European Urology Today October - December 2018 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology Looking ahead to EAU19

12-13

What goes into making live surgery a success?

Vol. 31 No.5 - October/December 2018

The John Wickham Lifetime Achievement Award Full coverage of the ERUS18 robotic meeting and inaugural prize winner Prof. C-C. Abbou

HIFU and cryotherapy

Evaluating focal therapy as management strategy for localised PCa Dr. E. Barret

EMUC18 explores best practices and future advances A critical look at current challenges, novel therapies and breakthroughs for GU cancers By Erika De Groot and Loek Keizer Marking its decade-long dedication to the goal of pursuing multidisciplinary collaboration, the recent 10th European Multidisciplinary Congress on Urological Cancers (EMUC18) examined the best practices, advances and future prospects in managing genitourinary malignancies. The congress also identified current dilemmas and addressed gaps in clinical practice. Prof. Manuela Schmidinger (AT) of the European Society for Medical Oncology (ESMO), Prof. Peter Hoskin of the European SocieTy for Radiotherapy & Oncology (ESTRO) and Prof. Hein Van Poppel (BE) of the EAU welcomed 1,400 participants from 67 countries from 8 to 11 November in Amsterdam, The Netherlands. The collaborative congress was preceded by the 7th Meeting of the EAU Section of Urological Imaging (ESUI18), the ESUP Symposium on Genitourinary Pathology and Molecular Diagnostics, and the EAU-ESMO Bladder Cancer Consensus meeting. Organised with the main congress was the EAU Prostate Cancer Consensus meeting on Active Surveillance (EPCCAS). Indications for new imaging technologies Chaired by Prof. Georg Salomon (DE), the day-long ESUI18 meeting centred on the overarching theme “Getting it right: Indications for modern urological imaging”. The initial session “From finger-guided to imaging targeted biopsy” tackled topics on transrectal prostate

Imaging-Reporting And Data System), 3D modelling and other cutting-edge topics. ESUI18’s mpMRI session encompassed the reading, reporting and biopsy-related issues such as comparing PI-RADS and Likert scoring, lessons from fusion biopsies, future trends in PI-RADS v3.0, and the differences in MR fusion systems. Recognition and the Best Abstract Awards were granted to two winners this year. Dr. Sophie Knipper (DE) and her team received the award for their research "Metastases-yield and PSA-kinetics following salvage lymph node dissection: A comparison between conventional surgical approach and radio-guided surgery". Dr. Samantha Koschel (AT) and her team were award recipients for their research on "PSMA PET to detect and localise primary prostate cancer: concordance with mpMRI, biopsy and radical prostatectomy in a single centre retrospective series." This was followed by the session “What's up with that?” where technologies such as dual energy analysis, fluorescence diagnostics in cystoscopy, contrast-enhanced ultrasound for the kidney, and mpCystoscopy for bladder cancer were thoroughly examined. ESUP symposium On the same day as ESUI18, a symposium was organised together with the European Society of Pathology. In her lecture “Update on bladder cancer treatments”, Prof. Susanne Osanto (NL) foresaw increased use of checkpoint inhibitors (metastatic 2L and 1L, neo and adjuvant space and even in nonmuscle invasive bladder cancer). Combinations of chemo- and immunotherapy, and in future systemic

Dr. Van Sloun discusses AI and Deep Learning

EMUC’s 10th edition launched on Friday with Plenary Session 1 “Prostate cancer management: Implementation without good evidence?”. In his lecture “Functional imaging for recurrent disease”, Dr. Stefano Fanti (IT) underscored the relevance of performing more randomised and multi-centre studies to produce and procure more quality and robust data. Prof. Rodolfo Montironi (IT) enumerated and expounded on the advantages of using digital (virtual) slides that include image sharing, interactive publication, quantitative image analysis, and information fusion. Dr. Sergio Bracarda (GB) stated that at present, abiraterone (ABI) or docetaxel (DCT) plus androgen deprivation therapy (ADT) are the new standards of care for cases presenting with high-risk metastatic castration-sensitive prostate cancer (HR-mCSPC), but which is better is not yet known. In generating good evidence in the coming decade, Dr. Laurence Collette (BE) concluded the Plenary Session and her lecture with the message: “Patient-centric trials are the future, as are multi-stakeholder collaborations with more than one company. Effective digitalization of our results will lead to bigger data for researchers.” Pros and cons In the point-counterpoint discussion “Immunotherapy for all patients as first line in kidney cancer?” Dr. Laurence Albiges (FR) presented her insights in favour of IO as first-line treatment. She stated that overall survival (OS) benefit with nivolumab +

ipilimumab is the new benchmark, and pointed out that some good-risk patients can achieve complete response (CR) with IO approach. Prof. Schmidinger pointed out that the debate was not about immunotherapy per se but about the “timing of immunotherapy” and that IO does not need to be the first-line treatment for all patients. She stated that favourable-risk and some intermediate-risk patients may be better off with delayed immune-checkpoint inhibitors (ICI) as using ICI combinations too early in the course of the disease could signify a loss of opportunity. In Plenary Session 5 “Kidney cancer in the frail patient”, Dr. Umberto Capitanio (IT) identified two main theoretical concepts of frailty: the frailty phenotype and the accumulation of deficits. The frailty phenotype is based on five criteria: shrinking (weight loss), weakness (declining grip strength), self-reported fatigue, a decrease in walking speed and self-reported low activity. He stated that there are a variety of ways to establish frailty such as via the Geriatric 8 (G8) screening tool and cross-sectional imaging. Trial updates “Cytoreductive nephrectomy (CN) should no longer be considered to be the standard of care in metastatic

8-11 November 2018 Amsterdam, The Netherlands

www.emuc18.org Continued on page 5

Engrossed audience during Prof. Wyatt's cfDNA talk

biopsies wherein a patient's travel history should also be taken into account, according to Prof. Dr. Florian Wagenlehner (DE). Further into the session, Mr. David Eldred-Evans (GB) stated that transperineal biopsy approach is becoming more feasible and deliverable as a universal approach, and eliminates the problems of sepsis. Parts I and II of the “Back to the future” sessions featured the rise of artificial intelligence, imagingrelated toxicities, development of VI-RADS (Vesical

therapy will be used in metastatic and high-risk non-muscle invasive and invasive or metastatic bladder cancer. Further into the symposium, Dr. Andrea Necchi (IT) gave a wide-ranging overview of the latest developments in the field of immuno-oncology (IO) such as data regarding neoadjuvant use of pembrolizumab and chemotherapy for locally advanced urothelial cancer. “In selected patients, we should really be brave and continue immunotherapy instead of complicating the process with chemotherapy.” Multidisciplinary teamwork EMUC18 emphasised the synergy from multidisciplinary teamwork to highlight that comprehensive cancer care is only possible when various experts work together to identify and achieve optimal treatment strategies.

August/September 2018

www.eau19.org

European Urology Today

Joint forces at EU level for kidney cancer care Equal access to diagnostic tools and treatment in all European countries? By Jarka Bloemberg As one of the most lethal genitourinary cancers, the recognition of kidney cancer as a major European healthcare challenge is a principal requirement. During the Kidney Cancer Europe Roundtable organised by the International Centre for Parliamentary Studies (ICPS), caregivers, researchers, industry and patient organisations gathered in Brussels to join forces to establish a better management of kidney cancer in Europe. Kidney cancer is of particular significance in Europe as it has among the highest incidence in the world, particularly in Eastern Europe. In 2012, the Czech Republic showed the highest incidence rates (34.9/100 000 in men and 15.0/100 000 in women). The incidence rates have been slightly increasing over time in some European countries and have remained All participants of the Kidney Cancer Europe Roundtable stable in others. The International Agency for Research on Cancer (IARC) projects a 22% increase worldwide by 2020. the needs of patients. The EAU Patient Information Significant differences in the incidence of kidney Initiative aims to provide every urological patient in cancer in European countries underscore the Europe with access to the highest-quality patient importance of primary prevention, early detection and information. Well-informed patients are better effective treatment to ensure an increased quality of equipped to talk about issues that worry them, and life. European action is urgently required to reduce about the way they experience their condition and the burden of kidney cancer on patients and society treatment, leading to better care. and to ensure equal access to diagnostic tools and innovative treatments across different European International differences in mortality countries and regions. Increased use of imaging techniques in Western countries has increased the detection of early stage disease, and has also already proven to reduce mortality rates in these countries. Equal access to diagnostic tools like MRI across different European regions will allow timely and accurate treatment which will lead to increasing number of kidney cancer survivors.

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.

Mark Behrendt, Rachel Giles, Lydia Makaroff, Hein Van Poppel and Alexander Smith (from left)

The Kidney Cancer Europe Roundtable, chaired by Professor Hein Van Poppel, EAU Adjunct SecretaryGeneral, was attended by politicians, like Mr. Francis Zammit Dimech of MEPs Against Cancer, representatives of patient organisations like the European Cancer Patient Coalition (ECPC) and the International Kidney Cancer Coalition (IKCC), academia and clinicians. During the event the Scientific & Policy Briefing on Kidney Cancer was also launched. This initiative by the EAU aims to stimulate a closer collaboration and knowledge sharing by EU member states and across the healthcare sector. It addresses key challenges in improving patientsâ&#x20AC;&#x2122; outcomes.

Deprived healthcare infrastructure and resources, lack of skilled healthcare professionals and complex regulatory and reimbursement pathways are barriers that should be tackled at EU level to achieve a patient-centred multidisciplinary approach for kidney cancer patients in Europe. Innovative healthcare technologies and the setting of standards at an international level through the EAU Clinical Guidelines are essential to continuously improve the lives of Europeans affected by kidney cancer. Despite the pressure to control the annual increase of healthcare costs, the EU should continue to fund research in innovations in uro-oncology. Future research for personalised treatment The European Commission has funded about 1,000 cancer-related projects with 1.5 billion euros from 2007 to 2013. Only 21 projects were dedicated to kidney cancer since 2002, which indicates a disproportional underrepresentation of allocated funds to renal cancers. Further research on the risk factors, diagnostics and personalised treatment will be beneficial to reduce the substantial inequality in kidney cancer care and improve survival rates all over Europe. With new research findings concerning the effect of gene

mutations linked to kidney cancer, effective biomarkers that predict the treatment response and immune checkpoint inhibitors, the future of kidney cancer treatment looks promising. Collaboration to move forward A close collaboration of multiple specialists is required to ensure the best outcome at the lowest costs. Unfortunately, in low-income countries this patient-centred multidisciplinary care is often not available. The scientific & policy briefing on kidney cancer was well received by all those who attended and it led to several commitments. It was agreed to join forces on a World Kidney Day, led by IKCC. The accompanying campaign will focus on lifestyle recommendations to prevent kidney and other types of cancer and should be actively advertised to the patient organisations. The EAU will continue to address the most demanding issues in urological care through its publications and scientific and educational activities; the ultimate goal being to achieve that all patients with kidney cancer have timely access to innovative treatments that are also affordable.

Scientific & Po

licy Briefing on

K IDNE Y C A NC E R

Awareness and prevention It has been estimated that up to half of the overall burden of all cancers can be prevented. Despite the increasing incidence of kidney cancer, the causes are poorly understood. The three most established modifiable risk factors of developing kidney cancer are cigarette smoking, obesity and high blood pressure. There is an important role for the EU to raise greater awareness for kidney cancer, highlighting the risk factors, but also sharing knowledge about the first symptoms. In the early stage of the disease, there are no clear symptoms to indicate the presence of kidney cancer. If the patient presents with symptoms such as haematuria, lower back pain, weight loss or fatigue, the disease is usually already in an advanced stage. A meaningful dialogue between the doctor and patient can be established by educating patients and their families and providing them with reliable patient information based on the latest scientific evidence, expert recommendations, and discussing

European Urology Today

October/December 2018

Update from the Guidelines Office Winter edition 2018 Chair, Board, Senior Associate and Social Media meetings The Berlin Marriott Hotel was the venue for the autumn 2018 Guidelines Office Board, Panel Chairs, Social Media Committee and Senior Associates meetings. During the course of these meetings the vision and direction of the EAU Guidelines in 2019 were discussed, along with a review of the Guidelines Office's achievements in the first three quarters of 2018. The Panel Chair meeting, in particular, was a very lively affair with a number of guest speakers. The meeting was opened with a presentation from Bertie Leigh, the esteemed British QC (Queen’s Counsel) and Consultant Chairman of the United Kingdom’s National Confidential Enquiry into Patient Outcome and Death (NCEPOD), entitled “The Role of Guidelines in Litigation – should we care?: How do we create a safety net for the patient without putting a noose round the neck of the surgeon”. This was followed by an inspirational account by Piarella Peralta, from the patient advocacy group Inspire2Live, on the role of the patient advocate. Bladder Cancer Consensus-finding Project The Guidelines Office is currently involved in two Consensus finding projects for both bladder cancer and prostate cancer. In the last issue of EUT we gave details of the prostate cancer project and, in the second of our articles on consensus-finding, we provide an overview of the Bladder Cancer Project.

EMUC18 explores best practices and future advances . . . . . . . . . . . . . . . . . . . . . . . 1 Joint forces at EU level for kidney cancer care. . 2 Update from the Guidelines Office . . . . . . . . . 3 ESUR18: Complete update on new research areas in urology. . . . . . . . . . . . . . . . 4 EAU strengthens ties with wide range of national societies. . . . . . . . . . . . . . . . . . . . 4

Senior associates meeting

Urology awareness alarmingly low. . . . . . . . . 6 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . 7-10 ELUTS18: “The crème de la crème of Functional Urology”. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 ELUTS18: A Spotlight on functional and reconstructive urology . . . . . . . . . . . . . . . . . . 11

EAU/ESMO Consensus-finding meeting on bladder cancer - plenary session

Is the EUREP resident programme for you?. . 14 Ebb and flow: EUREP18 welcomes change and progress . . . . . . . . . . . . . . . . . . . . . . . . 14 EUREP18 offers residents well-balanced programme . . . . . . . . . . . . . . . . . . . . . . . . . 14 EUREP18 highlights in my hometown. . . . . . 15 A Novi Sad resident’s impressions of EUREP18. . . . . . . . . . . . . . . . . . . . . . . . . . 15

The bladder cancer consensus-finding project is a Delphi study being conducted as a joint activity by the European Association of Urology (EAU) and the European Society of Medical Oncology (ESMO). The project aims to support the development of treatment recommendations and will attempt to find stakeholder-consensus on a number of treatment recommendations through use of a Delphi survey, break-out sessions and anonymous, electronic voting at a face-to-face meeting.

Potentially a brighter future for '3D' laparoscopy? . . . . . . . . . . . . . . . . . . . . . . . . 16 ESU section: New ART in Flexible cultivates stone treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ESU offers in-depth HOT course in Cáceres. . 18 ESU and RSU create stronger ties between East and West . . . . . . . . . . . . . . . . 19

Bladder cancer is quite a common cancer, which, at the initial stages often goes unnoticed. Muscleinvasive cancer is more likely to spread to other parts of the body and this type of cancer is treated much more aggressively than non-muscle invasive cancer. A number of treatment options exist but the most common options are removal of the bladder, or treatment of the bladder with radiation- or chemo therapy.

"...by virtue of involving a large group of stakeholders,... a balanced view as to what are considered the best available treatment options can be presented..." International guidelines exist, addressing the management of bladder cancer, but for a considerable proportion of the treatment recommendations presented in these guidelines, the evidence is of low-quality. This is a problem recognised by all those involved in the management of invasive bladder cancer and all efforts are made to set up studies to fill these gaps. This will take time, and may not even be possible for this entire field. In the meantime patients need to be treated according to the highest standards possible, to ensure a positive outcome whenever likely. In October, all relevant stakeholders were contacted to learn their opinions about a number of key statements linked to the treatment of muscle-invasive bladder cancer through completion of a two-round Delphi survey. Once the relevant parties had made their opinions known a number of participants were then invited to attend a face-to-face meeting, complete with breakout sessions, held on 8 November in Amsterdam, The Netherlands during EMUC18. The meeting was chaired by Prof. T.M. De Reijke with assistance from Prof. A. Horwich and Prof. F. Witjes, co-chairs of the Delphi project. Following the successful completion of the face-to-face meeting, the results of the exercise may assist in the development of guidelines recommendations. While the project will not solve Guidelines Office

October/December 2018

EAU19: Live Surgery at EAU19: A look behind the scenes . . . . . . . . . . . . . . . . . . . . . . . . . . 12 EAU19 Abstract submissions surpass previous congresses. . . . . . . . . . . . . . . . . . . . . . . . . . 13 How well do you know the EAU Guidelines?. 13

EULIS-ESUT Project identifies core outcome sets in stones. . . . . . . . . . . . . . . . . 20 Book reviews. . . . . . . . . . . . . . . . . . . . . . . . 20 Canadian Tour 2018 - Academic Exchange Programme . . . . . . . . . . . . . . . . . . . . . . . . . 21

EAU/ESMO Consensus-finding meeting on bladder cancer - breakout sessions

ERUS18: Expert audience leads to more advanced surgery. . . . . . . . . . . . . . . . . . . . . 22 Varieties in Office Urology across Europe. . . 23 EBU section: Coimbra’s Residency Training receives 3rd EBU Certification . . . . . . . . . . . . . . . . . . 24 European Urology honours Prof. Stefan C. Müller . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 ESUT: Hot and cold: FT energy sources for prostate cancer. . . . . . . . . . . . . . . . . . . . 26 ESFFU: Men with Parkinson’s disease, enlarged prostate and LUTS. . . . . . . . . . . . . 27 SEEM18: Promoting new research and young urologists. . . . . . . . . . . . . . . . . . . . . . 27 YUO section: How to excel in the European Board of Urology Exam. . . . . . . . . . . . . . . . . . . . . . Challenges in Laparoscopy & Robotics 2018 . . The road to a successful fellowship . . . . . . . Prague hosts ESRU Board meeting. . . . . . . .

EAU Guidelines Office Chairmen's meeting, Berlin

the problem of missing high-quality research data, by virtue of involving a large group of stakeholders in the management of muscle-invasive bladder cancer, a balanced view as to what are considered the best available treatment options can be presented. China Meeting A delegation from the EAU Guidelines Office attended the Chinese Urological Association (CUA) Uro-oncology meeting in November in Shenzhen, China. The Guidelines Office activities at the meeting included a workshop, on the topic of the evolving nature of guidelines production, and a number of invited lectures from Guidelines Panel members. These lectures included Mr. P. Cornford on “The management of metastatic hormonesensitive prostate cancer - what the evidence says”, Prof. A. Volpe with “What’s new in the 2018 EAU guidelines on RCC” and Prof. T. Loch on “Artificial intelligence in prostate cancer diagnostics”.

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

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ESUT supports HoLEP course programme in Turkey. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Obituary Flamur Tartari . . . . . . . . . . . . . . . . 31 ESOU19 to offer novel diagnosis & treatment approaches. . . . . . . . . . . . . . . . . . 33 Oibtuary Hubert Frohmüller. . . . . . . . . . . . . 33 EAUN section: Dutch nurses benefit from a Post-EAUN meeting. . . . . . . . . . . . . . . . . . . . . . . . . . . . BAUS Conference Report. . . . . . . . . . . . . . . Our passion for Urology Nursing overcomes barriers. . . . . . . . . . . . . . . . . . . . EAUN-AZUNS session puts spotlight on sexual health. . . . . . . . . . . . . . . . . . . . . .

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European Urology Today

ESUR18: Complete update on new research areas in urology EAU Sections of Urological Research and Uropathology join forces in Greek capital The 25th Meeting of the EAU Section of Urological Research (in collaboration with the EAU Section of Uropathology) took place in Athens, Greece from 4-6 October 2018.

associated fibroblasts interactions in prostate cancer. Main networking activities in urological research were presented by Endre Kiss-Toth (GB), Hing Leung (GB), Evangelos Xylinas (FR) and Anders Bjartell (SE) who www.esur18.org provided, respectively, overviews of the Train-Tribbles Network, the Transport Network, activities of the The venue was the Biomedical Research Foundation Antonia Vlahou (GR) on urinary epigenetic and young urologists forum and the EAU Research of the Academy of Athens, one of the leading research Foundation. proteomic biomarkers respectively for bladder institutes in Greece. More than 100 participants from cancer and Emil Christensen (DK) on the latest 20 European countries, China, South Korea, Taiwan developments on the application of cell-free DNA as Following a highly-interactive poster session, the and the USA, representing diverse clinical and a source of cancer biomarkers. Two relevant short afternoon programme included a provocative research disciplines, gathered in the Greek capital. presentations by Marie-Lisa Eich (US) and Lewis Au point-counterpoint session on the added value of This reflected, once more, the multi-disciplinary, molecular subtypes in bladder cancer management (GB) followed, focusing on urinary DNA-based tests research-intensive, lively ESUR spirit. for bladder and renal cancers. with presentations by Markus Eckstein (DE) and Gunter Niegisch (DE) moderated by Yves Allory (FR) Lively poster session The programme started with a pre-meeting, The meeting ended with the presentation of the and Alexandra Masson-Lecomte (FR). Relevant short highly-interactive ESU course, delivered by Stavros ARTP award to the best abstract on prostate cancer, presentations by Mario Cangiano (NL), Clementine and Egbert Oosterwijk (NL) delivered insightful talks Tyritzis, (GR), Michiel Sedelaar (NL), and Anders Le Magnen (CH), Yvonne Ceder (SE), Alessia this year conferred to Natalie Sampson (AT) for her Bjartell (SE) on the clinical challenges associated with on epigenetic mechanisms underlying cancer cell abstract entitled Cancer-associated fibroblast Cimadamore (IT) and Domenico Albino (CH) development and progression towards aggressive prostate cancer management and pertinent research heterogeneity within the prostate cancer stromal followed, addressing clinical and molecular aspects molecular phenotypes. The challenges associated advancements. Lively discussions touched upon the microenvironment and thankful closing remarks by with multi-source data integration, existing promising related to prostate cancer progression. contribution of existing molecular phenotypes and the ESUR and meeting chairs. The group will biomarkers in combination with treatment modalities tools and examples of their applications in biomarker The last day of the meeting set off with a session on re-convene in beautiful Porto, Portugal for and drug discovery were presented by Aristotelis to the management of localised and metastasised ESUR-SBUR19 (13th World Congress on Urological Chatziioannou (GR) and Leonidas Alexopoulos (GR) in biomarkers and clinical trials, with a presentation by disease. Research, 10-12 October 2019), chaired by Carmen a special session on Big Data. This also included short Thomas Keller (DE) on main statistical considerations and common pitfalls associated with Jeronimo. Following the opening of the ESUR meeting by Kerstin oral presentations by Rafael Stroggilos (GR), Yanti biomarker development. This was followed by Setiasti (NL), Annika Kohvakka (FI) and Francesca Junker (DE, ESUR Chair), Rodolfo Montironi (IT, ESUP comprehensive presentations by Aristotelis Bamias Antonia Vlahou Amoroso (GB), on bladder cancer subtyping, as well Chair) and Antonia Vlahou (GR, Meeting Chair), (GR) on biomarker inclusions in running urological ESUR18 Meeting Chair Francesca Demichellis (IT), Margaret Knowles (GB) as signalling networks and combination of imaging cancer trials, and Annelies Verbiest (BE) and Elfriede with molecular data towards better understanding Nossner (DE) on predictive biomarkers for kidney Kerstin Junker and/or management of prostate cancer. ESUR Chair cancer and immunotherapy response, respectively. The second day of the meeting opened with a session The session ended with a presentation by Holger Moch (CH) on the implementation of digital focusing on tumour cell-microenvironment pathology in new clinical trials. Short presentations interactions, including stellar presentations by were then delivered by Jacqueline Fontugne (FR), Catherine Muller-Staumont (FR) on the impact of Gerald Verhaegh (NL), Malin Hagber Thulin (SE), adipocytes on tumour growth, Martin Puhr (AT) on Linda Rushworth (GB), and Carmen Jeronimo (PT) therapeutic approaches involving the glucocorticoid on recent molecular findings of potential therapeutic receptor and Natasha Kyprianou (US) on impact of and predictive value for urogenital cancers. combination therapies involving TGFb blockade on advanced prostate cancer treatment. The session also Following a second lively poster session, the final included relevant short presentations by Britta SĂśderkvist (SE), Natalie Sampson (AT) and Johannes session of the meeting focused on liquid biopsies ARTP Award presented to Natalie Sampson, Innsbruck (AT) by including presentations by Ellen Zwarthoff (NL) and Jocelyn Ceraline, Strasbourg (FR) Linxweiler (DE) on tumour-stromal and cancer ESUR participants outside the Biomedical Research Foundation

EAU Edu Platform The online learning platform for GU cancers

Renewed

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ESUI Vision Award 2019 PROSTATE CANCER

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The EAU Section of Urological Imaging (ESUI) is calling for abstracts for the ESUI Vision Award 2019, 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

Visit uroonco.uroweb.org for the best curated content in GU cancers

Deadline: 21 January 2019, 23.59CET. The award will be handed out at the 34th Annual EAU Congress in Barcelona during the ESUI section meeting, on Saturday, 16 March 2019 from 10.00 - 14.00 in Green room 10. The award is supported by a grant of â&#x201A;Ź 1,500 by INVIVO, a Philips company.

European Urology Today

October/December 2018

Continued from page 1

renal cell carcinoma (mRCC), at least when medical treatment is required,” stated Prof. Arnaud Méjean (FR) during his presentation on the Clinical Trial to Assess the Importance of Nephrectomy (CARMENA) trial. A finding of the CARMENA trial included that sunitinib alone was not inferior to cytoreductive nephrectomy. Dr. Alison Birtle (GB) announced the successor trial POUT 2: Chemotherapy with or without immunotherapy following nephron-ureterectomy for upper tract urothelial cancer. The rationale for POUT 2 is that high incidence of microsatellite instability in Upper Urinary Tract Urothelial Carcinoma (UTUC) may predispose to immunotherapy sensitivity; and that it has proven feasible to combine immunotherapy with chemotherapy. The primary endpoint is disease-free survival. PCa evaluation In his lecture “Everything in prostate cancer pathology you were afraid to ask”, Prof. Jonathan Epstein (US) provided a forum for attendees to answer some of the more confusing and clinically important issues relating to prostate pathology. He stated that pathology experts say urological tumours are becoming more precisely classified based on a combination of morphology, immunohistochemistry, and molecular findings. With new developments, treatment regimens can, therefore, be tailored more accurately to the specific subtype of the tumour, according to Epstein. After a demonstration of emerging image processing techniques, Prof. Philippe Lambin (NL) concluded, “Radiomics is an emerging field that can translate medical images into quantitative data to enable phenotypic profiling for diagnosis, treatment decisions and treatment evaluation. There are several potential applications that relate to prostate cancer, such as screening, image-guided biopsies and active surveillance. It’s time to test radiomic approaches systematically in clinical trials.” Awards Four promising urologists were granted awards at EMUC18: Dr. Christian Fankhauser (CH) received the Best Abstract Award; Dr. Robert Abouassaly (US),

ESUI18

8 November 2018 Amsterdam, The Netherlands

www.esui18.org Drs. Malou Kuppen (NL) and Dr. Henrik Kjölhede (DK) were awardees of the Best Unmoderated Poster awards. Current dilemmas in mPCa During his lecture “Cell-free DNA in blood: The best source for response prediction?” Assoc. Prof. Alexander Wyatt (CA) stated that one of the strengths of plasma cell-free DNA analysis is that all patients are eligible for blood-drawing; while with metastatic tissue biopsy, some patients may be ineligible, e.g. patients with aggressive diseases that have rapid deterioration.

“We can’t treat all patients the same way. The diseases don’t behave in the same way.” Later in the session, Dr. Ganesh Palapattu (US) underlined to treat the patients, not the diseases. In his lecture “Why do some patients only get oligometastatic disease?”, he stated that there is a significant benefit for risk-based treatment allocation. “We can’t treat all patients the same way. The diseases don’t behave in the same way.”

Packed room at the ESU course on managing mPCa

Specialised ESU courses To further enhance the learning of EMUC18 and ESUI18 participants, the European School of Urology (ESU) offered complementary courses "Daily practice in the management of metastatic prostate cancer" and "Immunotherapy for urological tumours", as well as, the following hands-on training (HOT) courses: “ESU/ ESUI HOT course Prostate MRI reading for urologist”, “ESU/ESUT/ESUI HOT Course in MRI Fusion biopsy”, and “ESU/ESUI HOT course in Prostate PET in urologists”. EMUC18 concluded with a summary of take-home messages and the closing remarks of the organisers led by Prof. Van Poppel, Prof. Hoskin and Prof. Aristotelis Bamias (GR). Vienna will be the venue for the 11th edition of EMUC in 2019.

Participants boosting their skills during ESU's HOT course on MRI Reading

EAU strengthens ties with wide range of national societies Promoting urology through lectures at global events By Astrid Venhorst and Erika De Groot The European Association of Urology (EAU) continues to strengthen its ties with various national urological organisations in and outside Europe. Throughout the year, the EAU Executive Board and Section Office members participate in many international events held across the world to represent the EAU and help raise the level of urological care. Read on to know more about recent EAU contributions and activities. September events Last September, Adjunct Secretary-General & Executive Member Education, Prof. Hein Van Poppel (BE), travelled to Ireland to present his lectures on the future of urology and how to improve surgery for muscle-invasive bladder cancer (MIBC) at the annual congress of the Irish Society of Urology (ISU). In the same month, Secretary General Prof. Chris Chapple (GB) gave his lecture on contemporary management of benign urethral disease at the 70th congress of the Deutschen Gesellschaft für Urologie (DGU) in Germany. He then travelled to Seoul, South Korea to present during the EAU Symposium at the congress of the Société Internationale d’Urologie (SIU). Prof. Chapple was also invited to give a speech during the President’s Dinner of the Korean Urological Assocation (KUA).

Prof. Van Poppel [left] with previous ISU president Mr. Eamonn Rogers [right] International Relations Office

October/December 2018

October activities Chairman of the Scientific Congress Office, Prof. Arnulf Stenzl (DE), and Prof. Dr. Alexandre De La Taille (FR) provided relevant updates in bladder and prostate cancers at the 10th Congress of the Lebanese Urology Society organised in Beirut, Lebanon. Another significant event that took place in October, the annual meeting of the Società Italiana di Urologia (SIU) hosted a frontline EAU Section Session in cooperation with the EAU Section of Urolithiasis (EULIS) and the EAU Section of Urological Imaging (ESUI). Later in the month, previous ESUI Chair, Prof. Jochen Walz (FR), chaired the joint session of the EAU and the European Association of Nuclear Medicine (EANM) which was held during the EANM meeting in Düsseldorf, Germany. By mid-month, Adjunct Secretary-General & Executive Member Clinical Practice, Prof. Jens Sønksen (DK), presented his EAU lecture during the national meeting of the Czech Urological Society. November endeavours The month of November was packed with numerous EAU activities. From end October to early November, Prof. Chapple gave his state-of-the-art lecture on stress urinary incontinence at the annual meeting of the Western Section of the American Urological Association (AUA) which took place in Maui, Hawaii. Other internationally-known experts of the EAU and the European School of Urology (ESU) presented numerous lectures during the XXXVII Congreso de la Confederación Americana de Urología (CAU) and the 5th Confederación Americana de Urologia Residents Education Programme (CAUREP) held in Punta Cana, Dominican Republic. Dr. Maarten Albersen (BE) focused on topics of new therapies for erectile dysfunction and organ-sparing surgery for penile cancer during his presentations at

As part of EAU Day, Prof. Hashim Hashim (GB) gave a lecture at the Congreso Nacional LXIX de la Sociedad Mexicana de Urología in Leon, Guanajuato in Mexico early November. Later that month, EAU lectures and an ESU course on Paediatric Urology were presented by Prof. Serdar Tekgül (TR) and Chair of the EAU Membership Office, Prof. Igor Korneyev (RU), at the national congress of the Iraqi Urology Association in Baghdad, Iraq.

Prof. Chapple giving a speech at the President's Dinner of the KUA during the 38th Congress of the SIU

During the 61st Philippine Urological Association Annual Congress held in Manila, Prof. Maria Ribal (ES) shared her insights on radical prostatectomy for oligometastatic disease, and multimodality treatment for MIBC.

the Annual Scientific Meeting of the Indonesian Urological Association (ASMIUA) in Padang, Indonesia.

