European Urology Today Vol. 32 - No. 4 – Aug/Sep 2020 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology

Vol. 32 No.4 - August/September 2020

Don’t let anything stop you.

Looking back at EAU20

First Virtual Annual Congress increases global reach

Erectile dysfunction (ED) can affect many aspects of your life. Talk to your urologist about ED and ask about the best treatment for you.

20-23

#UROLOGYWEEK

urologyweek.org

Urology Week 2020

Visible lymph node treatment in PCa

Awareness posters on ED inside!

New imaging information missing in prognostic and validated tools

Prof. C. Bangma

“Prostate cancer has been overlooked far too long” EAU pushes for the inclusion of early detection of prostate cancer in the EU Cancer Plan By Juul Seesing In its constant devotion to improving patient care, the EAU has become increasingly active in the European political landscape. Prof. Hein Van Poppel (Leuven, BE), Adjunct Secretary General responsible for education, is the driving force behind the EAU’s activities in Brussels, in close collaboration with EAU policy coordinator Mrs. Sarah Collen (Brussels, BE). One of their current priorities is getting prostate cancer, the most common male cancer in Europe, on the EU political agenda. The goal is to get early detection and diagnosis of prostate cancer included in Europe’s Beating Cancer Plan (EU Cancer Plan). With the EU Cancer Plan, the European Commission aims to reduce the cancer burden for patients, their families and health systems. Prof. Van Poppel explains: “The EU Cancer Plan will be the first comprehensive EU strategy on cancer in thirty years, covering the whole continuum of cancer care: from prevention and early detection, through to treatment and care, and on to survivorship and quality of life. It will support, coordinate and complement EU member states’ efforts to fight cancer.”

“Multiple studies provide robust evidence confirming that early detection of prostate cancer saves lives and improves quality of life.” Since the announcement of a new EU Cancer Plan after the 2019 European Parliament election, the EAU has taken several actions. Prof. Van Poppel: “In April 2020, we updated our white paper on prostate cancer to respond to the EU Cancer Plan in partnership with Movember, the European Cancer Patient Coalition (ECPC), Europa Uomo, and the European Alliance for Personalised Medicine (EAPM). We want the EU Cancer Plan to provide funding for an EU-wide awareness-raising campaign on prostate cancer and to mandate and endorse clinical guidelines, such as the EAU Guidelines on Prostate Cancer, on early detection and diagnosis of prostate cancer. These guidelines can be taken up by EU member states in their national cancer plans. The EU already provides guidance on screening for breast, cervical and colorectal cancer. We are asking for prostate cancer to be added to the list. Multiple studies provide robust evidence confirming that early detection of prostate cancer saves lives and improves quality of life, and prostate cancer has been overlooked by the EU far too long.” “The EAU is well positioned to provide these clinical guidelines. We already have the scientific evidence and guidance available with our guidelines, so it is only a matter of endorsing them. To make this happen, we are working in partnership with our strategic partners such as patient organisations, research foundations, and industry partners, but also with the EU’s Joint Research Centre (JRC) and the Innovative Partnership for Action Against Cancer (iPAAC), within which we are working together with EU member states toward a joint EU action on cancer. PIONEER, the big data platform to enhance prostate cancer diagnosis and treatment, serves as a great example for our potential role in this specific part of

August/September 2020

the EU Cancer Plan; PIONEER is funded by the EU’s Innovative Medicines Initiative, and the non-industry consortium is led by our EAU Guidelines Office.” Progress achieved Prof. Van Poppel: “As a result of our clear, targeted strategy on prostate cancer in relation to the EU Cancer Plan, Sarah and I were invited for a virtual meeting with leading members of the European Commission as they draft the EU Cancer Plan. We met with a variety of high-level officials, including project leader Matthias Schuppe and John F. Ryan, the Directorate-General for Health and Food Safety (DG SANTE), who has the overall responsibility for the EU Cancer Plan. We were given the opportunity to present the white paper and our call for the EU to include guidance on early detection of prostate cancer. We have already produced an algorithm for what will be a potential way forward for risk-stratified early detection of prostate cancer in well informed men. This algorithm is at the time of writing [mid-August – Ed.] under review for publication in European Urology.” “We have also organised a number of European Prostate Cancer Awareness Days (EPADs) in the European Parliament to raise awareness among Members of the European Parliament (MEPs), European Commissioners, EU officials, and civil servants from across the EU. Besides EPADs, we have met with multiple MEPs to keep calling attention to our goals. For instance, we have met the two chairs of the MEPs Against Cancer (MAC) Interest Group: Veronique Trillet-Lenoir from France and Loucas Fourlas from Cyprus. Petra De Sutter from Belgium, vice-chair of MAC, signed up for our prostate cancer campaign. And we have a long-standing relationship with Cristian Busoi from Romania, whom I first met in Romania during its EU Presidency. He is the new chair of the European Parliament Challenge Cancer Intergroup and the spokesperson for the European Parliament on the new EU4Health Programme, which will be one of the vehicles for the funding of the EU Cancer Plan. Although COVID-19 has made it impossible to meet her in person, we have also been corresponding with Commissioner Stella Kyriakides and her cabinet.”

“Through a united front with patient advocacy groups, we will be able to reach our goals in Brussels.” A draft of the EU Cancer Plan is planned for release in the fourth quarter of 2020. "As a result of our successful campaign, we see from the results of the European Commission's public consultation on the EU Cancer Plan that there is strong support for the addition of prostate cancer to the list of cancers that need pan-European guidelines for screening. Prostate Cancer came second only to ovarian cancer on the list of priorities. This is a first significant success of our joint campaign work with national societies, which will allow us to approach the European Commission with more proof that this issue is a shared concern for citizens across the EU." “In anticipation of the draft of the EU Cancer Plan, we are arranging for a meeting with key European parliamentarians on Tuesday, 17 November, on the eve of the European Cancer Organisation’s annual summit,” Prof. Van Poppel says. “This summit brings together oncology specialists, patient advocates, politicians and policymakers both online and in Brussels. The day before, we want to promote scientific guidance on risk-stratified early detection of prostate cancer and to push for more EU action on this. MEPs Tomislav Sokol from Croatia and Tiemo Wölken from Germany will co-chair our

Prof. Hein Van Poppel (right) with Dr. Francesco De Lorenzo, co-founder and former president of ECPC, at the European Parliament on World Cancer Day (4 February 2020)

meeting. It will be helpful to have a German MEP chairing and to involve Germany in some way as Germany holds the EU Presidency from July to December 2020, which means they chair the meetings and try to steer the EU agenda.” Portugal (January-June 2021), Slovenia (July-December 2021), and France (January-June 2022) are up next to hold the EU presidencies. Patient advocacy All EAU’s political activities share the same ultimate goal: improving patient outcomes. Another factor in achieving this is patient involvement. Empowering patients to take co-responsibility for the management of their condition enhances medical outcomes. This is done by, among other things, transferring knowledge. For this reason, the EAU established the EAU Patient Advocacy Group (EPAG) in 2019 to help disseminate knowledge to patient advocacy groups, patient organisations, and caregivers. EPAG consists of healthcare professionals and patient representatives from five patient organisations: ECPC, Europa Uomo, the World Bladder Cancer Patient Coalition (WBCPC),

the International Kidney Cancer Coalition (IKCC), and the Association of European Cancer Leagues (ECL). Prof. Van Poppel: “Whatever we are doing in Brussels needs to make sense to patients and bring value to them. We want to achieve better outcomes for those who are impacted by cancer. That means that we need to be working hand-in-hand with those whose lives are impacted by cancer. For example, working with EPAG has helped us produce a leaflet on PSA testing that lists the pros and cons of going for a test.” “For our recommendations for the EU Cancer Plan, we have been working in partnership with patient advocacy groups to identify the main issues around prostate cancer for patients and to give recommendations that ensure patient outcomes will be as positive as possible. Not only is it the EAU’s ambition to increase patient involvement, but we also want to act as a united front with patient advocacy groups at the European political stage. Through this united front, we will be able to reach our goals in Brussels.”

Review all scientiic content of EAU20 visit www.eau20.org/rc

European Urology Today

EAU20 Virtual Congress & Theme

EAU20: Virtual out of necessity, but a scientific 35th Annual EAU Congress broke new ground with worldwide ten-day online event By Loek Keizer with additional reporting by Erika De Groot-Rivera and Juul Seesing The EAU can look back on its first fully online Virtual Annual Congress with a sense of pride. In only a few short weeks, the entire Annual Congress that had been scheduled to take place in Amsterdam was rebuilt to suit a global online audience. For 17, 18 and 19 July, the Scientific Congress Office organised a full-day EAU20 Virtual Congress, followed by the EAU20 Theme Week of evening sessions arranged by topic. The EAU20 Virtual Congress and Theme Week were free to attend for all EAU members and registrations were opened specifically for this new congress. This attracted many first-time delegates who might otherwise never have made the trip to a congress in Europe. Over the course of ten days, thousands of delegates from 130 different countries attended the congress. On-demand viewing was available to allow those in different time zones to catch up on any session they might have missed. The EAU20 scientific content remains available for EAU members and all other delegates in the EAU20 Resource Centre.

“The congress was a huge success and it covered all major areas of urology.”

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) Dr. D. Karsza, Budapest (HU) 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) Prof. S. Tekgül, Ankara (TR) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL) J. Seesing, Arnhem (NL)

As this was a wholly new experience for everyone involved, we spoke to some of the participating chairmen about their experiences with the online format and whether this is a feasible solution for the EAU’s meetings in the coming months. Initial impressions “Speaking personally and from what I’ve heard from my colleagues, EAU20 was well-received,” says Prof. Jochen Walz (Marseille, FR). Prof. Walz co-chaired the first Plenary Session on Friday, July 17th and was therefore among the first people to speak at the congress. “The congress was easy to access, the connection was stable, and for a virtual platform there was excellent interaction with the audience.” Prof. Kari Tikkinen (Helsinki, FI), co-chairman of Game-changing Session 2 on Saturday also received good feedback from his colleagues. “The congress was a huge success and it covered all major areas of urology. It included important clinical scenarios, as well as new research results from basic science, translational and clinical urology.” Prof. Dasgupta (London, GB) co-chaired the live session “Nightmare on robotics” with Mr. Tim O'Brien (London, GB) on the Sunday. Prof. Dasgupta: "The EAU20 Virtual Congress was a success and I am very glad that the EAU went ahead with the congress despite the pandemic.

Prof. Tikkinen co-chaired Game Changing Session 2 on Saturday morning. Here we see the live moderation and discussion with the speakers who joined the sessions where possible. Audience members submitted questions through the Q&A feature of the Congress platform and these were passed on to the speakers by the moderators

Difficult times need a fresh, modern approach and this should be seen as an opportunity. Congratulations to the EAU for doing just that.” Session highlights In Sunday’s nightmare session Mr. Bertie Leigh (London, GB), the EAU’s legal nightmares specialist, explored and probed the complications of robotic surgery through the prism of the law court. “It was the only completely live session and I was delighted to chair it with my friend Tim, who had organised similar ‘nightmares’ before,” Prof. Dasgupta says. “The highlight for me was Bertie Leigh. He was very factual just like in a real-life courtroom. He reminded surgeons that many do not know the outcomes of their own operations. Clear communication and documentation can get us out of sticky situations when things go wrong.” “The urologists who put themselves up for cross-examination by Bertie were very brave. Bertie reminded them in no uncertain terms that he was the one asking the questions and not them! I found the session incredibly educational and would rather be cross-examined at the Annual EAU Congress than in real life. I learnt about corporate responsibility, not being ashamed to seek help early when you are in trouble and showing genuine remorse if a patient has been harmed accidentally.” Prof. Tikkinen hailed the presentation of results of important new studies on bladder cancer in Game-changing session 2: “The NIMBUS trial investigated whether a reduced frequency of Bacillus Calmette-Guérin (BCG) installation

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Advantages and disadvantages EAU20 might have left a positive impression on participants, and important new developments were discussed, but the new format inevitably had to give some concessions to its online nature. Prof. Walz saw that the virtual congress helped the EAU reach a new audience: “Many attendees came from countries we usually don’t get to see at the same numbers, like India and China.” “One advantage of the regular Congress is discussion and interaction, but I think that the virtual platform did allow for this perfectly adequately. Its Q&A functionality was also very helpful and quite frequently used by the delegates.”

“We managed to have lively and fruitful discussions during the Virtual Congress.”

Plenary Session 5, or the “Nightmare on Robotics” session co-chaired by Prof. Dasgupta on Sunday morning featured one of the largest numbers of simultaneous discussants. This made it an engaging session for everyone who was tuned in

European Urology Today

“The other study reported on the safety and efficacy of nadofaragene firadenovec in patients with high-grade, BCG-unresponsive non-muscle invasive bladder cancer. The authors reported a complete response (defined as proportion of patients without recurrence based on urine cytology, cystoscopy, and bladder biopsy) of 53% (95% CI 43%-63%; n = 55) among those with carcinoma in situ (CIS) during the 12-month period in this unblinded study. Notably, all complete responses occurred in the first 3 months. More studies on nadofaragene firadenovec are very welcome and needed.”

Prof. Dasgupta is realistic and emphasises the positive effects for the ecological footprint of the EAU’s meetings: “I would rather have a virtual congress than none at all. The attendance is similar to a physical congress with no need for flights, thus reducing our carbon footprints. I like the flexibility of being able to choose the sessions from my home or the office without having to take leave.”

Disclaimer

during the induction and maintenance phases would result in similar efficacy to standard BCG protocols. If so, it could lead to lower adverse events, burden and cost. Recurrence rates were, however, somewhat higher in patients in the reduced frequency arm (27% vs 12%), suggesting that the dosing schedule is critical to efficacy of BCG.”

“Of course the disadvantage is not being able to meet friends and colleagues. I also fear that we may be becoming ‘zoombies’ as there is definitely fatigue to the eyes, neck, and mind from staring at a computer screen for hours. There are various tricks to counter such fatigue, though.” August/September 2020

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success nevertheless Similar observations were made by Prof. Tikkinen: “Naturally, the EAU20 Virtual Congress lacked some very important aspects of a traditional congress. Human interaction is important and some other social aspects of a congress were missing. Discussion is often harder in an online meeting. Nevertheless, we managed to have lively and fruitful discussions during the Virtual Congress.” “There are also advantages. Since travel was not necessary, it was more eco-friendly and the Congress’s digital format made it more accessible, especially to colleagues who couldn’t have attended the Congress easily if it had been held onsite. Additionally, the presentations were pre-recorded in excellent quality.” Wave of the future? With much uncertainty about how the COVID-19 pandemic will continue to affect international travel and events with several thousand participants, the EAU has to evaluate the feasibility of online meetings like EAU20. Our interviewees have their own views: “I definitely think virtual meetings are here to stay in one form or another,” says Prof. Tikkinen. “This will also partly depend on how the situation with the pandemic evolves. In post-pandemic meetings, perhaps some part of the programmes will be virtual, and more options will be realised regarding the format. Only time will tell. But for sure, the traditional format of meetings is greatly missed and will return somehow someday.”

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Prof. Walz sees a viable format “as the technical support will become more sophisticated and even more user-friendly. I think even beyond the pandemic, in the context of climate change and sustainability, digital or virtual meetings will be the future.” Prof. Dasgupta envisions a future for hybrid events: “The digital format has to be viable while we learn to live with the virus. I like the fact that the audience can revisit the recordings and I thank the EAU for posting our nightmare session in full in the EAU20 Resource Centre.” “The future could be a combination of digital and face-to-face congresses. Keeping both elements at a reasonable fee may bring engagement from colleagues living in nations less well-off or at distant locations, saving time and money. Having virtual industry rooms or stands which delegates can visit is a nice idea.” Fulfilling the EAU’s objectives In the end, EAU20 was subject to the same goals as the regular Annual Congress: offering state-of-theart urological science and education. Did EAU20 deliver? Dasgupta: “A resounding yes. It was more focussed and the take-home messages from the virtual congress had more prominence than usual, in my opinion. It was a charismatic online wave which brought a smile to my face, although it would have been nice to say goodbye to my many friends

face-to-face as I finished working as BJUI Editor-inChief after nearly a decade. But that’s a small price to pay when so many people have lost their lives and loved ones to an invisible enemy.”

“Plenary sessions work very well with the current set-up but we need more room for abstracts.” Prof. Walz was equally pleased but saw some room for improvement: “EAU20 did provide state-of-the-art education, however ‘science’ in the meaning of presenting new results was more limited. We will need to think about how to present and expose abstracts and the latest research in a better and more accessible way. This is where we will need new concepts and ideas. Plenary sessions work very well with the current set-up but we need more room for abstracts.” “Considering the pandemic situation, the EAU Virtual Congress did very well,” says Prof. Tikkinen. “The EAU is to be congratulated: its Office, Executive, its Scientific Committee which was led by Prof. Peter Albers, the speakers and participants did an amazing job. The Virtual Congress gave us the opportunity to be updated with the most important news and messages from the world of urology. This is truly significant so that we can continue to provide the best available care for our urology patients worldwide.”

