nocturia associated with overactive bladder 1b erroneous treatment of a presumed lower urinary 5α-Reductase inhibitors may be offered to men with nocturia who have moderate-to-severe LUTS 1b tract disease might miss the window of curability of a and an enlarged prostate (>40 mL) serious condition in which nocturia may manifest as an early symptom. Presumption of nocturia as a lower PDE5 inhibitors should not be offered for the treatment of nocturia 1b tract symptom, potentially, might be dangerously A trial of timed diuretic therapy may be offered to men with nocturia due to nocturnal polyuria. 1b misleading6. Screening for hyponatremia should be undertaken at baseline and during treatment. Agents to promote sleep may be used to aid return to sleep in men with Nocturia. 2 Mechanisms LE: level of evidence; GR: Grade of recommendation; PDE5: Phosphodiesterase type 5; *: upgraded on panel The underlying pathophysiologic process of consensus nocturia can be regarded as comprising five categories:

GR A* A* A B B C B C C

Consider this scenario: a 75-year-old man, presenting to his general practitioner, complained of nocturia 1) Global polyuria 2) Nocturnal polyuria underlying pathophysiology of the disease. (three voids at night), weak stream and prolonged Global polyuria is defined as a more than 40 ml/ Management of nocturnal polyuria depends on micturition. Physical examination was unremarkable, kg/24h urine output7. This overproduction of urine the underlying disease. Therefore, identification, Erroneous perception of nocturia exclusively as an and ultrasound revealed a 65 cc prostate with occurs during both day and night, leading to if possible, of the cause is a key step to expression of lower urinary tract dysfunction can be post-voiding residual volume of 25 cc. His PSA was increased frequency throughout the diurnal cycle. appropriate personalised patient management. misleading and can have serious implications for the 2.4 ng/ml and maximum flow rate (Qmax) was 9 ml/ Potential causes of global polyuria include poorly Aetiology-directed treatment might include appropriate management of the patients. Specifically, controlled diabetes mellitus, diabetes insipidus continuous positive airway pressure therapy in a urologist who is not alert to the systemic sec. His treating physician prescribed him a course of and primary polydipsia. cases of obstructive sleep apnea, adequate contributors may miss the opportunity to identify a α1 blocker. control of congestive heart failure, compression serious condition, and might proceed to an 2) Nocturnal polyuria therapy in case of peripheral oedema etc. interventional therapy which may risk harm while Six months later, nocturia persisted and he was The International Continence Society defines failing to bring benefit. referred to a urologist who suggested prostate nocturnal polyuria as a proportion of the 24-h 3) Lower urinary tract storage dysfunction surgery. The operation was “successfully urine generated while asleep of more than 33% In that sense, the urologist has a key role in deploying performed” but there was no improvement in Treatment of storage dysfunction should be (20% for patients below the age of 65)8. Causes of the appropriate diagnostic approach and treatment nocturia. Three months later, he had a fall and hip cause-specific and might include therapy tailored nocturnal polyuria include impaired circadian strategies, using specialist colleagues as needed for fracture when he woke up at night to void. His to relieve bladder outlet obstruction such as arginine vasopressin secretion, increased each individual patient. The use of a bladder diary clinical course deteriorated from an underlying administration of α1 adrenergic blockers, secretion of atrial natriuretic peptide due to congestive heart failure, which had not been 5-α-reductase inhibitors or surgical procedures for test is at the centre of management of the patient in congestive heart failure or obstructive sleep our clinical scenario, and all cases of nocturia. recognised as a factor in his nocturia. The benign prostatic obstruction. The European apnoea, chronic kidney disease, peripheral opportunity for timely diagnosis was missed, and he Association of Urology Guidelines Panel for Male oedema (e.g. venous insufficiency, liver failure, References died within one year. non-neurogenic LUTS, recognising nocturia as a congestive heart failure), diuretics and excessive key challenge, has recently published a systematic 1. Bosch, J.L. and J.P. Weiss, The prevalence and causes of intake of fluid before bedtime. nocturia. J Urol, 2013. 189(1 Suppl): p. S86-92. The above real-clinical-practice scenario demonstrates review to highlight the current state of medical the potential influence of non-urological factors in the 2. Tikkinen, K.A.O., et al., Is Nocturia Equally Common treatment of nocturia in men with lower urinary 3) Lower urinary tract dysfunction Among Men and Women? A Population Based Study in appropriate management of nocturia and highlights tract symptoms10. This meta-analysis showed that The pathophysiological mechanism underlying antidiuretic therapy using titration is more effective the importance of mastering the management by the Finland. The Journal of Urology, 2006. 175(2): p. 596-600. nocturia due to storage dysfunction is the than placebo in relation to nocturnal voiding 3. Gulur, D.M., A.M. Mevcha, and M.J. Drake, Nocturia as a urologist of such a common condition. mismatch between bladder capacity and frequency and duration of undisturbed sleep10. manifestation of systemic disease. BJU Int, 2011. 107(5): p. production of urine. Causes that might attribute Nocturia is a very common condition which is 702-713. to bladder storage dysfunction include benign erroneously thought of as an age-related disease, 4) Sleep disturbances 4. Parthasarathy, S., et al., Nocturia, sleep-disordered prostatic enlargement, detrusor overactivity, even though it affects all age groups. It is estimated Patients with nocturia due to sleep disorders breathing, and cardiovascular morbidity in a communityinflammatory (infective or interstitial cystitis, that nearly 20% of the younger population regularly might benefit from behavioural therapy, or based cohort. PLoS One, 2012. 7(2): p. e30969. radiation etc.) and extrinsic compression of the wake up to void at least twice each night while nearly sleep-promoting agents. 5. Fan, Y., et al., Meta-analysis of nocturia and risk of bladder. half of the population older than 50 years old all-cause mortality in adult population. International 5) Mixed disorders Journal of Cardiology, 2015. 195: p. 120-122. experience two or more nightly voids1. Nocturia affects 4) Sleep disturbances both sexes. Tikkinen and colleagues identified that 6. Drake, M.J., Should nocturia not be called a lower urinary tract symptom? Eur Urol, 2015. 67(2): p. 289-90. women in the age group between 18 and 29 years old Sleep disturbances and nocturia are interrelated. This category of patients might represent a Sleep disorders can be primary (insomnia and challenging situation, where a multimodal were nearly 10 times more likely to have nocturia than 7. Abrams, P., et al., The standardisation of terminology of parasomnias), or secondary (e.g. due to chronic interdisciplinary approach is appropriate. lower urinary tract function: report from the men of the same age2. heart failure, psychiatric disorders, medications Combination treatment strategies might be thought to Standardisation Sub-committee of the International etc.) result in better clinical outcomes in such situations, Nocturia is one of the most bothersome lower urinary Continence Society. Neurourol Urodyn, 2002. 21(2): p. though in reality response is often poor. tract symptoms (LUTS) for both men and women. 167-78. 8. van Kerrebroeck, P., et al., The standardisation of However, categorising nocturia as a LUTS overlooks the 5) Any combination of the above The role of the urologist in managing nocturia is thus very high proportion of people for whom nocturia terminology in nocturia: report from the Standardisation to serve as a broker for onward referral of cases reflects systemic illness, behavioural influences or sleep Assessment Sub-committee of the International Continence Society. A thorough medical history and clinical examination where systemic conditions are contributory, to disorder. In these people, nocturia may be better Neurourol Urodyn, 2002. 21(2): p. 179-83. improve inappropriate behavioural factors categorised as a systemic symptom3. Sleep insufficiency should make note of any known medical condition, 9. S. Gravas , T.B., M. Drake, M. Gacci, C. Gratzke T.R.W. and should consider the potential presence of a (injudicious fluid or salt intake), treat contributory caused by nocturia may have a detrimental effect on Herrmann, S. Madersbacher, C. Mamoulakis, K.A.O. condition in its early stages, not yet diagnosed by the lower urinary tract dysfunction, and consider patients’ comfort, physical functioning, mental health, Tikkinen, EAU Guidelines on Non-Neurogenic Male LUTS patient’s doctor. Use of a bladder diary is an essential symptomatic management (notably desmopressin). productivity and quality of life. including Benign Prostatic Obstruction Edn. presented at tool in the assessment of nocturia. It is a simple, the EAU Annual Congress London 2017. 2017, EAU reliable and objective diagnostic test that allows In conclusion, despite the high prevalence and its Despite its prevalence and impact on quality of Guidelines Office: Arnhem, The Netherlands. proper categorisation of the patient in one of the profound impact on quality of life, nocturia remains life, most people affected by nocturia are reluctant 10. Sakalis, V.I., et al., Medical Treatment of Nocturia in Men general categories. Additional tests may need to be problematic both in diagnostic and therapeutic to report or discuss their symptoms. with Lower Urinary Tract Symptoms: Systematic Review chosen based on the initial assessment, to hone in on decision-making arenas. This is compounded by our Embarrassment, uncertainty about treatment by the European Association of Urology Guidelines Panel possible causes9. Referral to another specialist might lack of understanding of the complexity of the availability and perception that nocturia is an for Male Lower Urinary Tract Symptoms. Eur Urol, 2017. also be considered when the underlying disorder is inevitable part of the aging process are all non-urological9. contributing factors leading to the under-reporting of nocturia. For this reason, practitioners should Treatment pro-actively inquire about nocturia in any routine Once simple behavioural factors have been dealt with, urological assessment. treatment strategies should be based on the underlying aetiology. Therapy recommendations of Besides its impact on quality of life, nocturia is the EAU Guidelines panel for Male LUTS are potentially associated with impaired physical health, summarised in Table 1. and hence increased morbidity and mortality. The Make sure we have your up-to-date address details! Sleep Heart Health Study demonstrated association 1) Global polyuria between nocturia and hypertension, cardiovascular Log in to your My-EAU account on uroweb.org to Management of global polyuria should be related disease and stroke4. Several lines of evidence have update your e-mail and correspondence addresses. to the underlying condition, and is likely to need associated reduced sleep quality with depression, relevant specialist input. This might include obesity, type 2 diabetes mellitus and various other appropriate glycaemic control in the case of www.uroweb.org/My-EAU diabetes mellitus, or management of diabetes EAU Section of Female and Functional Urology insipidus. 26

European Urology Today

October/December 2017

EUSP Fellowship Report Innovative research environment at the Netherlands Cancer Institute Dr. Teele Kuusk Tartu University Hospital Dept. of Urology Tartu (ES)

teele.kuusk@ gmail.com

I am beyond words in gratitude to my mentor Dr. Bex who accepted me to be his fellow and supported and helped me with the EUSP clinical fellowship, initially, for a month, and which was later extended to a full year clinical research fellowship. I was extremely fortunate that Dr. Bex gave me ideas, projects and inspired and guided me from the very beginning. Thanks to him, I was able to attend also clinical work. Furthermore, the staff conducted morning ward rounds and multidisciplinary meetings in English which made communication very easy. I experienced very warm hospitality and friendliness.

I was fortunate to be granted a European Urological Scholarship Programme (EUSP) fellowship for a year under the comprehensive supervision of Dr. Axel Bex.

I also realised how important it is to receive training in an expert centre. Learning starts from the environment: people, their values and attitude. The Netherlands Cancer Institute – Antoni van The vast expertise, wisdom and dedication are only Leeuwenhoek hospital (NKI-AVL) was established in a few words that describe my supervisor Dr. Bex and 1913 as a cancer institute with a focus on innovative all the other urologists in the institute. Highly skilled research. It is a dedicated cancer centre and is surgeons and excellent research have made the officially accredited as a Comprehensive Cancer Center institute one of the best uro-oncology centres in by the OECI being a global leader with significant Europe. I had the opportunity to see rare urological expertise in basic and translational cancer science. cancer cases and their management. Innovative The institute plays an important role both nationally approach, skill and dedication not only lead to the and internationally as a centre for scientific and best treatment options available, but also provide an clinical expertise, development and training. inspiring environment for fellows. Furthermore, all Multidisciplinary teams of surgeons, oncologists, the urologists are excellent teachers who take their radiologists and nurses work closely together to offer time and patience and kindly share their knowledge the best possible care. The hospital is recognised by and skills with the residents and fellows. its distinguished urologists: Dr. Axel Bex, Prof. Simon Horenblas, Dr. Henk Van Der Poel, Dr. Bas Van Rhijn, A regular working day would start at 7.30 or 8 o'clock, Dr. Kees Hendricksen and Dr. Esther Wit, who are all depending on the meeting schedule. My usual day outstanding surgeons and researchers. The urology started with a research project, which involved data department is an academic teaching and expertise collecting, analysis and writing manuscripts or division and also certified as an ERUS robotic host attending the operations. Every week there were centre. multidisciplinary meetings for all urological cancers and also virtual multidisciplinary meetings with other hospitals. Besides, there were research group European Urological Scholarship Programme Office meetings where new projects and ongoing projects

AVL-NKI urologists: (from left) Dr. Axel Bex, Dr. Henk Van Der Poel, Dr. Esther Wit, Dr. Kees Hendricksen, Prof. Simon Horenblas, Dr. Bas Van Rhijn

were discussed. One afternoon was dedicated to the following week’s operation plan where the indications and technical aspects were reviewed. In addition, there were staff meetings where division development and difficult patient cases were discussed. In 2016, NKI urologists performed 976 surgical procedures of which 345 were related to prostate cancer, 310 to bladder/urothelial cancer, 120 to penile cancer and 75 to renal cancer. Since the centre is a tertiary referral hospital, the cases were usually difficult cases which could not have been managed elsewhere. It made the operations extremely challenging and fascinating. The centre is also well-known for its expertise in lymph node dissection in different settings and sentinel lymph node projects with Prof. Horenblas, who is known as a pioneer in SLNB in penile cancer. Besides skilful surgical performance, the urologists have a great sense of humour, which helps in achieving efficient teamwork and performance. I would like to emphasis the outstanding tutorial skills of Dr. Bex who engaged me in his research

projects and clinical work. Despite the hectic schedule, he always found time to provide guidance and encouragement. The time spent for scholarship has been very efficient and productive. We published many articles and won a poster prize at the EAU17 Annual Congress in London for our main research topic: Lymphatic drainage from renal tumours: A prospective sentinel node study using SPECT/CT imaging. I remain heartfelt grateful for the trust, inspiration and valuable training I received under the mentorship of Dr. Bex who shared his expertise in renal cancer management. I would sincerely like to express my gratitude towards all the institute’s urology staff members: Prof. Horenblas, Dr. Van Der Poel, Dr. Van Rhijn, Dr. Hendricksen and Dr. Wit for their time and teaching. My appreciation also to the excellent expert nurses: Corinne Tillier, Jolanda Bloos, Eva Offringa, Erik Van Muilekom and my EUSP co-fellow Nikolaos Grivas and the fellows and residents. I am indebted to the EUSP for this scholarship, which provided a very educational, inspiring and valuable year at AVL-NKI.