Prof. Gommert Van Koeveringe (NL) was invited to give his EAU lecture on underactive bladder during the 112ème Congrès Français d'Urologie (CFU) in Paris. Both Prof. Arnulf Stenzl and Prof. Axel Heidenreich PSA screening, testicular and bladder cancers were the topics of choice of Prof. Peter Albers (DE) when he (DE) represented the EAU at the 27th Malaysian presented during the 4th Society of Urological Surgery Urological Conference in Kuala Lumpur and present in Turkey Meeting in Antalya, Turkey. their lectures on bladder-sparing treatment for MIBC and surgical options for Upper Tract Urothelial Carcinoma (UTUC), respectively. While Prof. Van Highly-informative EAU lectures and ESU hands-on trainings were showcased during the 7th Emirates Poppel was invited to give a lecture during the annual meeting of the KUA in Seoul. International Urological Conference (EUSC 2018) and 15th Annual Arab Association of Urology (AAU) Conference in Dubai, United Arab Emirates. Prof. Noel Clarke (GB) shared his insights on DNA damage response and changing practice in high-risk prostate cancer based on the STAMPEDE study during At the 25th Annual Meeting of the Chinese Urological the meeting of the Society Urologic Oncology (SUO) Association (CUA2018), Prof. David Castro-Díaz (ES) held in Phoenix, Arizona. The cooperation with the SUO shared his insights on bladder pain syndrome. This has flourished over the last year. One of the activities meeting was preceded by the 5th Chinese European that has resulted from this is a new scholarship Urology Education Programme (CEUEP) wherein previous EAU Secretary General, Prof. Frans Debruyne exchange programme wherein medical associations may send one of its members for a two-week (NL), and Prof. Castro-Díaz were faculty members. scholarship at a department of choice before or after the respective association’s annual meeting. EAU Treasurer & Executive Member Communication, Prof. Manfred Wirth (DE), was offered an Honorary Membership of the Russian Society of Urology (RSU) The EAU will deliver more essential updates through during its annual meeting in Yekaterinburg. lectures and hands-on trainings in future events of Additionally, the EAU and the ESU provided an various countries worldwide. Stay tuned and who interesting, educational programme onsite. knows, the EAU will be in your country as well. European Urology Today

Urology awareness alarmingly low

Urological Awareness in Europe

Men’s health issues involve partners too Public awareness of urological conditions is alarmingly low throughout Europe. That is the result of international study commissioned by the European Association of Urology (EAU) as part of Urology Week (24-28 September). Over 2,500 members of the public from France, Germany, Italy, Spain and the United Kingdom were asked to assess their knowledge of a range of urological conditions concerning Men’s Health. The new international survey also shows that women know more about men’s health issues than men do, men have poor knowledge of key urological symptoms and don’t take early signs of potentially life-threatening urological conditions seriously. Fundamental lack of knowledge of urology Responses showed that urology as a medical speciality still has a long way to go to reach general awareness: 40% of respondents were unable to identify what a urologist does, 10% stated that they had never even heard of a urologist and almost 15% believe that a urologist treats disorders of the skeletal, nervous or circulatory systems. The low level of awareness indicated by the survey is of particular concern as urological conditions are on a rise due to the ageing European population. Prevention and early diagnosis are crucial to save lives and to control increasing costs. “The results of our latest survey clearly demonstrate that people are ill-informed when it comes to urological conditions. Men in particular have less knowledge than women and turn a blind eye to symptoms and early diagnosis” comments Prof. Hein Van Poppel, urologist and Adjunct Secretary General of the EAU. “Persuading men to take their health seriously presents a serious challenge. They need to have a better understanding of the risk and symptoms of their conditions. They should be encouraged to seek support from a medical professional if they suspect anything unusual.”

International Survey (August 2018)

The prostate remains a mystery to many men Every year, almost 450,000 men across the continent will be diagnosed with prostate cancer, leading to 92,000 deaths in Europe. Despite prostate cancer being the most common cancer in males throughout Europe, three quarters of men admitted that they have limited knowledge of its symptoms. Men are, in fact, more confident in recognising the symptoms of breast cancer (31%) than they are of prostate cancer (27%). In addition to the low awareness of prostate cancer symptoms, just 1 in 4 respondents could correctly identify the location of the prostate and surprisingly, a higher proportion of women (28%) were able to identify the location of the prostate than males (22%). Worryingly, 54% of men believe that women have prostates. Erectile dysfunction and incontinence still taboos Erectile dysfunction (ED) prevalence in Europe is estimated at 50% of the sexually active men of 50 years and older. However, the topic remains a taboo leading to misunderstanding and ignorance. 75% of the respondents were not aware of the numbers of men that suffer from erectile dysfunction in their country. Similarly, 85% were unaware of the amount of people in their country that suffer from urinary tract issues. “Men’s health issues involve partners too”, says Prof. Van Poppel. “Women are more used to checking their bodies. They should encourage men to do the same and discuss their health more in detail. Women should actively participate in conversations with their male partners and doctors.” International differences in testicular cancer knowledge Testicular cancer is the most common type of

cancer to affect younger men. However, survey results stated that only 18% of male respondents knew that men aged 16 to 44 years have the highest risk. Whilst knowledge was found to be low throughout Europe, there were stark differences; only 10% of the respondents from Spain know the at-risk age group compared to 27% in the UK. Symptom awareness was also low with 70% of men lacking confidence in recognising the symptoms of testicular cancer, which may include a swelling or lump in one of the testicles and a dull ache or sharp pain in the testicles or scrotum. Significant delays in visiting the doctor Symptom awareness is recognised as a leading factor in the early diagnosis of urological conditions. The majority of deaths in male cancers occur because most men do not address their conditions in time. Despite this, they continue to ignore their symptoms and delay seeing their doctors. The survey reveals that 43% of people would not go to their doctor straight away if they notice blood in their urine; 23% would wait longer than a month if they suffered a frequent urge to urinate; 28% would wait for more than a week if they suffered burning or pain during urination; and only 17% of people surveyed associate pain in their lower abdomen with a serious problem. Professor of urology and Executive Member for Communications at the EAU, Manfred Wirth adds “Urological diseases are extremely common; they cause a lot of discomfort and at times, can be life-threatening. It’s time for Europe to change its attitude towards urology and invest in educational campaigns to increase urological knowledge and to break taboos.”

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2018

Q: Do you know what a urologist does?

Q: Can you indicate where the prostate is located?

Q: What percentage of men aged 50-80 years old do you think have erectile dysfunction?

Q: How confident are you in recognising the symptoms of the cancers?

Q: What percentage of men do you think suffer from urinary tract issues?

Q: Can you indicate on the visual where the prostate is located?

United Kingdom

Poland

The Netherlands Belgium

Q: How long would you wait after experiencing blood in your urine before visiting your doctor?

France

Italy Spain

Q: These celebrities all have lived with prostate cancer. Do you know how many men in your country suffer from prostate cancer?

More initiatives at ww.urologyweek.org or #urologyweek

Mark the date for Urology Week 2019: 23-27 September 6

European Urology Today

October/December 2018

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

Overall, RLP is an effective and safe treatment option that could be offer to patients with staghorn alternative to PCNL; however, costs are higher as well as invasiveness. Finally, remains unclear whether there is a subgroup of patients benefitting more than others, according to staghorn stone classification.

fsangue@ hotmail.com

Source: Perioperative and long term results of retroperitoneal laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for staghorn calculi: A single center randomized controlled trial. Ya Xiao1, Qianwei Li, Chibing Huang, Pingxian Wang, Jiaxi Zhang, Weihua Fu.

Results from a quasirandomised trial of efficacy and safety of laparoscopic pyelolithotomy as a treatment option for staghorn stones in comparison to PCNL There are data in literature regarding safety and efficacy of laparoscopic pyelolithotomy for large renal pelvis stones as a treatment option alternative to percutaneous nephrolithotomy (PCNL), providing immediate totally stone-free rates (SFR) without affecting renal parenchyma. However, this approach has never been investigated in the setting of staghorn stones as an appropriate competitor to PCNL; a recent publication from a Chinese team has put some lights on this topic by embarking a randomised controlled trial (RCT) comparing the retroperitoneal laparoscopy pyelolithotomy (RPL) to the standard PCNL. Notably, the laparoscopic approach included the aid of flexible cystoscopy to reach the calyces and targeted with laser lithotripsy. As the study design did not provide essential methodological details (e.g. calculation of sample size, randomisation modality, allocation concealment, etc.) it cannot be fully considered a RCT so that it should be referred as a quasi-randomised clinical trial. Moreover, other important clinical data like the degree of staghorn stones according to classification tools and not just to volume of stones were not provided. On the other side, appropriate tools where used to assess stone burden (= non-contrasted CT scan – NCCT) and renal function (eGFR and DMSA) at baseline, post-operatively and during the follow-up. Primary end point was the single session SFR (clinically insignificant residual fragment ≤ 4mm) at 2-day (single session), reassessed at 3-month post-op. Secondary end-point was complication rate. Further end-points reported included: 1) auxiliary treatment rate; 2) stone recurrence rate; 3) renal function changes; 4) costs. A total of 105 patients were recruited and assigned to the relevant treatment arm. Single-session SFR was significantly higher for the RPL group (88.2% vs. 64.8%) with also a significantly higher proportion of patients fully stone-free (76.4% vs. 51.9%). Also in terms of complications, the patients undergoing RLP showed a significant lower post-op drop of haemoglobin (0.4 vs. 1.7 g/dL) and fever rate (5.4% vs. 20.4%).

Single-session SFR was significantly higher for the RPL group (88.2% vs. 64.8%)... Moreover, auxiliary treatments were significantly more common in the PCNL group (11.8% vs. 3.5%). On the other side, no difference in terms of recurrence of stones was observed in the long-term (mean follow-up time: 47.3 months). At 1 year follow-up, renal function improved more significantly in the RLP group. PCNL performed better in terms of costs, especially considering the fact that more instruments were used during the RPL, the operative time was significantly longer (135 vs. 101 mins) as well as the hospital stay (5.3 vs. 4.7 days) though this latter outcome did not reach statistical significance.

Key articles

October/December 2018

WJU in press, doi.org/10.1007/s00345-018-2526-x.

A therapeutic algorithm to support decision-making for the treatment of renal stones in malformed kidneys One of the most challenging cases for endourologists in treating renal stones are patients with kidney malformations: the distorted renal anatomy, and the higher risk for stones to recur and/or for them to get infected, have prompted surgeons to attempt variation of techniques to get the best of outcomes. However, because of the relative rarity of these conditions, robust evidence to support standard approaches is scarce in the literature.

...authors recommended fURS in case of stones of 1.5 cm with low density (< 1000 HU at CT scan)... A group from a high-volume Indian centre has recently published their experience spanning from 1990 to 2014 in treating renal stones in ectopic kidneys (n = 47), horseshoe kidney (n = 85), malrotated kidney (n = 33), and autosomal dominant polycystic kidney disease (ADPKD) (n = 14). This article provides important details for practitioners to consider when dealing with such conditions, which are mainly based on the long-term experience accumulated in nearly 25 years with different surgeons. Though a proper/conventional methodology is lacking, an algorithm has also been proposed to guide surgeons in their decision-making. Percutaneous lithotomy (PCNL) has been the preferred approach in all the kidney malformation subtypes: on the one hand this does not come as a surprise as flexible ureteroscopy (fURS) was a technology only introduced at a later stage, and on the other hand stones used to present on a larger size than small or medium one. This factor prompted surgeon in several occasions to choose this approach. This was mostly the cases for the stones in horseshoe kidneys, which accounted for the majority of the cases: in particular, the authors highlighted the potential easier access to the upper pole than in orthotopically kidneys because of the usual lower position of the organs, which also favoured the navigation in the renal cavities. Interestingly, they also noticed that –in order to puncture a posterior calyx, usually positioned more medially- dilation of the percutaneous tract could be harder because it passes through stronger muscles (e.g. erector spinae). Finally, an interesting trick to avoid puncture of the bowel consisted of obtaining the tract under UltraSound (US) guidance, which helped in displacing the bowel by pushing the probe against the body of the patients. Another thing to consider was also that tracts may be longer than usual. Flexible URS was the second-most frequent approach used, and its employ was reserved for smaller stones. The main problems for this approach include the tortuosity of the ureter, ventral angulation of the renal pelvis, less favourable anatomy of the collecting system to facilitate drainage of the fragments. Authors recommended the regular use of the ureteral access sheath, though the one employed (12-14 Fr) may not represent current standard, in order to facilitate active retrieval of fragments. Because all of that, authors recommended fURS in case of stones of 1.5 cm with low density (< 1000 HU at CT scan): CT scan was then deemed mandatory to plan an appropriate approach in all these cases.

Extracorporeal Shock Wave was considered a third option especially for smaller stones and for favourable anatomical features, while the employment of laparoscopic surgery was mostly anecdotic.

Source: Changing trends in the endourological management of urolithiasis in anomalous kidneys. Abhishek G. Singh, Ankush Jairath, Sudharshan S. Balaji, et al. BJU International 2018 in press; doi:10.1111/bju.14575

Is MicroPerc a contender to RIRS for renal stones intervention? Results from a systematic review with meta-analysis Retrograde Intrarenal Surgery (RIRS) by means of flexible ureteroscopy (fURS) has quickly become a popular procedure competing with shock wave lithotripsy (SWL) and percutaneous lithotomy (PCNL) combining the minimally invasiveness of the former with efficacy of the latter, especially for medium size renal stones (1-2 cm). However, recent introduction in the market of miniaturised PCNL has challenged the safety and efficacy of RIRS in this particular setting of patients: with smaller and smaller instruments, comorbidities classically related to standard PCNL (e.g. blood transfusion, urine leakage, artero-venous fistula) dropped significantly whilst keeping the high efficacy with the aid of laser. MicroPerc is one of the latest devices developed consisting of an all-seeing needle of 4.85 Fr with a microcamera and a tiny working channel allowing the introduction of a laser fibre; the technique involve the laser fragmentation of the targeted stones, with fragments washed-out by flushing the renal cavity with water and by gravity.

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk Overall, MicroPerc seems to be a safe and effective treatment option for medium size renal stones, and could be a potential alternative to RIRS especially for lower pole stones with unfavourable anatomy of calyx and infundibulum.

Source: Micropercutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of renal stones: A systematic review and meta-analysis. Li X, Li J, Zhu W, Duan X, Zhao Z, Deng T, et al. (2018) PLoS ONE 13(10): e0206048. https://doi.org/10.1371/ journal.pone.0206048

Local therapy improves overall survival in low-volume metastatic prostate cancer Patients with metastatic cancer typically receive systemic therapy. However, local treatment to the primary tumour might be more useful than previously appreciated. In animal models, primary tumours metastasise not merely by disseminating tumour cells but also by producing factors to facilitate the development of metastasis at certain sites. In these models, local treatment inhibits not just the initiation of distant disease but also the progression of existing metastasis. This has been previously investigated in breast and lung cancer but showed no benefit and even in renal cell carcinoma where cyto-reductive nephrectomy was thought to be beneficial this has been questioned by recent data.

However, data regarding this promising device are still scarce in literature and limited to few comparative studies involving a relative small number of patients. A systematic review and meta- analysis has been recently carried out in an attempt to provide more robust evidence by pulling out some of the available outcomes.

...local treatment to the primary tumour might be more useful than previously appreciated...

Overall, MicroPerc seems to be a safe and effective treatment option for medium size renal stones...

In prostate cancer, the HORRAD trial randomised 432 men with metastatic prostate cancer to androgen deprivation with or without prostate radiotherapy and found no evidence of overall survival benefit. It did raise the possibility that survival might be improved in a sub-group of patients with less than 5 bone metastasis.

After searching in PubMed, Embase and Cochrane Library databases for comparative studies of the two interventions for the treatment of renal stones, authors selected and extracted data from 9 papers, of which 2 were dealing with paediatric patients, for a total number of 842 patients.

This study randomised 2,061 patients with newly diagnosed metastatic prostate cancer in a 1:1 ratio to standard of care or standard of care plus radiotherapy. Standard of care was life-long androgen deprivation therapy with up front Docetaxel permitted from December 2015 (18%). Of the seven papers dealing with kidney stones in Men allocated radiotherapy received either a daily adult patients, two were randomised controlled trials (55 Gy in 20 fractions over 4 weeks) or weekly (36 and the remainders accounted for retrospective cohort Gy in six fractions over 6 weeks) schedule that was studies. nominated before randomisation. The primary outcome was overall survival, measured as the Outcomes extracted included stone-free rates (SFR), number of death. Secondary outcomes were drop in haemoglobin levels, fluoroscopy time, blood failure-free survival, progression-free survival, transfusion status, operative time, hospitalization time metastatic progression-free survival, prostate and complications. cancer-specific survival, and symptomatic local event-free survival. Metastatic burden was Quality of the studies was reported to be sufficiently determined by retrospectively collecting retrievable good by using relevant assessment tools (Newcastlebaseline scans. Ottawa for non-RCT, Cochrane for RCT) in 6/7 of the non-RCTs and in 1/2 of the RCTs. Radiotherapy improved failure-free survival (HR 0·76, 95% CI 0·68–0·84; p < 0·0001) but not overall By performing the meta-analysis in the adult papers survival (0·92, 0·80–1·06; p = 0·266). Radiotherapy for the outcomes in observations, authors reported a was well tolerated, with 48 (5%) adverse events significant advantage for MicroPerc patients in terms (Radiation Therapy Oncology Group grade 3–4) of SFR (OR 1.62, 95% CI:1.03-2.48) at the cost of lower reported during radiotherapy and 37 (4%) after drop of haemoglobin (Mean Difference +0.59 mg/dL; radiotherapy. The proportion reporting at least one 95% CI:0.16-1..02), longer fluoroscopy time as well as severe adverse event was similar by treatment of hospital stay (MD +0.66 days; 95% CI: 0.17-1.15). group in the safety population (398 [38%] with Main limitations of these outcomes are the small control and 380 [39%] with radiotherapy). In a number of patients recruited in each study, different subgroup analysis by metastatic burden, 819 (40%) types of studies included in the meta-analysis and men had a low metastatic burden, 1,120 (54%) had inability to undertake subgroup analysis for stone a high metastatic burden, and the metastatic location (lower pole vs. other renal locations). burden was unknown for 122 (6%). There was Moreover, no costs analysis could be undertaken to evidence of an effect in patients with low metastatic evaluate cost-effectiveness. burden (sub-HR 0·65, 95% CI 0·47–0·90; robust p =

EAU EU-ACME Office

European Urology Today

Prof. Oliver Hakenberg Section Editor Rostock (DE)

Appropriate risk stratification based upon pathologic staging guides post-operative surveillance and is essential in selecting patients for potential adjuvant systemic therapy. This study suggests LN positive patients should be re-characterised as having stage IV disease. Certainly they represent a cohort with a poor outlook and should be followed up very closely.

Oliver.Hakenberg@ med.uni-rostock.de

Source: Changing trends in the endourological management of urolithiasis in anomalous kidneys. Abhishek G. Singh, Ankush Jairath, Sudharshan S. Balaji, et al.

0·010), but no evidence of a treatment effect was noted in patients with high metastatic burden.

BJU International 2018 in press; doi:10.1111/bju.14575

The clinical relevance of metastatic burden in patients with prostate cancer only became apparent following the CHAARTED trial which suggested no benefit for these low-burden patients from the addition of Docetaxel chemotherapy at presentation. This study suggests that these patients may be better treated with radiotherapy to the prostate. The feasibility of radical prostatectomy in this setting is also being tested in the g-RAMMP trial (NCT02454543) and in the TROMBONE feasibility study. The other question is the validity of the CHAARTED criteria especially as PET scan reveals that men often have more significant disease than is seen on bone scan and CT scan.

Should nephrectomy of non-functioning transplants be obsolete?

Source: Radiotherapy to the primary tumour for newly diagnosed metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial. Parker CC, James ND, Brawley CD, et al. Lancet. 2018; dx.doi.org/10.1016/S0140-6736 (18032486-3.

The importance of lymph node disease in renal cancer Despite early detection in patients without evident metastasis, the incidence of pathologic node-positive disease ranges from 2% to 10% with a poor 5-year survival rate ranging from 5% to 30%. The tumour size, Fuhrman nuclear grade, tumour histology, performance status, and surrounding fat invasion are well-known prognostic factors; however, lymph node (LN) metastasis also plays a key role in the survival of patients with locally advanced RCC. According to the recently published eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging, stage III includes 2 groups of patients: those with a primary tumour status (pT3) and those with pathologic LN involvement (pN1). This paper reassess if that is appropriate.

Appropriate risk stratification based upon pathologic staging guides post-operative surveillance and is essential in selecting patients for potential adjuvant systemic therapy The data from 1,497 patients who underwent radical or partial nephrectomy with LN dissection at the University of Texas MD Anderson Cancer centre was used to compare outcomes of patients with stage III and stage IV disease. (115 patients with pT1-3 N1 M0, 274 patients with pT3 N0 M0 and 523 patients with pT1-3 N0/x M1 [Stage IV]). Data was collected on preoperative variables, including symptoms at initial presentation, clinical suspicion of LN involvement based upon imaging, Fuhrman grading, the number of nodes removed, number of positive nodes and the presence of extra nodal extension. Patients with stage III node-positive disease were more likely to have grade 4 tumours (53.7% vs. 27%; p < 0.0001) and non-clear cell histology (12.8% vs. 40%; p < 0.0001). Among the 115 patients with stage III node-positive disease, 86 (74.8%) died and the median overall survival was 2.4 years which was similar to the 523 patients with stage IV disease: 395 (75.6%) died with a median OS of 2.4 years. It differs significantly from the 274 patients with stage III node-negative disease of whom just 101 (36.9%) died with a median OS of 10.2 years. Multivariate analysis showed that tumour grade 4 (HR 2.47; p < 0.0001), performance status >1 (HR 1.98; p = 0.05) and node-positive disease (HR 2.44; p < 0.0001) were significantly associated with worse OS among patients with stage III RCC. A similar pattern was seen when assessing cancer-specific survival although performance status was no longer a significant variable. Key articles

There is no standardisation on the timing of the best approach to treat a non-functioning renal graft. We reviewed the literature and performed a proportional meta-analysis of case series of transplantectomy and embolization for a non-functioning renal graft. The groups were compared for mortality and morbidity outcomes.

...percutaneous embolization was associated with lower mortality and morbidity rates but also with a high rate of post-embolization syndrome A total of 2,421 patients were included in this review. Of these, 2,232 patients underwent transplantectomy and 189 underwent percutaneous embolization. The mortality rate in the nephrectomy group was 4% [95% CI 2-7%; I² = 87%] as compared with 0.1% [95% CI, 0.1-0.5%; I² = 0%] in the embolization group. The rates of common morbidities were 18% [95% CI, 13-26%, I² = 79.7%] for nephrectomy compared with 1.2% [95% CI, 0.7-2.1%, I² = 26.4%] for embolization. The incidence of post-embolization syndrome was 68%, and 20% of patients needed post-embolization nephrectomy. Thus, percutaneous embolization was associated with lower mortality and morbidity rates but also with a high rate of post-embolization syndrome. However, in most cases this complication had easily manageable symptoms. Embolization is a new and attractive technique that can be considered in treating non-functioning renal grafts.

Source: Nephrectomy versus embolization of non-functioning renal graft: A systematic review with a proportional meta-analysis. Takase HM, Contti MM, Nga HS, Bravin AM, Valiatti MF, ElDib RP, Modelli de Andrade LG. Ann Transplant. 2018, 27;23:207-217.

High incidence of de novo ovarian cysts with mTOR inhibitor immunosupression after renal transplantation

(7.7%) with new ovarian cysts were identified. Ovarian cysts were significantly more frequent among patients receiving mTOR inhibitors. (20.5%) than in the control group (4.9%; p < 0.001). Also, the hospitalisation rate was higher (p = 0.05) in the mTOR group and ten patients (47.6%) required additional surgery. This complication of mTOR inhibitors and the potential clinical implications are not understood so far and probably warrant further investigation.

Source: High incidence of ovarian cysts in women receiving mTOR inhibitors after renal transplantation. Bachmann F, Glander P, Budde K, Bachmann C. J Womens Health (Larchmt). 2018, 27(3):394-398. doi: 10.1089/jwh.2017.6451.

Male gender and older age seem to be risk factors for reduction in GFR after live donor nephrectomy To establish the outcome of live kidney donors 5 years after donation, the authors investigated the risk for progressive renal function decline and quality of life (QoL). Data on estimated glomerular filtration rate (eGFR), creatinine, hypertension, QoL and survival were assessed in a prospective cohort of 190 donors, who donated between 2008 and 2010. Data were available for > 90%. The mean age before donation was 52.8 ± 11.5 years, 30 donors had pre-existent hypertension. The mean follow-up was 5.1 ± 0.9 years. Eight donors had died due to non-donation-related causes. After 5 years, the mean eGFR was 60.2 (95% CI 58.7-62.7) ml/min/1.73 m2, with a median serum creatinine of 105.1 (95% CI 102.5-107.8) μmol/l. eGFR decreased to 33.6% and was longitudinally lower among men than women and declining with age (p < 0.001), without any association with QoL. Donors with pre-existent and new-onset hypertension demonstrated no progressive decline of renal function overtime compared to normotensive donors. No donors were found with proteinuria, microalbuminuria or at risk for end-stage renal disease. After an initial decline after donation, renal function remained unchanged overtime.

Ovarian cysts were significantly more frequent among patients receiving mTOR inhibitors The authors retrospectively analysed 571 consecutive female kidney transplant patients in their centre between 2000 and 2008. The follow-up period was extended through December 31st, 2012. 102 (17.8%) patients received mTOR inhibitors for at least one month after transplantation. 44 women

oliver.reich@ klinikum-muenchen.de participants were considered regular smokers if they endorsed smoking at least once per month. Multivariable logistic regression was performed to analyze the relationship between THC and LUTS. Among 3,037 men who met inclusion criteria, 14.4% (n = 477) of subjects reported THC use. In multivariable analyses, adjusting for clinical variables, regular THC users remained significantly less likely to report LUTS (odds ratio of 0.55; CI 95% 0.408-0.751, p < 0.01) compared to non-users. Obesity, diabetes, and multiple co-morbidities are well-established risk factors for LUTS within the National Health and Nutrition Examination Survey. The authors conclude, that regular THC use, however, appears to be protective from LUTS in young community-dwelling men.

Source: The association between tetrahydrocannabinol and lower urinary tract symptoms: utilizing the National Health and Nutrition Examination Survey. Fantus RJ, Riedinger CB, Chang C, Helfand BT. Urology. 2018 Aug 21. pii: S0090-4295(18)30881-1. doi:10.1016/j.urology.2018.06.054.

Selective bladder denervation is a promising treatment option OAB The authors of this study report the 6-month efficacy and safety outcomes with selective bladder denervation in women with refractory Overactive Bladder (OAB). Women with refractory OAB and Urgency Urinary Incontinence (UUI) were enrolled in two prospective feasibility studies with the same entry criteria and received radiofrequency selective bladder denervation of the sub-trigonal region containing afferent sensory nerves. Patients were followed for 6 months and assessed for adverse events, OAB symptoms, and health-related quality of life measures.

Male gender and ageing seem to affect renal function overtime, while decreased renal function did not affect QoL ...the results of these prospective Male gender and ageing seem to affect renal function feasibility studies suggest that overtime, while decreased renal function did not selective bladder denervation is affect QoL. These data support further stimulation of living kidney donation programmes as seen from the a promising minimally invasive perspective of donor safety. treatment option... Source: Five-year follow-up after live donor nephrectomy - cross-sectional and longitudinal analysis of a prospective cohort within the era of extended donor eligibility criteria. Janki S, Dols LF, Timman R, Mulder EE, Dooper IM, van de Wetering J, IJzermans JN. Transpl Int. 2017;30(3):266-276. doi: 10.1111/tri.12872

Ovarian cysts are a common finding in women of reproductive age. Most of them are functional cysts that typically resolve spontaneously and require no treatment. However, ovarian cysts may also be adverse events associated with inhibitors of the mammalian target of rapamycin (mTOR). Both approved mTOR inhibitors, everolimus and sirolimus, are widely used as immunosuppressive agents after organ transplantation. The aim of this study was to compare the effect of mTOR inhibitors vs. non-mTOR inhibitor immunosuppression on the incidence, size and complication rate of ovarian cysts in renal transplant recipients.

Prof. Oliver Reich Section editor Munich (DE)

Tetrahydrocannabinol and lower urinary tract symptoms The authors of this study aimed to define the relationship between tetrahydrocannabinol (THC) and lower urinary tract symptoms (LUTS), specifically how THC use associates with the frequency of LUTS in young community-dwelling men in the United States.

In multivariable analyses, adjusting for clinical variables, regular THC users remained significantly less likely to report LUTS... The National Health and Nutrition Examination Survey (NHANES) database was queried (2005-2008). Men ages 20-59 who completed the urinary and substance abuse questionnaires were included. The presence of LUTS was defined as having ≥ 2 of the following: nocturia (≥ 2), hesitancy, incomplete emptying, or incontinence. THC use was self-reported, and

Among 35 women (mean age 66 years) enrolled in the study, all selective bladder denervation procedures were completed successfully. Over 6 months follow-up, symptom improvement based on 3-day bladder diaries was 59% for UUI (p < 0.001), 59% for urinary incontinence (UI) (p < 0.001), 39% for urgency (p < 0.001), 9% for urinary frequency (p = 0.01), and 27% for the total urgency and frequency score (p < 0.001), with the majority of this treatment benefit realized in the first month. Clinical success (≥ 50% reduction in UUI) was 70%, treatment benefit was reported in 75% of patients, and the dry/cure rate was 27%. Statistically significant improvements over 6 months were identified on Symptom Bother and Health-related Quality of Life scales on the OAB-questionnaire and on all King’s Health Questionnaire (KHQ) domains except General Health Perception. Device- or procedure-related adverse events were reported in 6 (17%) patients. The investigators conclude, that the results of these prospective feasibility studies suggest that selective bladder denervation is a promising minimally invasive treatment option for women with refractory OAB.

Source: 6-month results of selective bladder denervation in women with refractory overactive bladder. De Wachter S, Benson KD, Dmochowski RR, Rovner ES, Versi E, Miller LE, Tu LM. J Urol. 2018 Sep 18. pii: S0022-5347(18)43909-2. doi: 10.1016/j.juro.2018.09.043. [Epub ahead of print]

EAU EU-ACME Office

European Urology Today

October/December 2018

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

biochemical failure seems to be associated with an increased risk of moderate (i.e., grade 3 or worse) gastrointestinal toxicity. There remain ongoing studies to evaluate WPRT at a more conventional dose.

Participants were randomly assigned to drink, in addition to their usual fluid intake, 1.5 L of water daily (water group) or no additional fluids (control group) for 12 months.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

tebj@medisin.uio.no

Source: Sequence of hormonal therapy and radiotherapy field size in unfavourable, localised prostate cancer (NRG/RTOG 9413): long-term results of a randomised phase 3 trial. Roach M, Moughan J, Lawton CAF, et al.

The primary outcome measure was frequency of recurrent cystitis over 12 months. Secondary outcomes were the number of antimicrobial regimens used, mean time interval between cystitis episodes, and 24-hour urinary hydration measurements.

g.ploussard@ gmail.com

Lancet Oncology. 2018; 19: 1504-15.

Long-term outcomes for androgen deprivation and whole pelvis radiotherapy for localised prostate cancer Among the most important advances in the management of men with intermittent to high-risk localised prostate cancer is the recognition of the important role of androgen deprivation therapy (ADT) combined with external beam radiotherapy. The NRG/ RTOG 9413 trial was designed to address the importance of sequence of short-term androgen deprivation therapy when given with radiotherapy whilst also addressing the role of prophylactic whole pelvic radiotherapy (WPRT). For many other solid tumours, prophylactic lymph nodal radiotherapy is the standard of care but no definitive evidence of either benefit or harm was available. This paper presents the long term outcomes from this phase III study. 1,322 men with histologically-confirmed, clinicallylocalised prostate cancer and an estimated risk of pelvic lymph node involvement exceeding 15% were enrolled into four treatment groups to receive either neoadjuvant ADT 2 months before and during WPRT followed by a prostate boost to 70 Gy (NHT plus WPRT group), neoadjuvant ADT 2 months before and during prostate and seminal vesicles-only radiotherapy (PORT) to 70 Gy (NHT plus PORT group), WPRT, followed by 4 months of adjuvant ADT (WPRT plus AHT group), or PORT followed by 4 months of adjuvant (PORT plus AHT group). Stratification factors were T-stage (T1c and T2a vs. T1b and T2b vs. T2c–T4), PSA concentration (≤ 30 vs. > 30 ng/mL), and Gleason Score (< 7 vs. 7–10). All patients received combined androgen suppression consisting of goserelin 3.6 mg once a month or Leuprolide acetate 7.5mg once a month and flutamide 250 mg twice a day orally for 4 months.