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EAU20 Numbers Congress days

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Delegates

49 Countries

“Prostate cancer has been overlooked “Prostate cancer has been overlooked far too long” . . . . . . . . . . . . . . . . . . . . . . . . . . 1 far too long”. . . . . . . . . . . . . . . . . . . . . . . . . . 1 EAU20: Virtual out of necessity, EAU20: Virtual out of necessity, but a scientific success nevertheless . . . . . .2-3 but a scientific success nevertheless. . . . . . 2-3 ESTU: Kidney transplantations and ESTU: Kidney transplantations and the COVID-19 pandemic . . . . . . . . . . . . . . . . .4 the COVID-19 pandemic . . . . . . . . . . . . . . . . . 4 Update from the Guidelines Office . . . . . . . . .5 Update from the Guidelines Office . . . . . . . . . 5 Robotic intracorporeal neobladder Robotic intracorporeal neobladder configuration . . . . . . . . . . . . . . . . . . . . . . . . .6 configuration . . . . . . . . . . . . . . . . . . . . . . . . . 6 Clinical challenge . . . . . . . . . . . . . . . . . . . . . .7 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 Key articles from international medical Key articles from international medical journals . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11 journals. . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11 EAU RF section: EAU RF section: EAU Research Foundation. . . . . . . . . . . . . . . 12 EAU Research Foundation. . . . . . . . . . . . . . . 12 EAU and EANM recommendations on EAU and EANM recommendations on PSMA PET . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 PSMA PET. . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Dr.philos degree awarded for thesis Dr.philos degree awarded for thesis based on GPIU study. . . . . . . . . . . . . . . . . . . 13 based on GPIU study. . . . . . . . . . . . . . . . . . . 13 ESFFU: Female and functional urology ESFFU: Female and functional urology in the COVID era . . . . . . . . . . . . . . . . . . . . . . 14 in the COVID era. . . . . . . . . . . . . . . . . . . . . . 14 ESUO: Prostatic Urethral Lift ESUO: Prostatic Urethral Lift (Urolift® System) . . . . . . . . . . . . . . . . . . . . . . 16 (Urolift® System). . . . . . . . . . . . . . . . . . . . . . 16 The evolution of urology volunteerism The evolution of urology volunteerism in Haiti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 in Haiti. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 EAU21 features EAU’s first Patient Poster EAU21 features EAU’s first Patient Poster Track. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Track. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 ESOU opens the boundaries . . . . . . . . . . . . . 19 EAU RF section: Obituary: Prof.“start-up Djoko Rahardjo . . . . . . . . . . . 19 The EAU RF’s package” for beginning researchers. . . . . . . . . . . . . . . 23 The battle for EU health funds has begun . . 20 ESU section: EAU RF section: The legacy and future of the ESU . . . . . . 24-25 The EAU RF’s “start-up package” First virtual masterclass premieres. . . . . . . . 26 for beginning researchers. . . . . . . . . . . . . . 25 UROwebinars: "Stellar lectures on ESU section: a plethora of topics". . . . . . . . . . . . . . . . . . . 27 The legacy and future of resources the ESU . . . . . 26-27 OMInar delivers suite of First virtualurology masterclass premieres . . . . . . . 28 in general . . . . . . . . . . . . . . . . . . . . UROwebinars: "Stellar lectures on The battle for EU health funds has begun. . . 29 a plethora of topics" . . . . . . . . . . . . . . . . . . 29 OMInar suiteTellaloglu of resources Obituary:delivers Prof. Sedat . . . . . . . . . . 30 in general urology . . . . . . . . . . . . . . . . . . . 30 Obituary: Prof. José Manuel Reis Santos. . . . 30 Obituary: Prof. Sedat Tellaloglu . . . . . . . . . . 31 Treatment of visible lymph nodes in Obituary:cancer. . . . . . . . . . . . . . . . . . . . . . . Prof. José Manuel Reis Santos . . . . 31 prostate EUSP section: European Urological Scholarship European Urological Scholarship Programme (EUSP). . . . . . . . . . . . . . . . . . . . Programme (EUSP) . . . . . . . . . . . . . . . . . . . ESTU: European experience in robotic European experience in robotic kidney kidney transplantation. . . . . . . . . . . . . . . . . transplantation . . . . . . . . . . . . . . . . . . . . . . EULIS: Urological emergency visits EULIS: Urological emergency visits during COVID-19 outbreak. . . . . . . . . . . . . . during COVID-19 outbreak. . . . . . . . . . . . . . ESOU opens borders between disciplines. . . Treatment of visible lymph nodes in prostate . . . . . Rahardjo. . . . . . . . . . . ................. Obituary:cancer Prof. Djoko

32 32 32 32 33 33 34 34

YUO section: RESECT: Help improve the quality of TURBT surgery . . . . . . . . . . . . . . . . . . . . . . 35 surgery. . . . . . . . . . . . . . . . . . . . . . . Urologists prepared to fight rising antimicrobial resistance . . . . . . . . . . . . . . . 36 resistance. . . . . . . . . . . . . . . . ESUO: Networking in the urological office. . 37

51,000

7,500

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EAUN section: Urological passion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Spot on frailty in bladder cancer . . . . . . . . . 39 Spotlight on frailty in bladder cancer. . . . . . Synopsis of nursing research study . . . . . . . 40 study. . . . . . . .

European Urology Today

Kidney transplantations and the COVID-19 pandemic Lessons learned in Madrid, Spain devices) and the hospital stays as short as possible. In summary, the main objective of all measures is to achieve low complexity procedures with lower rates of Delayed Graft Function (DGF) and Primary non Function (PNF) that prolong the postoperative stay.

Prof. Joaquin Carballido Dept. of Urology University Hospital Puerta de Hierro Majadahonda Madrid (ES)

Lifting the measures On 29 April, the Spanish government gradually started lifting the COVID-19 containment measures, depending on the epidemiological and health situation in each area.

carballidojoaquin@ gmail.com

Dr. Patricia Ramirez Dept. of Urology University Hospital Puerta de Hierro Majadahonda Madrid (ES) p.ramirez.rb@ gmail.com Following notification on 31 December 2019 by the Wuhan Municipal Health and Sanitary Commission (Hubei Province, CN) of a group of 27 cases of pneumonia with unknown aetiology, on 7 January 2020 the Chinese authorities identified the causing agent of the outbreak. It was a new type of virus from the Coronaviridae family, which has been called SARS-CoV2 (Severe Acute Respiratory Syndrome coronavirus type 2). The World Health Organization (WHO) declared an international health emergency on 30 January 2020, and on 11 March the pandemic situation was declared. The latest data available report more than 13 million confirmed cases of COVID-19, including more than 500,000 deaths. This pandemic has confronted the world with an unprecedented and rapidly changing situation. Spain has been one of the most severely affected countries in the world. Since the official declaration of the state of alarm on 13 March 2020, donation and transplant activities have decreased significantly (see Fig.1). The saturation of the health system and ICUs, as well as the risk of infection in patients, led to a surgical prioritisation in order to offer the scarce resources to the most severe cases. This situation affected not only transplant activities but also the general surgical and oncological activities1. Official statement The Spanish National Transplant Organisation (ONT) is the authority that coordinates, supervises and organises the donation and clinical use of tissues, cells and human organs in Spain. On 18 March, an official statement suggested that each transplant programme should carry out an individualised assessment of the feasibility of performing a transplant based on the availability of ICU resources and free COVID-19 circuits, as well as the patient's clinical situation and need for transplantation. They recommended maintaining both - the critical donation and transplant activities offering transplants to patients in emergency situations, as well as to recipients difficult to transplant with a compatible organ during this period (e.g. hyperimmunised patients).

Since then, the incidence of cases in the community has decreased, the saturation situation of hospitals and ICUs was relieved, and COVID-19 free circuits started being available. At that point, each coordination and transplant team assessed the possibility of progressing towards normalisation of transplantations, guided by their corresponding Regional Coordination Transplant authority.

Fig. 2: Screening for SARS-CoV-2 on potential organ and tissue donors

In medical practice, some highly affected areas were forced to postpone their donation and transplant activities due to overburdened healthcare systems, exhausted ICU capacity, overworked healthcare workers and reduced personnel availability (according to the regional and local health authorities indications). Transmission of infection The risk of transmission of infection through transplantation is theoretical but cannot be completely excluded, therefore maximum caution is paramount. To our knowledge, no cases of COVID-19 in recipients have been reported that have their suspected origin in the donor, nor in the international literature, nor in the Spanish experience. To date, several case series of COVID-19 in solid organ transplant recipients have been reported in the literature. This information will allow a clinical description of the evolution of the disease in the specific context of the transplant, identify prognostic factors and evaluate the optimal therapeutic approach for these patients. The ONT is collecting centralised information of cases of COVID-19 in organ transplant recipients. The preliminary analysis shows greater severity of the disease in these patients compared to the general population.

Priority category Definition

Nevertheless, donation from confirmed or suspected cases that have recovered from COVID-19 will be admitted if the RT-PCR in a respiratory tract sample is negative after a minimum period of 21 days after resolution of symptoms (see Fig. 2). Recipient screening Prior to kidney transplant, recipients are contacted by phone to carry out a detailed medical history in order to assess possible contacts with COVID-19 patients and symptoms that may suggest an active infection.

Low Priority Clinical harm very unlikely if postponed 6 months • •

Level of evidence COVIDrecommendation

Donor selection During the initial and more critical pandemic phase, brain dead donors (DBD) and donors from controlled donation after circulatory death (cDCD) were selected, avoiding more complex forms of donation such as uncontrolled donation after circulatory death (uDCD). The ONT screening is based on RT-PCR (Reverse transcription polymerase chain reaction) in a respiratory tract sample (ideally lower respiratory tract) within 24 hours prior to organ retrieval. Confirmed cases of COVID-19, as well as with positive or non-conclusive RT-PCR screening, should be discarded as donors. Also, if the potential donor has high clinical suspicion of COVID-19, donation will be discarded regardless of the results of the laboratory tests.

Renal Transplantation

Non-urgent renal transplantation with living donor Renal transplantations with complex medical, surgical and immunological situations (e.g. desensitisation protocols, presence of donor specific antibodies), that require increased resource use, prolonged hospital stay, and/or more intense immunosuppression (e.g. Antithymocyte globulin [ATG] induction).

Expert advice Defer

Our hospital (University Hospital Puerta de Hierro in Madrid (ES) was one of the first to control the situation of COVID-19 in our region. This enabled us to start an early and progressive return to donor and transplant activities, as well as clinical solid organ transplant research as it was prior to the pandemic, from 11 May 2020. Patients on the elective waiting list were added to the previously mentioned critical cases. Regarding donors, expanded criteria on donation and donation-oriented intensive care programmes were implemented. In our current protocol, antigenic or serological tests and thoracic CT scans are included as a complement to the RT-PCR screening. During the critical phase of the pandemic, between March and April 2020, no kidney transplants were performed at our institution. Normal donation and transplant activities were resumed on 12 May 2020. The early start of our programme allowed us to perform nine kidney transplants in 15 days at our institution and lead the transplant activities of the region. Thanks to careful selection criteria of donors, transplant recipients and well-structured protocols, no complications were observed in the

Intermediate Priority Clinical harm possible if postponed 3-4 months but unlikely • Standard candidate to renal transplantation with expected long waiting time with deceased donor e.g. having a perfect full match kidney offered.

High priority Clinical harm very likely if postponed > 6 weeks

Expert advice Case-by-case discussion

Expert advice Perform Renal transplantation

•

Combined transplants (Heart and kidney, Liver and Kidney).

Emergency Life threatening situation •

Urgent dialysis-access problems

Expert advice Perform renal Transplantation

Fig. 3: Recommendations from the EAU Renal Transplantation Guidelines Panel applicable during the COVID-19 pandemic3

The screening for organ transplant recipients should also be based on the RT-PCR from a naso- and oropharyngeal sample. The ONT does not recommend antigenic or serological tests as an alternative or complement to RT-PCR screening. If a patient on the waiting list is a suspected or confirmed case of COVID-19, he/she should be excluded temporarily until complete recovery and a negative RT-PCR test after a minimum period of 21 days from resolution of symptoms. In each case, an individualised risk/benefit assessment should always be taken into account.

postoperative stay in any of the kidney transplants performed after the pandemic. It has been a challenge to face the situation during the critical stage of the pandemic, and even more to resume activities as they were prior to the pandemic. The health of our patients and that of the transplant team involved must be guaranteed, applying the appropriate preventive measures. Therefore, correct organisation and collaboration outside and inside the transplant institution are essential. References

Quick guide The EAU panel of experts has proposed a quick guide for the management of urological conditions during the current COVID-19 pandemic3. The specific recommendations for kidney transplantation are summarised in Fig. 1. Fig. 1: Impact on donation and transplant activity in Spain. Modified from the ONT web page2 EAU Section of Transplantation Urology (ESTU)

European Urology Today

When kidney transplants are performed, the stay in the operating theatre must be as short as possible, the transplantation team as small as possible (all members always work with adequate protection

1. Oderda M, Roupret M, Marra G, et al. The Impact of COVID-19 outbreak on uro-oncological practice across Europe: Which burden of activity are we facing ahead? Eur Urol. 2020 Jul;78(1):124–6. 2. The Spanish National Transplant Organization (ONT). http://www.ont.es/infesp/Paginas/Impacto_tx.aspx. 3. Ribal MJ, Cornford P, Briganti A, et al. EAU Guidelines Office Rapid Reaction Group: An organisation-wide collaborative effort to adapt the EAU Guidelines recommendations to the Coronavirus disease 2019 era. Eur Urol. 2020 Jul;78(1):21–8.

August/September 2020

Update from the Guidelines Office Virtual PIONEER Annual General Assembly Meeting focuses on sustainability of platform PIONEER at a glance - For a quick and comprehensive overview of the objectives and workflow of PIONEER checkout our latest infographic: PIONEER convened its 3rd Annual General Assembly Meeting with over 50 members gathering online to report on the progress of their work packages and to exchange ideas. In particular, attendees were asked to focus on how PIONEER can develop and implement an effective sustainability plan to ensure that the PIONEER platform is utilised well beyond the lifetime of the project. For more information on the progress of PIONEER read our summarised meeting report: https:// prostate-pioneer.eu/pioneer-virtual-general-assemblymeeting-may-2020/. The first PIONEER virtual hackathon was held on 11 May. The goal of the hackathon was to demonstrate the full potential of what we are building in PIONEER by exploring the PIONEER datasets with the ODHSI ATLAS toolbox; producing preliminary analyses using SAS Advanced Analytics, ATLAS and additional R functionalities; and setting goals for future data analyses. Goal achieved: Twelve hour hackathon with 62 volunteers engaged on seven channels, 31 concept sets created, 5 cohorts defined, 2 working R scripts and 4 SAS analyses created and the work has just begun! Look out for our studyathon in AutumnÂ 2020. First Data Sharing Agreement signed with external data contributor Active Biotech AB. Active Biotech AB has now shared data collected in a phase 3 randomised, double blind, placebo controlled study of tasquinimod in men with metastatic castrate-resistant prostate cancer. The data from 411 men was collected between 2011 and 2015 and has been shared to the PIONEER platform using the Central Data Sharing model. Launch of the EAU Guidelines Office IMAGINE project - IMpact Assessment of Guidelines Implementation and Education Adherence to national and international Guidelines is suboptimal throughout Europe. Even with the availability of comprehensive urological Guidelines, based on standardised and high-quality methodology, a significant gap still exists in terms of Guidelines application in clinical practice, hampering the delivery of high-quality urological care. Implementation science is the appropriate framework to identify the barriers to knowledge transfer, or more importantly, the optimum interventions to limit or overcome such barriers to improve Guidelines adherence allowing for the optimisation of healthcare resources whilst ultimately improving patient outcomes. In order to design interventions to increase adherence to Guidelines, we must first measure baseline adherence to Guidelines across Europe. To effectively measure baseline adherence, IMAGINE have launched a European wide multi-centre retrospective observational study in collaboration with European National Urological Societies endorsing the EAU Guidelines. IMAGINE has created a bespoke online data collection platform, to facilitate data capture. The audit will provide a robust map of guideline adherence to prioritised recommendations in Europe as well as a validated platform to map adherence to other recommendations in the future. We would like to take this opportunity to thank the European National Urological Societies for engaging in this collaborative project; together we can improve patient care. Guidelines Office Methods Committee The Guidelines Office Methods Committee, headed by professor Richard Sylvester, was set up some 6 years ago. This Committee was mainly responsible for providing high quality systematic review training to both the Guidelines Panel members and the Guidelines Associates involved in supporting the Guidelines. The Methods Committee also ensure that the methodological quality of all GO review activities can withstand any criticism by assessing protocols and

PIONEER infographic

processes prior to the start of any systematic review. They created, and continuously update, a systematic review handbook and numerous templates to facilitate the work of the Associates and the Guidelines Panels. In addition, the Methods Committee guide the Guidelines Office Board in all things methodological. The Methods Committee generally organise two face-to-face training sessions annually (COVID-19 dictated a pause this year), but at the onset of the project, professor Sylvester and his team spent almost every other weekend training Panels or groups of Associates to ensure that all involved in guidelines development had the required expertise. As of March 2020, Richard Sylvester decided to step down as the chairman of the Methods Committee. However, he will stay involved in the EAU GO as a member of the EAU NMIBC Guidelines Panel and will continue to support a number of special projects, amongst which several Individual Patient Data meta-analyses, which is an area where his passion and expertise clearly come together. He will also be available to provide assistance to the incoming chair of the Methods Committee, professor Nicolas Lumen.

Guidelines Office

August/September 2020

This panel consists of 8 urologists involved in the management of urethral stricture disease

representing academic and non-academic centres from different countries across Europe. This panel is assisted by 5 guideline associates who are conducting 2 systematic reviews to further improve the existing evidence for the present guidelines. The Stricture Guidelines will encompass recommendations not only about the treatment, but also on the proper diagnosis and follow-up. Not only males are affected by urethral strictures, but also females and transgender patients. Their management will be highlighted as well. The new Guideline will be published in March 2021.

Apply for your EAU membership online!