A memorable EUSP fellowship Rewarding clinical scholarship at SLK-Kliniken Heilbronn Dr. Çaglar Yildirim Resident, Dept. of Urology Fatih Sultan Mehmet Research & Training Hospital Istanbul (TR) c_yildirim_87@ hotmail.com The Department of Urology of the SLK-Kliniken Heilbronn, Baden Württemberg, in Germany is a urological centre of excellence in several urological fields, especially in robotic and laparoscopic surgery. The department is chaired by Prof. Dr. Jens Rassweiler who helped develop laparoscopic and robotic surgeries as part of the training centre. Besides his extensive experience in the robotic field, he is also an excellent surgeon and a very good teacher. I spent a six-week training EUSP scholarship at SLK Kliniken from July 31 to September 9 this year. SLK Kliniken offers robotic and laparoscopic surgery training using Da Vinci robotic surgery, allowing surgeons and their teams to learn new surgical techniques and share their skills with colleagues back in their own hospitals. The SLK Kliniken training encompasses theory and practice and is provided by expert instructors with practical experience. They use the technology in several clinical applications with the results reported and reviewed. Moreover, trainees can also experience live surgery with this excellent team.

for me to be included in current clinical researches and live operations. I was very lucky since I attended most of Prof. Rassweiler’s surgical operations as a bedside assistant.

On weekends I visited nearby towns and museums. During the last few days of my stay, there was a wine festival in Heilbronn and I and the other fellows enjoyed the event.

There are two Da Vinci robots at the SLK Kliniken, the models Si and Xi. I consider it a wonderful chance to be part of a robotic training centre since I had a limited number of opportunities to observe robotic surgeries. Moreover, actively participating in the surgeries gave me very useful experience and practical insights which I can use.

A rewarding experience My experience as an EAU scholar in Heilbronn was most rewarding and expanded my clinical and surgical knowledge in robotic and laparoscopic surgery, and also surpassed my expectations. I would strongly recommend to all urology residents and young specialists, interested in being EAU scholars, to consider the Department of Urology of the SLK Kliniken for a clinical visit or a fellowship.

On the last weekend of my clinical visit, professional engineers and experienced nurses who have an expertise with Da Vinci robots trained us in the principles of Si and Xi robots' working systems and how to use the Da Vinci consoles. They also provided

In the second week I was involved in several laparoscopic procedures as bedside assistant

theoretical and practical lessons on the robotic surgery assistant. We also performed robotic simulation exercises and recorded our scores for camera and clutching, needle control and driving, suturing, energy and dissection, fourth arm integration, and endo-wrist manipulation. We repeatedly practised on robotic simulation exercises and recorded our scores as post-course scores. Our scores on robotic simulation exercises were evaluated statistically, and there was a remarkable increase in our scores when we compared our post and pre-course scores.

I would like to express my gratitude to all the staff (medical, nursing and administrative) of the Department of Urology for their hospitality and courtesy (both professional and personal), particularly to Prof. Rassweiler and Dr. Ali Serdar Gözen. Finally, I would like to thank the EUSP Board who gave this priceless opportunity and my special thanks to Ms. Angela Terberg for her assistance.

Surgical curriculum The SLK Kliniken’s operating theater has 12 digital operating rooms, three endoscopy rooms and two Da Vinci robots. Strict protocols regarding prevention of infection, patient safety and privacy, and surgical quality control are followed. During the clinical visit, I observed advanced surgical procedures with the console, participated as bedside assistant in several robotic / laparoscopic surgical operations, and used the SLK lap training facilities.

On my second week, Prof. Rassweiler discussed my programme in Heilbronn and offered the opportunity

October/December 2017

2 Laparoscopic retroperitoneal mass excision; 2 Laparoscopic adrenalectomy; 1 Laparoscopic pyeloplasty; 1 Laparoscopic inguinal lymphadenectomy; and 2 Laparoscopic sacrocolpopexy.

The centre trains many doctors from various countries of the world in robotic/laparoscopic surgeries, enabling them to improve their surgical skills. During my training, there were three other fellows from Turkey, Mexico and Nigeria. We worked as a team and shared practical insights.

Scholarship activities On the first day, Dr. Ali Serdar Gözen introduced me to his colleagues, assistants, and other fellows. All staff members (medical, nursing, and administrative) of the clinic have been so kind and helpful. Initially, I spent most of my time in endoscopy unit during the first week. I observed the Robo-flex URS operations, which for me is a new technology.

European Urological Scholarship Programme Office

• • • • •

Saatchi Art Artist Mirek Kuzniar; Painting ‘’City train of Heilbronn’’

I participated as bedside assistant in the following procedures: • 14 Robot-assisted radical prostatectomy with/ without laparoscopic extended lymph node dissection; • 2 Open radical cystectomy with intracorporeal neobladder or ileal conduit; • 8 Laparoscopic partial nephrectomy; • 1 Laparoscopic radicaly nephrectomy;

With Prof. Rassweiler

European Urology Today

EBU Certification Programmes Apply online to become one of the high-standard EBU certified centres with a European quality mark The following programmes are currently available: 1) Certification Residency Training Programme in Urology

consistent and transparent manner. • Certified centres attract (inter)national residents interested in high-quality training. 2) Certification EBU-EAU Host Centre

This evaluation process brings many benefits to the training programme. It enables the centres to gain insight into how consistent their standards are throughout the years and which areas need further improvement. The certification is based on the application, and on the 1-day site visit of the department. Some of the benefits. • Residents trained at an EBU-certified training centre can benefit from the quality control procedure since it reflects the high standards maintained by a centre. • Participating centres are part of a growing number of institutions across Europe that aim to implement best practices in healthcare in a

The EBU-EAU Host Centre Certification Programme is a common initiative of the EBU and the European Association of Urology (EAU). It aims to streamline the certification process for training centres hosting European Urological Scholarship Programmes (EUSP) and to become more responsive to new developments in continuing medical education. An EBU-EAU Certified Host Centre practises a multidisciplinary approach to the treatment of one of the following urological fields: • Andrology • BHP • Oncology: Renal, Penile, Prostate, Testicular and Urothelial

• Female urology and incontinence • Neuro-urology • Paediatric urology • Reconstructive urology • Stone disease • Transplantation 3) Certification Sub-specialty Centre Urology has become more advanced, diversified and technically demanding. Over the years urology has branched into several sub-specialties. Not all urological disorders can be successfully treated in one medical institution and with the wide range of various techniques not available or taught in every department. The emergence of sub-specialised medical centres certified by a regulatory body like the EBU has become important. An EBU certified sub-specialty centre is a high-volume

centre, which practices a multidisciplinary approach to the treatment of the following urological disorders. • Andrology • BPH • Cancer: Renal, Penile, Prostate, Testicular, Urothelial • Female Urology and Incontinence • Neuro-urology • Stone disease  • Transplantation An EBU certified sub-specialty centre is also ready to share its knowledge in a number of ways, including fellowship programmes and/or short-term visits. The applicant can rely on the EBU quality mark. For further information please check www.ebu.com or contact Mrs. Wilma Gietman, Executive Director of the EBU at w.gietman@ebu.com.

Third term Certification for Urology Department Donauspital Growing capacity for uro-oncologic centre for Vienna-North and neighbouring areas Prof. M. Rauchenwald Chair, Dept. Of Urology SMZ Ost - Donauspital Vienna (AT) michael. rauchenwald@ wienkav.at Vienna is the capital of Austria and covers an area of 415 square kilometres. In the greater city area live about 2.6 million people who are medically supported mainly by the university clinic and six public hospitals. The second biggest hospital in Vienna is the Danube Hospital (Donauspital), run by the Krankenanstaltenverbund, a company owned by the City of Vienna. The Danube Hospital is part of the Social Medical Centre East (Sozialmedizinisches Zentrum Ost or SMZ-Ost), which also encompasses a geriatric centre and a nursing school. The hospital was newly built and opened in 1994 being the first major hospital north of the Danube River where the two biggest and still fastest growing Viennese districts covering about 330,000 residents are located. The hospital itself has 1,000 beds and every year about 55,000 inpatients and about 500,000 outpatients are treated.

Department of Urology and Andrology The urological department consists of eight urologists and three residents and is headed by Prof. Michael Rauchenwald. A general practitioner and two interns are responsible for the ward covering 32 beds. Around 2,500 inpatients and another 14,000 are treated in the outpatient clinic. Scheduled for the end of 2018 a second 800 bed hospital will be opened north of the Danube but without a urology department. The urology service will be served by the DSP department, which is also the uro-oncologic centre for this area and the neighbouring parts of Lower Austria. In addition, currently we are in a transformation process where another department of Urology at one of the other general hospitals will be closed and the capacity distributed to two other Urology departments, one being the DSP. The department is known for performing all of the major open and most of the laparoscopic operations as well as all common endoscopic and reconstructive procedures. The department is the Austrian centre for urethroplasties and more than 60 mostly complicated cases with buccal mucosa are done every year. Residents’ training As there is a 3:1 ratio of urologists to residents and the ward is organised by a separate team, residents mainly spend their time in the operation theatre and in the outpatient clinic. Routinely the urologist on duty is responsible for the outpatient department on

that day and so especially young residents in their first year always have an experienced teacher within reach to discuss patients or get help if needed. Although DSP Urology constitutes - compared to large University clinics - not a high-volume department, residents spend a lot of their time in the operation theatre and start doing their own surgery right from the beginning. Within the first year residents should learn operations of the external genitalia, the insertion of ureteric stents and percutaneous nephrostomies. Furthermore, they should get to know all common surgical procedures by assisting them. In the second year residents are trained in transurethral procedures with the help of video teaching and supervision. As there is no ESWL performed at the department residents usually spend several months at another Viennese hospital to learn this intervention. On the other hand, the frequency of ureterorenoscopies due to urolithiasis is quite high. Thus, residents start their education with inserting ureteral stents, but get their chance of extracting or even laser-fragmenting stones in the ureter or renal pelvis by ways of retrograde ureterorenoscopy rather soon. The education in more complex operations like a radical prostatectomy, open or laparoscopically performed partial or complete nephrectomy or reconstructive operations like a urethroplasty depends on the one hand on the resident’s focus and on the

other hand on the training opportunities. In Vienna there is a strict regulation of working hours by a maximum of 45 hours a week and because residents have to spend 5 to 6 nights on duty including Saturdays and Sundays they are missing quite a lot of core working hours. Thus, residents have to specialise quite early and decide whether they concentrate on a surgical or a more conservative career. Independent of the surgical training all residents learn how to perform urodynamic studies and prostate biopsies. They are closely involved in tumour board meetings and usually prepare and present the cases to be discussed. As a rule, all residents take part in the yearly EBU In-Service-Assessment in every year of their training. Thus, it is possible to get used to the type of examination as well as monitor the educational progress. The EBU Written Examination is approved as the compulsory Austrian Board Certification for a Specialist in Urology. Therefore, nearly all Austrian residents use the study material provided by the EBU and take the chance to participate in the EUREP course in Prague. Regularly, the residents complete the EBU Examination with the oral part to become Fellow of the European Board of Urology (FEBU). The department was first granted the EBU Certification in 2005 and is proud to continue this tradition for a third term until 2022.