...this improvement in progressionfree survival and biochemical failure seems to be associated with an increased risk of moderate (i.e., grade 3 or worse) gastrointestinal toxicity With a median follow-up of 8·8 years (IQR 5·07–13·84) for all patients and 14·8 years (7·18–17·4) for living patients (n = 346), progression-free survival across all time points continued to differ significantly across the four treatment groups (p = 0·002). The 10-year estimates of progression-free survival were WPRT

PORT

Neoadj ADT

28·4% (CI 23·3–33·6)

23·5% (CI 18·7–28·3)

Adjuvant ADT

19·4% (CI 14·9–24·0)

30·2% (CI 25·0–35·4)

The four treatment groups did not differ significantly in terms of overall survival, prostate cancer-specific failure, local progression, distant metastasis, or regional or nodal failure. Bladder toxicity was the most common grade 3 or worse late toxicity, affecting 18 (6%) of 316 patients in the NHT plus WPRT group, 17 (5%) of 313 in the NHT plus PORT group, 22 (7%) of 317 in the WPRT plus AHT group, and 14 (4%) of 315 in the PORT plus AHT group. Late grade 3 or worse gastrointestinal adverse events occurred in 22 (7%) of 316 patients in the NHT plus WPRT group, five (2%) of 313 in the NHT plus PORT group, ten (3%) of 317 in the WPRT plus AHT group, and seven (2%) of 315 in the PORT plus AHT group. Progression-free survival was improved with neoadjuvant ADT plus whole pelvis radiotherapy. This also appeared to translate into an improvement in the Phoenix criteria biochemical failure. Unfortunately, this improvement in progression- free survival and Key articles

October/December 2018

Tacrolimus (FK506) fails to prevent post-RP Erectile Dysfunction Radical prostatectomy (RP) is associated with erectile dysfunction, largely mediated through cavernous nerve injury. There are robust pre-clinical data supporting a potential role for neuromodulatory agents in this patient population. This study assessed tacrolimus in improving erectile function recovery rates after RP. A randomized, double-blind trial compared tacrolimus 2-3 mg daily and placebo in men undergoing RP. Patients had localized prostate cancer and excellent baseline erectile function, underwent bilateral nerve-sparing RP, and were followed up for at least 18 months after RP. Patients received study drug for 27 weeks and completed the International Index of Erectile Function erectile function domain (EFD) questionnaire at baseline and serially after surgery.

...tacrolimus used in this fashion in the RP population failed to demonstrate any superiority over placebo Data were available for 124 patients (59 tacrolimus, 65 placebo); mean age was 54.6 ± 6.2 years. No patient experienced permanent creatinine or potassium elevation. At baseline, mean EFD scores were 28.6 ± 2.1 (tacrolimus group) and 29 ± 1.5 (placebo group). By week 5, mean EFD scores had dropped to 8 ± 9.4 (tacrolimus) and 9 ± 10.7 (placebo). At 18 months, mean EFD scores were 16.0 ± 11.3 (tacrolimus) and 20.2 ± 9.0 (placebo) (P = .09). Tacrolimus failed to meet significance (hazard ratio = 0.83; P = .50), with no difference in: (i) percentage of patients achieving normal spontaneous erectile function (EFD score ≥24), (ii) time to normalization of EFD score (≥24), (iii) percentage of patients capable of intercourse in response to phosphodieserase type 5 inhibitor (PDE5i), and (iv) time to achieve response to PDE5i. Despite supportive animal data, tacrolimus used in this fashion in the RP population failed to demonstrate any superiority over placebo. (ClinicalTrials.gov number, NCT00106392).

Source: A Randomized, Double-Blind, PlaceboControlled Trial to Assess the Utility of Tacrolimus (FK506) for the Prevention of Erectile Dysfunction Following Bilateral Nerve-Sparing Radical Prostatectomy. Mulhall JP, Klein EA, Slawin K, Henning AK, Scardino PT. J Sex Med. 2018 Sep;15(9):1293-1299. doi: 10.1016/j. jsxm.2018.07.009.

Increased water intake is an effective antimicrobial-sparing strategy to prevent recurrent cystitis Increased hydration is often recommended as a preventive measure for women with recurrent cystitis, but supportive data are sparse. The objective of the present study was to assess the efficacy of increased daily water intake on the frequency of recurrent cystitis in premenopausal women. The study was a randomised, open-label, controlled, 12-month trial at a clinical research center (years 2013-2016). Among 163 healthy women with recurrent cystitis (≥3 episodes in past year) drinking less than 1.5 L of fluid daily who were assessed for eligibility, 23 were excluded and 140 assigned to a ‘water’ or ‘control’ group. Assessments of daily fluid intake, urinary hydration, and cystitis symptoms were performed at baseline, 6- and 12-month visits, and monthly telephone calls.

Participants were randomly assigned to drink, in addition to their usual fluid intake, 1.5 L of water daily... The mean (SD) age of the 140 participants was 35.7 (8.4) years, and the mean (SD) number of cystitis episodes in the previous year was 3.3 (0.6). During the 12-month study period, the mean (SD) number of cystitis episodes was 1.7 (95% CI, 1.5-1.8) in the water group compared with 3.2 (95% CI, 3.0-3.4) in the control group, with a difference in means of 1.5 (95% CI, 1.2-1.8; P < .001). Overall, there were 327 cystitis episodes: 111 in the water group and 216 in the control group. The mean number of antimicrobial regimens used to treat cystitis episodes was 1.9 (95% CI, 1.7-2.2) and 3.6 (95% CI, 3.3-4.0), respectively, with a difference in means of 1.7 (95% CI, 1.3-2.1; p < .001). The mean time interval between cystitis episodes was 142.8 (95% CI, 127.4-160.1) and 84.4 (95% CI, 75.4-94.5) days, respectively, with a difference in means of 58.4 (95% CI, 39.4-77.4; p < .001). Between baseline and 12 months, participants in the water group, compared with those in the control group, had increased mean (SD) urine volume (1.4 [0.04] vs 0.1 [0.04] L; p < .001) and voids (2.4 [0.2] vs -0.1 [0.2]; p < .001) and decreased urine osmolality (-402.8 [19.6] vs -24.0 [19.5] mOsm/kg; p < .001). The authors conclude that increased water intake is an effective antimicrobial-sparing strategy to prevent recurrent cystitis in premenopausal women at high risk for recurrence who drink low volumes of fluid daily. Trial Registration: ClinicalTrials.gov identifier: NCT02444975.

Source: Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: A randomized clinical trial. Hooton TM, Vecchio M, Iroz A, Tack I, Dornic Q, Seksek I, Lotan Y. JAMA Intern Med. 2018 Oct 01; DOI: 10.1001/ jamainternmed.2018.4204, PMID: 30285042

Preoperative BMI reduction and maximal preoperative medical optimisation for lowering SSI rates after radical cystectomy The purpose of this study was to compare the surgical site infections (SSI) rate after radical cystectomy (RC) over time and ascertain whether antibiotic prophylaxis should be enhanced.

RC was performed in 405 patients, of which 96 (23.7%) developed SSI... All medical records of RC patients in a single tertiary uro-oncology centre between 2007 and 2017 were analysed. SSI was defined using the criteria of the US Centers for Disease Control and Prevention. All bacterial culture results and antimicrobial resistance rates were recorded. Lastly, multivariable logistic regression analysis was performed to ascertain SSI predictors. RC was performed in 405 patients, of which 96 (23.7%) developed SSI. No differences were demonstrated in the mean age, gender, NIDDM prevalence, neoadjuvant chemotherapy, positive preoperative urine culture, bowel preparation, and surgery time between both groups. However, statistically significant higher median BMI, ageadjusted Charlson Comorbidity score, usage of ceftriaxone preoperatively, and intensive care unit (ICU) hospitalisation were noted in SSI patients. Overall, 62/96 (63.5%) of SSI patients had a positive wound culture, with only 16.7% of the pathogens being sensitive to their perioperative antibiotics.

Lastly, on multivariable analysis, rising BMI, preoperative ceftriaxone and ICU hospitalization were associated with a higher SSI rate. It is concluded that preoperative BMI reduction, and maximal preoperative medical optimization in an attempt to lower ICU admittance rates, should be part of the ideal strategy for lowering SSI rates. Additionally, preoperative antibiotics should be enhanced to harbour wide spectrum coverage, based on local resistance rates.

Source: Predictors of surgical site infection after radical cystectomy: should we enhance surgical antibiotic prophylaxis? Goldberg H, Shenhar C, Tamir H, Mano R, Baniel J, Margel D, Kedar D, Lifshitz D, Yossepowitch O. World J Urol. 2018 Sep 15; DOI: 10.1007/s00345-0182482-5 PMID: 30220044

Genomic difference of prostate cancer aggressiveness between Caucasian and Caribbean men The higher incidence of prostate cancer in men of African ancestry is supported by genetic factors. However, the higher mortality observed in these men remains largely debated with various competitive environmental, social, and biological factors. In French West Indies, the increased risk of aggressive prostate cancer has been associated with exposure to agricultural pesticides. In the present series, the authors performed a whole-genome sequencing (WGS) and RNA-sequencing of 25 aggressive prostate cancers from 10 African Caribbean patients and 15 French Caucasian patients. Only aggressive cancers defined by ISUP >2 were included. A pooled analysis of their copy number variation profiles with an additional dataset of 132 tumour tissues was also done.

...linked to the specific exposure to organochlorine pesticides used for banana cultivation... The main somatic copy number variation events were amplification at locus 8q24.21 in 18% of cases (genes PCAT1, MYC, NCOA2), deletions at loci 8p21 (NKX3.1), 13q14 (RB1); 6q14 (ZNF292), and 8p11 (FGFR1). The results showed that a deletion at 1q42-43, encompassing PARP1, was significantly more frequent in African Caribbean patients. Interestingly, this molecular event could be linked to the specific exposure to organochlorine pesticides used for banana cultivation in French West Indies. This lower expression of PARP1 suggested that these patients would not benefit from treatment with PARP inhibitors and should rather receive another treatment, such as mTor inhibitors. Overall, the mean number of somatic single-base mutations and insertion/deletion mutations per sample was not different according to the ethnic group. However, CDK12 truncating mutations were more frequently seen in the African Caribbean population. Transcriptome analyses also showed an overexpression of genes related to androgen receptor activity in African Caribbean tumours. The oncogenic long non-coding RNA gene PVT1 at the 8q24 locus was found to be overexpressed in this population. This study provides new insights on the differences observed in molecular alterations between prostate cancer from men of African and Caucasian ancestry suggesting that clinical profiles between ethnic groups may be driven at least partly by genetic background.

Source: Mutational profile of aggressive, localised prostate cancer from African Caribbean men versus European ancestry men. Tonon L et al. Eur Urol 2018 ; doi : 2018.08.026.

EAU EU-ACME Office

European Urology Today

Intravesical gentamicin instillation reduced the number of UTI episodes and antimicrobial resistance in multidrug-resistance Antimicrobial resistance leads to complications in the management of recurrent urinary tract infections (rUTIs). In some rUTI patients with limited treatment options, intravenous therapy with reserve antibiotics is often required. In this article, authors aimed to assess the effectiveness, safety, and feasibility of prophylactic treatment with intravesical gentamicin in patients with refractory rUTI caused by multidrugresistant (MDR) microorganisms.

The mean number of UTIs was reduced from 4.8 to 1.0 during intravesical treatment. The resistance rate of the uropathogens dropped from 78% to 23%..... In this prospective trial, 63 adults with rUTI caused by MDR pathogens, were enrolled at one academic and one general hospital in the Netherlands between 2014 and 2017. Patients received overnight intravesical instillations of gentamicin for 6 months. The primary outcome was the recurrence rate of UTIs compared to that in the preceding 6 months. Secondary objectives included the assessment of the safety of intravesical gentamicin instillation and its influence on the development of antibiotic resistance in uropathogens. The mean number of UTIs was reduced from 4.8 to 1.0 during intravesical treatment. The resistance rate of the uropathogens dropped from 78% to 23%. No systemic absorption or clinically relevant side-effects were observed. It is concluded that intravesical gentamicin instillation reduced the number of UTI episodes and the degree of antimicrobial resistance.

and were managed by intradetrusor botulinum toxin injections or posterior tibial nerve stimulation.

...these findings suggest that the robot-assisted technique for AUS is safe and reproducible...

In a highly-screened cohort, promotion of physical activity could positively influence the risk of any grade Taken together, these findings suggest that the robot-assisted technique for AUS is safe and reproducible, given the number of surgeons involved. Each surgeon has performed from one to fourteen cases only. This laparoscopic approach could decrease surgical morbidity and improve postoperative outcomes. Nevertheless, comparative data between robot-assisted and open procedures are awaited. If confirmed, this could lead to a wider use of this option in female with severe stress urinary incontinence and sphincter deficiency. This is worthy to note that another limitation for the diffusion of AUS in female patients is the lack of high-level-of-evidence studies for supporting the use of AUS compared with midurethral slings. Dr. Hirron Fernando

Artificial urinary sphincter in female: Let’s do it robotically! The artificial urinary sphincter (AUS) implantation remains the gold standard for stress urinary incontinence due to severe sphincter deficiency. However, the technique is not widely used in female because of technical difficulty and surgical morbidity via an open retropubic approach. In the present study, the authors reported the surgical outcomes after a robot-assisted laparoscopic approach in the multicentre series including multiples surgeons using the same technique. All patients were followed at one year post-operatively. Five institutions shared their data with operations starting from March 2012 to March 2017. The procedure was carrying out by a transperitoneal approach using five ports. Overall, forty-nine female patients underwent a robotic AUS implantation by 10 surgeons. Median age was 70 years. The vast majority of patients had already undergone at least one midurethral sling surgery. Four patients concomitantly underwent sacrocolpopexy. Median operative time and hospital stay were 180 minutes and 4 days, respectively. Overall, eight intraoperative complications occurred: five bladder neck and three vaginal injuries with completion of the implantation in all cases. The rate of postoperative complications was 18% with only 2 grade 3 Clavien complications. Only one AUS explantation occurred after intraoperative vaginal injury and postoperative suspicion of device infection. Median follow-up was 18.5 months during which three revisions were performed. The 3-month rate of full continence was 81.6%, with six patients claiming improved incontinence (12.2%) and three patients with unchanged incontinence. At a longer follow-up, de novo overactive bladder occurred in three patients

and aggressive prostate cancer, and may be beneficial at a population level. As a modifiable risk factor, this could be an important goal for public health intervention.

Source: A prospective study of the association between physical activity and risk of prostate cancer defined by clinical features and TMPRSS2:ERG. Pernar CH et al. Eur Urol 2018 doi : 2018.09.041

“The crème de la crème of Functional Urology” ESU ESFFU Masterclass on Female & Functional Urology Milan 2018

Source: Robot-assisted AMS-800 Artificial urinary sphincter bladder neck implantation in female patients with stress urinary incontinence. Peyronnet B et al.

Resident, Airedale General Hospital City of Bradford (GB)

Eur Urol 2018 doi :10.1016/j.euruol.2018.07.036

Physical activity and prostate cancer risk Physical activity influences several processes, such as hormonal, insulin, anti-inflammatory pathways. Epidemiology suggests that physical activity may lower the risk of aggressive prostate cancer. Nevertheless, studies remain contradictory to definitely link fatal disease and physical activity. Potential correlations between activity and molecular characteristics of prostate cancer have not been thoroughly assessed.

Potential correlations between activity and molecular characteristics of prostate cancer have not been thoroughly assessed

Source: Intravesical gentamicin treatment for recurrent urinary tract infections caused by multidrug-resistant bacteria. Stalenhoef JE, van Nieuwkoop C, Menken PH, Bernards ST, Elzevier In the present study, the authors used the Health Professionals Follow-up Study (HPFS) to examine the HW, van Dissel JT. J Urol. 2018 Oct 11; DOI: 10.1016/j.juro.2018.10.004 PMID: 30316898

This prospective cohort analysis suggests that vigorous physical activity is inversely correlated with the risk of advanced, lethal prostate cancer. Interestingly, correlations between physical activity and clinical behaviour of prostate cancer are, for the first time, supported by molecular aspects and by the TMPRSS2:ERG status.

associations between long-term, pre-diagnostic physical activity and the risk of developing prostate cancer. The HPFS is an ongoing cohort initiated in 1986 among 51,529 American male health professionals aged 40-75 years at baseline. Physical activity was assessed by biennial questionnaires and quantified by the sum of metabolic equivalent of task (MET). A measure of MET-hour per week was derived for each activity. Prostate cancer incidence as well as disease progression were captured self-reported and confirmed through medical records and pathology reports. The TMPRSS2:ERG status was evaluated on tissue microarrays constructed from 910 radical prostatectomy and 35 transurethral resection specimens. To examine long-term activity, cumulative average physical activity was categorised into quintiles from baseline to the time of prostate cancer diagnosis. Several adjustments on potentially confounding factors were performed into multivariable analyses.

...there was a trend for lower risk of ERG-positive disease in the subgroup of patients with vigorous activity

hirron22@ yahoo.co.uk The 11th edition of the ESU-ESFFU Masterclass on Functional urology was held on 20-21 September, in Milan, Italy. It was held in collaboration with the second edition of the European Lower Urinary Tract Symptoms Meeting (ELUTS18) (see next page). With successful editions conducted since 2008, this masterclass has earned its reputation as a reliable and comprehensive programme where participants gain a deeper knowledge in this sub-specialised field.

overactive bladder, sexual dysfunction and other topics. Afterwards these topics were illustrated with real cases from clinical practice. Participants were asked to send in and present cases from their own clinic. These cases were extensively discussed by the faculty members and all participants. The idea behind this is that everyone should realise that at some moments the guidelines and textbooks don’t give all the desperately-needed answers and experience from others specialist is needed and given. Moreover the discussed cases show that there are more ways to find a solution for a functional urological problem.

As a participant I can say that I learnt more about functional urology in the two days, than what I knew before I came to the masterclass. The masterclass was interactive with real life cases with a unique approach to each case. The feedback was excellent from the faculty and interaction with the participants on a case by case basis was superb. If I The faculty consisting of Prof. Fiona Burkhard (CH), sum up the overall experience, I would say it is the Prof. Elisabetta Costantini (IT), Prof. George Kasyan crème de la crème of Functional Urology. (RU), Mr. Nikesh Thiruchelvam (GB), Prof. Hashim Hashim (GB) and chairman Dr. John Heesakkers Lastly it has given me the opportunity of (NL) is renowned for their scientific as well as networking with colleagues around the world. I clinical skills on nearly the complete array of can’t think of better place than Milan to have functional urological disorders. masterclass in functional urology. It is an amazing city and the excellent faculty with great experience During the masterclass again a short in dealing with some of the challenging complex introduction was given on the various topics like cases we see in our daily practice, has given me neurourology, tapes and meshes for stress and my colleagues new tools to handle these kinds incontinence and pelvic organ prolapse, of cases at home.

ELUTS19 European Lower Urinary Tract Symptoms meeting

31 October - 2 November 2019 Prague, Czech Republic

www.eluts19.org

Between 1986 and 2012, 6,411 men were diagnosed with prostate cancer including 603 advanced and 888 lethal disease. The TMPRSS2:ERG status was positive in 48% of cases. There was no association between total activity and risk of prostate cancer (overall or any clinical subgroup). However, for vigorous activity, men in the highest quintile had a significant 30% lower risk of advanced disease (95% CI: 0.53-0.92) and a 25% lower risk of lethal disease (95% CI 0.59-0.94) than men in the lowest quintile in the total cohort. Similar findings were reported when assessing the TMPRSS2:ERG status. In the overall population, no clear association was noted. Nevertheless, there was a trend for lower risk of ERG-positive disease in the subgroup of patients with vigorous activity. Potential benefit from vigorous activity was more marked after restricting to the highly-screened subcohort.

Key articles

European Urology Today

October/December 2018

ELUTS18: A Spotlight on functional and reconstructive urology ESFFU-ESGURS-ESU join forces in three-day LUTS meeting By Loek Keizer While functional urology might at times feel “under threat” from onco-urology, which generally attracts more funding and indeed audiences, it is set to remain at the core of urology, predicts EAU Secretary General Prof. Chris Chapple (Sheffield, GB).

www.eluts18.org if you are attentive. We can offer rare cases as long as we make sure that they should only be offered in expert centres because of the complication rates. We don’t disapprove of these procedures or hypotheses, but we need to be clear to the audience that these are not the standard.”

“With ageing populations, and the associated increase in LUTS, urologists will continue to treat patients,” Chapple explained. “With rapid developments in immunotherapy and robotic surgery, the future of onco-urology is perhaps more uncertain for urologists.” The second edition of the European Lower Urinary Tract Symptoms Meeting attracted over 250 participants to Milan on 20-22 September. The meeting is a collaboration between the EAU Sections of Female and Functional Urology (ESFFU) and Genito-Urinary Reconstructive Surgery (ESGURS) as well as the European School of Urology, which held a masterclass that was partly integrated into the wider scientific programme. ELUTS18 offered a wide scientific programme for its delegates, consisting of a two-day ESU Masterclass on Functional Urology (see page 10), and parallel programmes organised by ESFFU and ESGURS, focused on functional and reconstructive urology respectively. Topics included over- and underactive bladder, male and female LUTS, urodynamics, neuro-urology, stress urinary incontinence and post-prostatectomy incontinence. On the surgical side, topics included urethral surgery, female urethral strictures, and Peyronie’s disease. The ESGURS programme also included a semi-live surgery session, demonstrating procedures like the implantation of prosthesis into a neophallus, robotic neobladder and urinary diversion troubleshooting. Most topics were discussed as part of case discussions, featuring voting and much audience participation. Highlighting practical urology Prof. Chapple was in Milan as a member of the ELUTS18 Organising Committee. ELUTS is a meeting that is close to Chapple’s heart, covering a topic that he feels the EAU should give special attention to: “As members of the EAU, we need to cater to all of the issues that we meet in working practice. There’s no doubt that oncology and onco-urology are important parts of daily working practice and it’s essential that we promote that.” “But equally we mustn’t forget that functional urology causes a huge amount of morbidity and interferes with the quality of life of patients across the whole world. It’s dealing with those issues which aren’t going to go away, particularly with increased lifespan as a consequence and the ageing population.” ESGURS Chairman Dr. Djinovic (Belgrade, RS) sees a similar need for the EAU to offer more visibility to functional and reconstructive topics, in addition to the attention it gives urological cancers: “This is definitely a part of urology that is getting more and more patients. As oncology is reaching its peak in treatment standards and training, urologists can start to focus on the other group of patients that occupy our offices. Not in huge numbers, but they are becoming an important group of patients. At ELUTS18, we are covering a wide field with both reconstructive and functional urology in one place, at the same time.”

Prof. Chapple adds to the discussion on female stress urinary incontinence on the second day of ELUTS18. Profs. Burkhard and Chartier-Kastler have just finished a clinical case discussion that included audience voting

Dr. Djinovic feels that younger urologists have much to learn at ELUTS meetings: “Previous generations did not have a real chance to learn this field of surgery, unless you were lucky enough to have an expert at your clinic. Now we are trying to make this field more wide-spread, to popularise it among young people. Interest is growing, but we are the ones who need to provide opportunities to learn. We need more meetings, and to better reach the younger urologists.” ESFFU Chairman Prof. Cruz similarly warned against too great a focus on onco-urology. “We never know what will happen in oncology in the coming years. At the moment, surgery is the main treatment for many oncological diseases. However, treatment seems to be rapidly moving away from urology into the medical oncology field.” “Urologists should have a good background in functional urology, the basic activity of any urologist. Even patients with prostate or other urinary cancers will first present with lower urinary tract symptoms, so we need to be familiar with the conditions and if necessary refer them to the right person.” Supplementing Prof. Djinovic’s point about a lack of specific training in functional urology and reconstructive surgery: “We need to think about the education of the younger generation. Many more centres are dedicated to oncology than functional urology so you need to create a balance. The EAU organises several meetings on oncology and having one dedicated to functional and reconstructive urology should also be an objective for the Association.” Practical implications While guidelines and training are plenty and evidence-based when it comes to oncological topics in urology, there is a danger of functional urology and reconstructive surgery becoming largely eminencebased. A recurring theme, particularly during the ESFFU programme was the demand for more practically-applicable advice. Prof. Van Kerrebroeck (Maastricht, NL) played devil’s advocate from the audience and urged the speakers to come with concrete advice for treatment. Prof. Chapple: “Philip did a fantastic job, pointing out that what we really needed to do was explain how we should cope with the difficult issues in practice and not focus too much on esoteric issues. Nevertheless, I think that these discussions bring a lot of interest to people. Philip is correct that we need to give practical information, based on evidence and the EAU guidelines.” “We must also bear in mind that when it comes to surgery, the evidence base is limited, and more eminence-based. We thankfully had plenty of experienced colleagues to share their experiences.”

Prof. Trombetta presents a semi-live surgical case on microsurgical revascularization in ED as part of the reconstructive surgery programme. Prof. Bettocchi and ESGURS Chairman Dr. Djinovic act as “provokers” to stimulate insights

October/December 2018

“When it comes to reconstructive urology, we still don’t have firmly established standards of care,” Dr. Djinovic added. “Here we have panel discussions and lectures and they clearly show that all of us are still on our way to working these out. We still need stronger communication and a stronger sharing of our experiences. Our section should be joining together in a better way to slowly define guidelines and standards. If we want to give clear messages for certain situations and patients, we still need to improve.” Is functional urology underrepresented in the EAU Guidelines? “Absolutely. The guidelines are mainly

oncology-focused, and rightly so. The field covered at ELUTS18 is a smaller part of urology, generally, and economically it is not as impactful as oncology. So it is completely justified. It just needs to be discovered and we need to work hard to improve this. That’s why these meetings are important.”

"...we mustn’t forget that functional urology causes a huge amount of morbidity and interferes with the quality of life of patients across the whole world." Quality of evidence is similarly low in non-surgical treatment of LUTS, Prof. Cruz confirms. “You might want to increase the number of case discussions at ELUTS, but there is the risk that the cases go into areas where there simply isn’t enough scientific data and it becomes only eminence-based. If we start discussing male incontinence after radical prostatectomy, for instance, what evidence do we actually have? Its quality is still poor. That’s why some speakers are hesitant to offer concrete advice. You want to avoid having a room in which everyone is giving a personal rather than scientific opinion.” On whether this is disappointing for the audience that hopes to hear practical advice: “I think it’s important for ELUTS delegates to understand the current state of knowledge, you will still learn a lot

“Criticising the EAU Guidelines when they are unclear or incomplete is one thing. But for the audience that we are addressing at these meetings, I do not believe that it’s helpful if we say that there are lots of flaws. We need to be clear that the EAU Guidelines for continence is the best scientific information that they can currently get and should not be disregarded.” Looking ahead As one of the youngest meetings that the EAU currently organises, the exact format of the ELUTS meeting is still evolving. Ideally, the organisers would like to appeal to a younger audience by offering more training options and attract a larger audience by involving more EAU Sections. “Over the past two years, ELUTS has gone from strength to strength, and we hope next year will be even more successful,” said Prof. Chapple. “We want ELUTS to be the major platform for discussing the latest in functional urology, roughly six months after the Annual EAU Congress every year. We are looking at involving more partners, both inside and outside of the EAU.” Several EAU Sections cover topics that match the goals that the EAU has for ELUTS: the EAU Section of Andrological Urology (ESAU) and the recently established EAU Section of Urologists in Office (ESUO). As they also do not currently have regular section meetings of their own, involving them in the organisation of ELUTS would be beneficial for all parties. ELUTS organisers are also keen to involve the International Continence Society (ICS) in future meetings, and forms of cooperation are currently being explored. ELUTS19 will take place in Prague (CZ) on 31 October - 2 November 2019.

David Ralph new ESGURS Chairman In one of the many new developments at ELUTS18, ESGURS Chairman Dr. Djinovic (Belgrade, RS) announced that he would not be seeking reelection after his first term finishes in the spring on 2019. The Prof. David Ralph ESGURS board nominated Prof. David Ralph (London, GB) as its next Chairman, effective following the 33rd Annual EAU Congress in Barcelona (15-19 March). Dr. Djinovic explains his decision: “It may seem unusual that I’m not continuing after my first term, but I don’t think it would be fair to my colleagues. If you consider our career span of 25-30 years, I don’t feel I can occupy eight years of this period when I have so many worthy colleagues. I think it’s fair to give this opportunity to other colleagues to try and bring some changes about for the section. I don’t believe that I’m the only one who could achieve this, it can always be better.” EAU Secretary General Prof. Chapple (Sheffield, GB) also commented on the changing of the guard at the EAU Section for Genitourinary Reconstructive Surgeons: “It’s up to all of the EAU’s sections to be self-governing. There has been a vote within the section. Dr. Djinovic has done a fantastic job in his first term, and has

found that due to other commitments he wishes to pass the position on to Prof. Ralph.” An experienced surgeon Prof. Ralph is a consultant urologist and honorary lecturer at University College London Hospitals and an expert in male reconstructive urology, particularly ED and penile disorders and gender assignment issues. He is currently president of the Sexual Advice Association, and previously held positions as President of the European Society for Sexual Medicine, Chair of the International Consultation of Sexual Medicine and board member of the European Society of Andrological Urology. Prof. Chapple commended Ralph’s career and reputation: “I know David Ralph very well. We have worked together for 30 years, and he is an extremely professional and experienced colleague, and a true international opinion leader in his field. He is well-respected and has excellent organisation skills.” Dr. Djinovic also praised his successor: “David is obviously an experienced surgeon, with a great team in London. He is very open-minded and collaborates well with everybody. He puts the interests of the group ahead of his personal interests, a good quality for a chairman.” “I firmly believe that he will continue my work for ESGURS in the same or in a better way. I will give him my full support and share my experience with him so that ESGURS can continue its activities at full strength.”

European Urology Today

#EAU19 Cutting-edge Science at Europe’s largest Urology Congress

Live Surgery at EAU19: A look behind the scenes Live surgery is a special part of the EAU’s Annual Congress. It represents the peak of technical know-how and innovation and it has great educational value for the visiting urologists. We spoke to three key parties that are working together to make the live surgery in Barcelona reach new heights: Chairman of the EAU Section of Uro-Technology (ESUT) and session chairman Prof. Evangelos Liatsikos (Patras, GR), on-site organiser at the Fundació Puigvert Department of Urology Dr. Alberto Breda (Barcelona, ES) and Mr. Wim Samyn (Melle, BE), Commercial Director of mediAVentures, the technology company in charge of the live surgery logistics on behalf of the EAU.

and conventional cases in real life. Edited case presentation videos are interesting but still, people are really keen to see live scenarios.” “In the future, live surgery will continue to be a part of the Annual Congress and other EAU surgical meetings. What we may start to do is transmitting some of the live cases from the operating surgeon’s own familiar operating theatre, with his or her own team. This is one of the projects that ESUT is going to establish and develop in the near future.”