Without his enthusiasm, unsurpassed commitment and immense expertise in all things methodological, it would have been impossible to set up such a Committee and take such enormous strides. The EAU GO owe him a debt of gratitude for his invaluable contribution to the Guidelines. Professor Sylvester has also been nominated for an EAU Honorary Membership by the organization, in recognition of his long-term contributions to the urological field. All readers of EUT will, without a doubt, recall one of his seminal publications. The EAU Methods Committee will continue to play a key role within the Guidelines Office, under the guidance of Professor Lumen. Recently two young clinicians have also joined the Committee, Dr. Thomas Van Den Broeck (Leuven, BE) and Mr. Arjun K. Nambiar (Newcastle, UK) to complete the team. The need for EAU guidelines on urethral stricture management By Prof. Nicolas Lumen Almost every urologist will encounter patients with urethral strictures in his/her clinical practice. Adequate diagnosis, treatment and follow-up is necessary to optimise the outcomes of patients suffering from a stricture. Management of urethral strictures has been mainly driven by expert opinion rather than being based on evidence. Numerous narrative reviews have been published to guide urethral stricture management but well-conducted systematic reviews in the field of urethral stricture disease are very sparse.

Professor Richard Sylvester stepping down

the fact that randomised controlled trials have been conducted or are presently recruiting. It is of utmost importance to collect all the existing evidence in a systematic and transparent way in order to be able to produce clinical practice guidelines (CGPs) based on the best available evidence. These CGPs are aimed to improve the management of patients with urethral strictures. This is the key task of the EAU Urethral Stricture Panel.

Nevertheless, a lot on management of urethral stricture disease has been published in the past decade(s) and the evidence is increasing thanks to prospective data collection on urethral stricture management and due to

Becoming an EAU member now is fast and easy! In a matter of minutes, you can be part of the fast-growing, international community of healthcare professionals from within and beyond Europe. Sign up now to enjoy all the benefits the EAU membership can offer! Simply go to www.uroweb.org/membership and click on Membership to receive the best practices and the latest developments in urological research and care. Be an EAU member now!

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European Urology Today

Robotic intracorporeal neobladder configuration Studies demonstrate a trend towards decrease of operative times and complications in time Dr. Giuseppe Simone IRCCS Regina Elena National Cancer Institute Dept. of Urology Rome (IT) giuseppe.simone@ ifo.gov.it Bladder cancer is the 7th most commonly diagnosed cancer in males1. In approximately 25% of cases it is not confined to the mucosa or submucosa, making a radical treatment necessary. Radical cystectomy (RC), a complex and morbid procedure performed predominantly in elderly patients2, is the standard treatment for muscle-invasive bladder cancer. Robot-assisted radical cystectomy In the last decade, robot-assisted RC (RARC) has progressively emerged as a minimally invasive alternative to open RC (ORC), succeeding to replicate open surgical principles with encouraging oncologic and functional outcomes3,4. However, it remains a challenging procedure, which is moreover burdened with long operative times and the need for specific surgical skills which have raised concerns about its reproducibility, especially when an intracorporeal urinary diversion (ICUD) is planned. To date, extracorporeal (EC) urinary diversion (UD) remains the preferred approach at most centres4. The available randomised controlled trials comparing ORC vs RARC only included ECUD cases5,6. Notably, the benefits of RARC are likely to be minimised by performing an ECUD; moreover, the complications of RARC are mostly depending on UD. Therefore, we are conducting a randomised controlled trial aimed at comparing ORC vs RARC with ICUD [NCT03434132]. Neobladder techniques compared Several neobladder models have been described. In order to guarantee good compliance of filling and a complete voiding, all of them should have the following features: high capacity, low pressure, absence of reflux, and complete voiding by abdominal straining and perineal relaxation7.

Port placement and patient positioning In our centre, in a RARC procedure, ports are placed as shown in Fig. 1. An additional suprapubic miniport is placed to introduce double-J stents, while motorised articulated EndoGIA staplers (Covidien, Dublin, Ireland) are used through the 12-mm midclavicular ports. After RC and extended pelvic lymph node dissection, Trendelenburg position is reduced from 45˚ to 20˚. RC and pelvic lymph node dissection RARC is performed according to the technique described by Desai et al13. Distal ureters are cut between Hem-o-lok clips and sent for frozen section. The urethra is incised and the Foley catheter retracted in tight conjunction with the bladder neck and secured with Hem-o-lok clips to avoid urine spillage. A meticulous separate package extended pelvic lymph node dissection, including obturator, internal, external, common iliac, and presacral nodes, is performed as described for open surgery14. Choice of ileal segment to construct the neobladder For neobladder configuration approximately 42 cm of ileum is used (Fig. 2A). We choose the most sloped part of the ileum at a variable distance (minimum 20 cm) from the ileocecal valve in relation to the mesentery structure of each patient. Proximal ileum is divided using only one stapler load (60 mm), while isolation of the distal extremity of the ileal segment is carried out with a 6 to 8-cm deep section of the mesentery using two consecutive stapler loads (60 mm and 45 mm). The bowel loop to create the neobladder neck is basically identified about 13 cm proximal to the distal ileal section edge after ensuring a tension-free approach to the urethral stump (Fig. 2B). The proximal half of the loop is used to configure the left base and the dome of the neobladder. The remaining ileal segments are used to construct the rest of the neobladder (Fig. 2C): the right plate (8 cm of ileum), the neck configuration (10 cm), the left plate (8 cm), the dome (16 cm folded in a ‘‘U’’ configuration).

Detubularisation and configuration of the neobladder A 10-cm inverted U-shaped neobladder neck is Our ICUD, the PIB, first described in 1990 by Pagano et created with a stay suture approximating the ileum al8, meets the required symmetry of the pouch and is segment at 8 cm and 18 cm from the distal ileum perfectly allocated in the small pelvis in a true border. After detubularising the 8 cm of distal ileum orthotopic position. The double sequential orthogonal along the antimesenteric border, motorised stapler folding of the ileal segment generates a low-pressure, arms are introduced through the two branches of the high-capacity, spheroidal reservoir that maintains inverted U to approximate them and create the stable volume and maximal capacity at long-term neobladder neck (Fig. 2B). urodynamic evaluation9. One 60-mm or two sequential 45-mm stapler loads Robotic ICUD is performed with the intent of exactly are applied to detubularise and simultaneously reproducing the surgical steps of open “vescica ileale suture 10 cm (5 cm + 5 cm) of ileum, creating the Padovana”. Staplers are used to configure the neck of the neobladder. The remaining 24 cm of the ileum are subsequently detubularised starting at the neobladder neck and to suture the left aspect of the neobladder, as is conventionally done in open proximal ileal edge (Fig. 2D). The neobladder is then surgery9. The use of the staplers contributes to shaped as a triangle with 8-cm sides and the vertex reduced operative times, increasing at the same time at the neobladder neck (Fig. 2E and 2F). the risk of stone formation inside the urinary tract10. The 16-cm folded segment at the left horn is finally approximated to the proximal ileal cut point (right However, in our initial experience with the first 45 robotic PIBs, incidence of stone formation was 4.4%; neobladder horn) with a transverse fold, and the this data appears to be comparable with data inner borders of the created pouch are hand-sewn, completing the posterior aspect of the neobladder previously reported in Literature. Fontana et al11 (Fig. 2G and 2H). reported a 6% rate of stone formation in their titanium stapled ileal neobladder series, comparable Urethroneoneck and ureteroileal anastomosis to the 5.0% rate with conventionally hand-sewn reservoirs12. After cutting the reservoir at the most sloped part of the neoneck, the urethroileal anastomosis is performed with two end-knotted 2-0 Monocryl Visi-Black running sutures. A 22-French haematuria catheter is used, and the balloon is inflated with 5 ml of saline solution.

Fig. 1: Ports are placed in RARC procedure

European Urology Today

Ureters are passed through the posterior aspect of the neobladder and spatulated. Ureteroileal anastomoses are performed with 4-0 Monocryl interrupted sutures. Guidewires and 6/7-French double-J stents are inserted

References

Neobladder neck 5 cm

42 cm

5 cm

8 cm 24 cm

10 cm

8 cm 24 cm

10 cm 8 cm

8 cm

16 cm

8 cm

10 cm 8 cm

8 cm

16 cm

Fig. 2: Stages of neobladder configuration

through a prepubic miniport trocar. Finally, the anterior aspect of the neobladder is hand-sewn with two 2-0 barbed running sutures, with a serous– serous suture which has the intent of intussuscepting mucosal layers Diffusion of RARC: a problem of safety and reproducibility? Robotic intracorporeal neobladder was first described in 2003 by Beecken et al15. They performed an intracorporeal Hautmann pouch with an operative time of 8.5 h. Long operative time is a constant in the majority of reports about ICUDs, regardless of the type of reservoir performed16-19. Nevertheless, with increasing experience, the operative times for ICUD decreased18, boosting the diffusion of RARC. High-volume centres reported a stepwise reduction of operative times with good outcomes, tracking a step-by-step standardised technique3-20. Outcomes Regarding the safety and reproducibility of RARC with ICUD, we must consider the high morbidity of RC itself, regardless of surgical approach. Open RC is associated with a high risk of complications (> 60%), a considerable risk of high-grade complications (13–40%), and 90-d mortality up to 7%21. Moreover, orthotopic UD is associated with higher risks of perioperative complications22. Patient selection is then crucial to individuate the ideal candidates at the beginning of the RARC learning curve to keep the perioperative complication rates at the minimum23. Strict follow-up after discharge In the paper awarded with the Hans Marberger prize, we described the surgical technique of robotic intracorporeal Padua Ileal Neobladder and we demonstrated a significant decrease in operative time and a trend towards a significant decrease (p = 0.06) in complications, severe complications, and duration of hospital stay after the first 30 cases. Our results also highlight the need for strict follow-up after discharge due to a significant risk of developing complications by 6 months after treatment, some of which can be potentially life threatening24. With the aim of overcoming the available pentafectas that neglect functional outcomes, more recently we described a novel trifecta to provide a comprehensive measure of key outcomes of RARC with IC neobladder. This trifecta is likely to be a step towards a standardised measurement of key outcomes for this challenging surgery25. No definitive data exist in favour of robotic approach versus open. Notably, one of the only two prospective randomised trials on RARC versus ORC is ongoing in our centre and is in the recruitment phase (NCT03434132). We hope to provide robust evidence to various unanswered questions in the future.

1. Ferlay, J., et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer, 2013. 49: 1374. 2. Chang SS, Cookson MS, Baumgartner RG, et al. Analysis of early complications after radical cystectomy: results of a collaborative care pathway. J Urol 2002;167:2012–6. 3. Goh AC, Gill IS, Lee DJ, et al. Robotic intracorporeal orthotopic ileal neobladder: replicating open surgical principles. Eur Urol 2012;62: 891–901. 4. Hayn MH, Hussain A, Mansour AM, et al. The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 2010;58:197–202. 5. Bochner BH, Dalbagni G, Marzouk KH et al. Randomized Trial Comparing Open Radical Cystectomy and Robotassisted Laparoscopic Radical Cystectomy: Oncologic Outcomes. Eur Urol. 2018 Oct;74(4):465-471. doi: 10.1016/j. eururo.2018.04.030. Epub 2018 May 18. 6. Parekh DJ, Reis IM, Castle EP, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet. 2018 Jun 23;391(10139):2525-2536. doi: 10.1016/S01406736(18)30996-6. 7. Hautmann RE, Abol-Enein H, Hafez K, et al. Urinary diversion. World Health Organization (WHO) Consensus Conference on Bladder Cancer. Urology 2007;69:17–49. 8. Pagano F, Artibani W, Ligato P, Piazza R, Garbeglio A, Passerini G. Vescica ileale padovana: a technique for total bladder replacement. Eur Urol 1990;17:149–54. 9. Ferriero M, Simone G, Rocchegiani A, et al. Early and late urodynamic assessment of Padua ileal bladder. Urology 2009;73:1357–62. 10. Steven K, Poulsen AL. The orthotopic ileal neobladder: functional results, urodynamic feature, complications and survival in 166 men. J Urol 2000;164:288–95. 11. Fontana D, Bellina M, Fasolis G, et al. Y-neobladder: an easy, fast, and reliable procedure. Urology 2004;63:699– 703. 12. Turk TM, Koleski FC, Albala DM. Incidence of urolithiasis in cystectomy patients after intestinal conduit of continent urinary diversion. World J Urol 1999;17:305–7. 13. Desai MM, Berger AK, Brandina RR, et al. Robotic and laparoscopic high extended pelvic lymph node dissection during radical cystectomy: technique and outcomes. Eur Urol 2012;61:350–5. 14. Simone G, Papalia R, Ferriero M, et al. Development and external validation of lymph node density cut-off points in prospective series of radical cystectomy and pelvic lymph node dissection. Int J Urol 2012;19:1068–74. 15. Beecken WD, Wolfram M, Engle T, et al. Robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic ileal neobladder. Eur Urol 2003;44:337–9. 16. Pruthi RS, Nix J, McRackan D, et al. Robotic-assisted laparoscopic intracorporeal urinary diversion. Eur Urol 2010;57:1013–21. 17. Jonsson MN, Adding LC, Hosseini A, et al. Robot-assisted radical cystectomy with intracorporeal urinary diversion in patients with transitional cell carcinoma of the bladder. Eur Urol 2011;60: 1066–73. 18. Canda AE, Atmaca AF, Altinova S, et al. Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases. BJU Int 2012;110: 434–44. 19. Sala LG, Matsunaga GS, Corica FA, Ornstein DK. Robotassisted laparoscopic radical cystoprostatectomy and totally intracorporeal ileal neobladder. J Endourol 2006;20:233–6. 20. Collins JW, Sooriakumaran P, Sanchez-Salas R, et al. Robot-assisted radical cystectomy with intracorporeal neobladder diversion: The Karolinska experience. Indian J Urol 2014;30:307–13. 21. Novara G, Catto JW, Wilson T, et al. Systematic review and cumu-lative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015;67:376–401. 22. De Nunzio C, Cindolo L, Leonardo C, et al. Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort. Eur J Surg Oncol 2013;39:792–8. 23. Wilson TG, Guru K, Rosen RC, et al. Best practices in robot-assisted radical cystectomy and urinary reconstruction: recommendations of the Pasadena Consensus Panel. Eur Urol 2015;67:363–75. 24. Simone G, Papalia R, Misuraca L, et al. Robotic Intracorporeal Padua Ileal Bladder: Surgical Technique, Perioperative, Oncologic and Functional Outcomes. Eur Urol. 2018 Jun;73(6):934-940. doi: 10.1016/j. eururo.2016.10.018. Epub 2016 Oct 22. 25. Brassetti A, Tuderti G, Anceschi U, et al. Combined reporting of surgical quality, cancer control and functional outcomes of robot-assisted radical cystectomy with intracorporeal orthotopic neobladder into a novel trifecta. Minerva Urol Nefrol. 2019 Dec;71(6):590-596. doi: 10.23736/ S0393-2249.19.03566-5. Epub 2019 Oct 10.

August/September 2020

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

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

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 66

Case study No. 65 This 28-year-old man complains of poor urinary stream with a feeling of incomplete emptying since 6 months. He is a keen horse rider since the age of 14.

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

There is no history of injury, infection or urethral catheterisation. The maximum urinary flow is 10 ml/sec. Urethrography shows a bulbar urethral stricture. Discussion point • What are the options?

This 26-year-old female was referred with the provisional diagnosis of a renal abscess. She had presented with fever (38.6°C) and left flank pain for two days. A similar episode occurred five months earlier but subsided spontaneously. There is no medical history otherwise. Physical examination is completely unremarkable except for a slight left flank tenderness. Temperature is normal. C-reactive protein is 37.6 mg/l (reference < 5), leucocyte count 11.6 103/µl (reference 4-9). Other laboratory parameters (blood count, electrolytes, liver function tests) are normal.

A clear case for non-transsecting urethroplasty Comments by Dr. Alexei Zhivov, Moscow (RU)

To me, this is a clear indication for non-transecting anastomotic urethroplasty (NTAUP). This patient has no severe blunt perineal trauma which would speak against this technique. This stricture is short and anastomotic urethroplasty is more reliable in the long-term than augmentation with buccal

mucosa. Classic EPA may jeopardize urethral vascularization and lead to sexual complications. I would dissect the urethra from the cavernous bodies and mobilize it extensively, then I would cut it dorsally and perform NTAUP. If extensive fibrosis is present, I would switch to classic EPA.

One trial of optical urethrotomy is indicated Comments by Dr. Félix Campos, Santander (ES) This young gentleman presents with a midproximal bulbar stricture, of around 1 to 1.5 cm. If he did not undergo any previous endoscopic

treatment, I would discuss with him a therapeutic attempt by one direct vision internal urethrotomy. By doing so, we could assess the true length of the narrow segment and the degree of spongiofibrosis. On the other hand, if the patient prefers a more definitive treatment, I would suggest a urethroplasty as first option. Being a horse-rider could lead us to suspect a traumatic injury of the bulbar area, favouring a transecting anastomotic repair.

But with no clear history of perineal fall/stride injury nor a complete obliteration, I would suggest to perform first a circumferential mobilisation of the urethra and a dorsal stricturotomy first. This approach would allow us to assess the stricture and the degree of spongiofibrosis as this case could be suitable for a non-transecting bulbar urethroplasty. Discussion point • Which management and treatment is advisable?

Case study No. 65 continued By Dr. Amin Bouker If we zoom in on the affected area in the urethrogram we can clearly see that only a very short segment is almost obliterated (fig.1 and 2)). Since this young patient has a stricture length < 2 cm, it would be good to offer an endoscopic attempt which is effective in 50-60% of cases. When there is no severe spongiofibrosis due to straddle injury, dilatation over a guidewire is quite equal to direct vision internal urethrotomy. Moreover, if it fails, it will not compromise the vascularity of the urethra nor lengthen the stricture. In such

cases, I use an S-Curve urethral dilator set which provides dilatation from 8 to 20F (fig. 3). Then, further dilatation will be provided by a rigid cystoscopy which will assess the real length of the dilated stricture and check the absence of bladder damage and stones.