EBU re-certifies Urology Department in Croatia University Hospital Sestre Milosrdnice welcomes feedback to maintain quality standards Assist.prof. Igor Tomaškovic´ KBC Sestre Milosrdnice Urology Clinic Zagreb (HR) igor.tomaskovic@ kbcsm.hr University Hospital “Sestre Milosrdnice“, in Zagreb, Croatia was founded in 1846. Today, it is a large tertiary healthcare centre with 863 beds and facilites associatied to The University of Zagreb School of Medicine, School of Dental medicine and University of Applied Health Sciences. The university hospital is a multispecialty academic medical centre that integrates clinical and hospital care with research and education, making it one of the leading academic institutions in Croatia. The Urology Department has 40 beds with a professional EBU Certified Centres

European Urology Today

staff of 12 urologists with subspecialties in oncology, stones, functional and female urology and andrology. There are three urology residents at the department at the moment, and four others who are specialising in urology for other hospitals. There were 2,000 surgical procedures performed annually including 200 open radical prostatectomies, 160 PCNLs, 120 radical or partial nephrectomies, over 300 transurethral procedures, 150 URS, 70 fURS, 480 TRUS biopsies and 450 SWLs. There were an estimated 25,500 visits in the outpatient department. The Urology Department covers the entire spectrum of the speciality (except for transplantation) with an emphasis on uro-oncology and stones. A specialised staff of 70 nurses provides postoperative and urological care. The Urology Department is nationally accredited as the reference centre for prostate tumours by the Ministry of Health of the Republic of Croatia. EBU certification Our centre gained EBU certification in 2011 for the first time, and in 2017 it earned re-certification- the only centre in the country to achieve this recognition. One of the main goals of the urology residency is to educate residents for them to independently provide, at the end of their training, comprehensive and expert

care to patients suffering from urological diseases. Urological residency in Croatia lasts five years and it includes rotations in general surgery, vascular surgery, reconstructive and plastic surgery, gynaecology, radiology nephrology and urology. Urological training itself is split between urological subspecialties. After the five-year period residents have to pass a theoretical and practical exam to become certified urologists. The programme also provides the opportunity for residents to engage in research and teaching activities, giving them a foundation in these areas should they wish to pursue a career in academic urology. The medical staff of our Urology department

At our department, residents attend weekly uropathology and multidisciplinary team meetings and daily case conferences (cases scheduled to undergo surgery the following day). They are encouraged to publish and present especially in local, national and regional meetings such as the Central European Meeting (CEM). Residents are also encouraged to take an active part in regional, national and international educational courses and the EBU In-Service assessment. Although the EBU exam is not mandatory to certify a Croatian urologist, we believe the assessment is an excellent way to validate the

residents’ knowledge based on high European standards. Our fifth-year residents participate in the EBU Online Written Examination. We believe that the EBU recertification we recently gained is a mark of excellence and reflects our commitment to maintain high residency training standards. Additionaly, applying for it gave us a valuable opportunity to gain external feedback, which is always helpful when continuous improvement is a goal. October/December 2017

EBU Certified Residency Training Programmes in Urology Austria Hanusch Krankenhaus Krankenhaus der Barmhezigen Brüder Vienna Landeskrankenhaus Leoben Landeskrankenhaus Wiener Neustadt Medical University of Graz Medical University of Vienna, Comprehensive Cancer Center SMZ Ost - Donauspital Vienna SMZ Süd - Kaiser-Franz-Josef-Spital Vienna University Hospital Salzburg Belgium AZ Maria Middelares Ghent University Hospital Onze-Lieve-Vrouw Ziekenhuis Aalst University Hospitals Leuven Croatia University Hospital “Sestre milosrdnice” Zagreb Czech Rep Charles University Faculty of Medicine in Pilsen Charles University Hospital Motol General University Hospital and Charles University 1st Faculty of Medicine Prague Estonia Tartu University Hospital North-Estonian Medical Centre FoundationAffiliated to Tartu University Hospital Finland Oulu University Hospital Germany Asklepios Klinik Barmbek Hamburg Ev.-Luth. Diakonissenanstalt zu Flensburg Helios Marien Klinik Duisburg Julius-Maximilians University Medical Center Würzburg Justus Liebig-University Giessen Klinik für Urologie und Kinderurologie Klinikum Bamberg Klinik für Urologie, Klinikum Ludwigsburg Klinik für Urologie, Universitätsmedizin Mannheim Klinikum Braunschweig Klinikum Garmisch-Partenkirchen Klinikum Kassel GmbH SLK Kliniken Heilbronn St. Antonius-Hospital Gronau GmbH Technische Universität München Klinikum rechts der Isar Uniklinik der RWTH Aachen Universitätsklinikum Essen Universitätsklinikum Halle (Saale) Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Urologie Universitätsklinikum Schleswig-Holstein, Campus Kiel University Hospital Carl Gustav Carus, TU Dresden University Hospital Schleswig-Holstein, Campus Lübeck University of Bonn University of Regensburg - Caritas St. Josef Medical Centre Urologische Klinik der Universität Düsseldorf Urologische Klinik und Poliklinik des Universitätsklinikums Jena Urologische Klinik, Klinikum der Stadt Ludwigshafen GmbH

EBU Certified Sub-Speciality Centres Institute Sub-Specialty

Greece Sismanoglio Hospital Athens University of Crete

Belgium University Hospital Leuven

Female & Reconstructive Urology

Hungary Semmelweis University Budapest

Germany St. Antonius-Hospital Gronau GmbH

Prostate Cancer

Italy General Hospital of Bolzano

United Kingdom Leeds Teaching Hospitals NHS Trust

Renal Cancer

Malta Mater Dei Hospital Msida

Certified EBU-EAU Host Centres

Netherlands VU University Medical Centre Amsterdam Onze Lieve Vrouwe Gasthuis – locaties West & Oost – Affiliated to VU University Amsterdam Norway Sørlandet Sykehus HF Kristiansand Sørlandet Sykehus HF Arendal Affiliated to Sørlandet Sykehus HF Kristiansand Vestfold Hospital Trust Tønsberg Poland European Health Centre Otwock Interdisciplinary Hospital Miedzylesie Warsaw Medical University of Warsaw Pomeranian Medical University Szczecin Specjalistyczny Szpital Miejski im. M. Kopernika Torun University Hospital in Kraków Spain Cliníca Universidad de Navarra in Pamplona Fundació Puigvert Barcelona Hospital Clínic de Barcelona Hospital del Mar (Parc de Salut Mar) Barcelona Hospital Universitari de Bellvitge Hospital Universitario la Paz in Madrid Vall D'Hebron University Hospital Barcelona Sweden Urologiska kliniken Universitetssjukhuset Örebro Switzerland Geneva University Hospital Kantonsspital St. Gallen Kantonsspital Winterthur University Hospital Zürich University of Berne Turkey Ankara University Medical Faculty Istanbul University, Istanbul Faculty of Medicine Uludag University in Bursa

Institute Specialty Belgium Onze-Lieve-Vrouwziekenhuis Aalst Onze-Lieve-Vrouwziekenhuis Aalst Onze-Lieve-Vrouwziekenhuis Aalst Onze-Lieve-Vrouwziekenhuis Aalst Onze-Lieve-Vrouwziekenhuis Aalst University Hospitals KU Leuven University Hospitals KU Leuven University Hospitals KU Leuven UZ Leuven France Pitié-Salpétrière Hospital Pitié-Salpétrière Hospital University Paris 6 - Pitié Salpétrière academic hospital Germany University Hospital Bonn Heinrich-Heine University, Medical Faculty, Düsseldorf Heinrich-Heine University, Medical Faculty, Düsseldorf Heinrich-Heine University, Medical Faculty, Düsseldorf Heinrich-Heine University, Medical Faculty, Düsseldorf University Hospital Carl Gustav Carus Dresden University Hospital Leipzig Lithuania National Cancer Institute The Netherlands Canisius-Wilhelmina Hospital Nijmegen Radboud University Medical Center Nijmegen Radboud University Medical Center Nijmegen United Kingdom North Bristol NHS Trust North Bristol NHS Trust

Female Urology & Incontinence BPH Prostate Cancer Renal Cancer Urothelial Cancer Prostate Cancer Neuro-urology Female Urology & Incontinence Paediatric Urology Prostate Cancer Renal Cancer Neuro-urology Neuro-urology Urothelial Cancer Prostate Cancer Renal Cancer Testicular Cancer Prostate Cancer Prostate Cancer Prostate Cancer

Prostate Cancer Prostate Cancer Paediatric Urology Female Urology & Incontinence Stone disease

EBU Oral Examination

EBU In-Service Assessment

Date: Saturday 2 June 2018 Venue: Warsaw (PL)

Dates: Format: Duration: Time:

The EBU Oral Examination is the second part of the European Board Examinations in Urology. It is a one-day examination with the objective to test the candidate’s ability to evaluate and manage common cases in every day practice. The candidates are examined by a team of two urologists and will be tested by means of three clinical cases. Participation is subject to eligibility. An eligible candidate must have passed the EBU (Online) Written Examination between in 2013 and 2017 and belong to one of the following categories:

Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, • Final-year Resident who is trained as part of an Turkey, United Kingdom. official national urology training programme in a UEMS/EBU member country. The training The FEBU Diploma is issued to urologists who have must be completed before 31 October 2018. passed the European Board Examinations in Urology. The FEBU Diploma is considered as a mark • Certified Urologist who is fully qualified as a of excellence, it is not a license to practise urology. urologist by the recognised national authority from a UEMS/EBU member country. Worldwide more than 5,000 urologists carry this title. UEMS/EBU Member Countries: Austria, Belgium, Croatia, Czech Republic, Denmark, Estonia, Finland, For more information and registration visit our France, Georgia, Germany, Greece, Hungary, website www.ebu.com.

October/December 2017

1 and 2 March 2018 Online test 2 hours Both days between 00.00 and 23.59 Greenwich Mean Time (GMT)

Every resident and trainee wants to succeed. Medicine, as a whole, and surgery, in particular, are competitive fields. So, no matter how competent an individual, some anxiety is always felt by everyone when they are studying. Have I learnt enough? Have I learnt the right things? How am I doing compared to others?

And it will provide Certified Urologists with a method of demonstrating their continuing medical education to their own local authorities as well as themselves. Both individual and group registration is available. Candidates who are registered as part of a group get their results through their Programme Director. Many Programme Directors use the ISA as a method of assessing how their residents are progressing. For more information and registration visit our website www.ebu.com.

The EBU ISA (In-Service Assessment) provides a perfect way to help. The ISA is a test anyone can take. Both residents and trained urologists choose to take the test each year to assess their knowledge. The assessment is conducted once a year. This is not an “exam” in the sense that there is a pass/fail mark. It is meant to help you in your studies. It will give Residents in training programmes a means of comparing themselves against other residents, not just in their own country, but across the world and in the same year of training.

European Urology Today

Management skills courses for urologists and nurses YUO and EAUN offer Leadership for Medical Professionals Courses in Copenhagen management and communication skills, leadership, finances, and related topics. Part of this programme is the course on leadership meant for young (under 45 years) urologists and related health professionals who have the potentials to be future leaders. With a panel of expert speakers, the emphasis is on the development and successful implementation of a personal and creative leadership style and business strategy. Participants will learn how to become more decisive in reacting to developments within their organisation whilst acquiring effective management-skills. Applicants should have: The EAU Young Urologists Office (YUO) will offer • A letter of motivation stating the applicant’s two courses designed for urologists and nurses on interest for the course; Monday 19 March 2018 during the Annual EAU • Recommendation letter from applicant’s Congress to be held in Copenhagen. immediate superior or supervisor; • Proven fluency in English; and The EAUN Leadership Course will be from 08.00 • Readiness to submit essay-type articles in to 12.00, while for urologists the Leadership for preparation for the course. Medical Professionals Course will be from 13.00 to 17.00 hours. Sedelaar said regardless of their career plans, the course will provide to participants stimulating Both are compact and comprehensive courses ideas, tips and other valuable strategies to boost which aim to give expert recommendations on one’s managerial and decision-making capacities. how to develop leadership and management skills. Last year, many urologists attended the first The YUO board will review all applications on a course in London and gave it a high rating. The first-come, first-serve basis and selected EAUN course will be offered for the first time participants will come from countries across during EAU18 in Copenhagen. Europe. A small token fee of €50 will be required to ensure attendance by selected applicants. The YUO Chairman Prof. Michiel Sedelaar said course will be handled by a Dutch management participants will be selected on a first-come-first- and communications specialist team led by Herman serve basis for the course. Rijksen and Jaap Zijlstra. “We aim to provide skills training in various areas including management, decision-making and presentation skills, among others,” he said.

Call for

ESUI Vision Award 2018 The EAU Section of Urological Imaging (ESUI) is calling for abstracts for the ESUI Vision Award 2018, which will be given to the first author of the most innovative imaging study published in urology during the last year. How to apply? 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

Deadline: 31 January 2018, 23.59CET. The award will be handed out at the 33rd Annual EAU Congress in Copenhagen during the ESUI section meeting, on Saturday 17 March 2018 from 10.15 - 14.00 in Green room 3. The award is supported by an educational grant of € 1,500 by INVIVO CORPORATION

For interested candidates or to inquire for details, email the YUO at a.terberg@uroweb.org

The YUO is working on its Personal Development Programme by organising courses that focus on

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!