A suitable hospital While surgeons might come from across Europe or in some cases from all around the world to operate during the EAU Annual Congress, patients are Preparing the scientific programme almost always treated in their local centre. In “All congress participants love to see great surgeons Barcelona, all live surgery will be broadcast from the at work in a live setting, showcasing the latest Fundació Puigvert Department of Urology (led by technological advances,” Prof. Liatsikos explains. ESU Chairman Prof. Joan Palou). Dr. Alberto Breda is “ESUT has always done its best to create a full day of the on-site organiser for the live surgery during very interesting surgeries and is doing the same for EAU19. EAU19 in Barcelona.” As it currently stands, the live surgery will mainly take place during the joint Section Meeting of the EAU Sections of Uro-Technology, Urolithiasis (EULIS) and Robotic Urology (ERUS) on Saturday, March 16th. The programme will last more than eight hours and is broken into four parts. Sixteen different procedures are expected to be broadcast live from the Fundació Puigvert in Barcelona, performed by surgeons from all over Europe. Innovative live surgery is interspersed with pre-recorded cases, allowing for a seamless experience for the audience. Liatsikos: “As every year, we aim to present the latest technology, surgical techniques, and the most experienced surgeons operating. We want to show the audience a range different companies and equipment, and a range of innovations in software, hardware and instruments.” “This year, we anticipate a lot of new technology companies to want to showcase their products in Barcelona. We want to facilitate this so that the participants can draw their own conclusions on these new technologies.” The European Section of Uro-Technology has always been at the forefront of organising the Live Surgery day during every year’s EAU Congress: “All of the ESUT board members are actively participating either as moderators, chairman or surgeons in order to accommodate as many surgeries and as many new technologies as possible in these hours of transmission.” Prof. Liatsikos is convinced in the continued educational value of live surgery: “Urologists love live surgery and typically want to see as much of it as possible. This is because they really want to see how an experienced surgeon deals with problems

“All congress participants love to see great surgeons at work in a live setting, showcasing the latest technological advances” Centres that host live surgery for EAU events have to follow the strict protocols of the EAU Policy Statement on Live Surgery Events. The 16-page document covers the responsibilities of the local organisers, the selection process for surgeons and patients, and pre- and post-operative care. It includes a procedure checklist, and requires that all details are passed on to the EAU for approval before official endorsement. A form for patient consent is also included. Every year, the current status of the previous year’s live surgery patients is reported on at the beginning of the live surgery session. In Barcelona, delegates will be updated on the recovery and possible complications that the patients who were treated in Copenhagen had following their procedures. The Fundació Puigvert is an experienced live surgery centre. Dr. Breda: “Generally speaking, live surgery does have an impact on the regular running of a hospital. It becomes more challenging since there are many external people around, and a lot of new materials and instruments to deal with. However, we are very used to live surgeries since we organize over 30 courses each year and we are therefore very well adaptable to these kinds of situations.” The technical side Aside from the visiting surgeons (who sometimes also bring their assistants or nurses), other “external people” who will be present in the Fundació Puigvert and indeed in the EAU19 venue are the technicians of mediAVentures.

The eURO Auditorium in Copenhagen, earlier this year during EAU18. mediAVentures builds the screens and facilitates the simultaneous transmission of live surgery images in ultra-high resolution and 3D

The Belgian multimedia production company is a long-time partner of the EAU, supporting the Annual Congress’s live surgery since 2010 and all of the audiovisuals of the eURO Auditorium since 2012. The eURO Auditorium is designed with a capacity of 2000 people. Since EAU18 earlier this year, mediAVentures has also started to support the secondary plenary room. The rooms are designed and decorated by mediAVentures from scratch. “Year after year we strive to do better,” says Wim Samyn, the company’s Commercial Director. “We improve and upgrade the quality and experience for a more impactful learning experience.”

4K quality also means other signal convertors, video mixers, encoders and decoders. It impacts the complete technical chain.”

“Typically, in the main eURO Auditorium we build three big seamless screens which allow both 3D and/or 2D HD/4K multi-Picture in Picture projection. The largest of the screens is the size of a swimming pool. We can manage the showcasing of up to seven operating theatres from multiple hospital locations.”

“We lead the market with more than 200 filming and live case transmission days every year, at more than fifty events. Every year, we broadcast more than 500 hours of live transmissions. We have become a home supplier for many international organisations in the cardiovascular, urological, orthopaedic and other medical disciplines. Our two largest projects are the annual support for the annual European Society of Cardiology (ESC) and Leipzig Interventional Course (LINC) meetings.

“Over the years, the number of ORs has gone up, and the costs for transmission (whether it’s satellite, microwave or fiber) has come down for ever more bandwidth and better video quality (resolution, contrast and colour range, etc). Broadcasting and projecting in 3D requires specific knowledge about convergence to create razor-sharp and natural-looking content.” A technical evolution, such as the introduction of an ultra-high definition video standard (4K) immediately has a knock-on effect on the entire production. Samyn: “Adapting the workflow to

mediAVentures will bring a 35-person crew of cameramen, audio engineers, video and uplink/ downlink engineers and four trucks with equipment to make all of this possible. Samyn: “The Annual EAU Congress is one of our most important projects and one that we are extremely proud of.” mediAVentures is specialised in medical congresses and supports high-end conferences, especially when they feature live surgery transmissions.

Important dates Congress 15-19 March 2019 Exhibition 16-18 March 2019 Abstract selection outcome 19 December 2018 Early fee deadline 15 January 2019 Late fee deadline 12 February 2019 Abstracts (full bodies) are available in the EAU19 resource centre for EAU members only 15 February 2019

Check out the programme ove

www.eau19.org The introduction of new technologies like 3D transmission and projection has a knock-on effect on the entire technical chain.

European Urology Today

rview at

A look at some of the technology that mediAVentures uses to facilitate the live transmission of surgery from the OR to the congress venue

October/December 2018

#EAU19 Cutting-edge Science at Europe’s largest Urology Congress

EAU19 Abstract submissions surpass previous congresses A record-breaking number of abstracts for poster and video presentations were submitted for the upcoming 34th Annual EAU Congress (EAU19) in Barcelona. There were approximately 5,500 submissions for EAU19, which surpassed the number of submissions of all previous congresses. The Copenhagen congress in 2018 obtained a total of 4,676 abstracts and the London congress in 2017 received 5,038 abstracts. Submissions for EAU19 came from 80 countries across the globe, the majority of which were from Europe and Asia. Abstracts for the Copenhagen congress originated from 78 countries, and 81 countries were recorded for London. Poster sessions The increase in the number of poster submissions means that the Scientific Programme will accommodate more poster sessions. Also the aim of the Scientific Congress Office is to have a higher acceptance rate for posters. Therefore, EAU19 will feature more of the poster-guided tours that were introduced in at EAU18 in Copenhagen, in addition to the regular poster sessions. The very good interaction between moderators,

authors and the attendees allows the discussion of more posters per session with an even better quality of discussion. Ranked according to popularity, the top five topics for poster submissions were prostate cancer screening/diagnosis, biopsies and imaging; prostate cancer treatment and surgery; nephron-sparing approaches for renal tumours; functional LUTS (lower urinary tract symptoms) in terms of incontinence, neuro-urology and treatment; and BPH (benign prostatic hyperplasia) diagnosis and treatment. Video sessions Striking is the increased number of video abstract submissions. For EAU19, 465 video abstracts were submitted. This is a significant growth compared to Copenhagen (318 videos) and London (345 videos). These will be accommodated in 11 video sessions in Barcelona. Awards All accepted abstracts are eligible for prizes of the best abstracts in various categories such as oncology, non-oncology, abstracts by residents and for the three best video abstracts.

How well do you know the EAU Guidelines? Do you consider yourself an EAU Guidelines expert? Show off your skills at the EAU Guidelines Cup, which is set to take place during the YUORday at the upcoming EAU Annual Congress in Barcelona. You could be named champion! What is the EAU Guidelines Cup? The EAU Guidelines Cup is a competition which will determine who among EAU junior members knows the EAU Guidelines best. The Cup will consist of three rounds. The first and second rounds will be online and questions will be multiple choice questions. The top three participants from the second round will compete during the live finale on YUORDay19 on 16 March 2019. How to participate Here’s how you can join the Guidelines Cup in 3 easy steps: 1. Look out for your invitation to join the Cup. If you are eligible to take part, you will receive in the week of 17 December 2018 an email from the EAU with a personalised link.

2. Click on the link to enter the online quiz. 3. Answer the questions correctly and as fast as you can. You will receive immediate feedback on how many answers you got correct. If you are one of the top scorers of the first round, you will receive an invitation to participate in the second online round. Let the games begin! The finale The three best participants of the second round will receive a free registration for EAU19 and will be invited to compete for the title of the Guidelines Cup champion on stage during YUORday. The one with the most right answers and the quickest responses will be crowned as winner. The audience can join as well by competing anonymously via voting pads. Prizes to win The third-place winner and the audience member with the highest score will receive one-year full access to over 60,000 items of quality scientific content via UROsource, the largest knowledge base in the field of urology.

The prize for second place is the four-volume set of Campbell-Walsh Urology (11th edition). This series features 22 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. 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 • E SU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer • ESU-Weill Cornell Masterclass in General urology • ESU-ESUT Masterclass on Urolithiasis • ESU-ESUT-ESUI Masterclass on Focal Therapy for Localised Prostate Cancer You could be this year’s EAU Guidelines Cup champion. Are you up to the challenge?

Join the Guidelines Cup Young urologist! How well do you know the EAU Guidelines? Finale: YUORday at EAU19 16 March 2019

EAU19: Good to know Transport pass Delegates will receive a 5-day transport pass valid for unlimited travel within the city of Barcelona.

Register in advance for HOT courses Don’t miss out on attending your favourite Hands-on Training (HOT) course. These courses are often sold out even before the start of the congress. You can select the courses you want to follow and book them when you register. If you already registered, you can add a course to your registration. Check out eau19.org for more information!

Book hotel accommodation through K.I.T. K.I.T. is the only official housing provider appointed by the EAU to handle the hotels for EAU19. Please be wary of third parties selling hotel rooms and registrations for eau19. Visit the EAU19 website for more information.

Social media: #EAU19 Share your EAU19 updates and join the conversation. Include the hashtag #EAU19 in your tweets. For more essential urology updates, follow the EAU on Twitter (@uroweb) and on Facebook www.facebook.com/eaupage.

Registration desk opening hours Thu 14 March Fri 15 March Sat 16 March Sun 17 March Mon 18 March Tue 19 March

Win a masterclass of your choice

08.00 - 20.00 hrs. 07.30 - 20.00 hrs. 06.45 - 19.30 hrs. 07.00 - 19.30 hrs. 07.00 - 17.30 hrs. 07.00 - 13.30 hrs.

eau19.org/guidelinescup October/December 2018

European Urology Today

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

Is the EUREP resident programme for you? A wrap-up of EUREP18, new faculty members and participant testimonials If you are resident in your final year, the European Urology Residents Education Programme (EUREP) is one programme you should not miss. EUREP is a flagship programme of the European School of Urology (ESU) held annually in Prague, Czech Republic. Since its inception in 2003, EUREP has

offered a top-level programme to young and eager minds such as yourself. It consists of five modules allocated in six days, and carried out under the guidance and tutelage of distinguished European faculty and trainers. Mornings are reserved for riveting lectures and discussions, while afternoons are dedicated to videos and test-your-knowledge sessions.

At EUREP, you will have the exclusive opportunity to participate during the hands-on training courses, wherein you will enhance your skills in laparoscopy, ureteroscopy and transurethral resection. These courses are a fundamental component of EUREP that have varying levels based on a participant’s proficiency. On top of it all, you will have the chance to

connect with other enthusiastic residents who come from different parts of the world. Read on to know more about the impressions and testimonials of past participants, faculty updates, overview of the recently-concluded EUREP18, and more information on how to join the programme.

Ebb and flow: EUREP18 welcomes change and progress ESU’s EUREP remains as a top resident programme The recent EUREP has brought new developments; some bittersweet but as always, the EUREP team remains optimistic and confident in what the future holds. Thank you, Dr. Veneziano For almost a decade and once a EUREP participant himself, Dr. Domenico Veneziano (IT) was the coordinator and one of the programme’s esteemed Hands-on Training (HOT) tutors. This year, he bids arrivederci to his EUREP family. “My role as HOT tutor has been (and continues to be) special. I have had the honour to participate in EUREP in 2010, became a tutor in 2012, then coordinator from 2014 onwards. It’s been a real privilege to help build the foundation of what hands-on training is today. I feel that one of my biggest achievements has been encouraging the enthusiasm and the passion of what the tutors have for surgical training; they are true experts in their fields who help spread our teaching protocols 2010

2012

teaching formats. Increasing interactivity will further improve the residents’ motivation to follow the lessons and encourage them to share their expertise with the faculty.”

worldwide. Becoming a EUREP tutor is not only about this huge responsibility, but also about being part of a family and taking care of it.”

training platform during residency (no more involving patients) and to show evidence that it is truly possible to do so.”

Dr. Veneziano recalled, “One of the most memorable things I remember was during the barbecue dinner on my first year as coordinator; all the tutors raised me up in the air and chanted ‘Hip hip hooray!’ And then this year, I received heartfelt speeches from ESU Chair, Dr. Juan Palou (ES), and from Dr. Michiel Arnolds (NL) who spoke on behalf of the tutor team. Moments like these are very important to me which are indicative of the appreciation for my efforts and affirmation that ‘I did it well’.”

Welcome to the family As EUREP said farewell to Dr. Veneziano, it also welcomed Assoc. Prof. Berk Burgu (TR) and Prof. Thomas Steuber (DE) as its new faculty members. Prof. Burgu presented during the Module 5: Paediatric urology, trauma and infection session, and Prof. Steuber in Module 2: Prostate cancer and male voiding LUTS.

A Philippine participation Last year, two urologists and members of the Philippine Urological Association (PUA) came to Prague to observe what the programme offers. This year, two PUA residents had their EUREP experience.

“The organisation of EUREP has a perfect balance of academically high standards and fruitful, social interactions. The programme even gave me the opportunity to build closer relations with the residents from Turkey,” stated Prof. Burgu. “The paediatric urology sessions I was responsible for were highly interactive. From what I’ve observed, the level of basic paediatric urology experience and know-how of the residents varies greatly. I think this is a unique aspect of EUREP since their knowledge depends on the department and country of origin.”

“EUREP 18 was a wonderful experience for me; a once-in-a-lifetime opportunity that I will always cherish,” said Dr. Jardine Lua (PH). “Participating in this programme helped us review for our upcoming urology specialty board examination. EUREP18 gave us a great overview of current international trends and practices in urology, and a chance to meet and mingle with colleagues with different nationalities. It was an honour to be taught by well-known professors whose names we usually only see in journals. Joining the HOT sessions is highly recommended! All in all, I think every urology resident should attend this course. Thank you for the experience.”

When asked about his future plans, Dr. Veneziano shared, “EUREP is never the goal, but the beginning of a new path. The programme enabled me to bring several novelties in the educational field and to build up a team of colleagues who strongly believe in the value of simulation. My mission is to continue to search for the best ways of using simulation as a 2014

2018

Dr. Veneziano throughout the years, as participant (1st photo) HOT Tutor (2nd photo) and EUREP Coordinator (3rd & 4th photo)

Prof. Steuber shared, “I was impressed by the perfect organisation of the programme, the inspiring talks from multiple experts, and the magnitude of educational options for the residents. EUREP has such an acclaimed reputation within the European residential community that I was already approached by various German residents, who are concerned about not getting into the programme next year.” When asked about future changes in the programme, Prof. Steuber said, “Due to its success and popularity, increasing the number of participants could be considered. In addition, given the volume of content in the sessions, we aim to introduce more interactive

Dr. Christian Dale Feri (PH) stated, “This is the first time that Filipino urology residents are invited to this prestigious programme. EUREP18 offered possibilities and opportunities to its residents who are willing to explore the various specialties in the field. It was not just about lectures and skills improvement, but also about building camaraderie with fellow residents and renowned EUREP professors. I highly recommend this programme to senior residents who aim to further bolster their training. EUREP18 will always be one-of-a-kind experience to me, one that I will always be thankful for and be proud of.”

EUREP18 offers residents well-balanced programme Comprehensive training paired with social activities By Dr. Lazaros Lazarou National and Kapodistrian University of Athens Athens (GR) EUREP18 is the recent edition of an excellent training programme for final-year residents for the past 16 years. The enthusiasm, drive and high spirits of experts who make up the faculty and residents from all over the world kept the level of education high but also the motivation alive.

covered the essentials that will make a difference in practice and provided evidence-based data to guide participants. We were encouraged to contribute during the deliberations and conversations. We exchanged ideas and strategies in how to treat and deal with patients in all urological aspects.

Dr. Lazaros Lazarou

In my opinion, the EUREP modules were designed to deliver relevant and beneficial information from the latest EAU Guidelines, and to address the challenges commonly faced in daily clinical practice. The faculty 14

European Urology Today

Exploring Prague

It would be a mistake not to mention the big karaoke night of EUREP18 as it was an exhilarating experience, especially with the rain providing ambience. It reminded me of an ERASMUS party with a lot of singing and dancing which brought the urologists there closer together. At EUREP18, the social activities provided a good balance to training our skills and testing them afterwards during hands-on training (HOT) sessions in endourology and laparoscopy with amazing and educative tutors who shared their tips and tricks. The core message of EUREP18 is that proper diagnosis and management is crucial to give our patients the best treatment we could give and for challenging cases, we must continue to discuss, exchange ideas and pursue development in treatment and strategies.

Meeting new people at EUREP18

October/December 2018

EUREP18 highlights in my hometown Programme offers excellent learning opportunity for urology residents Dr. Jan Novák General University Hospital Prague (CZ) After starting my residency, I was surprised when a colleague of mine Dr. Jan Novák told me that my hometown Prague turns into the education capital for European urology residents every September. Based on her positive experience, she recommended participating at EUREP and advised to register as soon as possible due to the programme’s popularity and limited capacity. Later on, I learned that the Czech Urological Society (CUS) helped the European Association of Urology (EAU) to start the first EUREP in Prague back in 2003. Several Czech academic urologists have been participating in the EUREP faculty since the beginning, such as Profs. Hanuš, Kočvara, Babjuk, and Hora. EUREP18 experience At the Clarion Congress Hotel, EUREP18 commenced Friday morning of the 31st of August and all the faculty members were introduced. The teachers were respected urologists, mostly known as authors of scientific papers or members of EAU Guidelines Panels. The six-day intensive programme covered almost the whole spectrum of urology (e.g. onco-urology, LUTS, functional urology, andrology, lithiasis, infections, trauma, and paediatric urology) and provided us with a comprehensive knowledge of the EAU Guidelines. The programme was divided into five modules with four teachers per module wherein the lectures were

interactive seminars rather than a passive intake of facts. The residents had the opportunity to improve their surgical skills during hands-on training (HOT) sessions, which became a popular and inseparable part of EUREP throughout the years. In total, there were 24 stations for laparoscopy and endoscopy that provided realistic experience of different procedures. Laparoscopic skills were tested at either basic or advanced level during the E-BLUS exam. In endourology there was a possibility to choose between ureteroscopy and transurethral resection. Since every station had one HOT tutor, residents were encouraged to interact with them in order to gain the maximum from the session. On Sunday evening, a barbecue party took place at the Letenský zámeček restaurant, which has a marvellous view of Prague (I still admire the view even though I was born and raised here). After sunset, the party turned into a karaoke party where popular songs were performed. Some of the participants spent some nights and early mornings at the James Dean Prague, a club in the historical centre which became a EUREP staple in the last years. EUREP’s excellence was achieved by several measures such as attendance was checked twice a day, and teachers were evaluated by the residents. Those who reached less than 4 out of 5 points will not be invited next year. A unification of European urology residents definitely brings advantages such as making contacts and

exercising “European English”, as said by ESU Chair Dr. Joan Palou during his welcome speech. Moreover, an arrangement of such an extensive event within individual countries has been made possible. Nevertheless, the first foray into national residents education programmes might be #BUREP (Belgian version of #EUREP) organised at KU Leuven, as recently announced on Twitter. Why we should apply early Current requirements for Czech urology residents were released in 2011. It takes at least five years; a two-year urological trunk, and three years of specialised training, which includes clinical rotations in neighbouring specialities (e.g. general surgery, gynaecology, oncology, paediatric urology), and specialised courses. There is a list of mandatory procedures that the residents must perform. After two years, they take the first exam at the end of the urological trunk which gives them clinical competencies. At the end of residency, they take written and oral exams. These exams are not compulsory for residents who have European Board of Urology (EBU) certification and these residents are required to only write their thesis on the subject close to their topic of interest in urology. The expenses related to the EBU

My unbelievable and unforgettable experience in Prague By Dr. Senjin Djozic, Clinical Centre of Vojvodina, University of Novi Sad, Faculty of Medicine, Dept. of Surgery, Novi Sad (RS)

I have read about EUREP in European Urology Today and I was overwhelmed when I received a confirmation e-mail in June. Knowing that there are only 360 places, I found it very useful to answer the multiple-choice questions (MCQs) and earn CME credits; this motivated me to read European Urology articles and work on my scientific development. The venue was set in the beautiful four-star Clarion Congress Hotel located in the outskirts of Prague which was well-connected to the city centre. The first thing I noticed upon my arrival at the hotel was the exceptional organisation from the staff of EUREP, EAU and the hotel; they were willing to help and give instructions regarding the programme. We were divided into five groups. A different urology module was scheduled for each day and within six

October/December 2018

EUREP was a great opportunity to meet and talk to some of the world’s greatest experts in their fields, not just during the courses but during social events as

Laparoscopy training during the break

Out of 360 participants from 44 countries, 10 residents were from Czech hospitals. This reflects the necessity of early application to the unique educational event such as EUREP. EUREP definitely surpassed my expectations. It challenged me and the rest of the residents to uphold the very high standards the programme has bestowed on us, and encouraged us to perform better in our clinical practice.

Me with fellow residents and with Prof. Hora (faculty member from Czech Republic)

A Novi Sad resident’s impressions of EUREP18 days, almost all urology fields were covered. The lectures began in the mornings and were very intensive but far from dull and boring. Each lecture was an opportunity to learn new things and update our knowledge with the most recent evidence-based Every year, urology residents from studies. There was constant interaction between within and beyond Europe who are residents and teachers, lively discussions, interesting Dr. Senjin Djozic in their final year gather in case reports, MCQ’s and tips for daily clinical practice. wonderful Prague for the European Urology Residents Education Programme (EUREP). One of the highlights of EUREP was the definitely EUREP is a comprehensive programme widely known hands-on training (HOT) sessions. We were able to for its excellence in education and training, and a train in laparoscopy, transurethral resection of the must-attend event for future urologists. prostate (TURP) and ureteroscopy (URS) for 60 minutes using state-of-the-art equipment and with It is customary for Serbian residents to attend EUREP. guidance from inspiring and supportive endoscopy They are mostly from Belgrade but this time after 14 tutors, who came from the best training centres in years, a resident from Novi Sad (the second largest Europe. There was also the possibility to take city in Serbia) received the opportunity to join the European training in basic laparoscopic urological programme. I feel proud to have been part of it and skills (E-BLUS) and Endoscopic Stone Treatment - step what an experience it was! 1 (EST-s1) exams.

certification are compensated by the CUS if the residents pass. The residency programmes are organised by the Czech Ministry of Health and medical faculties (formerly by the Institute for Postgraduate Medical Education).

Liked what you've read? Interested in EUREP 2019? If you are interested in applying for EUREP 2019 (6-11 September 2019) please be aware of the following:

With Prof. Shariat (left) and Prof. Rouprêt (right)

well. They were always kind, open for conversation and willing to offer advice. Besides being one of the best training platform for residents, EUREP is also designed as a place for young people to share knowledge and make new friends from all over the world. Karaoke night is one the EUREP traditions that everybody remembers and talks about afterwards. That Sunday evening began with a barbecue, where residents and faculty members got together and enjoyed the relaxed atmosphere which later on intensifies into an amazing karaoke party! I think EUREP is a must-attend programme for every urology resident as it opens new doors and possibilities beneficial for their professional careers. I am very thankful to have had the opportunity to be a part of EUREP18. I would like to express my gratitude to the organisers, faculty members, and to everyone who was involved in making this meeting truly one of a kind. It was an unbelievable experience that will never be forgotten.

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 • December 2018 – Website will open • 7 January 2019 – Registration opens All registrations should be accompanied by a copy of your passport and proof of status.

European Urology Today

Potentially a brighter future for '3D' laparoscopy? Weighing its impact on perioperative outcomes and looking ahead Dr. Riccardo Bertolo Young Academic Urologists Group Research Fellow at Dept. of Urology Cleveland Clinic Foundation Cleveland (US) @RicBertolo

Focusing on the advent of 3D optical systems in laparoscopy, they became available on the market in parallel with the evolution of 3D television screens (around 2010). Initially, the 3D display was based on the “shutter glass” technique, providing poordefinition images and being harmful to the eyes of the surgeon. More recently, the film-type patterned retarder 3D laparoscopes were introduced, starting the “era of 3D laparoscopy”, with higher definition stable images, reducing the visual stress [3, 4].

Such benefits have been described in both the perioperative outcomes of surgery itself (with minimised surgical trauma, faster recovery, reduced postoperative analgesic use and shorter hospitalisation), and the learning environment (with widespread easier delivering of surgery in the operating rooms, classrooms and medical conferences) [1].

After more than 5 years with reports from single institutions, the European Society of Uro-Technology (ESUT) endorsed a systematic literature review aimed to analyse the objective impact of the use of 3D laparoscopy on the perioperative outcomes of urological interventions [5]. In particular, the analysis of data was focused on the procedures including the intracorporeal suturing (i.e. radical prostatectomy, partial nephrectomy and pyeloplasty). Advantages in shortened operative time have been found at the overall analysis and in the subgroup analysis of prostatectomy case-studies, together with reduced blood losses and shorter length of stay. Results have been confirmed by another similar report about the topic, that found reduced operative time and blood losses in prostatectomy and shorter ischemia time in partial nephrectomy [6].

But laparoscopy is known for its technical and ergonomic challenges as well, namely the limited range of motions and the poor depth of perception with the two-dimensional (2D) imaging systems, resulting in a longer learning curve. Laparoscopic robotised instruments and tri-dimensional (3D) imaging systems have respectively been introduced in an attempt to mitigate such drawbacks [2, 3].

As concerning the subjective impact of 3D vision, a few evaluations showed that surgical vision is felt superior with 3D, with no increased eye fatigue. Nevertheless, some authors pointed out that there is the potential that some surgeons might not adapt to 3D, given the prevalence of adverse effects from 3D in the general population. This is probably also what prevented a broader adoption of the technology.

Indeed, after the introduction of such technologies, literature experiences have reported improved laparoscopic dissection, suturing quality, ergonomics and depth perception, suggesting a shorter learning curve.

For a better understanding of the technological environment in which we are living, we need to look at the overall market of 3D screens that gave us 3D laparoscopy. During the Consumer Electronic Show held in Las Vegas, Nevada, USA, in 2010, the claim

The advent of laparoscopic surgery has represented one of the most significant milestones of the 20th century in the field of surgery and particularly urology. Laparoscopy has become the preferred choice for many surgeons for its surgical and clinical benefits over open surgery.

Credit Registry Report 2018 Make sure to check your registered credits! More than 15,000 urologists from Europe and beyond have already joined the EU-ACME programme. However, only 39% have collected CME/CPD credit points last year. Members of the EU-ACME programme are collecting CME/CPD credits in compliance with EBU CME/CPD credit system, which recommends obtaining a minimum of 300 credits in five years – 250 CME credits and 50 CPD credits. The EU-ACME programme provides access to the online CME/CPD portfolio (MyCME), allowing its members to check and register activities at any time. Many members have already used our online system and registered activities attended in 2018. The EU-ACME office collects and registers events and activities until 15 January 2019. How to check your online account? Log in to MyCME - your online CME/CPD portfolio, through www.eu-acme.org, go to Credit Registry Report and check if all activities are properly listed under your name. How to add activities to your online CME/CPD portfolio – MyCME? If you miss any CME/CPD activity you may register it directly online in MyCME by going to Request registration of CME/CPD activity. You will find manuals in the Document Library on our website. During the application process you will be prompt to upload a documental proof: • Whenever you attend a live educational event, e.g. conference, congress, meeting – you should receive a certificate of attendance. If the meeting is accredited it should be clearly stated on the certificate by which institution with the total of granted credits. EU-ACME Office

European Urology Today

Please indicate on the certificate how many hours you actually spent in the educational activity.

• If you wish to have credits added to your account for a scientific publication/ presentation, etc., please send a documental proof e.g. a certificate, an article, a copy of a programme, with clearly visible title and authors of the presentation/scientific publication. (point 8 of the manual) After validation of your application and checking a documental proof we will update your account accordingly. You may as well send copies of documents to EU-ACME office by e-mail. How to request a new password? If your forgot your password please click on the link Forgot password on log in screen to reset it. Electronic Credit Registry Reports As of 2019 the yearly Credit Registry Reports for EU-ACME members will be generated electronically only. This way you will be able to access and print your CRR at any time. If you wish to receive a hard copy of the yearly CRR, please log in to your online account and check the box for the option: “I wish to receive a hard copy of my yearly CRR.” Make sure your personal data and e-mail address are correct, so that the EU-ACME office can send information on the Credit Registry Report 2018 to you on time and to the correct address! Further information: www.eu-acme.org

“I saw the future of TV, its name is 3D” witnessed the importance of the upcoming revolution of the image displays. Nevertheless, nowadays something has changed and the interest towards the 3D screens has been almost abandoned, with the 3D screens taking up less than 15% of the market. This probably happened due to the mandatory 3D glasses, and the headaches and even the nausea related to the use of 3D. “Customer is king” is the sad proverb of the market. Not surprisingly, leaders in the field of the TV screens have spoken out with phrases like “None of the new models we will distribute will have 3D features” or “3D TV is dead”. As such, the ascending trend of the 3D screen market has known a sharp stop with the evolution of TV screens going towards the ultra-High Definition and the 4K technologies.

"...ultra-D technology is able to create a natural glasses-free 3D viewing experience..." The latest advances brought OLED technology in the field, aiming a more natural fruition of the image. With OLED, the images are as real as they can get. With self-lighting pixel technology, the screen can range from blazing white to the darkest black, with a sense of realism and depth. But StreamTV Networks Inc. (Philadelphia, Pennsylvania, USA) presented at the 2018 edition of the Las Vegas Consumer Electronic Show the ultra-D technology. This represents a combination of hardware and software able to create a natural glasses-free 3D viewing experience. The depth perceived by the viewer is less marked, but the 3D effect is maintained within a view angle of 120 degrees. This is something really exciting and I believe we all need to look forward to seeing such technology in the operative room. Up to date, anecdotal study groups attempted to design a glasses-free 3D electronic

laparoscopic system, aiming to get a wide-field 3D display [7, 8]. Primary experimental results of the simulation using the system showed advantages in terms of time for completing laparoscopic exercises, but no clinical experiences are reported so far. In conclusion, some efforts have been made to prove that 3D laparoscopy is able to offer some advantages over 2D laparoscopy in the perioperative outcomes of surgery. Maybe not in its current form, but more likely after a consistent development in parallel with the development of TV displays, 3D laparoscopy could become a more viable alternative to facilitate the surgical gestures, particularly in the settings with no access to robotic technology. References 1. Basiri A, de la Rosette JJ, Tabatabaei S, et al. Comparison of retropubic, laparoscopic and robotic radical prostatectomy: who is the winner? World J Urol, 2018. 36(4): p. 609-621. 2. Criss CN, Ralls MW, Johnson KN, et al. A Novel Intuitively Controlled Articulating Instrument for Reoperative Foregut Surgery: A Case Report. J Laparoendosc Adv Surg Tech A, 2017. 27(9): p. 983-986. 3. Wenzl, R., N. Pateisky, and P. Husslein, [First use of a 3D video-endoscope in gynecology]. Geburtshilfe Frauenheilkd, 1993. 53(11): p. 776-8.4. Buchs et al. Surg Endosc. 2013. 5. Current Status of 3D Laparoscopy in Urology: An ESUT Systematic Review And Cumulative Analysis. Bertolo R, Checcucci E, Amparore D, et al. J Endourol. 2018 Aug 1. doi: 10.1089/end.2018.0374. [Epub ahead of print] 6. Dirie NI, Wang Q, Wang S. Two-dimensional versus three-dimensional laparoscopic systems in urology: A systematic review and meta-analysis. J Endourol. 2018 Jul 4. doi: 10.1089/end.2018.0411. [Epub ahead of print] 7. Khoshabeh R, Juang J, Talamini MA, et al. IEEE Transactions on Biomedical Engineering 2012 Oct; 59(10):2859-2865. doi: 10.1109/tbme.2012.2212192. 8. Gu D, Jiang J, Li J, et al. Zhongguo Yi Liao Qi Xie Za Zhi. 2017 Sep 30;41(5):317-321. doi: 10.3969/j.issn.16717104.2017.05.002.