Figure 1

Figure 2

Help urologists collect CME credits and register your activity today! (Inter)National Urological Associations and the CME providers (organisers of CME activities) are invited and encouraged to send in requests to register nationally accredited CME activities or requests for European accreditation.

www.eu-acme.org August/September 2020

With a follow-up of 11 months, this young man is very happy and has a maximum flow rate of 26 ml/sec. If recurrence occurs, I would offer a non-transecting anastomotic bulbar urethroplasty (NTABU).

Figure 3

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

Any comments or suggestions on articles in EUT are welcomed at: EUT@uroweb.org

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

tebj@medisin.uio.no

Treatment of patients with uncomplicated gramnegative bacteremia Antibiotic overuse drives antibiotic resistance. Gram-negative bacteremia is a common infection that results in substantial antibiotic use. The objective of this study was to compare the clinical effectiveness of C-reactive-protein (CRP)–guided, 7-day, and 14-day antibiotic courses 30, 60, and 90 days after treatment initiation. The study was a multicentre, non-inferiority, point-of-care randomized clinical trial in adults hospitalized with gram-negative bacteremia, conducted in 3 Swiss tertiary care hospitals between April 2017 and May 2019 with follow-up until August 2019. Patients and physicians were blinded between randomization and antibiotic discontinuation. Adults (aged ≥ 18 years) were eligible for randomization on day 5 (±1 d) of microbiologically efficacious therapy for fermenting, gram-negative bacteria in blood culture(s) if they had been afebrile for 24 hours without evidence of complicated infection (e.g., abscess) or severe immunosuppression. Randomization was done in a 1:1:1 ratio according to an individualized CRP-guided, antibiotic treatment duration (discontinuation once CRP declined by 75% from peak (n = 170), fixed 7-day treatment duration (n = 169), or fixed 14-day treatment duration (n = 165)). The primary outcome was the clinical failure rate at day 30, defined as the presence of at least one of the following with a non-inferiority margin of 10%: recurrent bacteremia, local suppurative complication, distant complication (growth of the same organism causing the initial bacteremia), restarting gram-negative–directed antibiotic therapy due to clinical worsening suspected to be due to the initial organism, or death due to any cause. Secondary outcomes included the clinical failure rate on day 90 of follow-up.

CRP-guided antibiotic treatment and 7-day antibiotic treatment is non-inferior to 14-day treatment Among 504 patients randomized (median [interquartile range] age 79 [68-86] years; 306 of 503 [61%] were women), 493 (98%) completed the 30-day follow-up and 448 (89%) completed the 90-day follow-up. Median antibiotic duration in the CRP group was 7 (interquartile range 6-10; range 5-28) days; 34 of the 164 patients (21%) who completed the 30-day follow-up had protocol violations related to treatment assignment. The primary outcome occurred in 4 of 164 (2.4%) patients of the CRP group, in 11 of 166 (6.6%) of the 7-day group, and in 9 of 163 (5.5%) of the 14-day group (difference in CRP vs 14-day group, −3.1% [1-sided 97.5% CI, −∞ to 1.1]; p < .001; difference in 7-day vs 14-day group, 1.1% [1-sided 97.5% CI, −∞ to 6.3]; p < .001). By day 90, clinical failure occurred in 10 of 143 patients (7.0%) of the CRP group, in 16 of 151 (10.6%) of the 7-day group, and in 16 of 153 (10.5%) of the 14-day group. Investigators concluded that among adults with uncomplicated gram-negative bacteremia, 30-day rates of clinical failure for CRP-guided antibiotic treatment duration and fixed 7-day treatment were noninferior to fixed 14-day treatment. However, interpretation is limited according to the large non-inferiority margin compared with the low observed event rate, as well as the low adherence and the wide range of treatment durations in the CRP-guided group. Key articles

The primary outcome was the clinical failure rate at day 30.

Source: Effect of C-Reactive Protein–Guided Antibiotic Treatment Duration, 7-Day Treatment, or 14-Day Treatment on 30-Day Clinical Failure Rate in Patients With Uncomplicated Gram-Negative Bacteremia. A Randomized Clinical Trial. Elodie von Dach, Werner C. Albrich, Anne-Sophie Brunel, Virginie Prendki, Clémence Cuvelier, Domenica Flury, Angèle Gayet-Ageron, Benedikt Huttner, Philipp Kohler, Eva Lemmenmeier,Shawna McCallin, Anne Rossel, Stephan Harbarth, Laurent Kaiser, Pierre-Yves Bochud, Angela Huttner. JAMA. 2020;323(21):2160-2169. doi:10.1001/ jama.2020.6348

Sublingual bacterial vaccine proves effective in reducing the number of UTI episodes Recurrent urinary tract infections (R-UTIs) are very common amongst women, and alternatives to antibacterial prophylaxis are necessary. This study evaluates the effectiveness of a sublingual bacterial vaccine for the prophylaxis of R-UTIs.

Investigators conclude that the vaccine is an effective treatment for women with recurrent urinary tract infections The authors conducted a quasi-experimental pretest-posttest study of 166 women diagnosed with R-UTIs. Both before and after the start of the treatment with the vaccine, they analysed the total number of R-UTI episodes, the urine culture results, and the type and number of antibiotic packages consumed. Symptoms and urine cultures were evaluated 3, 6, 9, 12, 18, and 24 months after initiating the treatment with the vaccine. The mean time of follow-up after vaccination was 1.7 years. After vaccination, there was a 54.6% reduction in episodes of UTI, and a 56.2% reduction in positive urine cultures. At 3 months, 74.4% of the patients had no R-UTI; this rate fell to 68.1% at 6 months, 52.4% at 12 months, and 44.5% at 24 months. The cumulative probability of maintaining negative urine cultures was 76% at 3 months, 37% at 12 months, and 18% at 2 years. Investigators concluded that the use of a sublingual bacterial vaccine for the prophylaxis of R-UTIs in women is an effective treatment that contributes to a reduction in the number of UTI episodes.

Source: Analysis of the Efficacy of a Sublingual Bacterial Vaccine in the Prophylaxis of Recurrent Urinary Tract Infection. CarriónLópez P, Martínez-Ruiz J, Librán-García L, Giménez-Bachs J.M, Pastor-Navarro H, Salinas-Sánchez AS. Urol Int 2020;104:293–300. https://doi. org/10.1159/000505162

Prostatic borderline and in situ neoplasia associated with familial risk Although prostate cancer is common, knowledge about risk factors is sparse. Family history appears to be the strongest predictor with the EAU Guidelines suggesting earlier screening for those at risk. Several types of prostatic borderline or in situ neoplasia (PBISN), found during prostate biopsy, have been proposed to be precancerous lesions, including prostatic intraepithelial neoplasia, atypical small acinar proliferation and proliferative inflammatory atrophy. These are increasingly diagnosed but it is unclear if they also are also associated with an increased risk of invasive prostate cancer or death in other family members.

This study combined data from the Swedish population register and national censuses, the Swedish cancer register and the Swedish cause of death register. The updated research data set included 6,343,727 men of which 4,813,332 has first-degree relatives in the data set. Standardised incidence ratios (SIRs), standardised mortality ratios (SMRs) and lifetime cumulative risks of prostate cancer were calculated for men with different family history.

The lifetime risk of developing prostate cancer in a man with a first degree relative diagnosed with PBISN was 24% 238,196 men (3.8%) were diagnosed with prostate cancer and 5,756 men were diagnosed with PBISN, of which 3,272 men were classified as having borderline neoplasia and 2,484 as having in situ neoplasia. During 58 years of follow-up 1,165 patients originally found to harbour PBISN developed prostate cancer (17%). Having one first degree relative with PBISN was associated with a 70% increased risk of invasive prostate cancer (SIR 1.7; CI. 1.5-1.9) compared to men with no family history. A higher relative risk was seen in patients who received a diagnosis of PBISN at earlier ages, especially in patients diagnosed below 60 years of age. The lifetime risk of developing prostate cancer in a man with a first degree relative diagnosed with PBISN was 24%. Twice that in men with no family history of PBISN. There was a corresponding increase in death from prostate cancer in first degree relatives of men diagnosed with PBISN (SMR 1.7; CI. 1.3-2.2). Excluding those men who went on to develop prostate cancer did not substantially change the findings. It is clear that having a family history of PBISN is associated with an increased risk of invasive prostate cancer and prostate cancer death. This information should be shared with those affected and deserves careful consideration in risk adapted counselling and early detection strategies.

Source: Risk of invasive prostate cancer and prostate cancer death in relatives of patients with prostatic borderline or in situ neoplasia: A nationwide cohort study. Xu X, Fallah M, Tian Y, et al.

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

Ninety-three patients were included. Twenty-eight (30%) patients had DDR mutations, most frequently in ATM (8.6%), BRCA2 (7.5%) and CDK12 (4.3%) genes. There were no statistically significant differences in baseline characteristics between the groups. The median age was 68 years and 55.9% of patients had previously received taxane-based chemotherapy.

...evidence-based guidelines on sequencing of these therapies are lacking, and biomarkers are needed to help guide clinicians DDR+ patients showed prolonged OS (median 36.3 versus 17.0 months; HR 2.29; CI 1.21-4.32. p = 0.011). DDR+ patients more frequently completed all six radium-223 injections (79% versus 47%; p = 0.047). Secondary endpoints, TAP and TST in the DDR+ and DDR- patients was 6.9 versus 5.8 months (HR = 1.48; p = 0.146), and 8.9 versus 7.3 months (HR = 1.58; p = 0.083), respectively favouring the DDR+ group, but this was not statistically significant. No difference in biochemical responses were seen. This was a retrospective study, and as such can be no more than hypothesis generating, but suggests a role for radium-223 in patients harbouring DND damage repair defects.

Source: Impact of DNA damage repair defects on response to radium-223 and overall survival in metastatic castration-resistant prostate cancer. Van der Doelen MJ, Velho PI, Slootbeek PHJ, et al. Euro J Cancer. 2020; 136: 16-24 .

Cancer. 2020; doi.org/10.1002/cncr.33096.

DNA damage repair defects and response to Radium-223; Is there a link? Several life-prolonging therapies have been registered for treatment of patients with metastatic castration resistant prostate cancer (mCRPC). However, evidence-based guidelines on sequencing of these therapies are lacking, and biomarkers are needed to help guide clinicians. Radium-223 is a therapeutic option for mCRPC patients with symptomatic bone metastases and no evidence of visceral metastases. It is an alpha emitter, that selectively binds to areas of increased bone turnover in bone metastases and emits high-energy alpha particles of short range (< 100 µm) causing double-strand DNA breaks. Normally repaired by DNA damage repair (DDR) genes by homologous recombination. Therefore, mutations in homologous recombination genes, such as BRCA1, BRCA2, PALB2 or other genes constituting the DNA damage machinery, such as ATM, ATR, or CHEK2 might make cells more vulnerable to radionucleotides such as radium-223.

Kidney transplant recipient can mount immune response to COVID19 The COVID-19 pandemic has had implications for organ transplantations. Important questions have remained largely unanswered so far. One of them was whether kidney transplant recipients are capable of mounting an effective anti-SARS-CoV-2 adaptive immune response despite chronic immunosuppression. In this study, the authors tried to answer this question by analysing the peripheral blood cell surface and the intracellular cytokine phenotype by flow cytometry along with serum antibody testing of 18 kidney transplant recipients with active COVID-19 infection and 36 matched transplant recipients without COVID-19.

Empirical reductions in immunosuppressive therapy for all kidney transplant recipients with active COVID-19 may not be required

A significantly lower total of lymphocyte cells and circulating memory CD4+ and CD8+ T cells were This retrospective study assessed DDR mutation status seen in the COVID-19 subjects. Those individuals using next-generation sequencing, in mCRPC patients also had fewer anergic and senescent CD8+ T cells, treated with radium-223. Patients with visceral but no differences between the two groups were metastasis or prior treatment with radionucleotides, noted neither in exhausted CD8+ T cells nor in any PARP inhibitors or platinum chemotherapy prior to of the CD4+ T cell subsets. Furthermore, greater initiation of radium-223 were excluded. Patients were frequencies of activated B cells were found in the grouped by presence (DDR+) or absence (DDR-) of COVID-19 patients. 16 out of the 18 COVID-19 subjects (likely) pathogenic somatic or germline aberrations in tested for anti-SARS-CoV-2 serum antibodies DDR genes. They assessed overall survival (OS), showed positive IgM or IgG titers. Additional biochemical responses (PSA and ALP), time to ALP analyses showed no significant correlations progression (TAP), and time to initiation of subsequent between immune phenotypes and degrees of systemic therapy (TST) between DDR groups. COVID-19 disease severity.

EAU EU-ACME Office

European Urology Today

August/September 2020

Dr. Francesco Sanguedolce Section editor Barcelona (ES)

fsangue@ hotmail.com

Thus, these reported findings indicate that immunosuppressed kidney transplant recipients admitted to the hospital with acute COVID-19 infection can mount SARS-CoV-2-reactive adaptive immune responses. One conclusion might be that empirical reductions in immunosuppressive therapy for all kidney transplant recipients with active COVID-19 may not be required.

Source: Evidence of potent humoral immune activity in COVID19 infected kidney transplant recipients. Susan Hartzell, Sofia Bin, Claudia Benedetti, Meredith Haverly, Lorenzo Gallon, Gianluigi Zaza, Leonardo V Riella, Madhav C Menon, Sander Florman, Adeeb H Rahman, John M Leech, Peter S Heeger, Paolo Cravedi Am J Transplant, 2020 Aug 12, doi: 10.1111/ajt.16261. Online ahead of print

Synergistic effect of enhanced recovery and prehabilitation pathways in robot-assisted prostatectomy Enhanced recovery after surgery (ERAS) regimens have demonstrated their benefits for improving perioperative outcomes after major oncology surgeries. In the urology field, in which mainly data exist for radical cystectomy, few reports of ERAS in robot-assisted radical prostatectomy have been published and no publication from the ERAS Society gives guidance to urologists performing prostate cancer surgery. In addition to ERAS, prehabilitation by promoting patient education and counselling could also play an important role in improving postoperative recovery and return to normal life. In the present series, the authors have assessed the impact of both ERAS and prehabilitation on per- and postoperative outcomes after robotic radical prostatectomy. They included 507 consecutive patients operated between 2016 and 2019. The implementation of ERAS and prehabilitation pathways was progressive, and 3 patient sub-groups were compared as follows: ERAS-/PreHab-, ERAS+/PreHab-, ERAS+/ PreHab+. The ERAS programme was extrapolated from an existing radical cystectomy programme. The prehabilitation pathway consisted of a 1-day programme 2-3 weeks before surgery including various stakeholders’ interventions such as physiotherapist, specialised nurses (pain, oncology), dietetician, psychologist. The cost of this journey was 250 euros per patient. Main endpoints were the duration of hospital stay, peroperative parameters, readmission rate, and overall costs. The authors found that length of stay was significantly reduced by implementing ERAS and PreHab pathways (1.6 days versus 3.5 days if ERAS only, versus 4.7 days if ERAS-/PreHab).

The authors found that length of stay was significantly reduced by implementing ERAS and PreHab pathways This reduction in hospital stay was obtained without compromising postoperative outcomes as the readmission and morbidity rates were not altered while continuously decreasing length of stay. In a multivariable analysis taking into account age, BMI, ASA score, operative time, and surgeon, both ERAS and PreHab pathways were independently correlated with a lower risk of prolonged length of stay. The odds ratio for prolonged stay was 0.144 in ERAS+/ PreHab- patients and 0.025 in ERAS+/ PreHab+patients (p<0.001). Overall costs significantly decreased when ERAS and PreHab pathways were combined. With the implementation of ERAS, costs Key articles

August/September 2020

were reduced by 10%. Cost saving continued decreasing with the implementation of PreHab despite the added preoperative 1-day programme cost (-11.6%). The cost reduction was mainly achieved by a reduction in the hospital stay without an increase in the readmission rate. ERAS and PreHab did not affect the length of stay at readmission or the delay between surgery and readmission. Although the generalisability of these findings may be limited by the differences in national health care systems and local economic pressures, especially when assessing the perioperative costs, this study report notable improvements in key perioperative outcomes through the use of ERAS and PreHab pathways. There was also a strong suggestion of synergistic improvements after the addition of PreHab to standard ERAS protocol. These findings highlight that the optimisation of perioperative care pathways plays a pivotal role in major oncology surgery, and not only in colorectal and bladder cancer surgery. Prehabilitation might change patients’ interpretation of their surgery by improving their psychological perception of the treatment and by reducing the risk of regret about treatment choice. Standardisation of these perioperative protocols is critically needed, as well as more patient-reported outcomes and satisfaction assessment studies, in order to better define our patients’ definition of quality and to adapt pre- and post-surgery pathways based on patient-centered experience, and not only on quantitative measures.

Source : A combination of enhanced recovery after surgery and prehabilitation pathways improves perioperative outcomes and costs for robotic radical prostatectomy. Ploussard G, et al. Cancer 2020

Kidney transplant recipients with COVID-19 carry higher risk of AKI Kidney transplant recipients (KTR) share unique characteristics, including disease vintage, immunosuppression and single functioning kidneys. The authors of this study reviewed the literature in a preliminary analysis to assess the impact of the coronavirus disease 2019 (COVID-19) on outcomes in KTR compared to non-transplant patients. Published information in peer-reviewed journals from 1 January 2020 to 24 April 2020 was evaluated with available data on acute kidney injury (AKI), renal replacement therapy (RRT), and intensive care unit (ICU) stay and death rate. The study compared clinical outcomes for KTRs vs non-transplant recipients with COVID-19.