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 January 2018! For more information and application, please contact the EUSP Office – eusp@uroweb.org or check our website http://www.uroweb.org/education/scholarship/

NGage®: Reach for the original. NGage Nitinol Stone Extractor

MEDICAL

European Urology Today

October/December 2017

ELUTS17: Inaugural EAU meeting focuses on LUTS Berlin hosts close to 300 participants in three-day programme with ESU Masterclass By Loek Keizer

“Functional urology and LUTS is sometimes considered a somewhat passé area for urologists. As surgeons, ELUTS17 marked a new collaborative meeting for the we are always interested in new techniques, and EAU, bringing together two of its functional sections, technological breakthroughs like minimally invasive the European Urogynaecological Association and an surgery and robotics. Nevertheless, the problems ESU masterclass. Together with hands-on training covered at this meeting will affect 40-60 percent of the “I would be very happy to see office urologists here because we cover topics that they deal with on a daily courses and industry sessions, the ELUTS17 scientific population by the age of 60-70.” basis. Treatment of lower urinary tract symptoms is programme was an exhaustive update on lower “We must take care to not forget our core, basic the main job for these urologists. The EAU Section for urinary tract symptoms. principles of urology. If one becomes too dependent Urologists in Office (ESUO) is a new section, and I’m on technology to the exclusion of the core principles sure that they would be interested in joining our LUTS The EAU is organising more of these “thematic” meeting. It would be a good platform to give them an meetings to complement or in some cases replace the of the specialty, it may have a detrimental effect for annual update.” annual Section Meetings that it held in previous years. the future of practice.” PCA17 is another example of these educational events. “Did this also spur on the organising of this meeting? Joining efforts will decrease the costs of having large The EAU Section of Female and Functional Urology Partially. Oncology is extremely important and a key scientific meetings, is one factor that Cruz has in (ESFFU) and the EAU Section of Genitourinary area for our Association. But LUTS is a very important mind. “The world is changing, our funding is Reconstructive Surgeons (ESGURS) took the lead in changing and we have to adapt. Pooling our designing the ELUTS17 scientific programme, with the area that causes significant morbidity. It might not directly cause mortality, but it has a significant impact resources is one way to reduce costs. The ESFFU, organising committee led by ESFFU Chair Prof. Francisco Cruz (Porto, PT) and EAU Secretary General on our patients’ quality of life.” Prof. Chris Chapple (Sheffield, GB). The underactive bladder Prof. Chapple on the importance of functional urology: Chapple also participated in the hour-long session on the underactive bladder, chaired by Prof. Philip “There might be a divide between functional Van Kerrebroeck (Maastricht, NL). The session mostly urologists and those involved in oncology, but I underlined the need for a consensus on definitions, consider functional urology to be at the very core of and the fact that there was still a lot of research to be our discipline. By bringing together ESFFU and conducted into the condition. One of the main ESGURS for this meeting, we are combining two problems for diagnosis is formed by overlap of sections that are concerned mainly with female and male functional issues, respectively. This way, ELUTS17 symptoms with other lower urinary tract dysfunctions. provided resources for all aspects of functional urology.” Generally speaking, the session concluded that the working definition of the underactive bladder is a The scientific programme featured state-of-the-art lectures on OAB, nocturia and quality of life in female symptom complex suggestive of detrusor underactivity, characterised by prolonged urination urology, and discussions on clinical trials, female time, with or without a sensation of incomplete stress urinary incontinence and the underactive bladder emptying, usually with a hesitancy, reduced bladder. In the afternoon of the first day, the sensation on filling and a slow stream. programme was split to accommodate the parallel sessions of the European Urogynaecological Association (EUGA) and ESGURS. Including the “Thankfully, in recent years there’s masterclass (see inset) the programme lasted from 12-14 October, 2017. been a realisation the patients can Prof. Cruz hailed the positive feedback from delegates. “They were happy. Our meeting touched on what is relevant and new in LUTS treatment and functional urology. Secondly, my compliments go out to our speakers. The quality of talks was really excellent and the information was up to date.” Key topics and Quality of Life Key topics that encapsulated ELUTS17, according to Prof. Cruz: “Incontinence, BPH and specifically incontinence in elderly, frail people who might also be suffering with dementia. This is a very difficult group to treat, which may require the use of drugs in a non-standard way.”

have bladder underactivity, which can explain disappointing results after surgery on, or removal of the prostate” Prof. Van Kerrebroeck explained the difficulty in identifying the condition for the clinician. “Patients will present with complaints that might potentially indicate underactive bladder. But there are also patients that come without specific symptoms, or symptoms where an underactive bladder could be a contributing factor to their more global problem. Most urologist are familiar with patients with outlet obstruction based on an enlarged prostate, but we have to realise that the bladder itself might also be to blame for poor flow.” “With the current set of diagnostic tools available to us, diagnosing poor flow and attributing it to obstruction or an underactive bladder (or a combination of the two) can only be done invasively. You need proof that bladder underactivity is playing a role in the patient’s situation, which is very difficult to distinguish.”

Profs. Van Koeveringe, Van Kerrebroeck and Chapple at the session on the Underactive Bladder

“The problem is that there are reports that antimuscarinic drugs or anticholinergic drugs, which are commonly used in urinary incontinence, in the long term may cause Alzheimer’s disease and dementia. We should be avoiding their use as much as possible when treating frail, elderly patients with incontinence, in order not to exacerbate problems they might have.” “Urologists must be wary to use low doses to select the ideal drug, and to even avoid antimuscarinic drugs altogether. This was a subject that offered a lot of new information for many of the delegates.” Prof. Chapple characterised the scientific programme as one that hits on the core tasks of the urologist, and one that addresses conditions that will affect the ageing global population. October/December 2017

“Thankfully, in recent years there’s been a realisation the patients can have bladder underactivity, which can explain disappointing results after surgery on, or removal of the prostate. The flow might remain poor or the bladder might not empty properly purely due to the underactive bladder. With research in Maastricht and Hannover, we can find the right tools for a (preferably non-invasive) prediction of obstruction, underactivity or a combination of the two.” Further potential collaboration Prof. Cruz also reflected on this first edition of ELUTS, considering some changes to the meeting and its scientific programme based on the experiences of 2017: “While we’re pleased with an attendance of nearly 300 people, at times this audience was spread a little thin between the masterclass and the parallel sessions. With the quality of the talks, it’s a pity that not everyone could hear everything.” One solution would be to integrate the surgical case discussion of the ESGURS session into the regular programme, for a more thematic approach to the scientific programme. According to Cruz, there is also potential to welcome another EAU Section to join future iterations of ELUTS:

12-14 October 2017 Berlin, Germany ESGURS and ESUO would be a complementary combination.” “I also feel strongly about the need to target residents, as I didn’t see many young urologists at the meeting. Residents are generally well-informed on topics of oncology, but not so much on functional urology. At ELUTS17, they could have a fantastic two-day review of this topic, with the best faculty one could wish for.” “These are all ideas that are coming out from our first ELUTS, so we have to do the ‘postmortem’ to see what went well and what we can improve!”

Prof. Karl-Dietrich Sievert (Rostock, DE) discusses the treatment of BPH Patients with the panel

10th ESU-ESFFU Masterclass Longest-running masterclass offers latest insights Over 30 participants convened in Berlin on 12-13 October, taking part in the annual ESU-ESFFU Masterclass on Female and Functional Reconstructive Urology. The masterclass is in its tenth year, making it one of the longest-running courses offered by the European School of Urology (ESU). The masterclass is a collaboration between the ESU and the EAU Section of Female and Functional Urology (ESFFU). The masterclass partially overlapped with the scientific programme of ELUTS17 meeting. Addressing complementary topics, it was decided to combine the masterclass with the regular scientific programme of ELUTS17. Experienced faculty members Dr. John Heesakkers (Nijmegen, NL), Prof. George Kasyan (Moscow, RU), Prof. Dirk De Ridder (Leuven, BE), Mr. Nikesh Thiruchelvam (Cambridge, GB) and Prof. Elisabetta Costantini (Perugia, IT) taught modules on stress incontinence, OAB, female reconstructive surgery, pelvic organ prolapse and the neurogenic bladder.

“Case presentations always bring up discussion,” Dr. Heesakkers explains. “We’ve always included case discussions in the past, dealing with them in an ad-hoc way. Now they’re integrated into the programme, and we can select the cases based on topic beforehand. Some are demonstrations, in some cases people look to the audience or faculty for answers. Participants are completely free to bring a problematic case that’s still ongoing or something that worked out fine.” Despite being a long-running masterclass that serves new generations of surgeons every year and must therefore cover a certain amount of basics, the actual contents of the scientific programme move with the times. Dr. Heesakkers reflects:

“For a start, we always look at the latest versions of the EAU Guidelines, taking any changes into account. We also try to look at the latest development in a specific topic with respect to Heesakkers: “Our masterclass offers a one-and-anew studies, new proof, that gives a focus on half-day programme, concentrating on the latest what you’re saying. Every year it’s up to date and insights, and based on the EAU Guidelines. We also adapted, and the faculty members are also lean heavily on real-life clinical practice, as with attuned to what will be coming up.” surgery, patients don’t always fit to the Guidelines. The faculty presents practical solutions for difficult “Over the past ten years there we’ve seen big problems.” developments in functional urology: the introduction of botulinum toxin, neuromodulation was a new development when we started the masterclass. And of course the whole issue of using foreign material in human body for the treatment of stress incontinence and prolapse being introduced and also causing problems. I’d like to think that we have also become more patient-oriented in the past ten years.”

Prof. De Ridder, teaching at the ESU-ESFFU Masterclass.

European Urology Today

Young Urologists/Residents Corner A successful 2nd Spanish Residents Day 82nd AEU Congress hosts Residents Day in Sevilla Dr. Cristina Ferreiro Urology Resident University Hospital of Bellvitge NCO Spain @ResidentesAEU working group Barcelona (ES)

Dr. Moisés Rodríguez Socarrás @moisessocarras Webmaster of @ESRUrology @ResidentesAEU working group Vigo (ES)

Dr. Juan Gómez Rivas @JGomezRivas Chairman-elect @ESRUrology Chair @ResidentesAEU

discussed and presented by both national and international experts. On Thursday, 8 June, three plenary sessions were held. The first focused on endourology with topics such as the limits of endoscopic treatment of upper urinary tract tumours (moderated by Dr. Galán) and the latest advances in the medical treatment of urinary lithiasis (moderated by Dr. Torrecilla, Coordinator of the AEU's National Lithiasis Group). J.M Cózar (AEU’s former president) and J.Gutiérrez (CAU secretary) led the second session. Dr. Octavio Castillo (Chile) discussed the laparoscopic limits of retroperitoneal lymphadenectomy. The last session focused on metastatic prostate cancer, while on Friday, June 9, the other three plenary sessions took up andrology, reconstructive surgery and oncology. More than 400 abstracts were presented (including posters, videos and oral presentations). Thanks to the presenters, we got to know the experience of local hospitals and the various cases often encountered by urologists. Training courses Interesting theoretical and training courses were held during the congress, such as laparoscopic lymph node dissection and the retroperitoneal approach. And for the second consecutive year, the E-BLUS exam was held, with J.M. Gaya and J. Gómez Rivas as tutors. There were also laparoscopic training exercises (required by the AEU-ESSCOLAP programme) and a robotic simulation contest. 2nd Resident Day After the success of the 1st Resident Day, the Spanish

residents and the Young Urologist Workgroup (RAEU) successfully held the 2nd Resident Day which took place on 7 June coinciding with the AEU17 congress. The workgroup, led by Dr. Juan Gómez Rivas as chairman, has exerted a lot of effort to improve the organization and contents of the first edition. Thus, we dealt with current issues in a more dynamic and practical way and had closer look at the concerns and challenges faced by residents. Over 130 residents and young urologists attended the meeting, and the morning session presented academic opportunities for residents. Newly elected AEU chairman Dr. Manuel Esteban presented the Spanish Association of Urology, Foundation for Urology Research and the American Confederation of Urology (AEU-FIU-CAU) lecture. Prof. Maria Ribal (ES) discussed the EAU’s scholarship programme, while Dr. Esteban Emiliani (IT) spoke on overseas fellowships and the Office of Young Urologists Academicians of the EAU (YAU-EAU). There were lectures by renowned urologists who gave insights and tips & tricks on several surgical techniques (URS, laser vaporisation of prostate, transperineal prostate biopsy and laparoscopic partial nephrectomy). One of the highlighted topics was the role of and opportunities in social networks. It should also be noted that thanks to social networks (such as @Residentes AEU on Facebook, and @residentesAEU on Twitter, or in our website residentes.aeu.es), a lot of residents from all over Europe and America can follow the event. Case reports of common urological conditions were also presented by experts such as Dr. Rafael Sánchez-Salas and Dr. Mario Álvarez Maestro, among

others, who shared their knowledge and expertise on low-risk prostate cancer, metastatic testicular cancer and the limits of partial nephrectomy. We also held the “Campbell Test” which was moderated by Drs. Coral Manso, Marina Alonso and Fernando Vazquez. The Resident’s Day ended with training courses which were held in three different rooms. The topics covered prostate cancer treatment, the use of a voiding diary, practical aspects of flexible ureterorenoscopy, and partial transperitoneal laparoscopic nephrectomy. In another course, several pathologies were discussed such as advanced percutaneous nephrolithotomy and prostatic enucleation, among others. Social media activity Once again, Social Media (SoMe) activity during the congress was very high, with 1.566M impressions and 1,262 tweets from viewers and participants in Spain, the rest of Europe and Latin America. We are proud that the congress has been a great success with its exciting academic program. We look forward to the next annual congress of the Spanish Association of Urology (#AEU18) and the 3rd Resident´s Day.