Check a meeting website for CME accreditation in advance! An accredited meeting is a prerequisite to obtain your CME credit points The key to receiving CME credit points is the accreditation of (inter)national meetings, which can be done either by a national accreditation authority - following the regulations of the respective country, or within the EU-ACME programme following the EBU CME/CPD credit system. In most cases national and the EU-ACME accreditation complement each other. Meeting organisers are expected to communicate clearly to participants not only that the event is accredited (web site, programme book, certificate of

attendance) but as well how many CME credits urologists may obtain and how the attendance is verified. Therefore before attending the meeting urologists should check the website of the meeting for detailed information, the programme book, contact their national society, call the EU ACME office or visit the CME Events Calendar page at www.eu-acme.org. Check a meeting website for detailed information regarding accreditation!

Win a free registration to Barcelona 2019! EU-ACME members, join the MCQ quiz published in European Urology For details, visit: www.eu-acme.org/europeanurology

Gain your CME credits at home All you need is a PC and internet access Visit www.eu-acme.org/europeanurology and answer a set of MCQs on-line. 80% of the answers need to be answered correctly to obtain 1 European CME credit point. Credits are attributed automatically at 1 credit point per article, allowing for a maximum of 50 credit points over a 5 year period.

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

October/December 2018

Report

New ART in Flexible cultivates stone treatment First edition offers a fresh take on treatment approaches By Erika De Groot A completely new concept that invigorates understanding of endoscopic stone treatment approaches, the Advanced Resident Training (ART) in Flexible was a massive success. The course was offered as a pilot programme to Italian and Spanish residents, and foreseen to expand to many other countries across Europe soon. What is ART in Flexible? ART in Flexible is a novel educational concept aimed to enrich knowledge in treatment approaches. The course is a complementary fusion of theoretical insights and hands-on training (HOT) sessions where even experienced participants see it as an opportunity to refine their technical skills. The tutors help identify and correct commonly-encountered pitfalls; assess the participants’ performance and improvement with the aid of an algorithm; and select the most skilled and the most enthusiastic to proceed to the subsequent phases of the course.

Intimate set-up is more conducive to learning

The residents and their tutors

challenging and complex tasks; from ultrasound and laser lithotripsy to basketing.

For Dr. Kallidonis, it was the ability to teach more than the basics of flexible ureteroscopy. He added, “Troubleshooting on how to use equipment and materials made the trainees to be more enthusiastic which in turn helped us trainers to go a step further and offer them more advanced tips and tricks.”

Dr. Bianchi shared, “The top things I’ve learned from this course are that there are tricks to protect the instrument from the laser; that there are no written ART in Flexible is the brainchild of the collaboration of rules in handling the instruments but you have to the European School of Urology (ESU), the EAU understand which positions work for you; and that Section of Urolithiasis (EULIS) and the EAU Section of you can always find a solution.” For Dr. Fernandez, it Uro-Technology (ESUT). was learning about how to rotate a Terumo guidewire; move with the access sheath and flexible ureteroscope properly; and identify the configurations for different effects.

The (simulation) tools of the trade

Three-step structure The course consists of a tiered structure based on increasing difficulty: ART in Flexible Steps 1, 2 and 3.

The final and advanced step, ART in Flexible Step 3, took place at the Centro de Cirugía de Mínima Invasión Jesús Usón (CCMIJU) in Cáceres, Spain in September. The six-day step involved the EST s3 protocol and complete procedures such as that of Retrograde Intra Renal Surgery (RIRS), Endoscopic Combined Intra-Renal Surgery (ECIRS), Ureterolithotripsy (URS) and Cystolithotripsy to name a few. The four selected participants applied skills learned in previous steps on animal models.

In enhancing urolithiasis treatment “Urolithiasis treatment is complex and requires a lot ART in Flexible step 1 centred on the Endoscopic Stone of expertise by the surgeon,” stated tutor Dr. Panagiotis Kallidonis (GR). “ART in Flexible can Treatment Step 1 (EST-s1) protocol focusing on basic skills such as simple manoeuvres e.g. navigating the provide advanced training in urolithiasis treatment operative channel using guidewires. The 48 with the potential to use all available equipment, including lasers. The acquisition of advanced skills participants were divided into two groups; the Spanish residents who participated in Barcelona back could prepare the trainee for the intricate environment of endoscopic surgery.” in April and the Italian residents who participated in Milan in July. Course Coordinator Dr. Domenico Veneziano (IT) added, “The course allows us to disseminate the “The main point of this kind of training is that it allows us to familiarise ourselves with these correct way of teaching about fine-tuning skills in upper tract stone treatment. It also offers young procedures safely and within the confines of a residents the opportunity to show their talent. I hope that the residency centres will apply the same protocols soon, as these would translate to as a monumental solution to future challenges.” Impressions from the faculty “ART in Flexible ran smoothly. The interest level for both trainers and trainees was high; their enthusiasm was clear and evident. And due to the advanced level of the trainees, we were also able to provide a more extensive overview of the techniques of flexible ureteroscopy,” said Dr. Kallidonis. “Additionally, the venue was conducive to learning, the equipment and materials allowed simulation of real-life surgeries.”

Dr. Veneziano is also optimistic about where the course is headed, “ART in Flexible had just begun and we are ready to make it a not-to-bemissed event for each third-year resident in Europe. Applications will open soon for the 2019 edition so stay tuned!”

As for the best parts of the programme, Dr. Kallidonis disclosed it was “the ability to use lasers on artificial stones” and to Dr. Veneziano, it was the HOT sessions. “While I particularly loved the insights about the history of endourology which gives us a better understanding of why we arrived to our current practice, the hands-on training was what I liked the most. And thanks to an algorithm, we were able to objectively select the most skilled participants who will proceed to the next step,” said Dr. Veneziano. What’s in store In terms of future plans for the course, Dr. Kallidonis said “I look forward to when laser lithotripsy training is standardised.”

The tutors who mould young minds

www.esubpo19.org

4th ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction 17-18 May 2019, Heilbronn, Germany An application has been made to the EACCME® for CME accreditation of this event

Lessons learned applied into practice

training room. Also, interacting with the tutors face-to-face is truly helpful, handy and educational,” said participant Dr. Alvaro Amancio Fernandez Alcalde (ES). When asked about how he prepared for the course, Dr. Fernandez stated, “I requested to practice with ureteroscopes at my hospital. I also searched for information about the different devices we were going to use.” Dr. Grazia Bianchi (IT), a participant who was selected until the last phase, said “And during the course, we were given enough time to improve our skills under the guidance of tutors who taught us and corrected us when necessary.” 16 residents advanced to ART in Flexible Step 2 which took place in Berlin, Germany in July. At an intermediate level, Step 2 focused on preliminary EST s2 protocol, which is comprised of October/December 2018

Italian residents with tutors in Milan

When asked about the most fulfilling part of the programme, Dr. Veneziano shared, “Participants loved the combination of the theoretical and practical aspects of the course. Our top faculty delivered state-of-the-art lectures which impacted what was going to be performed on the simulators. The faculty were enthusiastic about the concept of ART in Flexible as a ‘talent-scouting course’, encouraging participants to do their best and giving recognition to those who excelled. I’m absolutely pleased of the overall result of the course. Every aspect of it was truly interesting and exciting.” European Urology Today

Report

ESU offers in-depth HOT course in Cáceres A broad-gauged coverage of laparoscopy and endourology By Erika De Groot Enthusiastic urologists, residents and researchers from 11 countries participated at the Hands-on Training (HOT) course on Laparoscopy and Endourology from 11 to 14 September at Centro de Cirugía de Mínima Invasión Jesús Usón (CCMIJU) in Cáceres, Spain. Under the tutelage of internationally-known experts Prof. P. Kallidonis (GR) and Prof. L. Dragos (RO), participants went through an intensive training that enriched their knowledge which in turn, will benefit their patient care and clinical practice.

Dr. Alexander Minich (BY): “The training centre was huge and well-equipped with operating tables with modern towers. The training was a comprehensive and well-organised four-day programme. We had excellent, experienced tutors with great passion to teach and help. I received useful information from them during the endourology training as it enabled me to perform procedures which were not possible at my hospital e.g. flexible and rigid ureteroscopy and laser stone fragmentation.”

Dr. Lucian Grad (RO): “It was a wonderful, wellorganised course with an extremely useful training programme. The course was a great opportunity to learn and train in a unique facility under the Days one and two focused on laparoscopy. The supervision of knowledgeable tutors. Thank you very theoretical session covered topics such as comparative much!” anatomy and ESSCOLAP® (Evaluation System of Surgical Competencies in Laparoscopy). The HOT Mr. Mostafa Ragab (GB): “The faculty and staff were sessions included practicum on the pelvic trainer for approachable which gave friendly atmosphere right basic manoeuvers, tissue cutting and dissection, from the start. The course provided state-of-the-art laparoscopic intracorporeal suturing; and laparoscopic facilities and opportunities to operate on live pigs. nephrectomy (radical and partial). My laparoscopic skills increased tremendously. I feel more confident in dealing with renal hilum, urethral The final two days centred on endourology. anastomosis, upper tract urothelial malignancy, and Participants familiarised themselves with techniques, with difficult scenarios involving endopyelotomy and indications and complications of ureteroscopy, infundibulotomy. I am eager to apply my newly percutaneous nephrolitHOTomy (PNL) and retrograde developed skills in practice (under supervision, of intrarenal surgery. They had undergone HOT sessions course). I highly recommend this course to those such as ureteroscopy in bench and animal models; who are interested in increasing their efficiency, and also their knowledge including operative ex vivo model laser litHOTripsy; and handling ergonomics.” endourologic guidewires and catheters by fluoroscopic control, to name a few. Ms. Fiorella Roldan Chavez (PE): “The course was amazing and met my expectations. It was what Read on to know more about their experiences and education for surgeons should be: To be taught how overall impressions in their testimonials found below. to do it better with the right movements in a stress-free environment is incomparable. I truly Dr. Grazia Bianchi (IT): “I was selected for the HOT believe that to go through this kind of training is the course during the first edition of ART in Flexible. This best way to improve skills and to feel more confident experience was amazing! We had the opportunity to during surgeries.” improve our skills with animal models. Our tutors helped us in every single problem. I want to Dr. Raquel Ortiz (ES): “I had a great time during the emphasize that there was respect for the animal course. The facilities, faculty, tutors and the hands-on models in the training.” training were beyond amazing. I felt blessed for having the opportunity to go there. I am extremely “We were 20 young urologists and residents from all thankful to the ESU and to all the people who made it over the Europe who lived together for a week possible. It was my first opportunity to perform sharing experiences, fun and some beers. For sure, laparoscopy in vivo and I have the feeling that this I improved my skills in endourology and laparoscopy, experience has improved my skills in laparoscopy a but I also have to say that I met and gained more lot, since a pelvic trainer does not give you the same friends along the way as well.” feedback. A million thanks!”

Dr. Mikołaj Frankiewicz (PL): “It was an absolute honour for me to attend this extraordinary course. I expected something great but the level of preparation and engagement of the tutors exceeded my expectations. I would’ve never believed it if someone told me before how much you can learn in just four days. I am really happy that ESU invited me.”

even if slightly reducing the time for flexible ureteroscopy. But aside from that, the course was perfect. The tutors were not only professional and skilled, but also passionate about what they do and this made the training extraordinary. And I would also like to thank Ms. Lotte Kraaijeveld for providing clear and complete information on the course.”

“The only thing that could be added in future courses would be additional time for the kidney puncture procedure. I suggest three hours would be optimal

Would you like to know more about HOT courses and/or other highly-informative activities of the ESU? Visit www.uroweb.org/education for more information.

ESU Event Calendar Date

Event name

Location

DECEMBER 13-14 3rd ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer 15-16 ESTs1 at EAU KARL STORZ ‘’SET-UP’’ programme

Paris (FR) Beijing, China (CH)

JANUARY 2019 12-13 E-BLUS at EAU KARL STORZ ‘’SET-UP’’ programme 18-20 ESU course on Treatment of localised and locally advanced prostate cancer at the occasion of the 16th meeting of the EAU Section of Oncological Urology (ESOU)

Beijing, China (CH) Prague (CZ)

FEBRUARY 2019 7-9 URO Berlin Skills Teaching and Training (UROBESTT) 11-14 Hands-on training skills programme on Laparoscopy and Endourology 22-23 2nd ESU-ESOU Masterclass on Non muscle invasive bladder cancer

Berlin (DE) Caceres (ES) Prague (CZ)

MARCH 2019 15-19 34th Annual EAU Congress

Barcelona (ES)

APRIL 2019 12 ESU course on Update in urologic oncology at the national congress of the Urological Association of Serbia

Belgrade (RS)

MAY 2019 17-18 4th ESU-ESUT Masterclass on Operative management of Benign Prostatic Obstruction 24-25 ESU course on Bladder cancer at the 6th Baltic Meeting in conjunction with the EAU

Heilbronn (DE) Tallinn (EE)

JUNE 2019 6 ESU course at the national congress of the Slovak Urological Association 14 ESU course on Urinary tract infection at the national congress of the Ukrainian Urological Association 14-15 3rd ESU-ESUT Masterclass on Urolithiasis 23-29 ESU – Weill Cornell Masterclass in General urology

Martin (SK) Kiev (UA) Patras (GR) Salzburg (AT)

SEPTEMBER 2019 6-11 17th European Urology Residents Education Programme (EUREP) 11-13 ESU-ERUS courses at the 17th Meeting of the EAU Robotic Urology Section (ERUS)

Prague (CZ) Lisbon (PT)

OCTOBER 2019 10 ESU course at the 26th Meeting of the EAU Section Porto (PT) of Urological Research (ESUR) 31-2 ESU-ESFFU Masterclass on Functional urology at Prague (CZ) the European Lower Urinary Tract Symptoms meeting (ELUTS19)

NOVEMBER 2019

Learning by doing in Cáceres

European Urology Today

11 ESU course at the national congress of the Scientific Society of Urologists of Uzbekistan 14-17 ESU courses at the 11th European Multidisciplinary Meeting in Urological Cancers (EMUC)

Tashkent (UZ) Vienna (AT)

October/December 2018

Report

ESU and RSU create stronger ties between East and West Course on urolithiasis held at Siberian meeting Prof. Igor Korneyev Local congress organiser St. Petersburg (RU)

iakorneyev@ yandex.ru Held from 12 to 14 September this year in Krasnoyarsk, Russia, the Eastern Siberian meeting of the Russian Society of Urology (RSU) was host to a European School of Urology (ESU) course, which is one of two ESU courses scheduled in conjunction with RSU events in 2018. The next ESU course will take place during RSU’s annual congress in Yekaterinburg. These RSU events were and will be held in the epicentre of the country to attract and bring participants from the Western and even from the distant Eastern parts together. Urolithiasis was the chosen topic for the ESU course since it is one of the most common urological problems in all parts of Russia. Two ESU faculty members Assoc. Prof. Andreas Skolarikos (GR) and Dr. Bhaskar Somani (GB), together with RSU speaker Prof. Alexey Martov (RU), shared their knowledge in current approaches to stones disease with 198 participants, who mostly came from the Siberian part of Russia. After the welcoming speech of Dr. Fedor Kapsargin (RU), who is the local organiser of the ESU course, Prof. Skolarikos made an introduction from the EAU side. He discussed the benefits of an EAU membership such as updating knowledge and skills and helping develop careers in urology.

During the first half of the course, Prof. Skolarikos presented an overview of the EAU Guidelines recommendations on stents placement, in conjunction with Extracorporeal Shock Wave Lithotripsy (ESWL), percutaneous and retrograde endoscopic procedures in various clinical scenarios. He pointed out indications for decompression of obstructed collecting system in obstetric and paediatric practice. He also described an evidence-based approach to metabolic evaluation in patients with stone disease with the aim to prevent recurrent stone formation. Dr. Somani examined clinical implications of shockwave lithotripsy (SWL) and flexible ureteroscopy for stones of various types and locations. He mentioned that even if the number of SWL procedures have gradually decreased in previous years in favour of ureteroscopy, the individual decision-making per clinical situation should be justified. It should be based on probability to achieve a stone-free status, patient expectations of invasiveness, and repeatability of SWL treatment procedure. The second part of the ESU course was devoted to practical tips of stones treatment via percutaneous approach for large kidney stones and ureteral stones, with specific emphasis to complications.

A full house during the ESU course

Prof. Skolarikos and Dr. Somani presented a satisfaction with the amount of interaction they had with the faculty and look forward to the RSU hosting comprehensive overview of papers published in the last few years and shared their own experiences as another ESU course in the future. well. They concluded with recommendations for prevention, early diagnosis and treatment of complications in standard clinical settings. Prof. Martov presented a case report wherein he described a complication of a percutaneous approach, then proceeded to discuss the rest of the case details step-by-step. He encouraged discussions with the audience and intermittently asked them for their opinions on the case.

Participants filled out a questionnaire at the end of the course. The results showed that 98% of the participants think that the ESU course increased their professional knowledge, and 99% are confident it will Dr. Somani discusses implications of SWL and flexible ureteroscopy Prof. Skolarikos addresses a question from an audience member improve their patient care. They also expressed

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October/December 2018

European Urology Today

EULIS-ESUT Project identifies core outcome sets in stones COSTRUCT – Core Outcome Sets on Trials in Renal and UreteriC stone Treatments Dr. Francesco Sanguedolce Fundació Puigvert Dept. of Urology Barcelona (ES)

fsangue@hotmail.com

Dr. Panagiotis Kallidonis General University Hospital of Patras Dept. of Urology Patras (GR) pkallidonis@ yahoo.com Co-authors: Prof. Kemal Sarica, Prof. Evangelos Liatsikos Research in stone disease is untidy: outcomes in trials are variably selected and reported so appropriate comparison and/or pooling of data from different studies is difficult or impossible. Moreover, some papers may deliberately not include unfavourable or undesired outcomes, introducing severe bias. There is an urgent need for practitioners across the globe to standardise EAU Section of Urolithiasis (EULIS)

the reporting of relevant outcomes on trials regarding intervention in renal and ureteric stones. A clear example is the definition of stone-free rate after treatment for renal stones: which is the actual cut-off for a clinically insignificant residual fragments (e.g. < 4 mm, < 2 mm, none)? When should the outcome be evaluated (e.g. after 7 days, 1 month, 3 months)? Which is the tool that needs to be used (CT scan, US scan, X-ray)? Since the 1970s, the World Health Organization has promoted the standardisation of reporting of treatment outcomes; the first document in this regard was the WHO Handbook for Reporting Results of Cancer Treatment (1978), aiming to “develop a common language to describe cancer treatment and to agree on internationally acceptable principles for evaluating data”.

"There is an urgent need for practitioners across the globe to standardise the reporting of relevant outcomes..."

paul.meria@ sls.aphp.fr

Prostate Cancer, Clinical Case Scenarios The diagnosis and management of prostate cancer have dramatically evolved during the 20 past years. New strategies have emerged and most of them are now consensual or almost, but some controversies remain. In this textbook, editors Sam S. Chang and Michael S. Cookson, with the help of thirty experts, aim to organise an update on prostate cancer based on 13 clinical scenarios, frequently encountered in daily practice. The first chapter addresses prostate cancer screening in Afro-American men on the basis of a clinical case of high-risk prostate cancer. The chapters that follow are dedicated to elderly men presenting with asymptomatic elevated PSA levels and to the use of biomarkers in patients with negative biopsies. Active surveillance was discussed in low risk prostate cancers occurring in Afro-Americans and in patients with intermediate-risk cancers. Various other clinical situations were discussed, focusing on controversial attitudes and including adjuvant therapies for recurrences. High-risk, advanced and metastatic cancers were also addressed and the authors discussed the role of various treatments in such clinical situations. Book reviewsof Uro-Technology (ESUT) EAU Section

European Urology Today

• i ncrease consistency across trials • maximise comparison and/or pooling of data • m easure appropriate outcomes that matter to patients A strict methodology process on how to develop COS in medicine has been described by prominent physicians from the Core Outcome Measures in Effectiveness Trials (COMET) initiative. This organisation has developed a powerful platform to support studies aiming to identify relevant COS in interventions and/or health conditions, by providing a handbook to guide researchers, a publicly-accessible registry to avoid overlapping of studies and an IT platform to support the Delphi consensus process. In 2017, a joint project of the EAU Section of Urolithiasis (EULIS) and the EAU Section of UroTechnology (ESUT), in collaboration with the EAU Urolithiasis Guidelines has been developed to identify the COS that are to be consistently reported in trials regarding interventions in renal and ureteric stones. Initially, the The main aim was to standardise definitions and terminology of reporting outcomes, but the more accurate and useful methodology used in the development of COS was crucial to design a study with such an approach.

In the last two decades, this principle has been adopted in both oncological and non-oncological disciplines by identifying the so called Core Outcomes Set (COS), which is an agreed standardised set of outcomes that should be measured and reported, as a The COSTRUCT project has been designed by the minimum, in all clinical trials in specific areas of health Steering Committee and the protocol has been registered on the COMET webpage (www.cometor healthcare. initiative.org). A Systematic Review (PROSPERO registration number: CRD42018089303) is ongoing to This “minimum number” or core set of outcomes identify the outcomes reported in the RCTs of the last needs to include both benefits and harms that a 10 years involving interventions (SWL, PCNL, URS, treatment or health condition may cause, “what”, “how”, and “when” the outcomes should be reported surgery) for the treatment of renal stones in adults.

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

and does not exclude other outcomes to be included. The aim is to:

For every clinical scenario a short presentation of the case was done and the discussion was built on a review of the literature, focusing on consensual and controversial data. For each case a substantiated discussion was developed and consisted in sound argument.

An exhaustive survey was dedicated to various treatments currently available, including a description of preventive aspects with pelvic floor training. The authors had a look at pessary use and focused on the tool’s characteristics and use. Various techniques of surgical POP repair were addressed, including robot-assisted pelvic floor reconstruction. Controversies on vaginal mesh repair were detailed in a specific chapter, and future developments, such as stem cell therapies, were also considered. The role of hysterectomy, also source of controversy, was discussed.

This textbook is undoubtedly a useful and practical resource for urologists and trainees, involved in the management of prostate cancer.

The last part of the work was dedicated to postoperative outcomes and patient follow-up. The authors focused on assessment questionnaires and objectives outcome measures. They also considered various postoperative urogenital problems related to POP surgical management.

Editors: S.S. Chang, M.S. Cookson ISBN: 978-3-319-78645-2 e-Book: Available Published: 2018 Publisher: Springer International Publishing Edition: 1st Pages: 202 Illustrations: 15 (10 in colour) Binding: Hardcover Price: € 89.99 Website: www.springer.com

Management of Pelvic Organ Prolapse, Current Controversies Pelvic organ prolapse (POP) is a frequent condition that impairs quality of life and requires a multidisciplinary approach. Currently, patients require an uro-gynaecologic evaluation and a specific treatment is usually proposed. Nevertheless, some aspects of POP management remain controversial. In this textbook, editors Vincenzo Li Marzi and Maurizio Serrati have updated exhaustive information about recent advances and controversies in POP management. More than 30 worldwide experts contributed to this work. General remarks were addressed in the first part of the book, focusing on surgical anatomy, pathophysiology, epidemiology and associated functional disorders. The succeeding chapters were dedicated to clinical aspects and evaluation of patients, including imaging techniques and urodynamic assessment.

This pocketbook provides the reader with a good overview of POP management and related controversies. Urologists and gynaecologists will also find it contains explicit figures and practical advice. Editors: ISBN: e-Book: Published: Publisher: Edition: Pages: Illustrations: Binding: Price: Website:

V. Li Marzi, M. Serati 978-3-319-59194-0 Available 2018 Springer International Publishing 1st 178 55 (42 in colour) Hardcover € 89.99 www.springer.com

Surgical Techniques for Kidney Cancer Kidney cancer is currently the 14th most common cancer worldwide with more than 400,000 cases per year. The age-standardised rate in European countries varies from 9 to 16/100,000. Consequently, many

According Based on the results, a list of outcomes will be screened by a pool of stakeholders using the Delphi method: a number of experts in stone disease from all over the world, including not only urologists but also nephrologists, microbiologists, radiologists, as well as company representatives will eventually come to an agreement regarding which are the minimum set of outcomes that need to be consistently reported in literature, how and when to report them. However, the main stakeholders of the process will be patients from different countries, this is in order to have a balanced and a patient-centred evaluation. The selection of the outcomes will happen in multiple rounds of surveys where the participants will be asked to score every selected item (e.g. which is the most appropriate imaging tool to assess stone condition after a treatment? US, NCCT, X-ray, etc.); controversial items (i.e. those where no agreement was found among scorers) will be discussed in a consensus meeting for their inclusion or exclusion. At the end of the process, a core set of outcomes and their definitions will be included in the final statement which is meant to serve as a guideline for future trials on kidney stone interventions. References 1. WHO Constitution 1948 2. Clarke M. "Standardising outcomes for clinical trials and systematic reviews." Trials 2007:39. 3. Williamson et al. "The COMET (Core Outcome Measures in Effectiveness Trials) Initiative." Trials 2011 12 (Suppl 1):A70.

urologists will be involved in kidney cancer management, which requires surgical procedures in most cases. Nevertheless other strategies have been developed, including surveillance and ablative techniques. Editors Rakesh V. Khanna, Gennady Bratslavsky and Robert J. Stein, with the help of worldwide experts, have created this pocketbook for residents and trainees. Their approach was not exhaustive and they limited their work to certain aspects of renal tumours management. The first chapter was well illustrated and focused on imaging of various renal tumours, including cysts, benign and malignant tissue tumours. The role of mass biopsy was discussed in the following chapter before addressing some surgical techniques. The increasing role of partial nephrectomy was emphasised and the authors focused on open and robot-assisted procedures. Strategy and technical aspects of inferior vena cava tumour thrombus management were also addressed, considering open and minimally invasive approaches. Ablative techniques such as cryotherapy and radiofrequency were reviewed and the authors described combinations of such techniques with laparoscopic approaches and their possible complications. This textbook, intentionally non-exhaustive and sparsely illustrated, assembles some useful information for young urologists and trainees. Experienced urologists will also find some practical tips and tricks in this work. Editors: ISBN: e-Book: Published: Publisher: Edition: Pages: Illustrations: Binding: Price: Website:

R.V. Khanna, G. Bratslavsky, R.J. Stein 978-1-4939-7688-1 Available 2018 Springer Verlag New York 1st 104 30 (16 in colour) Hardcover € 66.99 www.springer.com October/December 2018

Canadian Tour 2018 Academic Exchange Programme Highlights and impressions of the three participants Prof. Frans Debruyne CUA/EAU Exchange Supervisor Arnhem (NL)

f.debruyne@andros.nl Co-authors: Dr. Bohdan Bidovanets, Dr. Nikolaos Grivas, Dr. Carme Mir We arrived in Montréal, Canada on June 13, 2018 for the CUA/EAU Academic Exchange Programme. As supervisor and mentor of the group, I had the pleasure of meeting three superb young urologists for the first time: Dr. Carme Mir (ES), an enthusiastic young onco-urologist from Valencia, Spain; Dr. Nikolaos Grivas (GR), a Greek urologist with a major interest in onco-urology as well; and Dr. Bohdan Bidovanets (UA) from Ukraine.

The meeting was extremely interesting because of the professional lectures on different fields of urology including urogenital malignancies (such as bladder cancer genomics and variant pathology as well as neoadjuvant chemotherapy, cytoreductive nephrectomies, immuno-oncology), functional disorders, paediatric and endoscopic urology and urethral stricture disease etc. The poster sessions were also well-informative and showed some fresh ideas. The CUA Accredited Courses on anticoagulation, adjuvant high-risk kidney cancer, advanced prostate cancer and post-prostatectomy incontinence management were very useful for our practice. It was only at the President’s Reception and Banquet on the last day of the CUA meeting that we learned that Prof. Saad became the new President of the CUA. Congratulations!

Summarising the whole CUA/EAU Academic Exchange Programme, I can say that I am proud to have been selected for this programme. It was a privilege to represent my country and the EAU in this prestigious activity. I am sure that these two weeks will have a great influence on my future academic and practical It was very interesting to travel with these three young career; I encountered new scientific achievements and urologists. We visited three excellent departments of original ideas, and I was able to share thoughts with urology: the Centre Hospitalier de l’Université de colleagues from Canada. I would like to thank Montreal (CHUM) under the great leadership of everyone who helped make participation in this Prof. Fred Saad; the Ottawa University Hospital and prestigious programme, a dream come true. another impressive academic institution; and the Victoria Hospital in Halifax where Prof. Jerzy Gajewski was our perfect host. In this article, three fellows share their experience of the exchange programme. Read on to know more. Impressions of Dr. Bidovanets The history of the EAU and Canadian Urology Association (CUA) started in 2011. This year, the CUA/ EAU Academic Exchange Programme started in Montréal, a beautiful Canadian city that has one of the largest seaports in North America. Most people in Montréal speak French which makes it even more charmant. On the first day we visited the operating rooms and met Prof. François Bénard

In the early morning of June 14, Prof. Frans Debruyne, Dr. Carme Mir, Dr. Nicolaos Grivas and I were met by Dr. Daniel Liberman and then the tour started! We visited a large building of CHUM where we met Prof. Fred Saad, the Chairman of the Department of Urology. After a very quick tour of the hospital departments (the detailed and comprehensive visit of the Department of Urology and Medical Oncology was planned for the next day) we arrived at the operating rooms where we met Prof. François Bénard with whom we had a nice discussion about stones and urinary tract infections. Afterwards, we were accompanied by Dr. Malek Meskawi, a senior urology resident. He was very kind; he answered all our questions and showed us everything. Later on, we met Prof. Luc Valiquette and Prof. Pierre Karakiewicz with whom we also had a great time sharing our thoughts! The day ended with an awesome dinner, our presentations and presentations by the CHUM residents as well. The next day was not less interesting as the previous one! We had a great tour of the hospital departments with Prof. Saad and we also visited the Research Centre. It was really impressive! Thereafter, we had the opportunity to talk to research fellows after their presentations. In the afternoon, we watched some surgeries in the operating room which included a robotic prostatectomy performed by Dr. Kevin Zorn. After that, we had a short walk in downtown Montréal with Dr. Daniel Liberman. The day ended with an incredible dinner hosted by Prof. Saad.

CUA/EAU programme experience of Dr. Grivas We proceeded to Ottawa, the capital of Canada and stayed from June 17 to 19. After our arrival, we received a warm welcome from Dr. Luke Lavallée and Dr. Neal Rowe who are professors at Ottawa University, as well as, from Dr. Kristen McAlpine and Dr. Luke Witherspoon who are senior residents. We visited the Canadian Museum of History where we had a two-hour guided tour where we learned about the past and modern history of Canada in detail. Afterwards we had an exciting one-hour canoe tour on the Ottawa River. In the evening, we experienced Canadian hospitality with a lovely dinner at the Shore club. The second day of our visit started with a tour of the Children's Hospital of Eastern Ontario (CHEO) where Prof. Michael Leonard showed us all the facilities of the hospital, such as the urodynamic laboratory, the surgery and post-surgery recovery units, the paediatric Radiology and Nuclear Medicine departments and the well-equipped paediatric ward where children are offered care from specialised nurses. Prof. Leonard informed us about the extensive and broad variety of surgical procedures offered for paediatric patients which include bladder exstrophy, bladder augmentation, ureteroscopic laser lithotripsy, hypospadias repair, and all types of laparoscopic paediatric surgeries.