The risk of death may not be significantly different between kidney transplant recipients and the general population A total of 19 published articles on studies were reviewed, studies which included a total of 88 KTR and 5342 non-transplant patients. The sample size varied between 2 and 2634. Mean age was 58.6 years vs 58.9 years in KTR vs non-transplant patients. Patient-level incidence of acute kidney injury (27.5% vs 13.3%, p< .001), RRT (15.4% vs 3.3%, p < .001), ICU stay (34.1% vs 15.1%, p< 0.001) and death (22.7% vs 16.2%, p= .10) was higher in kidney transplant recipients, representing relative risks of 2.06 (1.44, 2.96), 4.72 (2.62, 8.51), 2.25 (1.67, 3.03), and 1.41 (0.95, 2.08), respectively. These early results suggest that kidney transplant recipients are at a significantly higher risk of AKI, RRT and ICU stay from SARS-CoV-19 infection compared to the general population. However, the risk of death may not be significantly different.

Source: Early Report on Published Outcomes in Kidney Transplant Recipients Compared to Nontransplant Patients Infected With Coronavirus Disease 2019. Fahad Aziz, Didier Mandelbrot, Tripti Singh, Sandesh Parajuli, Neetika Garg, Maha Mohamed, Brad C Astor, Arjang Djamalict. Transplant Proc 2020 Jul 13; S0041-1345(20)32626-9, doi: 10.1016/ j.transproceed 2020. Online ahead of print.

Pentafecta after robotassisted radical cystectomy The global use of robot-assisted radical cystectomy (RARC) for muscle-invasive bladder cancer treatment has steadily increased during the last two decades. Several studies have demonstrated that the robotic approach could improve some perioperative outcomes such as blood loss and complication rates. However, high level of evidence is missing. In this multi-institutional Korean series, the authors have defined the success of RARC by a revised version of pentafecta. Five criteria were used as follows: negative soft tissue surgical margins, more than 15 lymph nodes retrieved, no major grade 3-5 Clavien complications at 3-month, no clinical recurrence, no uretero-enteric strictures. They included consecutive patients from 11 institutions who underwent RARC between April 2007 and May 2019. The KORARC database is a planned web-based electronic database originating from the Korean Society of Endourology and Robotics. Overall, 730 patients were included in the present analysis. Mean follow-up was 30 months. Only 16.7% of patients received neoadjuvant chemotherapy.

Five criteria were used as follows: negative soft tissue surgical margins, more than 15 lymph nodes retrieved, no major grade 3-5 Clavien complications at 3-month, no clinical recurrence, no uretero-enteric strictures The pentafecta was achieved in only 28.5% of patients. Patients with RARC-pentafecta attained had a lower ASA score and a lower rate of diabetes mellitus compared with patients who did not achieve RARC-pentafecta. Mean console time was 310 minutes and an orthotopic neobladder was chosen as urinary diversion in 37.7% of the cases. Mean blood loss was 516 cc (transfusion rate: 15%). Major complications were noted in 21.1% of patients including gastrointestinal (26%), infectious (25%), and urinary (23%) complications. Ureterointestinal strictures (8.1%) occurred mainly between 3 and 9 months after the surgery. Neobladder, intracorporeal reconstruction, a lower transfusion rate, a nerve-sparing technique, were correlated with the achievement of pentafecta. Fewer complications and readmissions were reported in the pentafecta sub-group. The most frequent reason for readmission was febrile urinary tract infection. A positive soft tissue margin was noted in 3% of cases. Mean lymph node yield was 19. Pathological grades and stages did not differ between patients who attained pentafecta and those who did not. The 5- and 10-year overall survival rates were 78.6% and 61.1%, respectively. ASA score, diabetes mellitus, diversion type, pathological T and N stages, and pentafecta attainment were significant predictors for overall death. This series confirmed the high risk of complications after radical cystectomy, even after a minimally invasive surgical approach, and the difficulty to achieve perfect oncologic and functional outcomes in a large proportion of patients. The present cohort involved 21 surgeons and therefore, represents an interesting source of real-world clinical data in the emerging field of RARC. The use of validated easy-to-use criteria such as this pentafecta may help to compare different series and to improve patient counseling and information before surgery.

Source: Oncological outcome according to attainment of pentafecta after robot assisted radical cystectomy among bladder cancer patients using KORARC database (730 multicenter robot radical cystectomy database).Oh JJ, Lee S, Ku JH, et al. Published online ahead of print, 2020 Jul 18]. BJU Int. 2020;10.1111/bju.15178. doi:10.1111/bju.15178

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com

Retzius-sparing robotassisted radical prostatectomy: Confirmed durable improvement in urinary function Retzius-sparing surgery has been suggested to improve early continence recovery after robotassisted radical prostatectomy (RARP). Main comments limiting this technique adoption were the concerns about the risk of increased surgical margins and the lack of long-term differences in urinary function. In the present series, the authors reported the comparison between 70 standard RARP (S-RARP) and the subsequent 70 Retziussparing RARP (RS-RARP) cases operated on by a single surgeon. The RS-RARP technique has been standardised and described. For this study, 140 consecutive patients were included, the aim was to mitigate the potential impact of learning curve and surgeon experience on outcomes. The 70 RS-RARP were compared with the 70 preceding S-RARP.

The regression analysis confirmed that RS-RARP was an independent predictor for better 12-month continence results All outcomes were prospectively collected, and long-term functional outcomes were assessed using the EPIC-CP questionnaire. Time to continence and standard oncological outcomes were also reported. Median follow-up was 12 months for RS-RARP versus 46 months for S-RARP. No significant differences were seen in pre-operative features except for PIRADS and Gleason grade which were higher in the S-RARP cohort. Console time, length of stay and complication rates were comparable in both cohorts. Blood loss was lower in RS-RARP (-150 cc, mean). Nerve-sparing procedures were performed in 84.3% and 74.3% of RS-RARP and S-RARP, respectively. No difference was reported in pathological parameters on surgical specimens. However, RS-RARP had fewer nonfocal positive surgical margins (7.1% versus 8.6%, p = 0.016) compared with S-RARP. Most positive margins were anterior in RS-RARP (54%) and posterior for S-RARP. Biochemical follow-up did not differ among groups. There was no benefit from RS-RARP when considering the 12-month continence rates defined by zero pad. However, when continence was defined as zero to one safety pad, RS-RARP was associated with improved outcomes (95.7% versus 85.7%, p = 0.042). Total EPIC-CP scores were better for RS-RARP at 9 and 12 months. Potency rates were comparable in both cohorts (63-65%). The regression analysis confirmed that RS-RARP was an independent predictor for better 12-month continence results (hazard ratio 0.18, 95% CI: 0.05-0.67). The other factors independently correlated with continence were the pre-operative EPIC-CP score and the nerve-sparing procedures. Pentafecta was achieved in half the patients without difference between the two groups. Mean time to continence was 59 and 182 days in the RS-RARP and S-RARP groups (p < 0.001). The rate of positive margins was high (one third) in a population of patients having a pT2 disease in two thirds of the cases. Although no difference was seen regarding the overall surgical margin rates in both cohorts, it would have been interesting to look at potential differences between surgical approaches according to the pathological stage of the disease (surgical margin rates in pT2 and pT3-4 cases).

EAU EU-ACME Office

European Urology Today

Prof. Serdar Tekgül Section Editor Ankara (TR)

serdartekgul@ gmail.com

The main limitations of this study were the lack of randomisation, the single-surgeon, singleinstitution design, and the potential impact of surgeon experience on outcomes due to noncontemporary surgeries. Moreover, no validated questionnaire was used for assessing the potency recovery. However, despite these concerns, this series suggested that RS-RARP was safe in terms of short-term oncology outcomes and might improve early and mid-term urinary continence as compared with S-RARP.

Source: Retzius-sparing robot-assisted radical prostatectomy leads to durable improvement in urinary function and quality of life versus standard robot-assisted radical prostatectomy without compromise on oncologic efficacy: single-surgeon series and step-by-step guide. Egan J et al. Eur Urol 2020

School toileting environment, bullying, and lower urinary tract symptoms (LUTS) in adolescent and young adult girls The aim of this investigation was to examine whether the school toilet environment at age 13, including bullying at toilets, is associated with female LUTS at ages 13 and 19, as little is known about the association among school toilet environment, voiding behaviours, and lower urinary tract symptoms (LUTS) in adolescent girls. The sample comprised 3,962 female participants from the Avon Longitudinal Study of Parents and Children (ALSPAC). At age 13, participants reported on 7 school toilet environment characteristics and a range of LUTS items. At age 19, participants completed the Bristol Female Lower Urinary Tract Symptoms (ICIQ-BFLUTS) questionnaire.

This is the first examination of associations between school toilets and LUTS All toilet environmental factors were associated with at least one LUTS outcome at age 13. Holding behaviour was associated with all school toilet environmental factors, with odds ratios (ORs) ranging from 1.36 (95% CI: 1.05, 1.76) for dirty toilets to 2.38 (95% CI: 1.60, 3.52) for feeling bullied at toilets. Bullying was associated with all daytime LUTS symptoms and nocturia; ORs ranged from 1.60 (95% CI: 1.04, 2.07) for nocturia to 2.90 (95% CI: 1.77, 4.75) for urgency. Associations between age 13 school toilets and age 19 LUTS were in the same direction as age 13 LUTS. This is the first examination of associations between school toilets and LUTS. Toileting environments were cross-sectionally associated with LUTS in adolescent girls. The authors conclude, that while further work is needed to determine whether these associations are causal, school toilet environments are modifiable and thus a promising target for LUTS prevention.

Thulium laser transurethral vaporesection versus transurethral resection of the prostate for men with LUTS or urinary retention (UNBLOCS): an RCT The authors aimed to investigate transurethral resection of the prostate (TURP) versus Thulium laser transurethral vaporesection of the prostate (ThuVARP) in men with lower urinary tract symptoms or urinary retention secondary to benign prostatic obstruction. In this randomised, blinded, parallel-group, pragmatic equivalence trial, men in seven UK hospitals with bothersome lower urinary tract symptoms or urinary retention secondary to benign prostatic obstruction were randomly assigned (1:1) at the point of surgery to receive ThuVARP or TURP. Patients were masked until follow-up completion. All trial surgeons underwent training on the ThuVARP technique. Co-primary outcomes were maximum urinary flow rate (Qmax) and International Prostate Symptom Score (IPSS) at 12-months post-surgery. Equivalence was defined as a difference of 2·5 points or less for IPSS and 4 ml/s or less for Qmax.

The investigators conclude, that TURP and ThuVARP were equivalent for urinary symptom improvement (IPSS) 12-months post-surgery, and that TURP was superior for Qmax 410 men were randomly assigned to ThuVARP or TURP, 205 per study group. TURP was superior for Qmax (mean 23·2 ml/s for TURP and 20·2 ml/s for ThuVARP; adjusted difference in means -3·12, 95% CI -5·79 to -0·45). Equivalence was shown for IPSS (mean 6·3 for TURP and 6·4 for ThuVARP; adjusted difference in means 0·28, -0·92 to 1·49). Mean hospital stay was 48 h in both study groups. 91 (45%) of 204 patients in the TURP group and 96 (47%) of 203 patients in the ThuVARP group had at least one complication. The investigators conclude, that TURP and ThuVARP were equivalent for urinary symptom improvement (IPSS) 12-months post-surgery, and that TURP was superior for Qmax. Anticipated laser benefits for ThuVARP of reduced hospital stay and complications were not observed. The trial is registered with the ISRCTN Registry, ISRCTN00788389.

Source: Thulium laser transurethral vaporesection of the prostate versus transurethral resection of the prostate for men with lower urinary tract symptoms or urinary retention (UNBLOCS): a randomised controlled trial. Hashim Hashim, Jo Worthington, Paul Abrams, et al, UNBLOCS Trial Group. Lancet 2020 Jul 4;396(10243):50-61. doi: 10.1016/ S0140-6736(20)30537-7.

Diagnostic assessment of LUTS in men considering prostate surgery: A noninferiority RCT of urodynamics in 26 hospitals Prostate surgery can improve lower urinary tract symptoms (LUTS) by relieving bladder outlet obstruction (BOO). However, surgery is less effective without BOO, or if detrusor underactivity is present. Urodynamics (UDS) can identify BOO and measure detrusor activity, but evidence in clinical practice is lacking.

Source: School toileting environment, bullying, and lower urinary tract symptoms (LUTS) in a population of adolescent and young adult girls: Preventing Lower Urinary Tract Symptoms Consortium (PLUS) analysis of Avon Longitudinal Study of Parents and Children (ALSPAC). David A The authors initiated Randomised Evaluation of Shoham, Zhenxun Wang, Sarah Lindberg, et al. Assessment Methods (UPSTREAM) aimed to Urology. 2020 Jul 14;S0090-4295(20)30827-X. doi: 10.1016/j.urology.2020.06.060.

Key articles

evaluate whether a care pathway including UDS would reduce surgery without increasing urinary symptoms.

Participants were randomised (1:1) to routine care (RC) diagnostic tests, or RC plus UDS. The primary outcome was the International Prostate Symptom Score (IPSS) 18 months after randomisation, with a noninferiority margin of 1 point. Urological surgery rates were a key secondary outcome.

The authors initiated Randomised Evaluation of Assessment Methods (UPSTREAM) aimed to evaluate whether a care pathway including UDS would reduce surgery without increasing urinary symptoms

Accordingly, if a salvage focal treatment is deemed to be an option, the gold standard for the selection of patients is the template transperineal prostate mapping (TTPM). Recently, a British team reviewed their cohort of patients (n = 145) who underwent the TTPM from 2007 to 2014. FDG or Choline PET/CT and bone scans were the imaging tools used to rule out distant disease; patients were deemed suitable for any form of focal ablative salvage therapy (FAST) as long as there were a single lesion, or multiple lesions in one lobe, bilateral focal lesion or even bilateral multifocal lesions with secondary ones being Gs 3+3 tumours involving < 3mm of the affected cores. Interestingly, either the index lesion grade or the risk-group of the recurrence were not considered as criteria to rule out/in the suitability for the FAST.

820 men (median age 68 yr) were randomised (393 and 427 in the RC and UDS arms, respectively). The UDS arm showed noninferiority of the mean IPSSs (UDS 12.6; RC 13.1; adjusted difference at 18 months -0.33 [95% confidence interval {CI} -1.47, +0.80]). In the UDS arm, 153/408 (38%) received surgery compared with 138/384 (36%) in the RC arm (adjusted odds ratio 1.05; 95% CI 0.77, 1.43). A total of 428 adverse events (UDS 234; RC 194) were recorded, with related events similar in both arms and 11 unrelated deaths.

According to this definition, the authors found that 75.9% of the patients were suitable for a form of FAST: quadrant ablation was the most common form of FAST (40.7%), followed by hemiablation and bilateral focal (14.5% each), and focal on index lesion (6.2%). Unfortunately, the authors did not provide data regarding which ablative treatments were used (HIFU, cryosurgery, etc.), as well as the oncologic and functional outcomes; hopefully, these important data will soon be published in a further publication.

In this population, the UDS randomised group was noninferior to RC for the IPSS but did not reduce surgical rates. The authors conclude, that routine use of UDS in the evaluation of uncomplicated LUTS has a limited role and should be used selectively.

Source: Intra-prostatic cancer recurrence following radical radiotherapy on transperineal template mapping biopsy: implications for focal ablative salvage therapy. Kanthabalan A, Arya M, Freeman A,et al.

Source: Diagnostic assessment of lower urinary tract symptoms in men considering prostate surgery: A noninferiority randomised controlled trial of urodynamics in 26 hospitals. Marcus J Drake, Amanda L Lewis, Grace J Young, et al. Eur Urol. 2020 Jun 29;S0302-2838(20)30431-0. doi: 10.1016/j.eururo.2020.06.004. Online ahead of print.

Focal salvage ablative treatment for locally recurrent prostate cancer after radiotherapy: Selecting patients based on template biopsy Biochemical recurrence after radical radiotherapy for clinically localised prostate cancer occurs mostly within 8 years after treatment. If extra-prostatic lesions are ruled out, treatment options span from observation to androgen deprivation therapy (ADT); although the latter could be considered as overtreatment, it has long been considered the option of choice, mostly because of the high risk of complications that salvage radical prostatectomy carries. In the last two decades, ablative treatments have been gaining consideration because of their relatively safer profiles than radical treatments; nevertheless, their oncologic efficacy is still under debate, regardless of the technological improvements that have progressively been introduced. However, while ablation therapies as primary treatment may find several opponents and critics, in the setting of salvage treatment after failure of radiotherapy the controversies are blunter.

...either the index lesion grade or the risk-group of the recurrence were not considered as criteria to rule out/in the suitability for the FAST A further evolution of the salvage ablative treatments consists in targeting the intra-prostatic recurrence(s), by sparing a variable proportion of the prostatic gland according to the presumed extension of the recurrent lesion(s); this approach has been fostered with the advent of multiparametric MRI, although it is not yet known whether the aftermath of the radiations may alter the ability of the MRI to detect the recurrent lesions.