Sevilla hosted from June 7 to 10 the 82nd Spanish National Urology Congress, annually organised by the Spanish Association of Urology (AEU). The congress was deemed a success considering the number of participants and the quality of scientific contributions. More than 1,200 urologists and residents from all over Spain and other countries participated in the event, known as one of the most important urological meetings held in Spanish-speaking countries. The congress was led by Dr. Castiñeiras and the scientific programme covered a wide range of urology topics. The four-day meeting enabled participants to attend six plenary sessions that dealt with current issues

GeSRU presents full programme at DGU 2017 Congress Young residents actively take part in sessions and training courses Dr. Med. Andreas Beck Klinik für Urologie, Asklepios Klinikum Harburg Hamburg (DE)

Dr. Angelika Cebulla Klinik für Urologie und Kinderurologie Universitätsklinikum Ulm Ulm (DE) angelika.cebulla@ uniklinik-ulm.de Under the slogan “Urology. For all. For everybody. For us”, the third largest congress in urology, the annual congress of the German Society of Urology (DGU), welcomed 6,500 visitors and 800 lecturers from Germany and other countries. As in previous years, the German Society of Residents in Urology (GeSRU) actively participated role in the congress by supervising several sessions. And besides the general meeting of the GeSRU, training courses 32

European Urology Today

for residents were also offered such as the “Operations for Beginners” where residents learned basic techniques and operations like circumcision, vasectomy or orchiectomy. Another popular session is “GeSRU StepS!” where several videos demonstrated how to perform step-by-step procedures in standard operations in urology .This year the videos dealt with Holmium Laser Enucleation of the prostate and penectomy, among others. These videos will be available online at the GeSRU home page. Two different sessions on rare clinical cases were held. Residents from various institutes all over Germany presented clinical cases of rare complications and their management. Topics included abdominal aortic aneurysm as cause of anejaculation, diagnosis and treatment of inguinal herniation of the bladder, and alcohol intoxication after sclerotherapy of renal cysts. The sessions triggered enthusiastic discussions and lively debates. Networking and research GeSRU also aims to boost the networking among residents. In support of residents engaged in scientific work, the GeSRU-Academics was founded some years ago. The meeting of the Working Groups of the GeSRU Academics was also part of the programme, which also included the Eisenberger-Stipendium award presentation for junior scientists. In the session “How Do Ideas of Residents, Medical Students and Heads of Department Match” the reality

of medical and surgical education was examined in various perspectives. Another session tackled “Urology Now, Tomorrow and the Day After Tomorrow” which presented interesting approaches and future prospects such as the application of augmented reality in a clinical setting, using big data and video-based doctor’s consultations. Potential urologists were invited to join the “Students Day,” with more than 100 high school students introduced to the work of a urologist. They were acquainted with and tested their skills in cystoscopy, ultrasound, laparoscopy and surgical suturing.

was the GeSRU Evening, an opportunity for participants to relax and form friendships while enjoying the cuisine of Dresden. This year’s GeSRU activities during the DGU congress were certainly a success, and the German residents are grateful for the opportunity to play an active role in the event. DGU Secretary General Prof. Dr. Michel himself underlined the strong links between the DGU and GeSRU, and we definitely look forward to more exciting meetings and activities in upcoming regional and national congresses.

The GeSRU also had a booth at the exhibit hall where visitors were given information about the GeSRU and its activities. GeSRU-members also met during the lunch session where residents exchanged ideas on humanitarian work and urology-related health campaigns such as Movember. Another social event October/December 2017

Young Urologists/Residents Corner Get involved in a BURST collaborative study Calling all residents to participate in a large prospective international multi-centre study: IDENTIFY Mr. Sinan Khadhouri BURST committee Urology Resident Ninewells Hospital NHS Tayside Dundee (GB) sinan.khadhouri@ doctors.org.uk

Dr. Kevin Gallagher BURST committee MRC Clinical Research Fellow & Urology Resident University of Edinburgh (GB) kevin.mjgallagher@ gmail.com

Dr. Veeru Kasivisvanathan BURST Chair Urology Resident West Herts NHS Trust and University College London (GB) veeru.kasi@ucl.ac.uk

Who are we? The British Urology Researchers in Surgical Training (BURST) research collaborative was started in the UK with the aim to deliver high quality international research and audit (Appendix A). The group has grown to include expert urologists and methodologists internationally. What do we do? Collaborative research is a novel research model across all surgical disciplines. Traditional research models have major challenges including a risk of producing underpowered studies. Collaborative research has a unique ability to deliver large-scale multi-centre studies that can change clinical practice. The model implemented by BURST1, demonstrates how this works to deliver fast, high-quality research with definitive answers. This is embodied by the success of our recent MIMIC study2.

A guiding principle is that scale can be reached quickly with relatively small workload from each individual “alone we can do so little, together we can do so much” (Helen Keller). We are passionate about recognising the input of our collaborators, with Pubmed indexed collaborative authorship. Furthermore, opportunities to present the study are offered to collaborators outside of the study committee.

the diagnostic value of different diagnostic strategies in patients with haematuria, comparing findings between different countries. This may help develop an optimal, individualised diagnostic strategy, which will take into account patient-specific factors such as demographics, presentation and risk factors. The advantage of such a well-powered large-scale multi-centre study will be two-fold: Firstly, the ability to investigate individualised diagnostic strategies in The Prize-winning MIMIC study: an example of a subgroups of patients and secondly, the ability to large-scale trainee-led research collaborative project analyse the diagnosis of rarer urothelial cancers such as upper tract TCC. MIMIC2 launched in October 2016, recruiting over 4,100 patients from 71 sites and seven countries IDENTIFY has already been piloted in over 800 within four months. MIMIC showed that white cell count was not associated with the likelihood of stone patients in the UK across seven hospitals. The passage in patients initially treated conservatively for study has then undergone rigorous internal and acute ureteric colic and is now being used to develop external peer review by medical experts in the a risk calculator for stone passage. field, statisticians and methodologists specialised in diagnostic strategies. The study is now recruiting centres and residents worldwide. The How do I get involved with BURST? All residents from all countries are invited to take part interest has been unprecedented with approximately 100 sites over 15 countries in the 5,000 patient IDENTIFY study. pre-registered, and numbers are rising every day. IDENTIFY has also secured significant funding from What is the IDENTIFY study? The Urology Foundation. The Investigation and DEtection of Neoplasia in paTIents reFerred with suspected urinarY tract cancer: The BURST model means that IDENTIFY has been a multi-centre analysis (IDENTIFY) is the next BURST designed so that relatively less work is required from collaborative study. It aims to determine current prevalence rates of urothelial cancer and to analyse each individual. Since this is an observational study, all of the data collected is from routine patient assessment. It is therefore a service evaluation or audit - this does not require ethical approval in most 1) Register Send an email with your name and countries. This aids with the fast recruitment rate. As your hospital to identifystudy@gmail.com interest a collaborator, your hard work will be recognised with PubMed indexed collaborator authorship for any publications that result from this study. Furthermore, We will notify you of updates and provide 2) highly recruiting individuals and sites will be the necessary documentation for Complete registration and data collection. recognised, having priority of authorship as well as your site Updates will also be tweeted on our Twitter registration being invited to present the study at international account @BURSTurology conferences. 3) Begin uploading data 4) Reach your patient recruitment target

5) Become a national coordinator

You will be given an individual logon for our online electronic database to collect data. Enter data for 50 patients between two residents per site which should take up to 10 weeks. If more than 2 residents per site want to get involved and for every additional resident, a further 25 patients are required. We welcome all residents from all countries. If you would like to increase your level of involvement with IDENTIFY and chances of presenting data yourself there is a position for National Coordinator for each country (Table 1).

Figure 1: “How do I get involved in IDENTIFY?”

More information about BURST and the IDENTIFY study This is available on our website (http://www. bursturology.com/p/identifyoverview.html) Queries can be sent to identifystudy@gmail.com. By contributing to this study, you can have a significant impact on the future of diagnostic pathways in suspected urinary tract cancer.

Advisory board Hashim Ahmed, Ben Challacombe, Mark Emberton, Graeme MacLennan, Robert Pickard, Stephen Hughes. References 1. Kasivisvanathan V, Ahmed H, Cashman S et al (2017). The British Urology Researchers in Surgical Training (BURST) Research Collaborative: an alternative research model for carrying out large scale multi-centre urological studies BJU Int doi:10.1111/bju.14040. 2. Shah T, O’Keefe A, Gao C et al. A multi-centre cohort study evaluating the role of inflammatory markers in patients presenting with acute ureteric colic (MIMIC) Eur Urol Suppl 2017; 16:e723-4.

Country

City

National Coordinator

Australia Belgium

Melbourne Leper

Canada

Edmonton, Alberta Prague

Todd Manning Anneleen Verbrugghe Mark Assmus

Czech Republic Denmark France

Lille

Hungary

Budapest

Italy

Rome

Netherlands

Groningen

Norway Poland

Vestfold Krakow

Republic of

Dublin

Vojtech Fiala Position available Jonathan Olivier Zsuzsanna Zotter Giancarlo Marra Peter-Paul Willemse Carl Knobloch Anna Katarazyna Position available Uros Bele Juan Gomez Rivas

Ireland Committee members Slovenia Maribor Veeru Kasivisvanathan, Ben Lamb, Taimur Shah, Sinan Spain Madrid Khadhouri, Kevin Gallagher, Arjun Nambiar, Matthew Jefferies, Kenneth MacKenzie, Eleanor Zimmermann, Eric Edison, Chuanyu Gao, Sacha Moore, Lynsey Table 1: “Recruited countries outside the UK with Williams. the corresponding National Coordinator”

Current status of scrotal varicocele and renal cancer Update from the Young Academic Urologists Men’s Health and Renal Cancer groups Dr. Paolo Verze Dept. of Urology University Federico II of Naples Naples (IT)

pverze@gmail.com

Dr. Giorgio Russo Urology Section, Dept. of Surgery University of Catania Catania (IT)

giorgioivan1987@ gmail.com

Dr. Maria Carmen Mir Department of Urology Fundación Instituto Valenciano de Oncologia Valencia (ES) mirmare@yahoo.es

In fact, since there is inconclusive evidence on extending scrotal ultrasound to include a renal assessment, EAU Guidelines on Male Infertility does not support this approach for the diagnostic evaluation of varicocele5. As over 80% of RCC is incidentally diagnosed by a non-invasive imaging test and harvest no symptoms at diagnosis, the incidence of varicocele is currently anecdotal at diagnosis. References

Renal Cell Carcinoma (RCC) is currently diagnosed as an incidental small renal mass. The incidence of RCC steadily increased from 1975. Nearly 90% of all kidney cancers are RCC and they are twice as common in men as compared with women. Metastatic renal cell carcinoma is present in approximately 15-18% of patients at diagnosis and up to 40% of patients with clinically localised RCC eventually will develop metastatic disease during follow-up.

with several paraneoplastic syndromes such as hypercalcemia (5%) or varicocele (2% of male diagnosis). Varicocele can be caused by either external compression or by tumour thrombus extending into the gonadal vein. Clinical examination remains extremely important in this setting. Acute varicocele should prompt further examination1. With the finding of scrotal varicocele, the referring clinician should request a scrotal ultrasound with renal examination in order to exclude a retroperitoneal or renal tumour2.

The classic triad of flank pain, haematuria, and flank mass is very uncommon (10%) nowadays due to the wide access to imaging techniques that precludes the diagnosis as small renal masses. RCC is associated

The first case report of varicocele related to RCC dates from the 1950s. Right and left varicoceles related to retroperitoneal/renal masses have been reported. Interestingly, in 2006 Shinsaka et al. published a case

October/December 2017

report of right varicocele testis caused by a tumour thrombus in the right spermatic vein but without a tumour thrombus in the IVC3. Right RCC, even with tumour thrombus in the renal vein, seldom develops testicular varicocele due to the right spermatic vein widely draining into the IVC. Strong evidence-based medicine on the current topic is lacking. Few case reports have been published to date. Recently, a systematic review by Robson et al.4 included 24 articles (reporting 35 cases), reporting the potential association of scrotal varicoceles and renal/ retroperitoneal masses. Unfortunately, the authors were not able to establish a direct correlation between the two variables (renal or retroperitoneal tumour and varicoceles) as they are randomly present4.