In the morning of June 16, we had a nice bus trip that and saw many interesting sights of Montréal. We went on a walking tour in the afternoon and then prepared to travel to Ottawa the day after. Participation at the CUA meeting The 73rd Annual Meeting of the Canadian Urology Association was held in Halifax, Nova Scotia from June 23 to 26. The city was the last stop of the Academic Exchange Programme Tour and birthplace of Nobel Prize laureate Charles Brenton Huggins in 1901. October/December 2018

We enjoyed the short walk in downtown Montreal with Dr. Daniel Liberman

The first day was concluded with a wonderful dinner and the presentations of CHUM residents and our own

Afterwards, we visited the general campus of the Ottawa Hospital where Dr. Lavallée informed us about the hospital’s electronical database where a patient’s history, clinical and pathological data are entered. These data are connected to a statistical database allowing fast and accurate analysis; the results are incorporated in the big number of clinical studies running at the Ottawa University. Later on, we joined the Research Symposium in which Prof. Debruyne, Dr. Grivas, Dr. Mir, Dr. Bidovanets, Dr. Breau, Dr. Cagiannos, Dr. Keays, and Dr. Hickling presented their research work focusing on precision diagnostics in prostate cancer, MRI in prostate cancer management, bladder preservation strategies, organ sparing surgery of kidney tumours, prevention of bleeding and blood loss during radical cystectomy, renal hypothermia during partial nephrectomy, surgical improvement through patient reported outcomes and genitourinary antimicrobial peptides, respectively. The second day ended with a fantastic dinner where Prof. Debruyne presented the history of the EAU, and the EAU-CUA wooden plate was offered to Prof. Stuart Oake. The final day started with a visit in the facilities of Ottawa Hospital Civic campus and the University of Ottawa Skills and Simulation Centre, where we were impressed by the training facilities offered to every level in the healthcare profession; from nursing tasks up to complex team activities such as simulation of reanimation and cadaveric workshops. Dr. Matt Roberts gave a detailed presentation on the well-structured residency programme of Canadian urological residents and Dr. Lavallée gave a very interesting talk on database creation and research. Finally, we had private tour to the Parliament Hill which included a meeting with the Speaker of the Senate of Canada, a tour of the latter, acknowledgement by the Speaker during a live session of the Senate, and the opportunity to observe the Senate and the House of Commons in session.

At a dinner hosted by Prof. Fred Saad we all received awards to remember this experience by

among 5ARI and alpha-blockers compared to non-users. Personal thoughts The CAU/EAU tour was a unique experience which allowed me to come in contact with expert colleagues from Canada who, aside from being hospitable, allowed me get to know the health system and the urological practice in the university hospitals of Canada. I was impressed by the research in the field of uro-oncology, especially at CHUM and I strongly believe that I will have research co-operation with my new Canadian colleagues and friends. Dr. Mir’s programme highlights In June 2018, the team travelled to Montréal, Ottawa and Halifax, where the CUA 2018 took place. In Halifax, previous president of the Canadian Urology Association and current member of the scientific committee for CUA, Prof. Jerzy Gajewski, received the whole team at Victoria Hospital. Afterwards, several outstanding research presentations by the in-house resident team were shown in preparation for the upcoming Canadian meeting. Then the primary results on a Canadian multi-institutional prospective database on high-risk locally advanced prostate cancer were presented. The utility of portable ultrasound probes for daily practice was also demonstrated, as well as, the results on a systematic

In conclusion, our second stop in Ottawa was very interesting from both scientific/clinical and social viewpoints. All urologists there should be congratulated for being such a highly professional and well-organised team. CUA meeting highlights Personally, I would like to emphasise two large studies with interesting results in the field of prostate cancer. Dr. Chin Joseph from Western University presented the results from a combined analysis of two large cohorts (268 patients) of salvage cryotherapy (SCRYO) for radio-recurrent prostate cancer. SCRYO provided impressive long-term survival outcomes with 15-year metastasis free survival and overall survival rates of 71% and 54%, respectively. Another hot topic was presented by Dr. Curtis Nickel from the National Institute of Health who analysed the effect of 5 alpha reductase inhibitors (5ARI) and alpha-blocker on prostate cancer (PC) incidence and mortality using a large (>20.000) population-based 20 years (1995-2014) database in Saskatchewan, Canada. In comparison to non-users and to alphablocker users, 5ARIs had >35% lower risk of PC diagnosis. Compared to non-users, alpha-blockers had 11% lower risk of PC diagnosis. For both 5ARIS and alpha-blockers users, approximately 30% higher risk of Gleason 8-10 cancer was demonstrated, compared to non-users. Overall, no significant increase in metastatic PC or PC mortality was noted

The EAU fellows: Dr. N. Grivas, Dr. C. Mir and Dr. B. Bidovanets

review and meta-analysis on transrectal biopsy and phosphomycin antibiotic usage. To highlight the outstanding long-term results on neurostimulation patients, a procedure where Dalhousie University Medical Center was pioneer within Canada. A very memorable part of our visit to Halifax was attending the afternoon tea hosted by the Halifax Governor House on behalf of the 92nd birthday of the Queen of England. The following day, Prof. Bell, Chairman of the department of Urology at the Halifax location, offered us a visit to the surrounding vineyards and a lobster dinner. As part of the exchange, we attended the previous presidents’ dinner, opening ceremony and the current presidents’ dinner at the CUA meeting. Outstanding hosts such as CUA President Prof. Fred Saad fostered the relationship between CUA and the EAU for rewarding and fruitful exchanges in the future. European Urology Today

ERUS18: Expert audience leads to more advanced surgery As robotic surgery matures, so does the live surgery 5-7 September 2018 Marseille, France

By Loek Keizer The EAU Robotic Urology Section is facing a change in the audience of its meetings: robotically-assisted surgery has become sufficiently widespread that demonstrations of technique and technology can now encompass more challenging cases. This is precisely what happened at ERUS18.

insides will be transmitted. In the end, each patient has his or her own reason to not accept, and sometimes they prefer their own surgeon.” “I won’t pressure my patients into something that they don’t want. I explain the nature of live surgery as honestly as possible. Still, in most cases patients agreed to participate and they were happy to contribute to the educational aims of ERUS18".

The 15th edition of the annual ERUS meeting took place in Marseille, France from 5-7 September. In addition to a multitude of live-streamed surgical cases, the meeting featured extensive case discussions, hands-on training sessions and even a whole day dedicated to young urologists’ needs.

The future of ERUS meetings Prof. Mottrie was pleased with the live surgery, noting the value for the audience of the more difficult (often larger) tumours in this year’s demonstrations. “We’re privileged to have a meeting like this, ERUS18 is a congress for the whole of Europe. Every year, we come to another country and we attract a worldwide audience. People come from North and South America, South Africa, New Zealand and Australia, and from East Asia.”

ERUS goes ERAS The majority of the ERUS18 Scientific Programme was made up of six live surgery sessions, accompanied by semi-live sessions and other case discussions. However, every year the ERUS Board likes to highlight one theme that runs through the proceedings. The triple-screen live surgery is in full swing in Marseille

In Marseille, delegates were presented with digital copies of the Enhanced Recovery After Surgery, or ERAS, protocol. (The full 19-page document can be found on the meeting website: www.erus18.org) “The protocol finds its origins in abdominal and colorectal surgery,” Prof. Jochen Walz (Marseille, FR), co-author and local organiser explains.

together add up to a more efficient and effective urology unit.” Implementing the ERAS protocol requires close collaboration with the nursing staff and anaesthesiologists. That’s why ERUS18 featured several two joint sessions together with the European Society of Anaesthesiology, also featuring lectures from the nurses’ perspectives. Mottrie: “The ERAS protocol is a practical set of measures and simple tips to optimise the workflow in the hospital, involving the whole multidisciplinary team.” Challenging the surgeons and audience ERUS featured six live surgery sessions, giving demonstrations in (high-risk) RARP, male cystectomy, partial nephrectomies, adenomectomy and a pyeloplasty, to name a few. Surgeons came from all over the world, often bringing their own assistant or in some cases their own nurses.

Several hands-on training options were available, including simulators

“The protocol offers measures for all patients, and can basically be applied to all interventions. It includes directives on IV and catheter use, getting the patient mobile after the operation, dietary guidelines and so on. The time has come to spread the protocols a bit more, as many hospitals and patients can benefit from it.” A show of hands during one of the several ERASrelated sessions revealed that around a quarter of the participating surgeons were familiar with the protocol and had started implementing it in their centres. Enhanced patient recovery can also be seen as part of a larger initiative to economise robotic surgery. ERUS Chairman Prof. Alexandre Mottrie (Aalst, BE): “In Europe, we have to start thinking economically when it comes to robotic surgery. We need to prep patients in order to reduce hospitalisation time and remove catheters and drains more quickly. This also reduces the risk of infection. All of these factors

Dr. Walz was pleased with the performance of the local teams of the Institut Paoli-Calmettes and the Hôpital Nord: “They rose to the challenge of the visiting urologists, and went beyond.” Typically, three procedures were taking place simultaneously, with the session moderators switching their commentary between the three. With live surgery, there is always the concern that the broadcasting process will affect the regular treatment of patients. Walz: “The EAU’s Live Surgery Policy needs to be strictly applied. My colleagues and I kept a close eye on proceedings ourselves. I briefed the teams that they were to monitor the level of care, making sure that the care given during the live surgery is as to be expected in our centres. These are our patients and our responsibility.” In selecting patients for the procedures that ERUS wanted to demonstrate in the scientific programme, Dr. Walz was tasked with selecting some more challenging cases. “The ERUS audience is more experienced in robotic surgery than the average audience at urology meetings. We want to use the live surgery to add something to everyone’s knowledge

and surgical technique, and not repeat the basics every year. We want to show how experienced surgeons improvise in more challenging situations.”

Nevertheless, Prof. Mottrie sees some developments that will change the successful shape of the current robotic urology meetings.

“This should not be taken to extremes,” Walz added, “patients should be carefully selected to not offer too many risks to the surgeons. You cannot allow a disaster to happen.”

“We shouldn’t rest on our laurels. We need to critically evaluate our previous congresses, and participant feedback is an important part of that. First of all, we should be thinking more and more about our online activities, surrounding the congress. I still think it is extremely valuable for professionals to meet in person. However, not everyone will be able to attend every single year, either due to costs or availability. We are looking at ways to reach these urologists.”

"Typically, three procedures were taking place simultaneously, with the session moderators switching their commentary between the three."

“Secondly, we are entering a phase in which new robotic systems be entering the market. We are an independent forum and have to figure out how to Patients were generally happy to cooperate: “My team adequately represent the upcoming robotic systems. In found the right patients, selected them, and also the past few years, we have hosted a technology motivated them to take part. They have to agree to be forum in which the audience is updated on the latest operated on by a surgeon they don’t know. Some developments by various companies. This forum may patients feel a certain shame in being broadcasted to have a larger role in future ERUS meetings, while the an audience, but they’re often reassured that only their technologies enter the market and mature.”

The John Wickham Lifetime Achievement Award Prof. Claude Abbou is the winner of the first John Wickham Lifetime Achievement Award for contributions to robotic surgery. The prize was awarded in Marseille, at the 15th annual EAU Robotic Urology Section meeting, ERUS18. The award was presented by Prof. Wiklund on behalf of ERUS. “Claude Abbou was a clear first choice for this award,” Wiklund said, “he contributed immensely to the development of robotics in urology.” Abbou wrote some of the first papers on the potential of robot-assisted radical prostatectomy at the turn of the century. Soon after, he pioneered robotic renal transplantations. “I am honoured to be the first recipient,” Prof. Abbou said on the occasion. He then gave an overview of major milestones in the two decades of robot-assisted urology, philosophising on an autonomous future. The award will be given on an annual basis, honouring surgeons who have made a significant contribution to robotic surgery. The prize consists of a medal featuring an engraving of John Wickham’s likeness. John Wickham The award is named after John Wickham (1927-2017), a true pioneer of robotic surgery. Together with Prof. Brian Davies of Imperial College, Wickham developed and engineered the first robotic device in urological surgery named the PROBOT. Wickham used the PROBOT to perform the very first robotic procedure on the prostate in London in April of 1991. He coined the

Prof. Wiklund (left) and Prof. Abbou (right)

phrase “minimally-invasive surgery” to describe the future of the field. Mr. Wickham passed away in late 2017, at the age of 89. Prof. Abbou had the pleasure of working with Mr. Wickham, both being members of the European Intrarenal Surgical Society: “He was a real prophet about everything, always thinking about the future. He saw the right direction of the field, and fortunately he lived to see the right ideas popularised.”

ERUS meetings can count on a worldwide audience and ERUS18 was no different

European Urology Today

October/December 2018

Varieties in Office Urology across Europe The current survey results Prof. Dr. Helmut Haas Chair ESUO Heppenheim (DE)

hf.haas-hp@ t-online.de Office Urology seems to be a clear-cut topic, but a closer look shows remarkable differences among European countries. But first, let us define what an office urologist does. An office urologist is an educated specialist in urology who is generally self-employed, and treats outpatients predominantly non-surgically either in his own office or a medical centre. He/she performs operations to a minor degree, and he/she treats outpatients not exclusively in connection with his/ her own surgical intervention. To learn more about office urologists throughout Europe, the EAU Section of Urologists in Office (ESUO) collected information via a questionnaire. Even if we have not received feedback from all European countries yet and information might have been based on estimations by respondents, we are convinced that the current acquired data gives us a picture of the diversity of this seemingly uniform issue. Figure 1 shows which countries we have information on which are highlighted in purple. We need more information on the rest of the countries. The findings Based on former surveys and regarding the development in single countries an estimated 7,000 to 8,000 office urologists are currently working in Europe, wherein 3,200 in Germany. The percentage of those who treat inpatients varies from 0% to 100%. In the majority of countries, over 80% of office urologists have the opportunity to treat their own patients in a hospital. Particularly in view of the large number of office urologists in Germany, of whom only a comparably small number treats inpatients, we expect a relatively large number of office-only urologists throughout Europe. In most countries, subspecialties Andrology, Female Urology, Paediatric Urology, Neuro-Urology, and Uro-oncology are integral parts of urology. In Estonia, only Andrology and Uro-oncology are included. In Norway, Andrology and Female and Neuro-Urology are missing; and in Iceland, Female and Paediatric Urology. There are only five diagnostic and therapeutic procedures which in all responding countries are performed in urologic offices (see Figure 2). Procedures performed in urologic offices in all responding countries ✓ Uroflowmetry ✓ Drug treatment of urinary tract infections ✓ Drug treatment of BPH ✓ Drug treatment of ED ✓ Testosterone substitution Figure 2. Only five procedures in urologic offices are common in all countries

Great variety • In all urologic offices, urinary tract infections are treated medically. However, a third of the countries’ urinalysis, and more than half of the urinary cultures are not examined in urologic offices but by other specialists. • B lood tests (including Prostate-Specific Antigen tests) and sperm analysis are carried out in a urologic office in two-thirds of the countries, whereas urine cytology is performed by office urologists in only a third of the countries. • A bdominal and transrectal ultrasound are common procedures in office urology and performed in an office in almost all countries, except for one to two, while duplex sonography is performed in two-thirds of the countries. EAU Section for Urologists in Office (ESUO)

October/December 2018

• R adiography performed in an office is a traditional in Central European countries such as Germany and Switzerland but with decreasing significance because of investment costs and greater reliability on CT and MRI. Thus, procedures such as voiding cyst-urethrography, retrograde urethro- and urography will also be performed in hospitals instead.

How you can help If you are living in a country that is not marked in purple on this map, your feedback would greatly support our section’s work! Simply request for the questionnaire via ESUO@uroweb.org, fill it out (it will take only 15 minutes) and send it back to us via the same email address.

• U rethrocystoscopy is a key procedure in urology which is performed as an office procedure in almost all countries but two; prostate biopsy in almost all countries but five. Urodynamic studies are exclusively tasks in clinics in three countries.

"Therefore, dear office urologists, your feedback and active participation are of great importance in customising our EAU activities to your requirements." • T reatment of sexually transmitted diseases is performed in two-thirds of the countries by office urologists. • A nalgesic and spasmolytic therapy and chemolitholysis are performed in nearly all countries as duties of office urologists. Whereas local therapy with oestrogens and especially drug therapy of tuberculosis, is carried out at a lower degree. • D rug therapy of urologic tumours is regarded as a key function of urologists, and office urologists in all countries except for Estonia, state they are treating these entities. Nearly all of the office urologists treat prostate cancer by luteinizing hormone-releasing hormone (LHRH)-substances and antiandrogens, only a few are allowed to use enzalutamide and abiraterone. In more than half of the countries, instillation therapy of bladder cancer is only done in urologic clinics. In Germany, office urologists with a special qualification are allowed to perform chemotherapy and drug treatment of renal cell carcinoma with the new substances, in their offices.

Figure 1. The countries we received information on

payments than given by the public insurances. If a special treatment is not covered by public or private insurance, it must be paid by the patient himself. What do we learn? In conclusion, Office Urology in European countries varies significantly, predominantly depending on the individual country’s rules. The EAU wants to give best information to all office urologists adjusted to their national spectrum of tasks. Knowledge about this variety will lead to bespoke offers in the EAU educational activities during

congresses, meetings, journals and onlineprogrammes. Therefore, dear office urologists, your feedback and active participation are of great importance in customising our EAU activities to your requirements. Become a ESUO affiliate member Get more and the newest information about Office Urology in Europe, contact us for more details. Email us at ESUO@uroweb.org.

• T he management of catheters and cystostomies is a urologic office’s duty in almost all countries except for Belgium, Iceland, and Georgia. • O utpatient surgery is performed in urologic offices in two-thirds of the responding countries. Work conditions and health insurances As diagnostic and therapeutic methods vary from country to country, the economic basis of office urologists is different throughout Europe. In the Netherlands, the tasks of office urologists are fulfilled in hospitals’ indoor outpatient departments and not in offices, and therefore, the urologists are not self-employed. On the one hand it is a comfortable situation as no individual is needed, but on the other their financial scope is limited.

Looking for ways to explain medical procedures to your patients?

In Greece, patients with public health insurance can visit private office urologists who collaborate with The National Organization for the Provision of Health Services (Greek acronym EOPYY). These urologists receive a limited number of patients without charging the first 200 patients monthly. If any additional procedure in the office is required, the patient is charged for that procedure. EOPYY covers the cost of 85% of some procedures whereas other procedures are not covered at all. The rest of the office urologists who are not collaborating with the EOPYY are paid directly by the patient or through special contracts with private insurance companies.

Showing a video of these may help your patient’s

In Switzerland, all its citizens have to have public health insurance but can take an additional private insurance.

Also available now in the German language:

In Germany, 90% of the patients are members of public health insurances who may be voluntarily upgraded by a private insurance. The public insurance roof-organisations are powerful and strictly regulating the number and equipment of offices, most of which cannot exist through private patients alone. 10% of the patients have complete private health insurance with remarkably higher

understanding. Check out our videos at the EAU Patient Information’s Media Library. Go to patients.uroweb.org/media-library

- PCNL

- Changing Stoma bag

- TURBT

- Double J-stent placement

Go to patients.uroweb.org/de/Bibiliothek

patients.uroweb.org European Urology Today

Coimbra’s Residency Training receives 3rd EBU Certification Portuguese centre gains recognition for top-rate programme Prof. Arnaldo Figueiredo (PT) Head of the Dept. of Urology Coimbra University Hospital Center ajcfigueiredo@ gmail.com The Department of Urology of the Coimbra University Hospital Center in Portugal was granted a third term of European Board of Urology (EBU) Certification for its Residency Training Programme in Urology (RTPU) last October. The certification is a mark of excellence and commitment in maintaining high residencytraining standards. All training programmes in Portugal undergo a mandatory assessment by the National Medical Council, where a positive evaluation is a sine qua non condition for receiving residents. Applying for the EBU Certification on top of that illustrates that a training programme is open to being examined based on international criteria, and compared with Europe’s most prominent centres. What is the EBU certification? EBU Certification offers national training centres the opportunity to have their residency training programmes evaluated against European standards. This assessment provides a structured and detailed recommendation on what to maintain and/or improve. Being EBU-certified is a testimony and a guarantee that a centre delivers a well-balanced and comprehensive training programme. Ultimately, the certification bestows additional credibility and prestige.

consequently, optimise patient care. A resident from a certified centre has more guarantees that his formation is being defined in agreement with the best Europeans standards. Consequence of a closer linkage with EBU standards, I anticipate a higher participation in the EBU in-Service assessment, allowing for a better preparation for a final exam, be it the EBU one or any other. On a more trivial aspect, residents will also benefit from a preferential rate for that assessment. “The programme ensured that my training in urology was provided with a balanced education in the cognition, attitudes and skills required for current urological practice,” stated Dr. Hugo Antunes (PT), a Coimbra University Hospital Center resident. “It provided me with real-life exposure and first-hand experience in patient care which included initial evaluation; methods of establishing the diagnosis; selection of the appropriate therapy and its implementation; and management of any resultant complications.” According to Dr. Antunes, the programme stimulated his work in scientific research, which enabled him to get involved in clinical investigations, publish some scientific papers in indexed journals, and start his PhD studies. “RTPU provides the residents with the facilities and resources necessary for training with high-quality standards, such as equipment for educational purposes, diagnostic and research facilities, among many others. And because the centre is truly dedicated to the goal of providing its residents the best training possible, I received exemplary training which also fulfilled the requirements established by the EBU.” RTPU setup The Portuguese residency training programme in urology lasts for six years, including one year of General Surgery. The programme includes a plan

Medical staff with (in the middle) the EBU site visit team

comprised of defined knowledge and surgical goals for each year. Each resident has a tutor assigned to him/her and is expected to progress in various competencies e.g. diagnostic and therapeutic know-how, research and teaching. The residents will also spend four months on specialties such as paediatric urology, imagiology, pathology or plastic surgery. The surgical skills of residents are honed from knowledge in basic procedures to more demanding surgeries such as radical prostatectomies, partial nephrectomies and radical cystectomies. Especially at the Coimbra University Hospital Center,

The certification process begins with an application from the centre, followed by a site visit (also known as an EBU audit). Specialists and residents are interviewed and the centre’s clinical activities, scientific production and resources are reviewed. The site visit is an excellent opportunity to receive valuable insights on the strengths and weaknesses of the centre and its programme. Then valuable feedback and recommendations are given during the formal final evaluation.

the programme places additional focus on training in renal transplantation, including organ procurement for transplantation (executed by urologists alone); and on all aspects of non-surgical onco-urology such as management of metastatic disease with new target and immune therapies and systemic chemotherapy. Residents are expected to present their abstracts in national and international meetings, and published papers in peer-reviewed journals. The residents take a formal exam at the end of each year. At the end of the programme, the residents (along with other residents from other programmes) will stand before the National Board of Examiners to receive the coveted title of “Urologist”. Get your centre certified Participating and certified centres such as the Coimbra University Hospital Center are part of a growing number of institutions across Europe that continue aim to implement best practices in healthcare. To know more about applying for an EBU Certification for your centre, visit http://www.ebu. com/certification-programmes/ for more information.

The site visit to Coimbra University Hospital Center took place on 20 September 2018. Benefits to the residents What is beneficial for a department as a whole will be beneficial to its healthcare professionals and will EBU Certified Centres

Interview with resident

FEBU Examinations

EBU In-Service Assessment

The European Board Examinations in Urology These are summative assessments and consist of 2 parts, the Online Written and Oral Examinations. Each examination is held once per year. Participation is subject to eligibility.

Dates: Format: Duration: Time:

- A final-year resident who is trained as part of an official national urology training programme in a UEMS/EBU member country. The training must be completed before the date set by the EBU. - A certified urologist who is fully qualified as a urologist by the recognised national authority from a UEMS/EBU member country. UEMS/EBU Member Countries: Austria, Belgium, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom. Fellow of the European Board of Urology FEBU A FEBU is one who has met the educational,

European Urology Today

practice and peer-review requirements set forth by the European Board of Urology. It is voluntary and not a requirement for practising urology. The FEBU Diploma is considered as a mark of excellence, not a license to practise urology. Worldwide more than 5,500 urologists carry this title. Dates 2019 Oral Examination: Saturday 29 June 2019 (Warsaw) Online Written Examination: Thursday 14 November 2019 (Pearson VUE test centres) For more information visit our website www.ebu.com.

7 and 8 March 2019 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. 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.

October/December 2018

EBU Certified Residency Training Programmes in Urology Austria Hanusch Krankenhaus, Vienna Landeskrankenhaus Wiener Neustadt LKH Hochsteiermark – Standort Leoben Medical University of Graz Medical University of Vienna, Comprehensive Cancer Center SMZ Süd - Kaiser-Franz-Josef-Spital Vienna SMZ Ost - Donauspital Vienna St. John of God Hospital Vienna University Hospital Salzburg Belgium AZ Maria Middelares, Ghent Ghent University Hospital AZ Nikolaas- Affiliated Institute - GUH AZ St Lucas Gent- Affiliated Institute - GUH Onze-Lieve-Vrouwziekenhuis Aalst University Hospitals Leuven

Czech Rep Charles University Hospital Motol, Prague Charles University Faculty of Medicine in Pilsen General University Hospital and Charles University 1st Faculty of Medicine Prague Estonia North-Estonian Medical Centre Foundation- Affiliated Institute, Tallinn Tartu University Hospital Finland Helsinki University Hospital Germany HELIOS Marien Klinik Duisburg Justus Liebig-University Giessen Klinik für Urologie und Kinderurologie Klinikum Bamberg Klinik für Urologie, Klinikum Ludwigsburg Klinikum Braunschweig Klinikum Garmisch-Partenkirchen SLK Kliniken Heilbronn St. Antonius-Hospital Gronau Technische Universität München Klinikum rechts der Isar Uniklinik der RWTH Aachen Universitätsklinikum Halle (Saale) Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Urologie Universitätsklinikum Schleswig-Holstein, Campus Kiel University of Bonn University Hospital Schleswig-Holstein - Campus Lübeck University Hospital Carl Gustav Carus, TU Dresden 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 Urologische Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Nürnberg Greece University of Crete Sismanoglio Hospital Athens

Institute Sub-Specialty

Hungary Semmelweis University Budapest Italy Central Hospital of Bolzano Malta Mater Dei Hospital, Msida The Netherlands VU University Medical Centre Amsterdam Onze Lieve Vrouwe Gasthuis - locatie West - Affiliated Institute VUMC Onze Lieve Vrouwe Gasthuis - locatie Oost - Affiliated Institute VUMC Norway Sørlandet Sykehus HF Kristiansand Sørlandet Sykehus HF Arendal - Affiliated Institute SSHF Kristiansand Vestfold Hospital Trust Tønsberg

Croatia University Hospital “Sestre milosrdnice” Zagreb

EBU Certified Sub-Speciality Centres

Poland European Health Centre Otwock Interdisciplinary Hospital Międzylesie Warsaw Medical University of Warsaw Pomeranian Medical University Szczecin Specjalistyczny Szpital Miejski im. M. Kopernika Torun Uniwersyteckie Centrum Kliniczne, Gdansk University Hospital in Kraków Portugal Coimbra University Hospital Center Spain Cliníca Universidad de Navarra, Pamplona Fundació Puigvert Barcelona Hospital Clínic de Barcelona Hospital del Mar (Parc de Salut Mar) Barcelona Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat (Barcelona) Hospital Universitario la Paz, 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 Ege University School of Medicine Urology Department, Izmir Hacettepe University Faculty of Medicine Department of Urology, Ankara Istanbul University, Istanbul Faculty of Medicine Uludag University in Bursa University of Health Sciences Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul

Germany St. Antonius-Hospital Gronau

Prostate Cancer

United Kingdom Leeds Teaching Hospitals NHS Trust

Renal Cancer

Certified EBU-EAU Host Centres 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 University Hospitals KU Leuven

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

France Pitié-Salpétrière Hospital, Paris Pitié-Salpétrière Hospital, Paris Pitié-Salpétrière Hospital, Paris

Prostate Cancer Renal Cancer Neuro-urology

Germany Eberhard Karls University Tuebingen, Klinik für Urologie Urothelial Cancer Heinrich-Heine University, Medical Faculty, Düsseldorf Urothelial Cancer Heinrich-Heine University, Medical Faculty, Düsseldorf Prostate Cancer Heinrich-Heine University, Medical Faculty, Düsseldorf Renal Cancer Heinrich-Heine University, Medical Faculty, Düsseldorf Testicular Cancer University Hospital Bonn Neuro-urology University Hospital Carl Gustav Carus, Dresden Prostate Cancer University Hospital Leipzig Prostate Cancer Lithuania National Cancer Institute, Vilnius

Prostate Cancer

The Netherlands Canisius-Wilhelmina Hospital, Nijmegen Maxima Medisch Centrum, Veldhoven Radboud University Medical Center, Nijmegen Radboud University Medical Center, Nijmegen Radboud University Medical Center, Nijmegen Radboud University Medical Center, Nijmegen

Prostate Cancer Prostate Cancer Prostate Cancer Paediatric Urology Neuro-urology Female Urology & Incontinence

Spain Universitary Hospital Ramon y Cajal, Madrid

Transplantation

Switzerland Institute of Oncology Research Bellinzona

Prostate Cancer

United Kingdom North Bristol NHS Trust North Bristol NHS Trust Sheffield Teaching Hospitals NHS Foundation Trust

Female Urology & Incontinence Stone Disease Reconstructive Urology

European Urology honours Prof. Stefan C. Müller 18 years of committed service to the EBU Prof. Arnaldo Figueiredo President, EBU Coimbra (PT)

president@ebu.com The spring meeting in Ljubljana, Slovenia marked the end of Prof. Stefan C. Müller’s eighteen-year commitment to the European Board of Urology (EBU) as he stepped down as EBU President. His activities in the EBU started in 2000 when he was appointed as delegate of the German Society of Urology for two years. But he was not to leave the EBU after; he eventually became an EBU expert from 2002 to 2018 and participated in about 30 EBU Board meetings. Prof. Müller was involved in the Accreditation Committee since its inception. He was nominated October/December 2018

as its Chair in 2006, a position he held until 2014. From 2006 until 2017, he integrated the EU-ACME Committee, a joint EAU-EBU Committee that deals with accreditation and continuous medical education. After having been elected Incoming President in 2012, Prof. Müller served as President from May 2014 until May 2016. Wisdom and stress-free diplomacy were a mark of his leadership. The accomplishments of the EBU during this period are a testimony to his pursuit for the highest standards in urology training and education around Europe. It was under his leadership that EBU’s Residency Curriculum was developed, along with the implementation of the EBU Medbook®, a modern electronic log book designed to assist residents and practicing urologists alike in keeping their activities updated in an easy and reliable way. Prof. Müller was also very active in the development of the EBU-EAU Host Centre Certification Programme, a joint venture that resulted from a close understanding between the EBU and the European Association of Urology

(EAU). Both recognised the advantages of certifying centres that receive fellows who are also granted with EAU fellowships. We express our gratitude for what he has given to the EBU and we look forward to his contributions to the EBU and to EAU’s official journal, European Urology.

Prof. Stefan Müller at the EBU Board Meeting in May 2006 in Stockholm

Mr. Jan Nawrocki (left) and Prof. Stefan Müller (right) at the EBU Board Meeting, May 2018

European Urology Today

Hot and cold: FT energy sources for prostate cancer HIFU and cryotherapy show promising results for focal approach Prof. Eric Barret Chair ESUT Ablative Group Institut Montsouris Dept. of Urology Paris (FR)

eric.barret@imm.fr Focal Therapy (FT) was introduced and evaluated as a mini-invasive treatment with the aim to improve management strategies for localised prostate cancer (PCa). The objective consists of ablating the dominant lesion while preserving the non-cancerous tissue as much as possible and only treating what is necessary. FT is an approach mainly based on using thermal means to destroy the prostatic parenchyma. An energy-based ablation of tumours is the local application of extreme temperatures – high or low depending on the case – to induce irreversible cell damage and ultimately, tumour apoptosis and coagulative necrosis. Even if various energy sources have been tested in clinical trials with encouraging outcomes, the two most commonly used energy sources are High Intensity Focused Ultrasound (HIFU) [Figure 1] and Cryotherapy [Figure 2], though other energy sources have been tried and with encouraging outcomes (1). Whichever energy is used, the principal mechanism of the focal approach is the precise delivery of the energy to the target. Multiparametric MRI (mpMRI) plays a crucial role in the detection and location of the significant lesions to be treated, and recent developments make use of MRI in treatment EAU Section of Uro-Technology (ESUT)

guidance. Such an approach could be recommended to improve more promising outcomes. HIFU and cryotherapy Guillaumier S., et al (2) recently published a multicentre study of five-year outcomes following FT in treating clinically significant non-metastatic PCa. In this series, out of the 625 patients who underwent a focal HIFU, 505 of them (84%) had an initial diagnosis of intermediate- or high-risk PCa, and the failure-free survival, metastasis-free survival, cancer-specific survival, and overall survival rates were 88%, 98%, 100%, and 99%, respectively. Due to the efficacy in the medium term and the low probability of side effects of FT, the authors deem that patients diagnosed with PCa suitable for FT should have the option of choosing between whole-gland radical therapy or FT. Focal cryotherapy has shown interesting results as well. Indeed, in a retrospective series comparing the oncologic and functional outcomes of partial versus whole-gland cryotherapy for men with intermediaterisk PCa, Tay KJ, et al (3) reported a 2-year and 5-year biochemical progression-free survival (BPFS) rate of 87.2% and 76.4% for whole-gland vs. the 80.7% and 70.0% respectively for partial ablation using Phoenix; and 72.3% and 69.6% for whole-gland vs. 82.1% and 75.0% respectively for partial ablation using the American Society for Radiation Oncology (ASTRO) criteria, and without any statistically significant difference. Moreover, the partial ablation of the prostate resulted in better post-treatment sexual function compared to whole-gland ablation in men with intermediate-risk PCa. Despite these encouraging results, the patients must be informed of the risks of failure. Indeed, no ablative technology has yet been demonstrated to be successful all of the time. Urologists must be made aware of the fact that the post ablation surveillance can present greater challenges after FT because of the prior treatment, and because a part of the prostatic parenchyma remains intact.