The Journal of Urology® (2019), doi: 10.1097/ JU.0000000000001201

The never ending issue of Ureteral Access Sheath safety: New long term evidence There are multiple studies supporting the use of the ureteral access sheath (UAS) during upper urinary tract manipulation for the treatment of urinary stones, especially when the retrograde intrarenal surgery (RIRS) is the selected approach: benefits include better visibility, reduced intrarenal pressure, multiple entrances of ureteroscope, quicker surgery and even improved stone-free rates. On the other side, insertion of UAS may cause a variable degree of ureteric injury in most of the cases (up to 80%); considering also the arguments regarding potential reduced blood supply in the ureteric wall for the compression of the device (especially when using larger UAS), concerns have been raised about risks of long-term side effects, specifically the ureteric stenosis. To reduce the risk of ureteric injury due to UAS, some centres have adopted a protocol in which stent insertion is done routinely when a RIRS is planned for larger stones and the insertion of a UAS is foreseen. Moreover, the miniaturisation of the latest generation of flexible ureteroscopes has reduced the calibre of UAS needed. Recently, two American centres have retrospectively reviewed their series of ureteroscopies (URS) for the treatment of urinary stones in order to find out the overall prevalence of post-URS hydronephrosis in the short and long-term, based on routine imaging performed at 8-week post-op and follow-up according to the former radiological findings. Clinical, operative and stone characteristics at baseline were recorded for the 1,332 patients treated between 2012 and 2016 at the two sites by mean of URS; interestingly, UAS were used in the majority of the cases (n = 1039; 78%), predominantly consisting of a 12/14 Fr (95.7% of the subgroup) as it could fit most of the available equipment. Stents were placed pre-operatively in 34.8% of the cohort; on the other hand, a post-operative stent was performed in more the 90% of the patients (n = 1205). At the 8-week follow up imaging time-point, hydronephrosis was observed in 127 patients (12%), mostly characterised as mild (74%) and severe in only 3.9%: factors associated to the hydronephrosis

EAU EU-ACME Office

European Urology Today

August/September 2020

Prof. Oliver Hakenberg Section Editor Rostock (DE)

While awaiting evidence from clinical practice, several “in vitro” experiments have been conducted to unveil their advantages. One of the latest publications evaluates the capabilities of the Thulium-fibre laser (TFL) regarding fragmenting/ dusting the different types of urinary stones and evaluates its effect on the debris composition.

Oliver.Hakenberg@ med.uni-rostock.de

Samples of the most common urinary stone types -including mono- and dihydrated calcium oxalate, uric acid, carbapatite, struvite, brushite, and cysteine- were retrieved from a large bio-stone bank and with > 90% of composition purity and equivalent sizes. Urinary stone samples were analysed morphologically and constitutionally by using electronic microscopy and infrared spectroscopy, respectively, at baseline and after lasertripsy.

included pre-and post-stenting, larger stone burden and longer operative time, in other words, UAS insertion seemed not to have contributed to this event. Most of these patients were followed up at 1 year post-URS, although 36 patients (28.3%) were missed at follow up. In most of cases (83.5%), the hydronephrosis resolved spontaneously, while obstruction due to documented stricture was observed in just 7 patients, being < 1% of the overall cohort.

...factors associated to the hydronephrosis included pre-and post-stenting, larger stone burden and longer operative time... A further subgroup of 205 patients received additional imaging and were followed up at 1 year, even though they were without hydronephrosis at the 8-week time point. Of these, 12 presented a de novo hydronephrosis but the authors failed to report the causes of the obstructions, and therefore it remains unknown whether further strictures developed or not. Overall, this paper shows once more the safety of the use of UAS, with or without pre-stenting and regardless of the employment of a larger calibre with respect to the 9.5-11 Fr or 10/12 Fr, which are currently the more popular UAS models in referral centres.

Source: The impact of ureteral access sheath use on the development of abnormal postoperative upper tract imaging after ureteroscopy. J.L Cooper, N. François, M W Sourial, et al. J Urol. 2020 May 27;101097JU0000000000001147. doi: 10.1097/JU.0000000000001147. Online ahead of print.

The lasertripsies with the TFL were conducted by putting the stone samples in glass cuvettes and applying a 0.05 J pulse energy, 320 Hz pulse frequency, and 200 mcs pulse duration, until a total of 2400 J energy was delivered. Dust was produced in all the stone type samples, though at different proportion and with a variable mean width of dust particles, with smaller particles produced in case of uric acid stones (116 µm) and larger ones formed by monohydrate calcium oxalate (254 µm). Similarly to what observed with the holmium lasertripsy, morphology and constitution of stones variably changed as a result of the thermal effect of the TFL, with greater changes reported in struvite and uric acid stones, while no effects were noticed in the more thermodynamically stable stones type like monohydrate calcium oxalate and carbapatite ones.

Dust was produced in all the stone type samples, though at different proportion and with a variable mean width of dust particles... Overall, this study provides more insights on the TFL mechanism of action and on the effects produced in the urinary stones, with potential advantages in terms of a finer stones fragmentation compared to classical Holmium-YAG laser: nevertheless, clinical data are warranted.

Source: Thulium fiber laser: Ready to dust all urinary stone composition types? E.X. Keller, V. De Coninck, S. Doizi, et al. World J Urol 2020 May 3. doi: 10.1007/s00345-02003217-9. Online ahead of print.

The Thulium fibre laser: Understanding the next frontier of the lasertripsy for urinary stones The introduction of the Holmium-YAG laser has been a game- changer in the recent history of the endourology; thanks to reduced sizes of the laser-fibre and their effectiveness to break every type of urinary stones, it allowed the quick development of miniaturised endoscopy of upper urinary tract, namely with the spread of the retrograde intrarenal surgery (RIRS) and of the mini-ultra-micro percutaneous nephrolithotomy. Depending on the hardness of the urinary stones, lasertripsy may cause the fragmentation or even the dusting of the stones, with the latter being the preferred outcome as it does not imply the extraction of fragments and reduces the risk for the need of ancillary procedures. All the endourologists are familiar with the relevant setting for the dusting technique, which basically involves set the generator with high frequency and low energy. More recently, new laser generators have been developed to further improve efficiency of these tools in the endourology field: while the ThuliumYAG laser has been already gaining popularity as a more powerful laser for treatment of soft tissue diseases (e.g. BPH, urothelial tumours, etc.), MOSES technology and Thulium-fibre laser are the latest technological innovations for the lasertripsy of urinary stones. Key articles

August/September 2020

15.8%) and kidney injury molecule 1 (KIM 1) (n = 6; 15.8%). Twenty-seven (71.1%) studies evaluated the effect of pyeloplasty on voided urine biomarker concentrations, comparing their values before and after surgery. Twelve (31.6%) studies investigated the correlation between preoperative biomarker concentration and the anterior posterior renal pelvis diameter (DAP) while 20 (52.6%) studies investigated the correlation between preoperative biomarker concentration with the split renal function (SRF) measured on nuclear medicine assessments. Some biomarkers offer promising results.

Some studies demonstrated that the urinary biomarkers could be useful in the evaluation of the surgical treatment success. Nevertheless, the existing literature is still lacking solid and definitive studies However, a critical analysis of the published studies demonstrates bias and lack of consistency, suggesting that larger multicentre and carefully designed prospective studies are still needed to evaluate the clinical usefulness of urinary biomarkers in the diagnosis and follow-up of children with congenital obstructive hydronephrosis.

Source: Urinary biomarkers in pelvic-ureteric junction obstruction: a systematic review. Paraboschi I, Mantica G, Dalton NR, et al. Transl Androl Urol. 2020;9(2):722-742. doi:10.21037/ tau.2020.01.01

What does the current literature say about childhood and adolescent idiopathic urethritis? Terminal haematuria in late childhood or adolescents, presenting itself as blood spotting of the underwear is one of the challenges in urology. Typically, idiopathic urethritis (IU) presents clinically as terminal void haematuria or blood spotting, accompanied with dysuria and occasionally suprapubic pain. It is a source of anxiety for the child and parents even if there are no accompanying symptoms of dysuria or pain. Authors of the below paper looked at 19 series and presented a summary of what is known about this condition.

Biomarkers in ureteropelvic obstruction in children. How useful are they? Antenatally detected hydronephrosis is a common finding on prenatal ultrasound and presents a challenge to clinicians. The challenge is the differentiation between those which will show spontaneous resolution from those which will get worse. This requires several serial studies and the aim is to be able to pick the ones which will go into permanent loss of renal function before it really happens. Serum biomarkers have been hypothesised to be useful for this purpose in many studies.

Urinary biomarkers have been extensively used as a promising tool for non-invasive assessment of PUJO in children Authors makes a systematic review of the available literature on biomarkers of renal injury, potential targets for diagnosis and prognosis of children with hydronephrosis. They looked at 38 articles analysing 41 biomarkers. The most frequent proteins investigated were neutrophil gelatinase-associated lipocalin (NGAL) (n = 9; 23.7%), monocyte chemotactic peptide-1 (MCP1) (n = 8; 21.1%), transforming growth factor β1 (TGFβ1) (n=7; 18.4%), epidermal growth factor (EGF) (n = 6;

The mean age at presentation is 7-9 years. The duration of symptoms extends from 6 to 10 months, but the chronicity of this entity is now known to extend up to years. Symptoms are usually persistent but may sometimes be episodic, lasting from 1 week to 1 month.

Blood spotting of the underwear or terminal haematuria is the most common symptom of idiopathic urethritis in children around the age of 7-9 years Despite several attempts to culture urethral swabs or perform histological analysis of urothelium biopsies, no organism was isolated as a cause of infectious aetiology. Despite some previously reported successful use of various antibiotics, more recent series have failed to show either reduction in duration of symptoms or in the recurrence rate following antibiotics. A viral aetiology was hypothesised but later refuted. Antiviral drugs have failed to eliminate IU symptoms, further refuting a viral aetiology. Idiopathic urethritis in the prepubertal population has been theoretically linked to hormonal imbalance as a possible aetiology. Impact of hormones on development of anterior urethra have been shown in embryological studies. The occasional association of physiological gynecomastia and squamous metaplasia in boys with IU has hinted on a role for hormones in the aetiology. Alterations in the

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk

hormonal milieu and its impact on the urethra has been shown in many cases with hormonal disturbances and it represents a culprit in the formation of squamous metaplasia. The most popular current hypothesis for IU emerges from the fact that the majority of boys with urethrorrhagia are circumcised and are infrequent voiders. The possible mechanism was related to the fact that during voiding, stretching of the urethra occurs. This causes small tears in the vascular urethra. At the end of the void, when the intraurethral pressure falls below the venous pressure, a small amount of blood oozes into the last drop of urine, the so called ‘terminal haematuria’. The differential diagnosis of IU in the paediatric age group includes several important conditions which are all rare but include infectious urethritis, calculus, tumour, urethral polyps, urethral stricture and arteriovenous malformation. Diagnosis is based on symptoms and their respective duration. Exclusion of infection, urethral obstruction or any lower urinary tract pathology warrants a urine analysis, uroflowmetry and ultrasonography. Evidence of obstruction or refractory symptoms are indications for cystoscopy. Idiopathic urethritis, may be a cause of bulbar strictures. Initial uroflowmetry will determine if there is evidence of obstruction. The literature on IU reveals the dilemma of utilising endoscopy. The reason for this controversy lies on the hypothesis that urethral strictures may be a consequence of cystoscopy performed in the situation of IU, rather than a consequence of the disease itself.

This condition may progress to formation of urethral strictures. It can persist to puberty and may have a recurrent course. In spite of no single aetiology being confirmed, several treatment approaches have shown some efficacy Initially, when infection was regarded as the cause of IU, treatment was with antibiotics and analgesia. However, many subsequent studies showed no efficacy. Because IU is also considered as a possible manifestation of dysfunctional elimination syndrome (DES), DES treatment protocol was used in some series. The dysfunctional elimination syndrome protocol which consisted of bowel and bladder regimens including timed voiding with increased water and dietary fiber intake and sitting during voiding to maximally relax the pelvic floor muscles have shown significant improvement. There have been reports of steroid therapy as an effective treatment for IU, both for the disease confined to the urethra or with extra-urethral manifestations. There is no high-level evidence base for any specific single management strategy. Dysfunctional elimination syndrome treatment protocols are non-invasive and should probably be the first treatment option. Steroid infusion into the urethra is sometimes an effective treatment but should probably be reserved for failure of DES management. Although no consensus has yet been established, the consideration of previous authors' experience and expertise may contribute to the development of a possible unified algorithm.

Source: Childhood and adolescent idiopathic urethritis: what does the current literature say? Degheili JA, Dickson AP. J Pediatr Urol. 2020;16(3):276-283. doi:10.1016/j. jpurol.2020.02.001.

EAU EU-ACME Office

European Urology Today

EAU Research Foundation Update on clinical trials and registries Dr. Wim Witjes Scientific and Clinical Research Director EAU Research Foundation Arnhem (NL) w.witjes@ uroweb.org

Dr. Raymond Schipper Clinical Project Manager EAU Research Foundation Arnhem (NL) r.schipper@ uroweb.org Research is vital to the mission of the EAU. The EAU Research Foundation (EAU RF) is active in several large areas promoting advancement and translation of science into clinical practice. Since its foundation in 2007, the EAU RF has designed and carried out several projects. Some of the projects are still running and there are more in development. Results of EAU RF research conducted by groups from all parts of the world are published e.g. in European Urology, reviewed for the EAU Guidelines, presented at EAU meetings and integrated into numerous ESU courses. NIMBUS The NIMBUS study assessed whether a reduced number of BCG instillations was not inferior to a standard number and dose during intravesical BCG treatment of patients with high-grade non-muscleinvasive bladder cancer (NMIBC). The primary endpoint was time to first recurrence. The target was to recruit 824 patients who had high-grade Ta-T1 urothelial carcinoma of the bladder with or without CIS and who did not receive any previous BCG intravesical instillation therapy. Safety analyses (cut-off date 1 July 2019) by the Independent Data Monitoring Committee (IDMC) showed that a reduced frequency schedule of BCG was inferior to a standard frequency schedule for time to first recurrence according to the previously defined stop criterion. Recruitment was immediately stopped and all participating sites were instructed to inform patients and offer patients in the reduced frequency treatment arm the possibility to switch to the standard frequency. The follow-up period, which was initially three years, was shortened until all patients had at least six months of follow-up. At the time the recruitment was stopped, a total of 359 patients from seven countries were randomised. Regarding patients with high-grade NMIBC, this study supports the use of the BCG standard regimen after complete tumour resection as recommended by the EAU Guidelines on Non-muscle-invasive Bladder Cancer (six weeks of induction followed by three weeks maintenance at three, six, and twelve months). The final analysis of NIMBUS and its sub-studies, e.g. on cytokines determined in patients participating in NIMBUS with a longer follow-up, will provide more mature information and allow a more detailed analysis.

Publications: • Grimm M-O, et al. Treatment of High-grade Non-muscle-invasive Bladder Carcinoma by Standard Number and Dose of BCG Instillations Versus Reduced Number and Standard Dose of BCG Instillations: Results of the European Association of Urology Research Foundation Randomised Phase III Clinical Trial “NIMBUS”). European Urology, in press. DOI: https://doi.org/10.1016/j.eururo.2020.04.066 • Nikas, Christine V. et al. Goldilocks and the BCG: Bacillus Calmette-Guérin Dose Reduction in the Age of Shortage. European Urology, in press. DOI: https://doi.org/10.1016/j.eururo.2020.05.021 EAU Research Foundation

European Urology Today

“The NIMBUS study supports the use of the BCG standard regimen after complete tumour resection.” Pegasus The Pegasus trial evaluates the relapse-free survival (RFS) of high-risk patients with muscle-invasive bladder cancer (MIBC) or upper-tract urothelial carcinoma who were previously treated with neoadjuvant cisplatin-based chemotherapy or who were ineligible to receive adjuvant cisplatin-based chemotherapy. These patients will receive adjuvant pemigatinib, an oral FGFR3 inhibitor, after radical surgery. Improvement of RFS may be regarded as an optimal endpoint for adjuvant therapy trials, given the availability of newer lines of therapies in the advanced stages that may affect the overall survival outcome in these patients. Secondary objectives are to evaluate safety, tolerability and overall survival. An explorative objective is to evaluate biomarkers for clinical benefit and to explore potential prognostic biomarkers. These biomarkers will be evaluated on the tumour tissue at the time of radical surgery, before the administration of the study drug.

The aim is to have eight to ten participating sites from different European countries (e.g., Italy, Belgium, France, and Spain). So far, the study was approved by the authorities in Italy. Two out of five Italian sites were initiated and the first patient was screened on 13 July 2020 by Dr. Andrea Necchi at the Foundation IRCCS - National Institute Dei Tumori in Milan, Italy. The study is currently submitted to the regulatory authorities in Belgium, France and Spain and the plan is to have the first patients from these countries screened in September 2020. SATURN The aim of the SATURN registry is to prospectively collect a pre-defined dataset of 1,000 male patients undergoing surgical treatment for stress urinary incontinence with medical devices such as AUS (Artificial Urethral Sphincter Device) or male slings to evaluate the short- and long-term efficacy and complications of these procedures along with the impact on the Quality of Life (QoL). The patients will be followed up for ten years with regard to safety and efficacy.

The study has started at 24 sites in eight countries (Belgium, Czech Republic, Germany, the Netherlands, Norway, Spain, the United Kingdom and Italy). New sites in Finland, Spain, and Sweden will become active soon. The project recruits ahead of schedule with a total of 651 patients recorded in the e-CRF (cut-off date 28 July 2020). Baseline data (cut-off date 1 March 2020, 587 patients recruited) show a 2:1 distribution of AUS compared to other devices. The major cause of Stress Urinary Incontinence (SUI) was prostatectomy, which in most cases was performed by RALP. Prospective collection of pre-defined data from patients undergoing surgical SUI treatment in multiple European centres will enable evaluation of long-term efficacy, safety and impact on QoL. Due to the real-life setting, we will be able to analyse the value of different techniques but also the significance of centre and patient characteristics. With the current inclusion rate, planned recruitment numbers are achievable and the registry will yield clinically useful results. Publication: Van Der Aa F et al. Prospective registry for patients undergoing

surgery for male stress urinary incontinence in multiple European centres. an update of the registry ‘SATURN’. European Urology Open Science Volume 19, Supplement 2, July 2020, Page e464.