1. El Abiad Y, Qarro A. IMAGES IN CLINICAL MEDICINE. Acute Varicocele Revealing Renal Cancer. N Engl J Med. 2016;374:2075. 2. El-Saeity NS, Sidhu PS. "Scrotal varicocele, exclude a renal tumour". Is this evidence based? Clin Radiol. 2006;61:593-9. 3. Shinsaka H, Fujimoto N, Matsumoto T. A rare case of right varicocele testis caused by a renal cell carcinoma thrombus in the spermatic vein. Int J Urol. 2006;13:844-5. 4. Robson J, Wolstenhulme S, Knapp P. Is there a co-association between renal or retroperitoneal tumours and scrotal varicoceles? A systematic review. Ultrasound. 2012;20. 5. Jungwirth A, Diemer D, Kopa Z, Krausz C, Tournaye H. EAU Guidelines on Male Infertility. Retrieved from http://www.uroweb.org/guideline/male-infertility/. 2017.

European Urology Today

Thank you for supporting New Urology Week poster campaign expands global reach This year, we took the initiative to raise awareness about these illnesses through Urology Week’s new Awareness Campaign Posters. These posters were focused on the significance of regular check-ups and being proactive in getting information from trusted sources as well. And the campaign was a huge success! The posters were translated into 13 languages: Bahasa Melayu, Dutch, English, French, German, Greek, Irish, Polish, Portuguese, Romanian, Spanish, Turkish and Urdu.

The campaign posters in your language?

What should be the next topics for the campaign posters? Which urological diseases should be next year’s topics for the Urology Week Awareness Campaign posters? Tell us by sending your topic suggestions to communications@uroweb.org.

LA SEMAINE DE L'UROLOGIE Para conscientização pública das condições urológicas

25-29 septembre 2017 Pour la sensibilisation du public sur les traitements urologiques

Help us spread the word about the benefits of urological health by translating the campaign posters in your native language to reach more people! Let us know by sending an email to communications@uroweb.org and we will send you the text to be translated.

Ne vous contentez pas d'être inconfortable Est-ce que vous perdez votre urine quand vous toussez, éternuez, courez, ou même quand vous portez vos courses? est-ce que vous avez besoin soudain d’aller aux toilettes et ne pouvez pas vous contenir? Si vous avez répondu “oui” à une de ces questions, vous pourriez souffrir d’incontinence urinaire (IU). Ce n’est pas pas facile d’en parler. Mais il ne faut pas en être géné, des millions de personnes souffrent de IU dans le monde. N’attends pas plus longtemps. Visitez un urologue. Pour plus d’information

urologyweek.org

United Kingdom

#urologyweek

The Netherlands

Nennen Sie einen guten Grund sich nicht untersuchen zu lassen!

Wenn Sie das Leben genießen möchten spielt auch die urologische Gesundheit eine wichtige Rolle. Warten Sie nicht länger und erfahren Sie mehr über Prostatakrebs und die Präventionsmöglichkeiten. Nutzen Sie eine vertrauensvolle Quelle und sprechen Sie mit Ihrer Urologin / Ihrem Urologen.

urologyweek.org

Você não tem que perder o sono por causa da sua próstata!

Em média 1 em cada 7 homens serão diagnosticados com câncer da próstata durante seu tempo de vida. É compreensível que esta estatística possa preocupá-lo. Mas você pode fazer alguma coisa sobre isso. Quando você aprende mais sobre a sua próstata você ajuda na prevenção. Esteja informado. Fale com um Urologista.

urologyweek.org

#urologyweek

Poland

Belgium

France

Romania

Portugal

Turkey

More initiatives at ww.urologyweek.org or #urologyweek

Mark the date for Urology Week 2018, 24-28 September 34

European Urology Today

October/December 2017

Free time well spent in London during EAU17 Presenting “Peeing in Art”: an upcoming publication by the EAU History Office metropolis. Here day labourers await jobs on the docks of Brooklyn on a grey winter morning. The towers of Lower Manhattan rise in the distance. Left on the foreground, in the shadow, a man is peeing into the snow while the others are looking to him. (Fig. 5b)

Dr. Johan J. Mattelaer Retired Urologist Kortrijk (BE)

As you can see, free time during a urological congress can be an ideal time to discover unknown urological art. In my case it was an great start for a new book: Peeing in Art!

Johan.mattelaer@ skynet.be London is a fantastic city with many beautiful treasures, particularly in its world-famous museums and many art galleries! During my visit to London to attend EAU17 last March, I visited two well-known museums in London: the Tate Britain and the National Art Gallery. What can a urologist with an interest in history and art see beyond what a normal individual would? Tate Britain In the museum we can see a beautiful view of the Old Horse Guards from St James’s Park painted by Canaletto (Giovanni Antonio Canal 1697-1768) around 1749. It was replaced in the 1750s with the white stone building that stands today. Canaletto’s paintings were in demand from rich patrons. (Fig. 1a)

Figure 4b

Figure 2

Figure 5a Figure 1a

Figure 4a

Figure 1b

But looking as an urologist we can see more! In front of the clock house building we can see a long blind wall, and more in detail we can see two men peeing on the wall! One with a blue jacket on the left and one with a yellow jacket while a man in pale blue is passing him without paying any attention. (Fig. 1b) National Art Gallery A painting with a very urological subject in the National Art Gallery is A Woman and a Boy with Animals at a Ford from 1657 painted by the Flemish painter Karel Dujardin (1626-1678). (Fig. 2) In the heat of the day, a woman and a boy paddle in a ford while their mule and dog drink. Nearby a cow stands motionless in the cool water. The most interesting is the peeing boy emptying his bladder with a very good flow directly into the water.

When we look to the right side of the house, just out of the dark we see a man peeing to the wall. (Fig. 3b) We know of three other similar paintings by Jan Brueghel the Elder with the same subject and nearly the same setting: one in the Kunsthistorisches Museum in Vienna, one in the State Hermitage Museum in St. Petersburg and one in the Royal Museum of Fine Arts in Antwerp. The paintings in London, Vienna and St. Petersburg show the same peeing man (although in St. Petersburg he stands a little bit further away from the house). The painting in Antwerp does not show him! Another very urological interesting painting, The Stonemason's Yard, is also by Canaletto (1697-1768) and shows an intimate view of Venice

Figure 3a

A better known painting is The Adoration of the Kings painted by Jan Brueghel the Elder (1568-1625) in 1598. (Fig. 3a) This painting is a display of minute observation, from a woman with a baby conversing with a man on horseback at the left, to the still life of carpenters tools in the lower right. The black king and his elaborate boat-shaped container are inspired by the work of Pieter Bruegel, the artist’s father, reminding us that artists’ drawings – templates for paintings – were often handed down from father to son.

October/December 2017

A last painting is more modern and shows Men on the Docks, painted in 1912 by George Bellows (1882-1925). (Fig. 5a) This painter arrived in New York in 1904 where he found rich subject matter in the lives of the poor workers in the booming

Figure 5b

For this relief, much thanks! Peeing in art

"Another very urological interesting painting is also by Canaletto (1697-1768) and shows an intimate view of Venice with the Campo San Vidal..."

EAU History office

with the Campo San Vidal filled with large pieces of masonry and a workmen’s hut. (Fig. 4a) The stone was probably intended for the façade of the church of San Vidal that is not shown. The campo still exists but the bell-tower seen across the canal collapsed in 1744. This is one of Canaletto’s most celebrated works. On the foreground at the left we can see a mother helping her fallen and crying child. (Fig. 4b) The child seems anxious and is peeing with a good and obvious jet of urine on the ground.

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.

Figure 3b

European Urology Today

Temporary implantable nitinol device (TIND) A new option for treating benign prostatic obstruction Prof. Francesco Porpiglia Chief of Division of Urology San Luigi Hospital University of Turin Orbassano (Torino, IT)

The first-generation device (“TIND”) was composed of four elongated nitinol struts and an nitinol anchoring leaﬂet all made of nitinol. The tip of the device was covered by soft plastic material to avoid injury to the bladder. The tail of the device has a nylon suture for retrieval attached to it. The struts were positioned to create prostate incisions anteriorly, at the 11, 1, 5 and 7 o’clock positions. As of 2014 the first-generation TIND is no longer commercially available.

criteria to select the patient for this procedure. Large prostate volumes could limit the efficacy of the device action and further studies are required to determine this point. For this reason, a prostate volume of < 60 ml at preoperative TRUS could be recommended when screening patients for this surgery. Another suitable indication is the Marion’s disease, the bladder neck stenosis that leads to an obstruction of the outlet of the bladder neck and LUTS, even in young patients.

porpiglia@libero.it Around 30% of men over 50 years are affected by Benign Prostatic Hyperplasia (BPH) that leads to moderate-to-severe lower urinary tract symptoms (LUTS). The prevalence of the disease in Europe and USA is estimated to be over 30 million men1. The first treatment option for the management of these patients is the medical therapy (α-blockers and 5α-reductase inhibitors), although for many patients it provides only modest symptoms relief2 and in some patients it can also cause undesirable side-effects. These side-effects, alongside inadequate symptoms relief, result in a drop-out rate from medical therapy of more than 25%. Patients who are either not responsive to, or refuse medical therapy, may opt to undergo surgical intervention3. The ‘gold standard’ surgical treatment for BPH is still considered to be Trans Urethral Resection of the Prostate (TURP), with a reported decrease in IPSS up to 70%, and increase in the maximum urinary flow rate (Qmax) up to 150%4. However, this surgery is not devoid of perioperative risks, such as bleeding, urinary retention, urethral strictures, incontinence and retrograde ejaculation, that can occur in up to 65% of patients treated5.

The second-generation device (“i-TIND”) has the same size as the first generation device, but has some structural differences. First of all, it is comprised of three struts, versus four, and the nitinol struts are double intertwined into the configuration of a "tulip" shape. The orientation of the struts is at 12, 5 and 7 o'clock positions, similar to the first generation device.

Figure 3: i-TIND placement

The other difference between the two generations is in regard to the tip. In the i-TIND device the three intertwined wires are all connected all together in the upper part of the device allowing each wire to exert action on the urethral mucosa at the level of the bladder neck, while avoiding any possible injury of the bladder mucosa and the need for a soft plastic cover. The other features of the new device have remained the same including an anchoring leaﬂet to be placed just cranially to the veru montanum, and a nylon retrieval suture at the tail end for the removal of the device. The i-TIND is currently available in the market (Figure 1).

Novel laser-based methods for the treatment of BPH (holmium or thulium laser enucleation of the prostate and photo-vaporisation of the prostate), and other non-laser-based minimally-invasive procedures (transurethral needle ablation – TUNA, transurethral microwave thermotherapy – TUMT) have been introduced in order to offer an alternative to TURP, however until now their role in the management of BPH still remains controversial6,7.

Figure 4: intraoperative image of the correct i-TIND placement under the bladder neck but over the veru montanum

After five days the device is removed from the urethra. The removal of the device can be performed in an ambulatory setting, under topical anaesthesia with lidocaine gel. For the removal, a 20-22 ch openended catheter is needed. The nylon retrieval suture that comes out from the penis is inserted into the catheter lumen with the aid of a snare, a metallic semi-rigid double wire. Then the catheter is pushed into the urethra while holding the suture at the same time. When the catheter reaches the lower part of the device the surgeon pulls the wire allowing the device retraction into the catheter lumen. Then the catheter can be removed (Figure 5).

Exclusion criteria for the device placement are the cystoscopic or TRUS evidence of a large median lobe, previous prostate surgeries, prostate cancer diagnosis, urinary tract infections or irritative symptoms related to neurological dysfunction. In this last case, the device action would not be inadequate to relieve the symptoms because the bladder muscular walls are not able to produce a valid contraction during micturition. Published clinical data The first clinical experience with TIND (MT-01) was published in 2015 and showed that the implantation of the device is feasible and safe in the treatment of BPH-related symptoms10. In the prospective singlecentre study, the authors treated 32 patients with the TIND device. The adverse events, changes in medications and functional results were evaluated for a 12-month follow-up period, at different time points. Median IPSS was reduced from 19 at baseline to nine after 12 months, while the mean Qmax increased from 7.6 ml/s to 11.9 ml/s (p values < 0.05). The statistical analysis showed a mean Qmax increase from baseline of + 67% and a mean IPSS decrease from baseline of - 45%. Moreover, at 12 months postoperatively, no patients required re-starting of medical therapy or surgical procedures for BPH. None of them experienced retrograde ejaculation. Ongoing studies MT02: A prospective multi-centre study, including nine sites across Europe as well as Hong Kong. A total of 75 patients were recruited and the 12-month follow-up will be completed in December 2017.