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Target

Prostate

Figure 1. Focal HIFU: Transrectal HIFU for a right posterior lesion ablation

Ice ball Prostate

Figure 2. Focal cryotherapy: Transperineal cryoprobes placement for a left anterior lesion ablation

PCa treatment follow-up is traditionally based on three things: the prostate specific antigen (PSA) test, imaging and the biopsy. However, PSA variations are difficult to analyse due to this partial gland destruction. But thanks to the technical improvements of the prostatic mpMRI, early detection of local recurrence after FT is now possible. mp-MRI is now considered to be the most important tool during the follow-up. It will help to guide the control biopsy and select patients for a new treatment session. Both HIFU and cryotherapy have positive control biopsy rates of between 20 and 30%. The advantage of these techniques is that if the treatment fails, application of said techniques can be repeated. Failure is mostly caused by the inability to clearly identify the lesion and/or inadequate amount of energy applied to the target. The management of failure depends on the characteristics of residual cancer at the control biopsy such as size, location and the Gleason score. The reasons for failure must be carefully studied and analysed before considering the option to salvage. If retreatment is necessary, different approaches can be considered. The most difficult lesions to treat using HIFU and cryotherapy are the apical lesions. This is due to their proximity to the urinary sphincter and the risk of thermal diffusion, which can have an immediate impact on continence. The location of the residual cancer (most frequently found at the apex) and the aim to minimise the risks of side effects will likely result to undertreatment. Initially, some limitations in the development of FT were due to uncertainties in managing failure. From the literature, we have been informed that in case of failure, the management of the residual cancer should be exactly the same as that of a primary disease. Indeed, active surveillance or FT or radical treatment are all salvage options (4). It is particularly important to highlight that, in the event of FT failure, recent evaluations have shown that a salvage radical

prostatectomy is not only feasible but has the added advantage of limited complication rates (5). Even if some questions regarding FT have not been fully answered yet for the reasons stated above, the indications should be expanded and eventually accepted as part of the general guidelines. HIFU and cryotherapy are two energy sources suitable for a focal approach. Since the indications of each have yet to be clearly defined, it might be interesting to carry out comparative studies to learn the optimal use of each energy source. References 1. Valerio M, Cerantola Y, Eggener SE, Lepor H, Polascik TJ, Villers A, Emberton M. New and Established Technology in Focal Ablation of the Prostate: A Systematic Review. Eur Urol. 2017;71(1):17–34 2. Guillaumier S, Peters M, Arya M, Afzal N, Charman S, Dudderidge T, Hosking-Jervis F, Hindley RG, Lewi H, McCartan N, Moore CM, Nigam R, Ogden C, Persad R, Shah K, van der Meulen J, Virdi J, Winkler M, Emberton M, Ahmed HU. A Multicentre Study of 5-year Outcomes Following Focal Therapy in Treating Clinically Significant Nonmetastatic Prostate Cancer. Eur Urol. 2018; 74(4):422-429. 3. Tay KJ, Polascik TJ, Elshafei A, Tsivian E, Jones JS. Propensity Score-Matched Comparison of Partial to Whole-Gland Cryotherapy for Intermediate-Risk Prostate Cancer: An Analysis of the Cryo On-Line Data Registry Data. J Endourol. 2017; 31(6):564-571. 4. Tay KJ, Amin MB, Ghai S, Jimenez RE, Kench JG, Klotz L, Montironi R, Muto S, Rastinehad AR, Turkbey B, Villers A, Polascik TJ. Surveillance after prostate focal therapy. World J Urol. 2018, In Press 5. Nunes-Silva I, Barret E, Srougi V, Baghdadi M, Capogrosso P, Garcia-Barreras S, Kanso S, TourinhoBarbosa R, Carneiro A, Sanchez-Salas R, Rozet F, Galiano M, Cathelineau X. Effect of Prior Focal Therapy on Perioperative, Oncologic and Functional Outcomes of Salvage Robotic Assisted Radical Prostatectomy. J Urol. 2017; 198(5):1069-1076.

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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 Urology Today

October/December 2018

Men with Parkinson’s disease, enlarged prostate and LUTS Urologists must recognise range of influences contributing to presentation of LUTS Prof. Marcus Drake ESFFU Board Member University of Bristol Bristol (UK)

Marcus.Drake@ nbt.nhs.uk Lower urinary tract symptoms (LUTS) are a well-recognised feature of ageing. In older men, benign prostate enlargement (BPE) is commonplace, which may directly lead to voiding LUTS as a consequence of bladder outlet obstruction. Parkinson's disease (PD) is a neurological condition, which is most clearly identified as a movement disorder leading to a characteristic tremor at rest, rigidity, and difficulty walking. LUTS in PD can be prominent. Urinary symptoms in PD can be voiding LUTS, potentially due to muscle dysfunction of the bladder neck and external urinary sphincter. In addition, storage LUTS, notably urgency and nocturia [1], are commonly experienced. The principal neurological deficit in PD is in the substantia nigra, a region which normally contributes to the inhibition of the detrusor during storage [2]. This appears likely to be a factor in the emergence of storage LUTS, particularly urgency. Frustratingly, bladder dysfunction in PD often fails to respond to medical treatment of PD, such as levodopa [3]. Consequently, the urologist may well be consulted to treat LUTS, even though the underlying pathophysiology can be complex and poorly understood, potentially with a neurological basis. LUTS severity corresponds to the progression of PD, and increases in line with other problems, such as impaired blood pressure control [4]. Consequently, it is vital for the urologist to recognise the range of influences contributing to a presentation of LUTS. LUTS contributors It is perfectly reasonable to undertake simple initial evaluation in LUTS, including history and examination, urinalysis, symptom score and bladder diary [5]. This can be used to make recommendations of conservative or medication therapy. In men with voiding LUTS, alpha blockers and 5-alpha reductase inhibitors have their roles to play. They may provide some limited help, and are unlikely to be problematic, though some men with PD have sufficient blood pressure issues that alpha blockers may cause significant hypotension.

transmission is a factor in the underlying neurological deficit. Ultimately, the favoured approach for most patients emphasises conservative therapy. Nonetheless, severity of symptoms and impact on quality of life may drive consideration of possible surgery to relieve bladder outlet obstruction (BOO). Alongside the general fitness of the patient to withstand the procedure, there are two key questions; will it help symptoms? Could there be an adverse outcome? Frustratingly, there is not much information in the general area of surgery for outlet problems in neurological disease, and thus the questions remain contentious and unresolved, even in 2018 [6]. If LUTS persist despite conservative measures, further testing is essential. This is aimed at identifying the underlying cause and potential risk factors for bad outcome. For the man with voiding LUTS and a large prostate, specific surgery such as TURP might be under consideration. Here, a vital distinction in the neurological situation is to be certain that the mechanism is truly PD and not actually multiple system atrophy (MSA). The latter may present in a manner similar to PD, but with minimal response to anti-parkinsonian medications, and the issue for the current context is the risk of incontinence if TURP is undertaken. The key points of distinction are the worse prognosis of MSA in terms of life expectancy, and the bad outcomes if any surgical intervention such as TURP is undertaken. MSA must be considered very seriously in men with poor response to medication found to have a post void residual of more than > 150 ml, as this seems to be a threshold indicating MSA rather than PD [7]. Patients with MSA generally have more severe urinary dysfunction than is seen in PD, and there can be sphincter denervation [8]. This latter feature is potentially extremely important, since any surgery to reduce bladder outlet obstruction could lead to a risk of developing incontinence. The findings of postmicturition residuals > 100 ml, detrusor-external sphincter dyssynergia, and an open bladder neck at the start of bladder filling suggest MSA [8] and they should lead to considerable caution

in selecting therapeutic intervention. A wellestablished study reported urogenital criteria which favour a diagnosis of MSA as: urinary symptoms preceding or presenting with parkinsonism; urinary incontinence and PD; significant post-void residual urine volume; erectile failure preceding or presenting with parkinsonism; and worsening bladder control after urological surgery [9].

References Wherever TURP is being considered in a PD patient, urodynamics is essential, aiming to check storage function, identify whether BOO is present (Figure 1), and exclude detrusor underactivity. During urodynamics for PD, the filling compliance of the bladder is generally normal, 62% have detrusor overactivity [10]. Crucially, voiding is associated with detrusor underactivity in 60% [10]; this is important, as consequently voiding LUTS are likely to persist if TURP is undertaken in a situation where the real cause is detrusor underactivity. Crucially, the voiding phase (measured by calculating the Watts Factor) shows a reasonable correspondence with PD severity (assessed by analysing gait) [11]. This suggests that men with bad PD are unlikely to benefit symptomatically from TURP, and of course they have some additional risk from their general health. Where BOO is identified, detrusor underactivity is absent and PD is not severe, TURP outcomes can be reasonable. Roth and colleagues reported the outcome of TURP for 23 patients with Parkinson’s disease, indicating that 70% maintained some degree of improvement at three years [12]. Staskin and colleagues performed TURP in 36 Parkinson patients and 83% who had abnormal sphincter control pre-operatively became incontinent, compared to 4% who had normal sphincter control [13]. In summary, LUTS in PD ideally should be managed conservatively. If voiding LUTS are problematic, urodynamics is needed to determine whether BOO is the cause. Provided detrusor underactivity is not causative, TURP may be successful. However, attention to potential risk factors that suggest the real neurological deficit is due to MSA is essential to avoid very bad outcomes. Thus, great caution is needed in any patient with a high post-void residual, poor

In those patients who have storage LUTS, fluid advice, and medications for OAB can be considered, though it may be sensible to consult with the neurologist regarding any antimuscarinic prescription, since an imbalance of cholinergic and dopaminergic EAU Section of Female and Functional Urology

voluntary sphincter control, incontinence at presentation, erectile dysfunction early in the disease course, or persisting PD symptoms despite antiparkinsonian medication.

Bladder outlet obstruction in a man with Parkinson’s disease. The urodynamic trace shows a very high detrusor pressure and a very slow flow rate. The video image shows hold-up at the bladder neck, and pooling in the bulbar urethra.

1. Sakakibara, R., Uchiyama, T., Yamanishi, T., Shirai, K., and Hattori, T. (2008) Bladder and bowel dysfunction in Parkinson's disease. J Neural Transm (Vienna) 115, 443-460. 2. Sakakibara, R., Tateno, F., Kishi, M., Tsuyuzaki, Y., Uchiyama, T., and Yamamoto, T. (2012) Pathophysiology of bladder dysfunction in Parkinson's disease. Neurobiol Dis 46, 565-571. 3. Uchiyama, T., Sakakibara, R., Hattori, T., and Yamanishi, T. (2003) Short-term effect of a single levodopa dose on micturition disturbance in Parkinson's disease patients with the wearing-off phenomenon. Mov Disord 18, 573-578. 4. Magerkurth, C., Schnitzer, R., and Braune, S. (2005) Symptoms of autonomic failure in Parkinson's disease: prevalence and impact on daily life. Clin Auton Res 15, 76-82. 5. Drake, M. J., Apostolidis, A., Cocci, A., Emmanuel, A., Gajewski, J. B., Harrison, S. C., Heesakkers, J. P., Lemack, G. E., Madersbacher, H., Panicker, J. N., Radziszewski, P., Sakakibara, R., and Wyndaele, J. J. (2016) Neurogenic lower urinary tract dysfunction: Clinical management recommendations of the Neurologic Incontinence committee of the fifth International Consultation on Incontinence 2013. Neurourol Urodyn 35, 657-665. 6. Noordhoff, T. C., Groen, J., Scheepe, J. R., and Blok, B. F. M. (2018) Surgical Management of Anatomic Bladder Outlet Obstruction in Males with Neurogenic Bladder Dysfunction: A Systematic Review. Eur Urol Focus 7. Yamamoto, T., Asahina, M., Yamanaka, Y., Uchiyama, T., Hirano, S., Fuse, M., Koga, Y., Sakakibara, R., and Kuwabara, S. (2017) Postvoid residual predicts the diagnosis of multiple system atrophy in Parkinsonian syndrome. J Neurol Sci 381, 230-234. 8. Sakakibara, R., Hattori, T., Uchiyama, T., and Yamanishi, T. (2001) Videourodynamic and sphincter motor unit potential analyses in Parkinson's disease and multiple system atrophy. J Neurol Neurosurg Psychiatry 71, 600-606. 9. Chandiramani, V. A., Palace, J., and Fowler, C. J. (1997) How to recognize patients with parkinsonism who should not have urological surgery. Br J Urol 80, 100-104 10. Kim, K. J., Jeong, S. J., and Kim, J. M. (2018) Neurogenic bladder in progressive supranuclear palsy: A comparison with Parkinson's disease and multiple system atrophy. Neurourol Urodyn 37, 1724-1730. 11. Terayama, K., Sakakibara, R., Ogawa, A., Haruta, H., Akiba, T., Nagao, T., Takahashi, O., Sugiyama, M., Tateno, A., Tateno, F., Yano, M., Kishi, M., Tsuyusaki, Y., Uchiyama, T., and Yamamoto, T. (2012) Weak detrusor contractility correlates with motor disorders in Parkinson's disease. Mov Disord 27, 1775-1780. 12. Roth, B., Studer, U. E., Fowler, C. J., and Kessler, T. M. (2009) Benign prostatic obstruction and parkinson's disease-should transurethral resection of the prostate be avoided? J Urol 181, 2209-2213. 13. Staskin, D. S., Vardi, Y., and Siroky, M. B. (1988) Postprostatectomy continence in the parkinsonian patient: the significance of poor voluntary sphincter control. J Urol 140, 117-118.

SEEM18: Promoting new research and young urologists Dr. Milan Potic Specialist urology, subspecialist oncology Nis Clinical Center Medical Faculty Nis (RS) uropota@gmail.com The 2018 South Eastern European Meeting, held in Belgrade, Serbia, gathered urology experts from the wider region with the idea to update and implement new protocols and methods for the treatment of urology patients. The EAU motivated young urologists not only to participate in the meeting and take part in debates, but to compete and present their own research as part of the “Young Urologist Competition”. Along with the state-of-the-art lectures, the Young Urologist Competition filled the room to the last seat. October/December 2018

As a participant and representative of my country, I presented my own work “The biocompatibillity profile of urogynaecology synthetic grafts and the underlying mechanism of action”. Our investigation stripped down the mechanical properties of synthetic grafts to the smallest details. We analysed in detail the inflammatory reaction and the collagen deposition through the foreign body reaction on an experimental model. Detailed electron microscopic analysis and new emerging aspect ‘oxidative stress’ managed to shed light in a new perspective. Oxidative stress proved to be the solitary independent factor for the final abdominal wall reinforcement with urogynecology synthetic grafts. It has been a pleasure and privilege to participate and win the prestigious Young Urologist Competition at SEEM18. The EAU is clearly promoting young urologists, urging them to take part in further career advancement and research.

SEEM18 Award Winners Young Urologist Competition Winner M. Potic (Belgrade, Serbia) The biocompatibillity profile of urogynaecology synthetic grafts and the underlying mechanism of action The Berlin Chemie Best Poster Presentation Award First Prize: D. Kalyvianakis, I. Mykoniatis, E. Memmos, P. Kapoteli, D. Memmos, D. Hatzichristou (Thessaloniki, Greece) Low-intensity shockwave therapy (LiST) for erectile dysfunction: A randomized clinical trial assessing the impact of energy flux density (EFD) and frequency of sessions

Late functional and psychosexual complications of primary hypospadias repaired in childhood Third Prize: G. Galiqi, A. Koni, A. Pesha, S. Ferko, A. Ndoj, B. Hoxha (Shkoder, Tirana, Fier, Durres, Albania) Buccal one-stage mucosal graft urethroplasty for urethral stricture: Results of 10 years of experience

Second Prize: M.J. Majstorovic, M. Bizic, B. Stojanovic, V. Kojovic, M. Bencic, V. Vukadinovic, M.L. Djordjevic (Belgrade, Serbia)

European Urology Today

Young Urologists/Residents Corner How to excel in the European Board of Urology Exam Practical advice from recent participants By Dr. Zsuzsanna Zotter, Section editor, Budapest (HU) Getting closer to your final year in urology means one thing for a huge proportion of the residents in Europe and beyond: You have the possibility to take the FEBU examinations. After completing it you will earn the FEBU title as a mark of excellence. The EBU exams are either obligatory for you or a wonderful opportunity to show, that you are a real master of urology. It is a really tough exam and the EBU takes care that those who pass, really know the essence of urology. So how would you start studying for the exam? There are not too many resources about it, so you should turn to colleagues who already passed it. We also did the same and interviewed three international successful examinees who passed the exam with 8-9 points either or both in the written and oral part: Why did you take the EBU exam? Duijvesz: The EBU exam and the oral examination is a perfect way to test your knowledge and to identify ‘problem-areas’ where you need to focus more in order to optimize your knowledge. The FEBU title is an acknowledgment of hard work and it is useful if you want to work abroad. Altenni: It is a formal part of our national examination, so it is obligatory for the residents in my country.

surgery training) we have 8 meetings where a majority of the guidelines are discussed. Therefore, we have acquired a broad knowledge. Altenni: I started reading the guidelines 3 months before the exam, in the last month I focused on repetition and on In-Service Assessment questions. What kind of resources did you use for the preparation of the EBU exam? Freire: Attending EUREP is very helpful. Remember, you will not learn all the subjects during EUREP (too much information!). The course is great to review some topics, consolidate and organise the knowledge you already have. Therefore, read (one more time!) the EAU Guidelines before attending EUREP.

“…earn the FEBU title as a mark of excellence…” Duijvesz: For the EBU exams I have read all the guidelines briefly, but focused on the questions used in previous EBU In-Service Assessments (you can buy the booklets during EUREP and online). Training on these past tests really helped to see what the level of the questions would be. A booklet has 200 questions, including correct answers, and I have studied these in the weeks prior to the exams.

Freire: This kind of study takes time! In my case, I did a two months rotation in my hospital so I could have some free time to study for the written part.

Altenni: The main resources were the official EAU Guidelines, EUREP lectures, and the Campbell book. Also, our national society organises an Exam Preparation Course every 3 months. However, I would like to highlight, that for me the most useful ‘resource’ was small group sessions with fellow examinees, where we could discuss questions together and practise viva cases made by us.

Duijvesz: Luckily our national society organises a bi-annual meeting where guidelines are discussed. In our four-year urology training (after 2-year

Some candidates express their preference either for the oral or the written part. Which one was more challenging for you?

For how long did you prepare for the EBU exam? When did you start to study focusing on the exam?

Duijvesz: The written part was more challenging. With a written exam, you really have to read carefully, because the knowledge that the exam is testing needs to be utmost precise. If you read the questions wrong, you will fail that specific question. Also, answering 100 questions in 2 hours is challenging and creates a substantial pressure on your performance. The oral part was also easier because I could do it in my own language and it is more based on experience acquired during your training. Altenni: The written part was more challenging; you really cannot prepare for it enough. The oral part was easier, as it is more practical, and I think we all met such cases during our training. But be careful, there were small twists in the cases.

aria José Freire (PT) M Urology and Renal Transplantation Department, Coimbra University Centre

iederick Duijvesz (NL) D Canisius Wilhelmina Hospital, Nijmegen

Would you do anything differently after passing the exam? Duijvesz: I would have taken more time off to read more, and practise more In-Service Assessment questions. Altenni: Yes, I think I studied from too many sources, and I did not re-read what I wanted from the Guidelines in the last three days. Most of the questions I missed were among the matters I had wanted to study once more. What would you advise for future candidates?

Mohammed Altenni (HU) Péterfy Sándor Hospital, Budapest

it will show you where the key points are, and that will be tested in the exam. Do not read the Campbell or other books because it is older than the guidelines. Get the previous In-Service Assessment questions that are available through the EBU. What I also found useful is to complete the test exams together with other residents. It will train your way of logical thinking.

Freire: Study the previous In-Service Assessments. Do not memorise answers - even if you know the correct one. You should read each possible answer and try to understand why it is wrong or right (some of the answers you will only find in articles, not in books or guidelines). You probably will not know the answer for some questions even after rigorous Altenni: Study in small groups with fellow researching – discuss it with other residents or candidates. Seek advice from colleagues who have consultants. been tested before, and go through all of the In-Service questions at least two times. Duijvesz: The best advice is to read everything (Guidelines), and to really focus on the things you For more information about the In-Service are not familiar with. Make exam questions yourself, Assessments: www.ebu.com

Challenges in Laparoscopy & Robotics 2018 One of the most exciting live surgery congresses in the world Dr. Leonardo Tortolero Blanco YUO Board Member Hospital IMED Levante Benidorm, Alicante (ES) leotor85@gmail.com As a young urologist, one of the most interesting and exciting things for learning is live surgery. Live surgery sessions bring you real case situations that happen every day in your hospital, where there is no space for editing tricks. The surgeon performs the surgery and you can see it live on the screen. If there is one congress that can have 95% of its scientific programme be made up of live surgery cases, performed by great urological surgeons from all around the world, the name of the congress is the “Challenges in Laparoscopy & Robotics”. The fourteenth edition of this event was held in the German city of Leipzig, famously the birthplace of the musician Sebastian Bach. Prof. Stolzenburg and the course directors created a diverse programme in a great environment of three days of live surgery challenging cases with a faculty including urologists like Vito Pansadoro, Inderbir Gill, Alberto Breda, Antonio Alcaraz, Richard Gaston, Aldo Bocciardi, Evangelos Liatsikos, James Potter and many others. One of the most amazing and interesting topics of this edition was the use of new technologies like augmented reality and 3D printing in real cases, 28

European Urology Today

allowing you to see how experts in the field incorporate these new tools into practice. My expectations were exceeded with three days full of live surgery procedures, with three screens showing three operating rooms all day long. The first day was dedicated to kidney surgery. We saw a masterful kidney robotics transplantation from a live donor performed by Alberto Breda. The team pointed out the tips and tricks of their technique, showing its feasibility. There was also a variety of challenging partial nephrectomies in many different approaches. On the second day it was time to address bladder surgery with many interesting procedures like robotic radical cystectomy with intracorporeal neobladder, robotic vesico-vaginal fistula repair, laparoscopic intracorporeal bricker and bladder diverticulectomy.

Course director Prof. Stolzenburg during his presentation

Country spread of the delegates

Three screens showing three operating rooms all day long

The meeting was very well attended

On the third and final day we saw prostate surgery from great surgeons with different techniques and approaches. It was really educational and motivating to see how the experts handle difficult situations during real cases. One of the most amazing benefits of the Challenges meeting is that you have the experts in performing live surgery cases on the screen, and at the same time you can actually ask them a question during the procedure in order to learn the tips and tricks, the details, the feelings, the experience of that manoeuvre. I have no doubt this congress has a great educational value for the urological community in general. In 2019 Challenges in Laparoscopy & Robotics will take place in Barcelona from 3-5 July.

October/December 2018

Young Urologists/Residents Corner The road to a successful fellowship Do your research and find a fellowship that suits your ambitions Dr. Jose Luis Marenco Jimenez University College London Hospital London (UK)

jlmarencoj@ gmail.com Co-author: Mark Emberton, London (UK) Many urologist trainees opt for pursuing further specialised training after completion of their urology residency. In this article I will try to expose my personal experience and give a fair overview of the implications that a fellowship programme can have for your professional career. ‘Fellowship’ is a broad umbrella term that generally refers to a training post following completion of a residency programme. It is crucial to have a deep understanding of the programme specification, as some posts will cater for development of research projects, surgical training or a mixture of these. Choosing the right post for your career priorities is of seminal importance. In some countries, fellowship programmes will typically start at a certain time of the year where all trainees generally “swap”. Moreover, the time to complete registration and visa regulation, if needed, can be variable. Nevertheless, as a rule of thumb you should apply for your fellowship programme at least a year in advance to effectively be able to start in time.

Selecting the ideal fellowship There is no “one size fits all” programme, and identifying your priorities is crucial to picking a successful fellowship. Key facts that should be held in mind for an adequate programme selection could be summarised in area of interest, opportunities for academic development and surgical exposure. Some programmes might be more balanced or shifted towards more surgical or more research work. It should be noted that if the interest is in a surgical fellowship, additional medical registration to comply with local policies might be needed as opposed to a purely research-based post. It is important also to know in advance the degree of surgical training that is to be expected. Some programmes will be more of an ‘observership’, with no real first surgeon role involvement, as opposed to a proctorship where progressive surgical exposure leads to become independent in a certain technique. Be aware that certain programmes might advertise for surgical training when in fact exposure as first surgeon might be very limited. Contacting the lead responsible for the programme as well as former trainees is highly advisable to have a realistic picture of what could be expected. Time spent enquiring about the programme is time well spent. Remember this will be a giant push in your career so wisely decide in which direction! Personal experience In my case, I desired to explore the innovative field of focal therapy for localised prostate cancer. I therefore applied for the clinical fellowship hosted at University College of London Hospitals (UCLH) led by renowned Professors Mark Emberton and Caroline Moore. After completing the application process through the NHS Jobs online portal, I was shortlisted for the

interview, which I successfully passed. In addition, I had to take the IELTS (International English Language Testing System) exam and submit my medical degrees to the General Medical Council (GMC) in order to be granted registration with license to practice.

the process of being selected for a fellowship post, especially if it is one that is in high demand.

If you need guidance (in selecting a post, choosing a research project, complying with medical regulation, etc.) the European Society of Residents in Urology (ESRU) is there for you. Do not hesitate After the somewhat arduous GMC registration to get in touch as this is a link to a dynamic I started my post where I progressively gained network of young dedicated urologists, many of exposure in the use of Mp-MRI and transperineal biopsies for prostate cancer diagnosis and selection of whom might be based in your destination centre/ patients for focal therapy. Furthermore, I was trained country or have completed a fellowship in the use of High Intensity Focused Ultrasound (HIFU) programme themselves. In any case helpful insight is ensured. and cryotherapy as ablative strategies. Together with this, I had the opportunity to meet exceptional colleagues, create bonds for future collaborative work and enjoy a city as thrilling as London. Looking back, this was a unique opportunity to train in a new and emerging treatment that I would not easily have been able to train in back in Spain. Along with a remarkable personal experience, the overall degree of satisfaction is unbeatable.

Essential toolkit for a successful Fellowship (SPIES) S Set your career priorities P Choose the adequate Programme to match these I Investigate the programme in depth E Extensive interview preparation S Find Support

Finding support It is important to note that some centres will offer non-remunerated programmes where the candidate is expected to be self-funded by grants/scholarships whereas others will offer a variable salary. The later usually implies that the candidate is expected to provide service for the unit. Different associations, namely EAU, AUA, SUO and others provide economic support upon satisfaction of different selection criteria. There are several steps in

Prof. Mark Emberton and the author

Prague hosts ESRU Board meeting ESRU meets to discuss future plans and activities Dr. Sven Nikles ESRU Member Sestre Milosrdnice University Hospital Center Zagreb (HR) sven.nikles@ gmail.com

The ESRU Board meeting held in Prague during the EUREP provided an excellent chance for the board members to discuss events and activities and gave new ideas on how to improve the position of residents in Europe. This meeting is held two times a year. The first one was held during the Annual EAU Congress in Copenhagen and the second one was part of the EUREP in Prague. There were new board members who attended the meeting for the first time and some of them were there for their last time. First, there were welcoming words by the current chairman Dr. Juan Gómez Rivas (ES) who gave an overview of all achievements from the past half-year. Then we discussed current and future projects within ESRU. Former chairman Dr. Juan Luiz Vasquez (DK) gave us an insight in the Patient Information project and the Robotic Olympics. Dr. Diego Carrion (ES) gave a comprehensive overview of surveys that had been done throughout the past year. This year we had a special guest, Dr. Veeru Kasivisvanathan (GB) who gave us a great lecture on BURST collaboration and the IDENTIFY study. We also hosted Prof. Serdar Tekgül (TU) from the EBU who gave a lecture on how the EBU is improving the EBU test regularly and increases October/December 2018

objectivity. Dr. Francesco Esperto (IT) talked about opportunities provided by ESRU for residents to attend various meetings. Following current trends, we also discussed the stronger presence of the ESRU in the social media. ESRU has pages across all the social media platforms which are growing in view numbers every year. Dr. Moises Rodriguez (IT) presented the activity data which showed that we are most active on our Twitter page. The main agenda of the meeting was to plan the Residents Day during the Annual EAU Congress in Barcelona. We exchanged new ideas and presented potential speakers and topics. Again this year we discussed questions for the Guidelines Cup.

"ESRU has pages across all social media platforms which are growing in view numbers every year." The meeting’s social event was the barbecue party which is a well-known activity carried over from the EUREP. This event was a great place to reconnect with old friends and also meet the new ones from all over the world. We reckon now that ESRU, as part of the EAU Young Urologists Office, is a great platform for new members and the current ones from all around Europe to have a bigger impact on local societies and to engage them in activities to improve the position of Urology residents in Europe. The ESRU hopes to see everyone’s involvement in our activities. At the next EAU Congress, we promise an exciting and meaningful Residents Day. Join us all in Barcelona, Spain.

The current ESRU Board and country representatives

Call for ‘Nightmare Cases’ For a new series in the YUO section of European Urology Today we need your contribution!

you encountered an even worse case yourself? If so…

Have you ever encountered a patient case that was extremely challenging but were able to resolve it despite the odds?

• What was the case? • What did you do? • Was it resolved? If yes, how?

Have you ever had a case which seemed common at first but the situation changed in an instant and you had to deal with every urologist’s worst nightmare?

We can learn from these cases to help us treat our patients better and enhance our everyday practice in the future.

Have you ever attended a Nightmare Case session and although you felt that the presented cases were truly problematic,

Please send the details of your personal Nightmare Case and photos to: Dr. Zsuzsanna Zotter, eut@uroweb.org

European Urology Today

www.cem19.org

CEM19 EAU 19th Central European Meeting in conjunction with the Austrian Society of Urology and the Bavarian Society of Urology 9-10 May 2019, Vienna, Austria An application has been made to the EACCME® for CME accreditation of this event

EAU Update on Bladder Cancer

17 -18 May 2019 Turin, Italy

Incl. free Live Surgery session on 16 May

www.bca19.org

www.baltic19.org

BALTIC19

EAU Update on Renal Cell Cancer

6th Baltic Meeting in conjunction with the EAU

7-8 June 2019 Prague, Czech Republic

24-25 May 2019, Tallinn, Estonia

EAU onco-urology series

www.rcc19.org An application has been made to the EACCME® for CME accreditation of this event

Call for Abstracts Deadline 1 April 2019

European Urology Today

October/December 2018

ESUT supports HoLEP course programme in Turkey Young trainees benefit from comprehensive training Prof. Lutfi Tunc Gazi University Faculty of Medicine Dept. of Urology ESUT Lower Urinary Tract Group

even after they have started performing HoLEP surgeries. It is also advisable to perform surgery with an experienced trainer with regards completing the learning curves. In this way they will have shorter learning time and reduce the risks of possible complications [14].