Spain and Germany and the first patient was screened by Dr. Luis López-Fando Lavalle at the Hospital Universitario Ramón y Cajal in Madrid on 23 June 2020.

PHOENIX The PHOENIX registry is a prospective collection with pre-defined parameters on the surgical treatment of 1,000 patients with male erectile dysfunction using penile prostheses implant (PPI) devices. The aim is to provide insight in daily clinical practice regarding the indication for surgical treatment, the choice of the type of prosthesis, and short- and long-term follow-up outcomes (efficacy, complications, quality of life, patient and partner satisfaction score) of patients treated with a variety of PPIs.

The EAU RF wants to support the collection of important clinical data and to build new registries to serve as platforms for work on relevant scientific questions. Therefore, the EAU RF decided to give researchers who are member of the EAU and who have developed a high-quality research proposal access to a data management system (Castor EDC) that satisfies all European legislation.

Within this registry, various patient questionnaires related to sexual function, treatment satisfaction and QoL will be used. Since not all questionnaires are available in the required languages, the questionnaires will be professionally translated according to the international ISPOR guidelines (the professional society for health economics and outcomes research), including forward and backward translation, as well as cognitive debriefing (testing by means of patient and partner interviews). Once all translated documents are available, which is expected to be in the third quarter of 2020, the EAU RF can start this very interesting project. In parallel with the translation of the questionnaires, the ethical committee review process has started. The study has already been approved in Belgium, Italy, France, Portugal, and Sweden and has been submitted in Germany, Spain, the Netherlands, and the United Kingdom. Quite some centres have already shown interest to set up this registry and are willing to participate by contributing their patient data after receipt of the patient’s consent. ADDITIONAL CENTRES ARE STILL WELLCOME.

eCORE COMET The first EAU RF project working with the Castor EDC database is the eCORE COMET survey. This is a prospective multicentre study with the aim to measure compliance with diet and/or medical treatment in patients with kidney stones. The target is to recruit 1,000 patients in fifteen to twenty centres. Since 19 June 2020, thirteen patient records from three different centres have been entered into the database (cut-off date 30 July 2020).

EAU-BRaVeRY The next database in development is for EAUBRaVeRY: a prospective, centralised, multicentre bladder cancer registry to study the prevalence and behaviour of urothelial-variant histologies and non-urothelial histologies in muscle-invasive disease. This database is scheduled to be ready in September 2020. For more information on EAU RF projects, please visit the EAU RF website via http://uroweb.org/research/ projects/. If you are interested in participating in one or more of our projects, please contact EAU RF at researchfoundation@uroweb.org.

VENUS The aim of the VENUS registry is to set up a registry database for female patients undergoing AUS implantation surgery (robot-assisted, laparoscopic, open, or other) for SUI due to intrinsic sphincter deficiency (ISD). The Registry database allows us to prospectively collect a pre-defined dataset from 150 female patients at multiple centres in Europe who receive AUS implantation as treatment for SUI due to ISD.

“The EAU RF gives researchers who are member of the EAU and who have developed a high-quality research proposal access to a data management system that satisfies all European legislation.”

The registry has been submitted to the regulatory authorities in Belgium and the United Kingdom and will soon be submitted to those authorities in France, Italy, and the Czech Republic as well. So far, the study has been approved by the authorities in

EAU Research Foundation • Anders Bjartell, Chairman • Wim Witjes, Scientific and Clinical Research Director • Raymond Schipper, Clinical Project Manager • Christien Caris, Clinical Project Manager • Joni Kats, Junior Clinical Project Manager • Joke Van Egmond, Clinical Data Manager • Hans Noordzij, Marvin System Assistant • Xandra Helmonds, financial officer

EAU Education Online presents: Urological Infections

EAU Guidelines E-Courses

Urinary Incontinence

Primary Urethral Carcinoma

Prostate Cancer

Non-muscle-invasive Bladder Cancer

How well do you know the EAU Guidelines?

Renal Cell Cancer

Thromboprophylaxis

The e-courses feature questions formulated by experts in the field, reviewed by the EAU Guidelines Office and the Young Urologists Office.

Muscle-invasive and Metastatic Bladder Cancer

Chronic Pelvic Pain

Renal Transplantation

Urolithiasis

Men’s Health

Paediatric Urology

All Guidelines e-courses are reviewed and updated annually according to the most recent EAU Guidelines. EAU Education Online e-Platform is fully accredited

uroweb.org/education

August/September 2020

EAU and EANM recommendations on PSMA PET Consensus on use of PSMA PET to evaluate response to prostate cancer treatment Prof. Anders Bjartell Chair EAU Research Foundation Malmö (SE)

anders.bjartell@ med.lu.se

Dr. Stefano Fanti European Association for Nuclear Medicine Bologna (IT)

After an initiative from Prof. Anders Bjartell (Malmö, SE), chair of the EAU Research Foundation (EAU RF) and Prof. Nicolas Mottet (Saint-Étienne, FR), chair of the EAU Guidelines Working Group on Prostate Cancer, together with Prof. Stefano Fanti (Bologna, IT) from the European Association for Nuclear Medicine (EANM), a panel of PCa experts in nuclear medicine, radiology, and/or urology met in Amsterdam, The Netherlands, on 21 February 2020 to formulate criteria for PSMA PET-based response in patients treated for metastatic PCa and optimal timing to use it.

“Adoption of PSMA PET in monitoring prostate cancer treatments, should be supported by precise criteria for interpretation.”

After having received thematic topics and relevant literature prior to the meeting, the panellists developed statements on how to interpret responses to therapies for PCa using a PSMA PET and on when to use this scan. A methodological expert, Steven MacLennan from the Academic Urology Unit at the Positron emission tomography (PET) with tracers University of Aberdeen (GB), was responsible for the targeting Prostate-specific membrane antigen (PSMA) statistical analyses and the process in which the is used for staging prostate cancer (PCa) and, in PCa panellists voted anonymously on a nine-point scale, patients already treated, presenting biochemical ranging from strongly disagree to strongly agree. recurrence (BCR). PSMA PET may also have a potential role in monitoring treatment effects in Consensus was reached patients with advanced PCa, but limited data are The PSMA PET consensus statements concerned available; moreover, there is a lack of established utility, best timing for performing imaging, criteria for response criteria. evaluation of response, patients who could benefit, and handling of radiolabelled PSMA PET tracers. Consensus was reached on all statements and the EAU Research Foundation panellists agreed that PSMA PET can be used before stefano.fanti@ aosp.bo.it

Photo from the expert panel meeting in Amsterdam on 21 February 2020. From left to right: Ken Herrmann (Nuclear Medicine, Essen, DE), Stefano Fanti (Nuclear Medicine, Bologna, IT), Olivier Rouvière (Radiology/Imaging, Lyon, FR ), Anders Bjartell (Urology, Malmö, SE), Boris A. Hadaschik (Urology, Essen, DE), Karolien Goffin (Nuclear Medicine/Molecular Imaging, Leuven, BE), Tobias Maurer (Urology, Hamburg, DE), Daniela E. Oprea-Lager (Radiology & Nuclear Medicine, Amsterdam, NL), Wim J.G. Oyen (Radiology/Imaging, Milan, IT, Nijmegen and Arnhem, NL), Steven MacLennan (Methodology, Aberdeen, UK)

and after any local and systemic treatment in patients with metastatic disease to evaluate response to treatment. Ideally, PSMA PET imaging criteria should categorise patients as responders, patients with stable disease, partial response, complete response, or non-responders. The panellists agreed on criteria to establish such categories; in specific clinical scenarios such as oligometastatic or polymetastatic, disease may deserve special consideration.

supported by appropriate indication for its use and precise criteria for interpretation. The results have been published in the European Journal of Nuclear Medicine and Molecular Imaging on 2 July 2020: https://doi.org/10.1007/s00259-020-04934-4.

Appropriate indication Prof. Bjartell and Dr. Fanti chaired the meeting and they fully agree that adoption of PSMA PET should be

The meeting was sponsored by an unrestricted grant from Janssen with no influence on the content of the meeting or on the publication.

“Consensus was reached on all statements.”

Dr.philos degree awarded for thesis based on GPIU study Dr. Zafer Tandogdu acknowledges urologists worldwide for providing important research data Prof. Truls Erik Bjerklund Johansen Oslo University Hospital Oslo (NO)

t.e.b.johansen@ medisin.uio.no The highest university degree The degree of Doctor of Philosophy (PhD) is the highest scientific degree in most universities, awarded in many different fields ranging from human sciences to scientific disciplines. Some universities, however, still award a classical dr.philos degree in recognition of a substantial and sustained contribution to scientific knowledge beyond that required for a PhD. In practical terms, this means about 25% more scientific content and a more extensive defence programme with two trial lectures.

The symposium was sponsored by an unrestricted grant from Zambon to the EAU RF. Scientific background Hospital-acquired infections in urology departments (HAUTIs) are complex and can hinder the recovery of patients following treatment. A further complexity arises from antibiotic resistance that hinders both prevention (prophylaxis) and treatment. This can become a significant problem in patients with severe HAUTI such as urosepsis and increase the likelihood of morbidity and mortality. Aims of the thesis Surveillance of infections using sequential measures is a method to improve prevention and management of HAUTIs. However, analytic methods to make best use of such data are still under development. The GPIU is a unique international study sponsored by the EAU and conducted in urology departments. Data

The ceremony On 3 March 2020, Dr. Zafer Tandogdu (UK) defended his thesis for the dr.philos degree at Oslo University (NO). The title of the thesis was "Healthcare Associated Urinary Tract Infections in Urology Departments. Pathogens, Resistance and Appropriate Empiric Antibiotic Choices. From a Global Point Prevalence Registration to Modelling based on Bayesian Approach". Dr. Tandogdu used advanced mathematical modelling to foresee resistance and appropriateness of antibiotic treatment. The defence ceremony was a full day event starting with two 45-minute public lectures and discussions before lunch and a three-hour presentation and defence of the thesis in the afternoon. The committee chair was Tone Tönjum, prof. of microbiology at the University of Oslo. Opponents were Prof. Suzanne Geerlings, infectious disease specialist from The Netherlands and prof. Franck Bruyere, prof. of urology from France. After the defence there was an ESIU-symposium related to the topics of the thesis chaired by prof. Anders Bjartell (SE), chairman of EAU Research Foundation. EAU Research Foundation

August/September 2020

Prof. Anders Bjartell, chairman of EAU RF, presents a gift to Dr. Philos Zafer Tandogdu during the faculty dinner. Prof. Bjartell underlined the importance of skills in advanced mathematics for modern urological research. Dr. Tandogdu is a consultant urologist at the University College London Hospitals (UK) mainly working with oncological robotic surgery

obtained from the GPIU study was utilised in Dr. Tandogdu`s thesis. The aims of the thesis were to determine the causative pathogens and their antibiotic resistance, and the impact of different clinical HAUTI conditions on these two measures. Another goal was to develop a compound measure for empirical antibiotic recommendations that can improve the utility of surveillance data and patient management. Finally, urosepsis patients affected by antibiotic resistance were studied at a global level. Contents and findings The thesis consists of five published papers and one study in peer review. The dr.philos candidate surrounded by opponents, supervisors and faculty members of the ESIU symposium in the old ceremonial hall at the University of Oslo. From left B. Köves, A. Bjartell, S. Study I reports the Geerlings, F. Wagenlehner, Z. Tandogdu, T.E. Bjerklund Johansen, K. Naber, R. Bartoletti, F. methodology applied in Bruyere, M. Çek, G. Bonkat the GPIU study that can act as a guidance for future studies. Study II-III demonstrate the geographical and HAUTI condition specific variability of pathogen spectrum and antibiotic resistance. The proportion of antibiotic resistance cases was highest in patients with urosepsis. An analytical approach to report the Conclusions chances of coverage of an antibiotic choice was This thesis suggests that condition specific HAUTI developed and utilised in study IV. Dr. Tandogdu surveillance can improve empirical antibiotic showed that adherence to infection prevention and treatment. It also highlights the importance of control measures influence available appropriate surveillance data and proposes a novel method to antibiotic choices. In Study V the novel analytic improve the utility of surveillance data. method helped consolidate the findings from study III The evaluation committee concluded that the thesis and also demonstrated that empirical antibiotic was of high quality and expected the impact of choices will be different if condition specific research data from numerous countries in the world surveillance data is used as opposed to pooled data to be very high on recommendations about sets. Finally, in study VI he analysed independent data prevention and treatment of UTI. Florian Wagenlehner sets with the methodology developed in Study IV. This from Germany and Truls E. Bjerklund Johansen from enabled him to estimate the incidence of urosepsis Norway were Zafer`s supervisors throughout the with antibiotic resistance in 17 countries. project. European Urology Today

Female and functional urology in the COVID era Long-term implications of reduction in functional urology clinical activity Prof. Salvador Arlandis Functional and Reconstructive Urology Section HUP La Fe Valencia (ES)

Table 1: Pre and peri-urodynamic adaptations (adapted from Hashim et al NAU 2020)4 Prioritisation

Pre-UDS

salvador.arlandis@ gmail.com

Prof. Hashim Hashim ESFFU Board Member Bristol Urological Institute Southmead Hospital Bristol (UK) h.hashim@ gmail.com The new acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 19 (COVID-19), have changed urology practice in most countries around the world1. Societies, health care and economic systems are being severely hit by the pandemic worldwide. Outpatient procedures During the acute (crisis) phase, hospital activity has changed dramatically. Some of the actions taken in urology departments include cancellation of face-to-face outpatient and non-urgent activities to maintain social distancing, screening of planned clinic appointments, consultations for patients with non-urgent conditions via telephone and rescheduling appointments for a few months later. Clinicians individually evaluated patients with known or suspected malignancies or other urgent conditions. Likewise, outpatient procedures were screened and stratified by urgency. For benign conditions, the majority of procedures were deferred2. Surgical activity of scheduled patients was cancelled, and only urgent or non-deferrable oncological surgeries were done. This was due to lack of personnel, who may have been diverted to other departments, and/or lack of technical resources, which had been diverted to the management of COVID-19 patients. Functional urology activities were reduced or even completely stopped in most hospitals, as they were deemed to be of low priority. Patients with benign and disabling conditions (such as urinary fistula, pelvic pain, urinary incontinence, pelvic organ prolapse, etc.) also suffered delays of medical attention with consequent negative influence on physical and psychological health, and on quality of life. Hardest hit Female and functional urology (FFU) has probably been the hardest hit subspecialty in urology, with massive cutdown in outpatient urological investigations, procedures and urological operations3. The likelihood is that the global effect of the COVID-19 pandemic will last for some time during which national health systems will have to treat COVID-19 and non-COVID-19 patients simultaneously. Therefore, functional urology units will have to reorganise their activity according to patient priority and the scope of the pandemic in each region. Urodynamic adaptations Certain adaptations to the urodynamics (UDS) procedure need to be considered in terms of prioritisation, before and during the urodynamic study4. Neurogenic patients at risk of upper urinary tract deterioration (spinal cord injury, spinal dysraphism and some multiple sclerosis patients) should be seen with high priority (within 4 weeks) as well as those with poorly compliant bladders (e.g. radio-cystitis), those waiting for a kidney transplant, or if UDS is considered necessary before second-stage neuromodulation implant. Intermediate priority (defer up to 3 months) includes men with benign prostatic obstruction (BPO) and recurrent catheter blockages or urinary tract infections (UTIs) and female patients with pelvic organ prolapse (POP) and hydronephrosis or vaginal ulcers. All other indications are low priority (can be delayed more than 3 months). Table 1 shows pre and peri-urodynamic adaptations. EAU Section of Female and Functional Urology

European Urology Today

Peri-UDS

• High: Neurogenic high-risk bladder, low compliance, kidney transplant • Intermediate: BPO with blocking catheters, rUTI, complicated POP • Low: the rest • Patients risk stratification • Daily case number reduction ≈ 30% • Take clinical history by phone to reduce time exposure • Ensure enough time for cleaning UDS room • Ensure safe pathway into and out of hospital • Maintain social distance in waiting rooms • Avoid public transport traveling to hospital • Come to hospital alone when possible (except disabled people or children) • Check COVID-19 symptoms and temperature at arrival • Patient: Hand gel or wash hands 20 secs + face mask • Reduce waiting time in the department • PPE for staff and patients according to national/local guidelines • Social distancing, when possible • Signal checking and stress manoeuvres with Valsalva or Credé (avoiding cough) • Dispose of used gloves and rectal probes in biohazard container

Table 2: Prioritisation criteria and strategies for Male LUTS, UI and neurogenic patients according to EAU Guidelines Office Rapid Reaction Group (Adapted from Ribal MJ et al, Eur Urol 2020 and https://uroweb.org/ wp-content/uploads/EAU-Guidelines-Office-Rapid-Reaction-Group-An-organisation-wide-collaborativeeffort-to-adapt-the-EAU-guidelines-recommendations-to-the-COVID-19-era.pdf)5

Definitions

Diagnosis

Treatment

Surgery Follow-up

Low Clinical harm very unlikely if postponed 6 months

• Delay diagnostic evaluation of male LUTS, UI and neurogenic patients • Exclude UTI • Conservative treatments • Drug therapy • TeleHealth • Do not start desmopressin • Delay male LUTS, UI and neuro-urological surgery • Defer if at least one visit before • TeleHealth • Keep neurogenic patient out of hospital as much as possible

Intermediate Clinical harm possible if postponed 3-4 months but unlikely

• Patients in retention with IBC• Teach CIC in case of retention • Male patients in retention • TeleHealth assessing efficacy and safety of new treatments

EAU guidelines recommendations On 17 April 2020, the EAU Guidelines Office Rapid Reaction Group published general recommendations instead of very specific ones because of large discrepancies and different realities in each country, region or even hospital, with different number of cases and different resources available§. Prioritisation criteria were established according to severity and potential hazard of the disease, patient characteristics, resource availability and potential risks associated. Other expert groups (see Table 3) have suggested more specific considerations for invasive and non-invasive functional studies, procedures and surgical activities during the COVID-19 crisis and in the post-COVID era6. Large asymmetry in pandemic impact There is large asymmetry around the world in terms of the impact of the COVID-19 pandemic: number of cases (new infected patients, intensive care unit admissions, cures and deaths), health resources availability (ICU beds, health professionals, hospital

High Clinical harm very likely if postponed > 6 weeks

Emergency Life threatening situation

• Suspected renal impairment • Suspected oncological causes

• Urosepsis

• Instruction in catheter unblocking • Fistula repair in very select cases • Sodium checking in patients using desmopressin

• Sodium checking when starting desmopressin

capacity, tests, positive cases epidemiologic surveillance, etc.), governmental strategies, etc. Different countries and regions may find themselves in different scenarios of the pandemic at the same time: from a very mild crisis with a low number of active cases and low impact on health resources, to a severe crisis in which most of these resources need to be dedicated to COVID patients (see Figure 1). Great uncertainty We are living in great uncertainty about the future. There is the threat of future waves7, uncertainty about vaccine efficacy and availability, the threat of future virus pandemics, etc. The likelihood is that the global effect of the COVID-19 pandemic will last for an unknown period of time, during which national health systems will have to treat COVID-19 and non-COVID-19 patients simultaneously. Therefore, functional urology units will have to reorganise their activities according to patient priority and the scope of the pandemic in each region. Dynamic scales showing resource availability and health care pressure may be useful to prioritise strategies in this new reality.