Figure 1: First and Second generation device

Notwithstanding the wide range of possible surgical treatments, there is still a considerable group of men dissatisfied with the symptoms improvement offered by the medical therapy, but who are not willing to undergo surgical treatment because of associated risks. Moreover, there are also patients who are unfit for surgery; specifically, those who cannot be anesthetized and/or who cannot discontinue anticoagulation/ antiplatelet therapy8. The prostatic urethral lift (PUL) was a step towards this direction9. PUL is a minimally-invasive approach that can be performed under local anaesthesia. This system is based on the placement, under cystoscopic view, of small permanent suture-based implants, allowing the opening of the prostatic urethra by retracting its encroaching lateral lobes, and which preserves sexual function.

The mechanism of action The mechanism of action is based on the circumferential force produced by the three nitinol wires. The radial expansive action causes a local ischemic necrosis of the urethral mucosa producing three bladder neck sagittal incisions at 5, 7 and 12 o'clock positions (Figure 2). With both TIND and i-TIND devices this effect is progressive: after five days the nitinol wires reach their complete Figure 5: i-TIND retrival through a 22 F catheter expansion, sinking into the periurethral tissues and solving obstructive BPH symptoms. The indications At present there are no restrictive age limits and a low peak urinary flow (less than 12 ml/s) and moderate to severe lower urinary tract symptoms (IPSS > 10) are the

MT03: A prospective, randomized controlled North American study, i-TIND vs sham, including 18 sites from the US and Canada. Recruitment of 172 patients has been completed and is pending follow-up. Continued on page 37

Some years ago, another novel technique was presented to treat patients with the same indications as PUL, but with a device that is not permanently implanted. Clinical experiences with Medi-Tates’s (Medi-Tate®; Medi-Tate Ltd., Or Akiva, Israel) temporary implantable nitinol device (TIND) is being gathered, and currently promising outcomes are being reported10. In this article, the TIND device and the surgical procedure for its delivery and removal are explained. Moreover, available clinical data and ongoing studies about the device are detailed. Temporary Implantable Nitinol Device The device The Medi-Tate TIND system is a CE Mark-approved device that comes preloaded on a delivery system. The TIND itself is made of Nitinol, a biocompatible super elastic alloy with shape-memory. The system is 12 Fr in diameter, and is compatible with most rigid cystoscopes. Notwithstanding the same delivery system, two different generations of the device have been produced.

EAU Section of Uro-Technology (ESUT)

European Urology Today

Figure 2: i-TIND mechanism of action on the prostatic urethral mucosa

Implantation and retrieval The implantation of the device is performed using a transurethral approach, under slight sedation, with a rigid cystoscope. The delivery system allows pushing the device to be pushed into the bladder through the cystoscopic sheath, after the removal of the rigid cystoscope. Once out of the sheath, the device is delivered in the bladder. The surgeon puts the cystoscope inside again to place the device at the level of bladder neck under direct view, withdrawing it into the prostatic urethra. For the correct orientation of the device its anchoring leaflet should be placed at the 6 o’clock position, under the bladder neck, but cranially to the veru montanum. In this place the nitinol leaflet prevents the displacement of the device and its retro migration into the bladder (Figures 3 and 4). To complete the device implantation, a cystoscopic check and bladder voiding are recommended.

Figure 6: Graphics of the preliminary results of MT-02 study (Qmax, IPSS and QoL until six months after i-TIND implantation), presented at AUA Meeting 2017, Boston, PD27-03.

October/December 2017

Continued from page 36

MT04: A prospective, randomized controlled UK study, i-TIND vs standard of care (alpha blockers + Foley) in patients with AUR. MT06: A prospective, multi-centre European study, including 200 patients with a minimum 12-month follow-up. Preliminary published ongoing studies results The preliminary results of the first 30 patients enrolled in MT02 were presented at AUA meeting in 2017. The inclusion criteria for the enrolment in the multicentre study were: IPSS score > 10, peak urinary flow (Qmax) < 12 ml/sec and prostate volume < 75 cc. All patients discontinued medical therapy for BPH before the implantation. Demographics, perioperative, three and six month’s functional results and quality of life (QoL) were evaluated. All of the implantations and the removals of the devices were successfully concluded with no intraoperative complications. The median IPSS was reduced from 25 at baseline to 7 after three and six months postoperatively, the median QoL was reduced from 4 to 1, while the mean Qmax raised from 7.5 ml/s to 12.4 and 14 ml/s (Figure 6). Differences in terms of IPSS score, QoL and Qmax, when comparing pre-operative and six months post-operative results, were statistically significant (p < 0.05). No patients reported ejaculatory dysfunction or required pharmacological treatment or surgery for BPH during the follow-up period. Conclusions Among the minimally-invasive treatment options for BPH-related LUTS, the i-TIND is an easily performed (both in regards to the implantation and retrieval of the device), safe and effective option. Many i-TIND studies are ongoing and their preliminary results are promising, suggesting that this kind of device can be included in the daily armamentarium of the urologist for the management of benign prostatic obstruction. References 1. Roehrborn CG. Current medical therapies for men with lower urinary tract symptoms and benign prostatic

hyperplasia: achievement and limitations. Rev Urol 2008; 10: 14–25 2. Verhamme KM, Dieleman JP, Bleumink GS, Bosch JL, Stricker BH, Sturkenboom MC. Treatment strategies, patterns of drug use and treatment discontinuation in men with LUTS suggestive of benign prostatic hyperplasia: the Triumph Project. Eur Urol 2003; 44: 539–45 3. Dahm P, Brasure M, MacDonald R, Olson CM, Nelson VA, Fink HA, Rwabasonga B, Risk MC, Wilt TJ. Comparative Effectiveness of Newer Medications for Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: A Systematic Review and Meta-analysis. Eur Urol. 2017 Apr;71(4):570-581. 4. Oelke M, Bachmann A, Descazeaud A et al. EAU Guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013; 64: 118–40 5. Muntener M, Aellig S, Kuettel R, Gehrlach C, Sulser T, Strebel RT. Sexual function after transurethral resection of the prostate (TURP): results of an independent prospective multicentre assessment of outcome. Eur Urol. 2007 Aug;52(2):510-5. 6. Oelke M, Bachmann A, Descazeaud A et al. EAU Guidelines on the treatment and follow-up of nonneurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013; 64: 118–40 7. Lourenco T, Pickard R, Vale L et al. Minimally invasive treatments for benign prostatic enlargement: systematic review of randomised controlled trials. BMJ 2008; 337: a1662 8. Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, Oelke M, Tikkinen KA, Gravas S. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol. 2015 Jun;67(6):1099-109. 9. Perera M, Roberts MJ, Doi SA, Bolton D. Prostatic urethral lift improves urinary symptoms and flow while preserving sexual function for men with benign prostatic hyperplasia: a systematic review and meta-analysis. Eur Urol. 2015 Apr;67(4):704-13. 10. Porpiglia F, Fiori C, Bertolo R, Garrou D, Cattaneo G, Amparore D. Temporary implantable nitinol device (TIND): a novel, minimally invasive treatment for relief of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH): feasibility, safety and functional results at 1 year of follow-up. BJU Int. 2015 Aug;116(2):278-87.

www.esou18.org

ESOU18 15th Meeting of the EAU Section of Oncological Urology 26-28 January 2018 Amsterdam, The Netherlands An application has been made to the EACCME® for CME accreditation of this event

ESUR17 boosts exchange among researchers, urologists Strengthening new collaborations and connections Prof. Kirsten Junker Chair, ESUR Homburg (DE)

Kerstin.Junker@ uniklinikumsaarland.de More than a hundred scientists from diverse fields in urological research, and urologists interested in research attended the 24th Meeting of EAU Section of Urological Research (ESUR17). Held in Paris, France last October, ESUR17 was chaired by Prof. Yves Allory (FR), Chair of the EAU Section of Uropathology Prof. Rodolfo Montironi (IT) and myself.

culture models on organ-on-chip devices were discussed by Dr. Anja Van De Stolpe (NL). Furthermore, tumour heterogeneity in bladder cancer was discussed from different point of views: Dr. Bas Van Rhijn (NL) focused on tumour heterogeneity of FGFR3 mutations in invasive bladder cancer; Dr. Lars Dyrskjøt (DK) talked about the clonal evolution and potential therapeutic targets in urothelial carcinoma; Prof. Dr. Antonio Lopez-Beltran (PT) discussed urothelial carcinoma variants and molecular subtypes; and Dr. Evanguelos Xylinas (FR) evaluated how bladder cancer heterogeneity matters for the urologist. To expound upon the DNA repair mechanisms and the role in tumour development and therapy response, Prof. Dik Van Gent, Rotterdam (NL) discussed the general aspects. Dr. David Liu (US) examined defects

The first session focused on the role of tumour microenvironment. Dr. Claire Magnon (FR) discussed the role of nerves in prostate cancer progression. Then data on the role of tumour microenvironment for drug resistance was presented by Prof. Arne Östman (SE) which was followed by presentation on the role of immune cells in tumour equilibrium and escape by Prof. Thorbald Van Hall (NL).

October/December 2017

Prof. Rogier Louwen (NL) presented the fundamental and technical aspects of the Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) system. Then Prof. Roland Rad (DE) addressed CRISPR and transposon-based approaches for highthroughput functional cancer genomics in mice. ESUR has collaborated with the Association de la Recherche sur les Tumeurs de la Prostate (ARTP) once again. This year, the ARTP organised the ESUR17 session “ARTP: Prostate Cancer” which included lectures such as targeting Hsp27 signalling pathways in castrate-resistant prostate cancer presented by Dr. Palma Rocchi (FR), and Sphingosine 1-Phosphate metabolism in prostate cancer bone metastasis discussed by Dr. Olivier Cuvillier (FR). Extracellular vesicles as a new biomarker system from liquid biopsies were examined. The lecture of Dr. An Hendrix (BE) focused on the standardisation of analysing techniques and Prof. Lorraine O’Driscoll (IE) discussed the role of extracellular vesicles as predictive markers.

The immune system was also the main topic of three other lectures: Prof. Georges Netto (US) discussed the immune scoring system in modern pathology; Dr. Emanuela Romano (FR) presented on the response prediction for checkpoint inhibitors; and Dr. Stephen Tait (GB) spoke of targeting immunogenic cell death to treat prostate cancer. On Friday morning, model systems to analyse the tumour complexity were presented by Dr. Geertje Van Der Horst (NL) including organotypic tumour slice culture. Dr. Claire Béraud (FR) deliberated on PDX models for anti-tumour activity studies of therapeutic compounds and resistance mechanisms in kidney, bladder and prostate cancers. And human disease

in DNA repair genes and their role in chemotherapy response in urological cancers. The molecular rationale for PARP1 inhibitor function was highlighted by Prof. Felix Feng (US) which was followed by the lecture of Dr. Joaquin Mateo (GB) on DNA repair in prostate cancer and biology and clinical implications.

In addition to the comprehensive lectures at ESUR17, recent results from experimental and clinical research from all fields in urology were presented in 22 compact lectures and during poster sessions. Altogether, 76 abstracts have been accepted for the meeting.

Examining the posters

According to a long tradition, an outstanding researcher in experimental and/or translational urological research was honoured with the Dominique Chopin Award. This year, Prof. Dr. George Thalmann (CH) received the coveted award for his work in prostate cancer. He has been very active in European

Mr. Heer receives the ARTP award on behalf Dr. Moad

Urology Research for many years, and acted as board member and Chair of the ESUR. Dr. Mohammad Moad (GB) of the University of Newcastle received the ARTP Award for the best abstract in prostate cancer research. Mr. Rakesh Heer (GB) accepted the award on his behalf. The ARTP Award for the best presentation in prostate cancer research was presented by Dr. Jocelyn Ceraline (FR) to Mr. Rakesh Heer (GB) on behalf of Dr. Mohammad Moad (GB). The ESUR meeting facilitated scientific exchange between researchers and urologists, as well as, new contacts and collaborations between research groups in European urology. The 25th Meeting of the EAU Section of Urological Research will be held in Athens, Greece from 4 to 6 October 2018. Join us!