HoLEP courses in Turkey The EAU Section of Uro-Technology (ESUT) is supporting the hands-on training and teaching for lutfitunc@gmail.com HoLEP in Turkey. ESUT lower tract and training group members Professors Lutfi Tunc and Yasar Ozgok have Lower urinary tract symptoms (LUTS) are secondary led these training courses. Four HoLEP courses have so to benign prostate hyperplasia (BPH) and are far been organised at Acibadem University Ankara Hospital in cooperation with Lumenis Holmium common diseases which affect aging men [1]. Until recently, transurethral resection of prostate (TUR-P) Academy. Dr. Giovannalberto Pini, an ESUT member was the gold standard surgical procedure for BPH [2]. from the University San Raffaele Turro joined the course held last 24 Feb 2018 as a speaker. Beside the However, the Holmium laser enucleation of the theoretical lectures and hand-on training models, live prostate (HoLEP) has quickly replaced the traditional surgeries were also held. The theoretical courses TUR-P method and is on the way to become the new consisted of ‘’The Surgical Treatment of BPH (Guideline gold standard technique [3-5]. HoLEP is a unique review),” The Detailed HoLEP Technique and comparison with the other standardised techniques method that can be applied independent of prostate size. There are many studies on very small prostates (Photo 1). [6,7], as well as in large prostates [8]. A total of 16 live HoLEP surgeries were performed HoLEP was introduced by Gilling et al. in 1995 and aside from the theoretical lectures. During the courses, described as the anatomic excision of prostate lobes to the HoLEP technique was explained and with the ESUT find out the prostate capsule [9,10]. Many studies have faculty and local experts responding to the questions of been conducted to evaluate the safety and efficacy of the participants during the live surgeries (Photos 2-3), which created a dynamic interaction during the live HoLEP. In the European Association of Urology (EAU) guidelines, HoLEP has become the first choice as a sessions. surgical treatment of prostate sizes >80mL and is an alternative to open prostatectomy [11]. However, despite the high efficacy of HoLEP, its wide adaption was limited, probably also due to the steep learning curve [12]. More specifically, compared to other endourological methods, the learning curve of HoLEP can be reached after, approximately, 20-70 cases [13]. Some suggestions can be made to speed up learning curves for new beginners who are learning to perform HoLEP. It is recommended for trainees to watch live surgeries and videos, especially those that have not been edited and continue to learn from these videos, EAU Section of Uro-Technology (ESUT)

HoLEP compared to other techniques

The interest of young urologists was remarkably high and 190 doctors from Turkey and neighboring countries attended the courses. The trainees were invited after the courses to ESUT training centres for them to take a one-on-one training, with guidance by ESUT expert surgeons in live cases. The aim was to encourage them to start performing HoLEP in their own centres. Upcoming courses are planned four times in a year under the auspices of the ESUT. References 1. Sivarajan G, Borofsky MS, Shah O, et al. The Role of Minimally Invasive Surgical Techniques in the Management of Large-gland Benign Prostatic Hypertrophy. Rev Urol. 2015;17(3):140-9. 2. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol2011;185:1793- 803.   3. Elzayat EA, Habib EI, Elhilali MM. Holmium laser enucleation of the prostate: a size-independent new "gold standard". Urology 2005;66(5 Suppl):108-13.   4. Michalak J, Tzou D, Funk J. HoLEP: the gold standard for the surgical management of BPH in the 21(st) Century. Am J ClinExpUrol2015;3:36-42.   5. Vincent MW, Gilling PJ. HoLEP has come of age. World J Urol2015;33:487-93.   6. Park S, Kwon T, Park S, Moon KH. Efficacy of Holmium Laser Enucleation of the Prostate in Patients with a Small Prostate (30 mL). World J Mens Health. 2017 Dec;35(3):163-169. 7. Lee MH, Yang HJ, Kim DS, Lee CH, Jeon YS. Holmium laser enucleation of the prostate is effective in the treatment of symptomatic benign prostatic hyperplasia of any size including a small prostate. Korean J Urol. 2014 Nov;55(11):737-41. 8. Elshal AM, Mekkawy R, Laymon M, Barakat TS, Elsaadany MM, El-Assmy A et al. Holmium laser enucleation of the prostatefor treatment for large-sized benign prostate hyperplasia; is it arealisticendourologicalterantive in developing country? World J Urol. 2016 Mar;34(3):399-405. 9. Gilling PJ, Cass CB, Malcolm AR, Fraundorfer MR. Combination holmium and Nd: YAG laser ablation of the prostate: initial clinical experience. J Endourol. 1995 Apr;9(2):151-3. 10. Gilling PJ, Cass CB, Cresswell MD, Malcolm AR, Fraundorfer MR. The use of the holmium laser in the treatment of benign prostatic hyperplasia. J Endourol. 1996 Oct;10(5):459-61.

During the live HoLEP surgery

ESUT faculty with local experts

11. Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann TRW, et al. EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO). EAU 2017. 12. Gravas S, Bachmann A, Reich O,et al. Critical review of lasers in benign prostatic hyperplasia (BPH). BJU international 2011; 107 (7):1030-1043. doi:10.1111/j.1464-410X.2010.09954.x 13. Brunckhorst O, Ahmed K, Nehikhare O,et al . Evaluation of the Learning Curve for Holmium Laser Enucleation of the Prostate Using Multiple Outcome Measures. Urology 2015; 86 (4):824-829. doi:10.1016/j.urology.2015.07.021 14. Kim M, Lee HE, Oh SJ. Technical aspects of holmiumlaser enucleation of theprostate for benignprostatichyperplasia. Korean J Urol. 2013 Sep;54(9):570-9. doi: 10.4111/kju.2013.54.9.570

Flamur Tartari

A life dedicated to urology 1943 - 2018

life. He was also very dedicated to his family and friends. Each time when I met him, he repeated: “Please come to see me in Tirana, see what we do and have been able to accomplish, visit my beautiful country, spend some holidays at our superb coastal areas and Black Sea beaches. So… please, be my guest!”

The news of the death of Prof. Flamur Tartari from Tirana (Albania) at the age of 75 came to me as a real shock. I learned about his unexpected passing from Prof. Bob Djavan through a Twitter message, no less. Bob, who headed the EAU Regional Office for years, was undoubtedly rapidly informed through his extensive network in Central and Eastern Europe. I first met Flamur in the nineties, in my position as Secretary General of the EAU. It was at one of the EAU Congresses, most likely Genua (1994). He was like all of us in those days: (very) young, active and extremely interested to collaborate with the EAU. He was already a leading Albanian urologist and most likely already the president of the Albanian Society of Urology; a position he held until the end of his life. To me he was “THE” eternal president. At our first meeting, Flamur was asking -in his specifically coloured English- numerous questions about the EAU, urology in general and how to improve relations and the integration of Albania and Albanian urology and urologists into the EAU. Initially we did our utmost to collaborate, but this did not work out very well, due to the

October/December 2018

particular situation in Albania at that time. The fact that Albania had been so isolated from the rest of the world for so many years, made it difficult for EAU to get a detailed insight how Albanian urology was organised and how Albanian urologists functioned. The situation changed slowly but gradually and so did our personal relationship. Flamur visited my department in Nijmegen on several occasions and this intensified our contacts. The first time he came, he stayed for several weeks. I met him almost daily and got to know him much better. I discovered that he was a devoted urologist, interested in all fields of urology

and eager to learn about whatever progress was achieved or whatever progress was on the horizon. I was not sure if the circumstances or facilities in his country were ready to implement what we demonstrated, but he took notice and during our next encounters he was ever so enthusiastic about what he had been able to realise in his department and for Albanian urology. Flamur was not a very extroverted or exuberant person. In fact, he was rather the contrary; a little bit shy, mostly soft spoken and very humble. But he was confident of himself and very proud of what he did and had achieved in his professional

His invitation was very sincere and tempting but it has never been materialised. Now I very much regret that I did not give sufficient priority to his repeated invitation to come to visit him in Albania. I have visited almost every country in the world in my function as a urologist, and in particular for the EAU, but unfortunately I never visited Albania. Flamur, it was still on my bucket list but now your untimely death will make it even more difficult to go. You are no longer there… I will miss you my dear friend, like many of my generation in the EAU will do. But you will be remembered as a devoted -and above all- very faithful servant of urology, both in- and outside your country. Frans M.J. Debruyne Former Secretary-General of the EAU

European Urology Today

www.eulis19.org

www.erus19.org

ERUS19 16th Meeting of the EAU Robotic Urology Section

Robotic Live Surgery

Creating consensus in robotic urology

EULIS19 5th Meeting of the EAU Section of Urolithiasis 3-5 October 2019, Milan, Italy

11-13 September 2019, Lisbon, Portugal An application has been made to the EACCME® for CME accreditation of this event

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

In conjunction with: Junior ERUS-YAU Meeting European School of Urology (ESU) Courses ESU/ERUS Hands-on Training in Robotic Surgery

· · ·

Call for Abstracts Deadline 5 June 2019

3rd EAU Update on Prostate Cancer 11-12 October 2019 Prague, Czech Republic

EAU onco-urology series

www.pca19.org 14-17 November 2019, Vienna, Austria

Implementing multidisciplinary strategies in genito-urinary cancers 11th European Multidisciplinary Congress on Urological Cancers In conjunction with the • 8th Meeting of the EAU Section of Urological Imaging (ESUI) • European School of Urology (ESU) • EAU Young Academic Urologists Meeting (YAU) • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP)

www.emuc19.org 32

European Urology Today

October/December 2018

ESOU19 to offer novel diagnosis & treatment approaches An interview with Meeting Chairman Prof. M. Babjuk Strengthening the onco-urology global community is one of the core aims of the upcoming 16th Meeting of the EAU Section of Oncological Urology (ESOU19). The meeting will provide all participants the opportunity to enrich what they know, and to connect with colleagues with diverse expertise. ESOU19 encourages the exchange of ideas and strategies to boost innovations in clinical practice and patient care. We interviewed ESOU19 Meeting Chairman, Prof. Marek Babjuk (CZ) of the Charles University in Prague Motol University Hospital for his insights regarding the meeting’s objectives.

Register now for the late fee! Deadline: 20 January 2019 What are the new developments that will be examined and discussed during the meeting? ESOU19’s Scientific Programme will cover the whole spectrum of contemporary diagnosis and treatments for onco-urological diseases. We will concentrate Prof. Marek Babjuk on new surgical techniques, imaging methods and their implementation in daily practice. What are topics and activities that participants can look forward to at ESOU19? Participants will receive comprehensive, relevant updates from top experts in onco-urology, as the ESOU strongly supports cooperation among experts of varied specialties. True to its goal of pursuing multidisciplinary collaboration, ESOU19 is where medical oncologists, radiation oncologists, pathologists, radiologists and other specialists will convene and share their expertise. The meeting will also examine the benefits of multiparametric magnetic resonance imaging (mpMRI) in the

diagnosis of prostate cancer (PCa), and evaluate the new drugs in the treatment of muscle-invasive bladder cancer (MIBC) and renal cancer. We will explore the role of genetics in PCa, share updates on checkpoint inhibitors, and discuss new bladder-sparing approaches in MIBC. To further involve and support young urologists, the STEPS (Sessions To Evaluate ProgresS in the management of urological cancers) programme will be the conducive platform for selected young urologists to discuss cases with established international experts. Participants shouldn’t miss the “Treatment of localised and locally advanced prostate cancer” course organised by the European School of Urology (ESU) wherein management of recurrent disease will be reviewed, and the ability of new developments in multimodal treatment to improve cancer control will be critically assessed. The course will provide practical tips and tricks, taking into account the most recent developments in the field. In your expert opinion, what are the current major challenges in the field of onco-urology? The desired goal is the improvement of oncological results in parallel with the decrease of treatment morbidity. We must concentrate not only extending a patient’s life but the quality of that life.

that high-quality and less-invasive surgical methods will still play a crucial role in the treatment of most solid tumours. Although I don’t expect dramatic changes in the approach to onco-urological diseases, we will continue to push forward with more research to build up robust, reliable data; and to explore more and more ways to incorporate technologies (e.g. artificial intelligence) into potential innovations for our clinical practice and patient care. About the meeting ESOU19 will take place from 18 to 20 January 2019 in

historic Prague, Czech Republic. The meeting’s diverse Scientific Programme will include debates on prostate, bladder and renal cancers. The multidisciplinary approach to a given cancer will be illustrated and discussed with clinical case presentations, video sessions and point counterpoint discussions. For more information about ESOU19, please visit www.esou19.org.

For the complete Scientific Programme visit www.esou19.org

ESOU19 16th Meeting of the EAU Section of Oncological Urology 18-20 January 2019, Prague, Czech Republic

Then there’s also the factor of costs. There are economic challenges connected with the increasing cost of new treatments. The implementation of said treatments in reimbursement systems will be of utmost importance.

Join the conversation at #ESOU19 What are the breakthroughs that you expect in the coming decade? I foresee new drugs in diverse therapies such as in immunotherapy, gene therapy and more. The indication of modern systemic treatments will be approaching lower stages of diseases. Prediction of prognosis of localised tumours and selection of those with the worse prognosis will be better. On the other hand, I believe

Hubert Frohmüller A life dedicated to urology 1928 - 2018

Prof. Dr. Hubert G.W. Frohmüller, an esteemed colleague and a good friend to many of us passed away in his home in Würzburg on October 5th, 2018.

laboratory. He published more than 300 papers in peer-reviewed journals. Hubert was always a cosmopolitan, but also very German. For him this was no contradiction. He was a founding member of the EAU and in 2007 he was awarded the EAU’s highest honour, the Willy Gregoir Medal. He was also very proud to become the first German Honorary Member of the AUA since the Second World War. He was also a member of the very prestigious American Association of Genitourinary Surgeons. He was the first German scientist to be given the Moses Swick Award of Mount Sinai Medical Center, New York.

Frohmüller was born in 1928 in Heidingsfeld. Here he went to school until January 1944, when he was recruited at 15.5 years old along with the rest of his class, as “Luftwaffenhelfer”. They were tasked with defending the important industrial city of Schweinfurt against the allied forces. On March 16th, 1945 Frohmüller was in his family home outside the centre of Würzburg and he saw the firestorm after the bombing of this medieval city. This event deeply affected him, making him inclined to international cooperation and harmony between nations. After the war, Frohmüller went to school again for six months and after taking his final exam he was entitled to study at University level. In April 1946 he began studying medicine at the University of Würzburg Medical School, obtaining his degree as doctor of medicine in 1952. He trained as a resident at the Department of Pathology and Internal Medicine in Würzburg and later at St. Joseph’s Hospital in Paterson, New Jersey (USA). He was then resident at the Department of Surgery, St. Antonius Hospital, Kleve and in different private practices in Switzerland. From 1950 – 1963 he worked as a Fellow in Urology at the Mayo Clinic in Rochester (USA). There, in 1963, Frohmüller received his master’s degree in science (MSc).

October/December 2018

He always considered this time to be the most important in his becoming a real urologist. Ormond Culp and John Emmet were his great mentors and he admired both. After leaving the Mayo Clinic he worked for a short period at the Division of Urology at Ludwig Maximilian University of Munich under the guidance of Egbert Schmiedt. In January 1965 he went back to the University of Würzburg where he became Chief of the Division of Urology, then still part of General Surgery. In 1971 Frohmüller was invited to become chair of the Department of Urology, at the Medical Academy in Hannover. In that same year he was appointed as Chairman of the new Department of Urology, University of Würzburg, Medical School. In his almost 25 years in this position he built a

modern urology department with excellent clinical and scientific facilities. Hubert Frohmüller was a very hard worker and also an example of discipline and honesty for his co-workers and residents. He was open to new developments but he would always question if they would benefit his patients before applying them. He was the first surgeon in Germany to perform a retropubic radical prostatectomy, in 1969. Prostate cancer was his primary scientific focus. Additionally, he developed new endoscopic techniques and instruments. After performing the first kidney transplant in 1984 he started a successful kidney transplant centre in Würzburg. In experimental urology, his main interest was tumour biology and important papers came out of his research

Hubert was also very active in the German Society of Urology (DGU) where he served on the Board for several years and was President from 1985-1986. He was also Honorary Member of the DGU and he received its highest award in 1995: the Maximilian Nitze Medal. In 2004 he was knighted into the Order of St. Sylvester by the Pope. Hubert is survived by his wonderful wife Inge, their three children and four grandchildren. Hubert and Inge were known to many friends as always friendly, warm-hearted and generous. Hubert will be sorely missed. To Inge and the Frohmüller family, we convey our deepest sympathies. By Manfred Wirth EAU Executive Member

European Urology Today

Dutch nurses benefit from a Post-EAUN meeting A report on the recent 7th Post-EAUN meeting Corinne Tillier Nurse Practitioner Urology Antoni van Leeuwenhoek Hospital Amsterdam (NL) c.tillier@eaun.org The 7th Post-EAUN meeting took place on 24 September in Amersfoort, The Netherlands. More than 90 participants from all fields of urology were present. The meeting was organised by Oncowijs, an association which initiates several educational courses and meetings. The EAUN had a successful booth at the meeting; we received a lot of questions about the advantages of the EAUN membership as not all participating nurses were EAUN members. Mrs. Corinne Tillier, (Chair of the SCO and EAUN board member) and Dr. Mrs. Hanny Cobussen-Boekhorst (SCO Member of the EAUN and nurse practitioner in continence and urostomy care) were there and answered questions about the EAUN. During the meeting, all speakers presented their lectures in Dutch. Most themes of these lectures were inspired by the sessions of the EAUN Meeting in Copenhagen held early this year. Clinical Nurse Specialist Erik Van Muilekom opened the meeting with a lecture about the hot topics in uro-oncology. In the last 30 years the incidence of urological cancers – prostate, bladder and kidney cancers – has increased in Europe. We see a correlation with growth, ageing population and lifestyle (obesity, smoking etc.). European Association of Urology Nurses

Treatments for these urological cancers are still improving (e.g. immunotherapy, targeted therapies, improvement surgical techniques, and radiotherapy). Patients with localised prostate cancer often have a choice among several treatments. Dr. Ms. Marie-Anne Van Stam showed that patients could have regrets about the choice they made for their treatment. To avoid regrets, patients need to be properly informed about the consequences of the treatment on their quality of life. They should be involved in shared decision-making if they want it (only 10% of patients want a passive role in decision-making). Aside from the regular treatment, patients often use alternative treatment; the current trend is the use of cannabis oil in prostate cancer. The author showed that there is no evidence that cannabis oil can cure prostate cancer. Patients should also be aware of the interaction of cannabis with regular medicine. In the morning, there were plenary sessions. One of the lectures was presented by urologist Dr. Ernst Peter Van Haarst, who explained the definition, diagnostics, prevention and management of urosepsis. Mrs. Cobussen-Boekhorst talked about a Dutch issue around the prescription of stoma and continence material. She showed a few flow charts from the EAUN Guidelines to help nurses to prescribe the appropriate stoma/continence material for patients which will depend on the following: - functional/anatomic possibility of the patient - activity (e.g. possible physical limitation) - possibility for patients to participate actively to the care

"Most themes of these lectures were inspired by the sessions of the EAUN Meeting ...."

Discussing the use of cannabis oil by prostate cancer patients

interesting lecture on urinary tract infections and self-catheterisation by nurse practitioner Mr. Henk-Jan Mulder, who presented the result of his study. Another interesting lecture was about the role of the pelvic floor muscles in overactive bladder, dyspareunia, and the possible treatment by biofeedback and electrical stimulation. The 7th Post-EAUN meeting for Dutch nurses was a success. It gave them the opportunity to gain access to the most important sessions in their own language, if they had not been able to attend the annual EAUN Meeting in Copenhagen held early this year.

Participation at a Post-EAUN Meeting could be advantageous to nurses in your country as well. Currently, only Denmark and The Netherlands have In the afternoon, the participants could choose two organised Post-EAUN meetings, but we hope that from the four organised sessions. Each session other countries will join this initiative, as their nurses will definitely benefit from it and the organisers will consists of 2 lectures. The field of functional urology was also represented at the meeting; there was a very have the EAUN’s support.

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

Susanne Vahr (DK) Paula Allchorne (UK) Stefano Terzoni (IT) Jason Alcorn (UK) Paula Allchorne (UK) Linda Söderkvist (SE) Corinne Tillier (NL) Jeannette Verkerk (NL) Giulia Villa (IT)

www.eaun.uroweb.org

Fellowship Programme

ELUTS19

European Association of Urology Nurses

European Lower Urinary Tract Symptoms meeting

31 October - 2 November 2019 Prague, Czech Republic

www.eluts19.org

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 1 January 2019 • Only EAUN members can apply • Host hospitals in Belgium, Denmark, the Netherlands, Sweden, Switzerland and the United Kingdom • A great way of widening your horizon For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

European Urology Today

European Association of Urology Nurses

October/December 2018

BAUS Conference Report Part 2: Posters on Uromune©, cystoscopy with positive dipstick, virtual stone clinic and MDTs Sue Osborne Urology Nurse Practitioner Auckland (NZ)

sue.osborne@ waitematadhb.govt.nz My role as a Urology Nurse Practitioner involves assessing individuals and delivering treatment plans, autonomously and collaboratively, in the context of many urological conditions including recurrent urinary tract infections; renal and ureteric calculi; flexible cystoscopy for haematuria diagnosis; and bladder cancer surveillance. In the last edition of the European Urology Today, I shared some session highlights from my attendance at the British Association of Urological Surgeons Limited (BAUS) conference held late June 2018. In this column, I would like to highlight other interesting topics from the poster section of the conference. One such poster described the first experience of using the novel treatment Uromune® (sublingual vaccine) in men with recurrent urinary tract infections (UTIs) in the United Kingdom. The study followed 22 men with proven UTI and clinical symptoms, with a mean age of 65 years. They each received three months of Uromune® vaccine with 21 men successfully completing the treatment protocol. Results indicated that 17 men did not develop UTI during the treatment period, but longer term follow-up showed that the vaccines effect wore off after around 14 months, with the UTI returning. The authors concluded Uromune® to be safe and effective, and a viable European Association of Urology Nurses

alternative to long- term antibiotics. A randomised controlled trial is planned. A second poster reported on a prospective clinical study examining if it is safe to carry out flexible cystoscopy when urinary dipstick is positive for “infection”. The driver for the study was the observation that one in six patients was having their cystoscopy appointments cancelled on the day due to positive urine dipstick result. This resulted in considerable underutilisation of clinic resources. The primary aim of the study was to identify the risk of UTI or urinary sepsis within two weeks of cystoscopy, when pre-cystoscopy urinalysis was positive for infection (positive leukocytes or nitrites). In the study, all patients had a cystoscopy even if they had positive urine dipstick results. Patients considered high risk for UTI, and those with the positive results were given a single dose of prophylactic prior to cystoscopy.

appointment needed; 45 (15%) were changed to nurse-led telephone appointments; the appointments of 127 patients (42.3%) were changed to specialist nurse outpatient appointments; and 63 (21%) were seen in a consultant-led outpatient clinic. The poster concluded that the virtual stone clinic had improved patient management while saving significant resources, in terms of time and money. The data showed that outpatient clinic pressures were significantly reduced, patient care expedited where appropriate and last-minute cancellations were prevented.

“The poster concluded that the virtual stone clinic had improved patient management while saving significant resources, in terms of time and money.”

In a six-month period, 1,625 participants were recruited and 18.25% had a positive urine dipstick result wherein a third had a proven urine culture as well. Results indicated that the overall risk of developing a post-cystoscopy UTI in this cohort was slightly higher, but remained low overall. They felt the risk was acceptable and resulted in significantly less procedures being rescheduled.

Another interesting session reported on a survey undertaken to ascertain physician views on Multidisciplinary Team (MDT) Meetings. The NHS Cancer Plan stated that “the care of all patients with cancer should be formally reviewed by a specialist team to ensure that patients have the benefit of the range of expert advice needed for high-quality care.” The practice of regular MDT meetings has been developed to formalise this consultative process.

Another interesting poster reported on a prospective audit designed to measure if a 90-minute, weekly virtual stone clinic had improved patient care at a reduced cost. It described how a new patient care pathway was introduced in response to pressure on outpatient clinic appointments. The pathway ensured that all stone patients were reviewed by the stone team and triaged to the appropriate stream of care.

An MDT meeting consists of a group of professionals from one or more clinical disciplines who make the decisions together regarding recommended treatment of individual patients. It is intended that an MDT meeting must consider the patient as a whole, not just focus on recommendations for optimal medical treatment.

Three hundred stone referrals were received and 65 (21.6%) had consultations via a virtual clinic with no

The physician survey findings indicated a common viewpoint that too many routine decisions are made at MDT meetings. The speaker commented that the

requirement to present all cases at MDT meetings is training doctors to feel unable to make their own decisions, in partnership with their patients. Survey respondents reported an increasing recognition that mandatory attendance of around 15 health professionals at an MDT session may be an inefficient use of a medical professional’s time. One NHS Trust indicated that 48% of their patients were discussed for less than two minutes and two thirds were discussed for less than three minutes at an MDT. There was a feeling that a lot of time was spent rubber stamping straightforward cases limiting time and energy for discussing complex cases. The speaker noted that NHS England plans to implement recommendation 38 of the NHS Cancer Strategy*: to streamline MDT processes, and will produce guidance to Cancer Alliances in support of this. There is likely to be a shift in focussing time and resources on identifying and prioritising those patients whose diagnosis falls outside of established treatment pathways or normal parameters. The discussion was fascinating from a New-Zealand perspective as we have followed the NHS lead, formally incorporating MDT into our cancer care pathways over the last few years. The model of MDT adopted where I work in urology follows these recent recommendations, focusing energy and resources on the more complex cases. I left the BAUS conference with plenty to report back to colleagues. I have enjoyed sharing some of my conference highlights with you through these columns. As I headed home, I was keen to spend some time refocussing our efforts to establish a virtual stone clinic process at my workplace, as well as, examine our flexible cystoscopy infection data, to see what stories lie within. This newfound inspiration is a hallmark of a worthwhile event. * Reference: https://www.england.nhs.uk/wp-content/ uploads/2016/05/cancer-strategy.pdf

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European Urology Today

Our passion for Urology Nursing overcomes barriers A report on the 4th ESUN Course on Holistic prostate cancer care Marinelle Doctor Clinical Nurse Consultant Urology Nepean Hospital Penrith (AU)

marinelle.doctor@ health.nsw.gov.au The 4th Course of the European School of Urology Nursing on Holistic Prostate Cancer Care took place on 14-15 September 2018 in Krakow, Poland. The organising committee received 70 applications from Europe, Africa, Asia, New Zealand and Australia, however the course can only accommodate a maximum of 30 participants. I was one of the two nurses from Australia who were selected to join the programme. Thanks to IPSEN’s generous educational grant, the EAUN organised my flight arrangements and overnight accommodation. Registration fee for the full course was only €100 (excl. VAT) for EAUN members and €135 (excl. VAT) for non-EAUN members.

localised, advanced and metastatic prostate cancer. Dr. James Green (GB) addressed various diagnostic procedures. The second hour centred on shared decision-making, the role of the nurse and how to avoid regrets in choosing a treatment. Ms. Franziska Geese (CH) superbly articulated why empowerment and knowledge are both necessary in shared decisionmaking. A short tea break followed, giving us a chance to stretch our legs and make new friends. After the break, we were divided into small groups to discuss genograms and its use in clinical practice. This is new to me and at that moment, I was already thinking of ways to incorporate genograms in my practice. The last part of the afternoon involved discussion on multi-professional approach to meeting the patients’ and their partners’ needs.

Dr. Green speaking on diagnostics

committee, making it convenient for participants to travel to the restaurant. The social programme finished late in the evening and everyone was ready to hit the sack by the time we got back to the hotel.

communication and dealing with challenging situations.

Day Two: Saturday, 15 September The programme of day two began at 9 AM. There After the main programme, the participants were were more interactive discussions and group work on invited to partake in dinner at Szara Ges, a restaurant this day. Parts one and two of “Let’s talk about Sex” located right on the Main Square. The decor of the session had compelling topics. As moderators, Mrs. restaurant was stunning, the service wonderful and Paula Allchorne (GB) and Dr. Green did a great job in the Polish cuisine was fantastic. Bus transfer to and eliciting a hearty exchange of opinions amongst from the restaurant was arranged by the organising participants regarding sexual problems in cancer and interventions.

Day One: Friday, 14 September The first day of the programme was a gloomy, rainy day — perfect for staying indoors. Although one can see the Vistula River from the huge windows of the conference room, the programme was far more interesting than the prospect of a cold, wet boat ride. We learned about the physiology and pathology of the prostate in the first hour. Mrs. Corinne Tillier (NL) presented the different therapies available for European Association of Urology Nurses

On day 2 there were several interactive discussions and group work

The group bonded quickly because of their shared passion for nursing

I enjoyed the role play performed by the delegates from Australia, Netherlands and Switzerland. One delegate portrayed the role of a patient with cancer, the other delegate was the wife of the cancer patient and the other two delegates were acting in the role of nurses providing counselling to the couple. The aim of the role play was to demonstrate effective communication among clinicians, patients and their carers to assess unmet needs and concerns. Ms. Geese and Ms. Tillier offered inspiring suggestions regarding practice-oriented

The programme concluded at midday and lunch was provided in the main part of the hotel. Once again, delectable traditional Polish dishes were offered. Overall, the programme content and course delivery were well-designed and the hard work of the organising committee is very evident. I thank the organising committee for the opportunity to join the programme and I will forever treasure this experience. I gained not only new knowledge to share with colleagues in Australia but have also found new friends. What I learned from this experience is that no matter which part of the world we work in, nurses have this innate caring spirit. We all have the insatiable desire to help, to serve, to give our patients quality care. Despite the obvious differences in race, culture, and English-speaking abilities of the participants, we all share the same belief that nursing is a universal gift to all. Our passion for Urology Nursing overcomes all cultural and language barriers.

EAUN-AZUNS session puts spotlight on sexual health Collaborations encourage open discussions between patients and health care professionals Steve Jobs once said, "Great things in business are never done by one person; they're done by a team of people."

Register now for the early fee! Deadline: 15 January 2019 The European Association of Urology Nurses (EAUN) has a long history of networking with individual experts and collaborating with national urological associations to boost the field of urological nursing. Next year at the 20th International EAUN Meeting (EAUN19) in Barcelona, the EAUN will underline its collaboration with other societies, such as the Spanish Association of Urology Nurses (AEEU) and the European Council of Enterostomal Therapy (ECET). Together with the Australian and New Zealand Urological Nurses Society (ANZUNS), a Thematic Session on “Sexual health matters” will be held. Ms. Franziska Geese (CH) and Ms. Kathryn Schubach (AU) will chair the joint session, and together with fellow experts from Australia, England and The Netherlands, they will help provide nurses with crucial skills and resources in assessing their patients’ needs, identify sexual health issues, and initiate a plan of care. This Thematic Session will not only represent the merging of expertise, but the

dedication and passion for urological nursing as well. Impact on sexual function In Australia and New Zealand prostate cancer is one of the most common diagnosis. Every treatment modality, aside from active surveillance, will have an impact on sexual function. Men have a very high success of cure and will often live for many years. Thus their quality of life may be impacted by their sexual dysfunction. Patients, like them, rely on nurses to take on the responsibility for developing, maintaining and optimizing urological care to increase the quality of life. While research suggests sexual dysfunction is common (some 43% of women and 31% of men report some degree of sexual dysfunction), it is still a topic that many people hesitate to talk about. The literature is similar in Australia and New Zealand. It also indicates that healthcare professionals (HCPs) feel that they lack experience in discussing sexual issues. We need to keep the conversation going, encourage it and break down taboos when talking about sexual dysfunction. Sexual health is an important aspect of patient care that should be acknowledged and examined within a holistic framework. Nurses are in the best position to assess their patients’ needs and provide care. And to enrich the knowledge and skills of nurses is to boost and optimise patient care.

varied approaches and best practices first-hand during hospitals visits at Fundació Puigvert, University Hospital Vall d’Hebron, or the University Hospital Clinic of Barcelona. Afterwards, unwind with colleagues and newfound friends, enjoy Catalan cuisine at the Barceloneta restaurant, and savour the views of fishing port, Moll dels Pescadors.

Save the date! EAUN19 promises a varied and insight-filled programme dedicated to the training and educational update needs of European urology nurses. Know more about this must-attend meeting and explore its Scientific Programme via

www.eaun19.org. To take advantage of discounted rates, register before 15 January 2019. We look forward to welcoming you in Barcelona!

20th International EAUN Meeting

16-18 March 2019, Barcelona 16-18 March 2019, Barcelona, Spain www.eaun19.org

Join the top of Urology Nursing!

For the complete Scientific Programme visit www.eaun19.org A place for you at EAUN19 Join us in this session and in all highly-informative joint and thematic sessions and activities at EAUN19. Additionally, as in previous congresses, hospital visits form part of the total learning experience. Examine 36

European Urology Today

October/December 2018