ESUR17

12-14 October 2017 Paris, France

European Urology Today

John Wickham

Visionary scientist and pioneering urologist 1929 - 2017 John Wickham was born in 1929 in West Sussex on England’s south coast. He studied medicine at St Bartholomew’s Hospital Medical School in London just after the Second World War. Initially he planned a career in neurology and then neurosurgery but developed an interest in renal medicine and surgery after working in the renal unit under Ralph Shackman at the Hammersmith Hospital in London. There, along with Geoff Chisholm he ran the early Necker Dialysis Unit. A spell at Bart’s under Alec Badenoch and Ian Todd further enhanced his enthusiasm for urology. A Fulbright Scholarship took him to Lexington, Kentucky where he was exposed to the technique of intra-operative cooling for ischaemic renal surgery. He almost remained in America as a Professor of Urology, but realising he wanted his children to grow up in Britain returned to St. Paul’s urological hospital in London and then took up a consultant post at St. Bartholomew’s in 1968. John Wickham had an enquiring and innovative mind and was quick to recognise and adopt new techniques. He constantly strived to minimise the trauma caused to patients by surgery and pioneered and named the surgical movement of Minimally Invasive Surgery. Using his American experience of renal cooling, and controlled ischaemia he promoted radial nephrotomies increasing total stone clearance in open stone surgery. He further strived for reduced invasion by introducing percutaneous nephrolithotomy to the UK. Not deterred by the resistance of conservative British surgeons at the 1980 British Association of Urological Surgeons (BAUS) annual meeting in Liverpool, he showed his PCNL’s reduced hospital stay from six weeks to two days, decreased

John Wickham’s other great legacy was encouraging similarly enlightened urologists to communicate, not just in Great Britain but internationally. In 1976 he was a founding member of the European Intrarenal Surgical Society (EIRSS) and, in 1983 with Peter Alken of Mainz, Joe Segura from the Mayo Clinic, Arthur Smith of New York and Ralph Clayman from St. Louis, he set up the Endo-urological Society, of which he was also its first president.

operative mortality and improved patient satisfaction. He famously recalled one PCNL patient, a London bus driver, who stopped his No. 38 bus outside the hospital just one week following his surgery to come in to say, “Thank you”! Wishing to further minimalise stone surgery he was the first to bring extracorporeal shock-wave lithotripsy to the UK securing a Dornier HM1 Lithotripsy machine in the private sector, but insisting that a proportion of the patients must be from the NHS and trainees must be allowed access to learn the technique. Wickham, recognising the possibilities of the laparoscope, assisted Malcolm Coptcoat to perform the first European laparoscopic nephrectomy at King’s College Hospital, London in 1991; the first laparoscopic nephrectomy for renal cell carcinoma in the world. He was also one of the first British

surgeons to perform retroperitoneoscopic ureterolithotomy. As director of the Academic Unit at the Institute of Urology he worked with many talented registrars. One of these, “clever young fellows” was Graham Watson. He suggested to Wickham that a 504nm laser fibre would fragment ureteric stones; they put it up a ureter and had a go; it worked- another modality in the minimally invasive weaponry for stone treatment. John Wickham, in collaboration with Professor Brian Davies of Imperial College, developed and engineered the first robotic device in urological surgery named the PROBOT; it robotically carried out the TURP operation. First tried clinically in April 1991, the PROBOT is considered the first to use an active robot to remove soft tissue from a patient. Although the PROBOT was the first robot to operate on a patient autonomously, it was too expensive to produce and like Wickham, was before its time.

Despite retirement in 1992, Wickham maintained an interest in minimally invasive surgery. His invention of the “Syclix”, a novel surgical instrument which allowed surgeons to handle tissues with a pen-like grip (as opposed to a conventional scissor grip) won the prestigious Horners Award in 2006. In 2013 Wickham was awarded one of the highest professional honours from the Royal College of Surgeons of England, the Cheselden medal in recognition of his outstanding contributions to innovation in stone surgery and laparoscopic urology. John Wickham’s contribution to urology cannot be underestimated and is best appreciated in his editorial piece “The new surgery”, which was published in the British Medical Journal in December 1987, where looking back to the “the rough and brutal” surgery of the past he looks forward to the elegant or minimally invasive surgery of the future. Mr. John Wickham passed away on 26th October 2017. By Jonathan Goddard

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BALTIC18

ESUT18-IEA

5th Baltic Meeting in conjunction with the EAU

6th Meeting of the EAU Section of Uro-Technology in conjunction with the Italian Endourology Association (IEA)

25-26 May 2018, Riga, Latvia An application has been made to the EACCME® for CME accreditation of this event

Live Surgery

24-26 May 2018, Modena, Italy An application has been made to the EACCME® for CME accreditation of this event

Call for Abstracts Deadline 1 April 2018

European Urology Today

October/December 2017

European Parliament meeting examines PCa White Paper EAUN brings crucial insights to meeting discussions Mr. Lawrence Drudge-Coates Past Chair EAUN London (UK)

l.drudge-coates@ eaun.org Last September 27 saw the EAUN took its rightful place at the European Parliament to discuss the implications of the Prostate Cancer White Paper during this year’s European Prostate cancer Awareness Day (EPAD). Together with Europa Uomo and the European Cancer Patient Coalition (ECPC), the European Association of Urology (EAU) organised the event to discuss White Paper recommendations on how to lower the risks and improve the management and care of prostate cancer patients. The White Paper was launched in January 2017.In his opening remarks Mr. Vytenis Andriukaitis, EU Commissioner for Health and Food Safety, stated: “A better understanding and knowledge of health risks and how to manage them are crucial. Preventing and controlling prostate cancer- and cancer in general- is of key concern to the European Commission.” He also underlined the importance of raising awareness for a healthy lifestyle and the need to further look into the opportunities of personalised healthcare as recommended in the Prostate Cancer White Paper. Andriukaitis invited all participants to share this valuable resource with the EU Health Policy Platform to ensure that it reaches all stakeholders.

health care education and addressing issues related to language and culture. Both Francesco de Lorenzo of the European Cancer Patient Coalition (ECPC) and Mr. Ken Mastris of Europa Uomo delivered the key message which was the inability of patients to tackle these aforementioned issues on their own, Thus, unity is essential amongst the key stakeholders for them to act as one and drive their goals forward. Moreover, there is the expectation for the EU to do more. EAU Secretary General Prof. Chris Chapple Secretary General also reiterated the need for collaboration. Disease prevention and screening Other key issues were education, disease prevention and data gathering and interpretation with regards the issue of screening. The discussion on screening raised controversial views on over-treatment and that screening would ultimately lead to identifying more insignificant PCa tumours. Regarding treatment, better differentiation between low and high-risk prostate cancers was viewed as crucial in preventing over-treatment. Related to this was the important role of modern diagnostic imaging techniques. The economics of PCa was also examined such as rising costs, impact of increased survival and equitable treatment access to care across the EU, particularly in low-income countries, which remains a key issue for the EU. Ian Banks of the European Men’s Health Forum also commented on workforce economics and noted that in fact there is economic benefit in getting men back to work after treatment. In discussing the role of treatment and support of PCa patients, the author commented: “Treatment just involves a small part of the patient’s journey… there is

Two Members of European Parliament (MEPs), Mrs. Marian Harkin and Mr. Alojz Peterle who are both committed to the joint mission, chaired the event. Awareness of prostate cancer was a key theme throughout the forum. The discussions also took up the crucial need to collaborate in raising public awareness particularly on issues or perceptions such as viewing prostate cancer as ‘an old man’s disease.’ Also taken up were equity with regards access to European Association of Urology Nurses

Discussion of the White Paper in the Parliament

a pivotal role that is being and can be played by non-medical professionals closer to the patient. Nurses play a pivotal role in providing holistic care, and that we should no longer talk about a multidisciplinary team, but about a multi-professional one.”

“We should no longer talk about a multidisciplinary team, but about a multi-professional one.” In his presentation the author outlined the impact of the nurse in the prostate cancer journey and the key role of the nurse, as part of a multi-professional approach to care. The presentation addressed the effects of prostate cancer and the significant impact on quality of life, and that PCa adversely affects every aspect of a man’s well-being, and far beyond treatment, thus requiring a more holistic approach. With more than 417,000 men diagnosed with PCa the author stressed the need for “A patient centered and focused approach that is multi-professional.” Urgent attention is also needed to look at strategic workforce planning to address the growing financial pressure to deliver timely and effective healthcare.

Download: http://uroweb.org/wp-content/uploads/ EAU_WhitePaper_PCa_final.pdf

however, noted the existing inequalities in nursing education and training which needs to be addressed by public regulators such as the EU. The author concluded his presentation with a quote from Ernest Hemingway: “It is good to have an end to journey Primary care was one of the specific areas highlighted toward, but it is the journey that matters in the end.” in this discussion, which is defined by the WHO as the At end of the meeting, Prof. Hein Van Poppel, EPAD “first contact” for individuals with cancer. The need co-organiser and on behalf of the EAU, emphasized for continued, comprehensive and coordinated care was also raised but which is hampered by significant that all parties present needed support from the inequalities in terms of access and infrastructure. The European Parliament and the European Commission, author also stated during the forum that “Cancer and but most importantly from patients. its consequences would be an increasingly prominent part of the primary care workload in the future, with the breadth of health care professionals needing to expand, such as community nurses to meet this demand,” as outlined in a recent ECCO position statement. With regards addressing quality of care and economics, the author added that ”nurses had shown beyond any doubt that they can deliver timely, cost and clinically effective patient care which positively improves patient outcomes.” However, there are prejudices or perceptions on nursing roles that have to be put aside. To think outside the box and consider the benefits that developing and enhancing these roles would bring are important. The author,

Title of my presentation for the EU Commissioner and the Members of Parliament

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European Urology Today

EAUN18: From best practices to new insights 19th EAUN Meeting boosts the links among urology nurses True to its aim to provide fresh updates and identify best practices, the Scientific Programme of EAUN18 is a compact and comprehensive examination of key nursing issues in urology ranging from oncology, infections, guidelines adherence, patient-centred care to anticipating future trends.

Registration is open Early fee deadline 15 January 2018 Online deadline 26 February 2018

Patient Reported Outcome Measures (PROMs) will be evaluated for its effect in shared decision-making. Stefano Terzoni, Chair EAUN

Corinne Tillier, Chair SCO

“There are changes in prostate biopsy guidelines, and urology nurses need to be aware of the impact on • Visit 2. Gentofte Hospital, 15.00 – 17.00 hrs. their practices. This will be taken up in a state-of-theThe department specialises in stone-surgery, art lecture where current standards and new practices andrology and LUTS. “In-depth and with focus on improving our day-towill be thoroughly reviewed,” said Tillier. • Visit 3. Herlev Hospital, 15.00 – 17.00 hrs. day clinical practices by using practical approaches, Visit to the Robotic Center, where you can do evidence-based nursing and the experiences or input The Plenary Sessions are expected to trigger hands-on exercises. of patients themselves, the various sessions in enthusiastic discussions with two thought-provoking • Visit 4. Rigshospitalet (Copenhagen University Copenhagen will aim to fulfil the educational needs of topics. Plenary Session 1 will tackle the theme: Hospital), 14.30 – 16.30 hrs. Urology care with participants,” said Corinne Tillier, chair of the “Urology nursing tomorrow: If not us then who?” a focus on cancer patients. Visit to the ward, Scientific Programme Committee. The session will look into generational differences the outpatient clinic and the operating theatre. between senior nurses and their younger colleagues In Copenhagen, the organisers will offer in three days, who are more computer-adept and technologically With its varied and insight-filled programme, two Plenary Sessions, 13 Thematic Sessions, five (digital) oriented. Questions such as “How can we EAUN18 promises another much-awaited boost to Specialty Sessions, and two European School of avoid misunderstandings, miscommunications and the training and educational update needs of Urology (ESU) courses. To be featured are six clash amongst the generations?” will be taken up to European urology nurses. It does not only aim to state-of-the-art lectures that will cover TRUS biopsy shed light on the dynamics of interpersonal relations match these expectations but to also go guidelines, impact of lifestyle habits among cancer in the hospital setting. beyond them to enable urology nurses survivors, patient experience of pelvic rehabilitation, to provide optimal patient care. and EAUN guidelines, among other topics. As in previous congresses, hospital visits form part of the total learning experience. Four hospital visits are Don't miss the early fee deadline: The Thematic Sessions will explore not only scheduled on Friday, 16 March in three major 15 January dilemmas in nursing practices but also new topics. Copenhagen hospitals. Below is a glimpse of the Updates in prostate care will be discussed in schedules: Thematic Session 2, where the evolution of radiological techniques, new treatments and • Visit 1. Herlev Hospital, 15.00 – 17.00 hrs. Visit to supportive nursing care (clinics) will be assessed by the theatre, robotic centre, outpatient clinic, nurse expert speakers. Patient-centred care will be the led procedures and the ward, including the areas Join us in Copenhagen! theme in Thematic Session 5 where tools such as for cystectomy and prostatectomy patients.

in conjunction with

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Preliminary ESU programme in Copenhagen ESU Courses Adrenals • Advanced course on upper tract laparoscopy (UPJ, adrenal and stones) • 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 Infections • Dealing with the challenge of infection in urology Kidney transplantation • Renal transplantation: Technical aspects, diagnosis and management of early and late urological complications Male LUTS • Management of BPO: From medical to surgical treatment • Post-surgical urinary incontinence in males Neurogenic and non-neurogenic voiding dysfunction • Chronic pelvic pain in men and women • General neuro-urology • Lower urinary tract dysfunction and urodynamics Paediatric urology • Paediatric urology for the adult urologist Course 1 • Paediatric urology for the adult urologist Course 2

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European Urology Today

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 • 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 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

ESU Hands-on Training Courses Unclassified and miscellaneous topics • How to proceed with a haematuria • Surgical anatomy • Ultrasound in urology • Laparoscopy for beginners • Update renal, bladder and prostate cancer guidelines 2018. What is changed? • Basic penile scrotal surgery and first steps in endourology • What has changed in the non-oncology guidelines • Practical aspects of cancer pathology for urologists. The 2018 WHO novelties • Prosthetic surgery in urology • First steps in the world of robotic surgery • Lymphadenectomy in urological malignancies • How to write introduction and methods • How to write results and discussion Urethral strictures • Advanced course on urethral stricture surgery 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

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

October/December 2017