Out-patient clinics in functional urology Functional studies are essential tools in the diagnosis of lower urinary tract dysfunction. They can be divided into invasive and non-invasive studies, bearing in mind the risk of SARS-CoV-2 infection for patients and healthcare workers. Invasive studies carry a higher risk of transmission of SARS-CoV-2 infection. Therefore, in COVID-19’s pandemic era, it is advisable to reduce invasive studies to mandatory life-saving ones. Another fundamental aspect to consider is that a patient who goes to the hospital increases the risk of contagion (if the hospital is considered a high-prevalence COVID-19 area) and may not maintain the necessary social distance required (> 1-2 m)8. The nosocomial transmission risk in in-patient care must also not be forgotten9. For FFU patients, our recommendation (based on expert advice) is to change all initial and follow-up consultations to telephone or video consultations. The patients who need to be examined or wish to have a face-to-face consultation can be invited to attend the hospital at a later date and time, after having weighed the pros and cons of attending the hospital10.

“Female and functional urology (FFU) has probably been the hardest hit subspecialty in urology.” Post-COVID crisis planning It is very likely that there is going to be a very large backlog of FFU patients waiting for procedures and consultations after the COVID-19 crisis. It is therefore important that plans are put into place to help ease the backlog, especially because all other specialties and subspecialties will be facing similar problems. These may include extra working hours during evenings and weekends or operating at different sites. It is important to communicate clearly with patients and make them aware of these difficulties. This includes the need for patients to self-isolate for a period of time before coming to hospital. Every hospital, city and country will face different challenges to get back on track but it is likely that most will not be able to do so for at least 6 to 12 months as some healthcare services were overstretched even before the COVID-19 crisis. Below are some recommendations to help manage the post-COVID era6: 1. Triage and prioritise all outpatient consultations, diagnostic procedures and operations early. 2. Devise a triaging system that can be followed by your team. 3. Communicate with patients to let them know about the plans to reduce anxiety. 4. Liaise with hospital management to try and see if consultations, diagnostics, and treatments including surgery can be offered elsewhere by your team, e.g. in another local hospital. 5. Ask your team if they have any suggestions and communicate closely with each other so that all are aware of the plans. Conclusion The SARS-CoV-2 pandemic had a significant impact on healthcare systems all over the world. Urology departments have entirely changed their daily practice to meet this new challenge. Functional and pelvic floor conditions have often been considered delayable in challenging times. The long-term implications of this reduction in functional urology clinical activity are currently unknown. Moreover, many patients will suffer delays in treatment with consequent impairment of their physical and psychological health and deterioration of their quality of life. Efforts should be made to minimise the burden for this patient group, without endangering patients and healthcare workers.

Key points • There is a great deal of asymmetry in the worldwide pandemic (in incidence, resource availability, strategies) • Functional urology activities have been severely affected by the pandemic and need to be reorganised and prioritised according to risk levels and dynamic scales • Telehealth has come to stay and will grow in the future, but many questions and challenges remain • New normality has to be defined • We need to be prepared for future pandemic Figure 1: Worldwide pandemic asymmetry. Image source: https://elpais.com/sociedad/2020/06/29/actualidad/1593428011_709853. waves and for the health consequences of the html?rel=friso-portada COVID-19 crisis August/September 2020

References 1. Dasgupta P, Campi R, Rha K, Gavazzi A, Guohua Z. Covid-19 and urology [Internet]. BJU International blog. 2020 [cited 2020 Jul 28]. Available from: https://www. bjuinternational.com/bjui-blog/covid-19-and-urology/ 2. Gravas S, Fournier G, Oya M, Summerton D, Mario R, Chlosta P, et al. Prioritising Urological Surgery in the COVID-19 Era : A Global Reflection on Guidelines. Eur Urol Focus [Internet]. 2020;1–7. Available from: https:// doi.org/10.1016/j.euf.2020.06.006 3. Teoh JYC, Ong WLK, Gonzalez-Padilla D, Castellani D, Dubin JM, Esperto F, et al. A Global Survey on the Impact of COVID-19 on Urological Services. Eur Urol [Internet]. 2020;78(2):265–75. Available from: https://doi. org/10.1016/j.eururo.2020.05.025 4. Hashim H, Thomas L, Gammie A, Farullo G, Finazzi‐Agrò

E. Good urodynamic practice adaptations during the COVID‐19 pandemic. Neurourol Urodyn [Internet]. 2020 Aug 19;39(6):1897–901. Available from: https:// onlinelibrary.wiley.com/doi/abs/10.1002/nau.24441 5. Ribal MJ, Cornford P, Briganti A, Knoll T, Gravas S, Babjuk M, et al. European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era. Eur Urol [Internet]. 2020 Jul;78(1):21–8. Available from: https://linkinghub.elsevier.com/retrieve/ pii/S0302283820303249 6. López-Fando L, Bueno P, Carracedo D, Averbeck M, Castro-Díaz DM, Chartier-Kastler E, et al. Management of Female and Functional Urology Patients During the COVID Pandemic. Eur Urol Focus. 2020;1–9.

“It is very likely that there is a very large backlog of FFU patients waiting for procedures and consultations after the COVID-19 crisis. It is therefore important that plans are put into place...” 7. Moore KA, Lipsitch M, Barry JM, Osterholm MT. COVID-19: The CIDRAP Viewpoint. Part 1: The Future of the COVID-19 Pandemic: Lessons learned from pandemic influenza [Internet]. 2020. Available from: https://www.cidrap.umn.edu/sites/default/files/public/ downloads/cidrap-covid19-viewpoint-part1_0.pdf

8. Coronavirus disease (COVID-19) advice for the public [Internet]. World Health Organization. 2020 [cited 2020 Jul 28]. Available from: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/ advice-for-public 9. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA [Internet]. 2020 Mar 17 [cited 2020 Jul 28];323(11):1061. Available from: https://jamanetwork. com/journals/jama/fullarticle/2761044 10. Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ [Internet]. 2020 Mar 12 [cited 2020 Jul 28];368. Available from: https://www. bmj.com/content/368/bmj.m998

Table 3: List of publications that address female and functional urology cases during the COVID pandemic. None are specific to female and functional urology, except the one published by the authors of this article and listed first in the table. Publication López-Fando L, Bueno P, Carracedo D, et al. Management of Female and Functional Urology Patients During the COVID Pandemic. Eur Urol Focus. 2020 12:S2405-4569 IUGA. https://www.iuga.org/news/message-from-the-president-guidance-for-the-managementduring-covid-19 Musco S, Del Popolo G, Lamartina M, et al. Neuro-Urology during the Covid-19 pandemic: triage and priority of Treatments. ICS. https://www.ics.org/Documents/DocumentsDownload.aspx?DocumentID=5892 Grimes CL, Balk EM, Crisp CC, et al. A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence. Int Urogynecol J. 2020 ;31(6):1063-1089. Ficarra V., Novara G., Abrate A., et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020 June;72(3):369-75 Goldman HB, Haber GP. Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 era. J Urol. 2020; 204(1): 11-13. M.J. Ribal, P. Cornford, A. Briganti, et al. EAU Guidelines Office Rapid Reaction Group: An organizationwide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era. Eur Urol 2020; 78(1) 21-28. Carneiro A, Wroclawski ML, Nahar B, et al. Impact of the COVID-19 pandemic on the urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period. Int Braz J Urol 2020; 46(4): 501-510. Katz EG, Stensland KS, Mandeville JA, et al. Triaging office-based urology procedures during the COVID-19 pandemic. J Urol 2020; 204(1): 9-10. Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol 2020; 77(6): 663-666. USANZ. https://www.usanz.org.au/news-updates/our-announcements/usanz-announces-guidelinesurological-prioritisation-covid-19 https://www.rcseng.ac.uk/coronavirus/surgical-prioritisation-guidance/

Scope Outpatients & Surgical; Female & Functional Urology

Methodology Expert

Country International

Outpatients; Female Urology/Urogynaecology

Society Guideline

International

Outpatients & Surgical; Neuro-Urology

Society Guideline

International

Outpatients; Female Urology/Urogynaecology

Society Guideline

USA

Outpatients & Surgical; Benign & Oncological

Expert

Italy

Outpatients & Surgical; Benign & Oncological

Expert

USA

Outpatients & Surgical; Benign & Oncological

Society Guideline

Europe

Outpatients & Surgical; Benign & Oncological

Expert

Brazil

Outpatients; Benign & Oncological

Expert

USA

Surgical; Benign & Oncological

Expert

International

Outpatients & Surgical; Oncology and minor benign

Society Guideline

Australia

Surgical; Benign and Oncological

Society Guideline

Urology Week 2020 focuses on ED EAU survey shows majority of respondents does not know what ED is Awareness of erectile dysfunction (ED) is alarmingly low in men and women aged 20 to 70, a new survey commissioned by the EAU has revealed. Majority of the respondents does not know what ED exactly entails, and one in four has never heard of any treatments for ED. The survey was conducted as part of Urology Week: an EAU initiative that brings together national societies, urology practitioners, urology nurses, the patients and their families, and politicians to create awareness of urological conditions among the general public. The survey examined the knowledge of and experience with ED of 3,032 men and women of different age groups between 20 and 70 years old in Spain, France, Germany, and the UK. When asked what ED is, the majority of the respondents either gave incorrect answers (34%) or stated they do not know what ED is (17%). German respondents scored worst on this question; only 49% answered correctly, compared to Spain where a solid majority (78%) did. “As ED is actually a common male medical condition, it is surprising that a majority doesn’t know what ED is,” comments Prof. Christopher Chapple, Secretary General of the EAU. Indeed, the EAU Guidelines 2020 on Sexual and Reproductive Health state that “epidemiological

August/September 2020

data have shown a high prevalence and incidence of ED worldwide.” The Guidelines mention among others the Massachusetts Male Aging Study, which reports an overall ED prevalence of 52% in men aged 40-70 years. In the EAU survey, when asked what percentage of men in their country aged 50-80 suffer from ED, respondents most often selected “21-30%”. “The risk of having ED increases with age, but it affects men of all ages and ethnicities,” Prof. Chapple continues. “As a result, there shouldn’t be any taboo against it. Although I am happy to see that the majority of the respondents who has experience with ED says to talk about it, there is still room for improvement.” Of the 17% of the respondents who have or have a partner who has ever experienced ED, approximately one in four (26%) admitted to not talking about it with anyone. Worrisome is that of those in a relationship, only 29% talk to each other about ED. German respondents most often gave “feeling uncomfortable to talk about ED” as the reason for not seeking professional help. Communication is the key “Clearly ED is a common medical condition. There’s absolutely no need for shame,” Prof. Chapple emphasises. “As urologists, we need to display that attitude by communicating openly. The patient needs

21-25 SEPTEMBER

to know that ED is common and that shame about it is Prof. Chapple: “I understand that ED is regarded as utterly unnecessary. Communication is the key to a private condition. But this should not prevent breaking the taboo.” people from improving their quality of life. We need to increase the public’s knowledge of ED. It is a common medical condition that is treatable, “The stigma to ED has to be nothing more than that. That stigma to ED has to be removed, and we all have a role to fulfil to achieve removed, and we all have a role that. During Urology Week, to begin with.”

to fulfil to achieve that.”

A small majority of 53% sought medical advice from a healthcare professional (a GP, urologist, sexologist, sexual therapist or psychologist). Respondents who didn’t seek medical advice were most likely to have no reason for it. “This could mean that they aren’t aware they can seek professional help,” Prof. Chapple says. One in four respondents has never heard of any treatments Prof. Chapple refers to another alarming outcome; one in four of the respondents (26%) has never heard of any of the seven treatments for ED listed in the survey: medication, sexual education and relationship therapy, a vacuum erection device, penile injections, penile implants, shockwave therapy, and topical therapies. Knowledge about ED treatment is most limited in the UK; 31% have never heard of any of the treatments listed (compared to 18% in Spain) and only 50% think ED is treatable (whereas 68% in Spain believe so).

You too can take part in Urology Week from 21 to 25 September 2020! Visit www.urologyweek.org to add an event, to view events planned, or to simply download our awareness posters and hang them in your clinic. No matter the effort, big or small, you can make a difference and help boost awareness. Share your event or your story via social media and include the hashtag #urologyweek.

European Urology Today

Prostatic Urethral Lift (Urolift® System) Treating benign prostatic obstruction in an outpatient setting Mr. Petros Tsafrakidis Victoria Hospital, NHS Fife (GB)

petertsaf@yahoo.gr Co-authors: Dr. Dimitrios Siatos and Dr. Stephanie Guillaumier, Victoria Hospital, NHS Fife (GB) More than half of men aged 60 years develop benign prostatic hyperplasia (BPH), with risk increasing with advancing age1. Men frequently experience bothersome lower urinary tract symptoms that can adversely affect many aspects of life. The main aims of treatment, therefore, are to relieve symptoms and improve quality of life. Traditional surgical treatments achieve the former with good results but carry risks of complications and permanently impaired sexual function and/or incontinence. Prostatic urethral lift (PUL), which is achieved with the Urolift® System, is a minimally invasive treatment option that may be performed in an outpatient setting under local anaesthetic. It achieves good, durable symptom relief, and preserves sexual function2. By setting up an ambulatory service for PUL, we have found also it has many positive effects on the BPH treatment pathway and opens the way for more out-patient based procedures. However, further data is required.

and decreased complications. In this first out-patient cohort, we applied several eligibility criteria to guide patient selection: a) History of bothersome LUTS of an obstructive nature. b) Preservation of antegrade ejaculation (desirable). c) Prostate size of 60cc or less. d) Absence of a median prostatic lobe. e) No history of urinary retention or presence of bladder stones. Suitability for TURP and/or PUL is decided based on International Prostate Symptom Score, flow test results, prostate volume, and cystoscopic findings. Patients also complete the IIEF-5 questionnaire.

Figure 1: The admission/recovery area

The outpatient PUL procedure In the Day Treatment Unit, there is a dedicated admission/recovery area and preparation and treatment We set up a one-stop BPH clinic to streamline the rooms (Figures 1–3). On arrival, the patient’s full whole pathway where all assessments and discussion medical history is reviewed and all current medications, of treatment options take place. The first patients were drug allergies and observations are recorded by a seen in September 2017. Patients referred by a general urology nurse; patients taking anti-coagulants are practitioner or a consultant are assessed and all requested in their appointment letter to stop them 5 treatment options (eg, fluid moderation, pelvic floor days pre-operatively. The patient is cannulated in the exercises if over-activity is present, watchful waiting, admission/recovery bay (Figure 1) before the procedure, TURP, Green-light LASER prostatectomy, PUL, and medication) are discussed. Appointments include plenty and intravenous gentamicin is administered. of time to allow the clinician and patient to discuss Additionally, 15–20 minutes before the procedure, two all bothersome symptoms and expectations from treatment. The consultant and patient, therefore, decide pre-filled syringes of lidocaine sterile gel, which are kept at 5°C in the clinical area, are administered the optimum treatment together, based on indications intra-urethrally by a trained urology nurse in the and the patient’s preference. Men who choose to have preparation room (Figure 2). A penile/urethral clamp is the PUL procedure undergo flexible cystoscopy and applied to prevent leakage of the gel and maximise the trans-rectal ultrasound measurement of prostate effect of the anaesthetic. volume either on the same or at a separate appointment and are provided with a patient In Fife, which has a population of roughly 372,000 The procedure is performed in a separate treatment information leaflet. We can offer a cystometrogram in room (Figure 3). Immediately before the operation, the people, among whom 20% are older than 65 years, equivocal cases, but we do not consider it essential. clamp is removed, and two more syringes of around 200 surgical procedures are performed per year Options are discussed in light of the findings and the anaesthetic gel are administered. Very rarely, a patient to treat urinary obstruction in men with BPH. The gold management plan is finalized. does not tolerate the endoscopy under a local standard surgical treatment is transurethral resection of anaesthetic, and the procedure is stopped and PUL the prostate (TURP), but this requires a general The first four PUL patients were treated as day cases, anaesthetic, around 90 mins of main theatre time, but in theatre under general anaesthetic to ensure that under general anaesthetic is scheduled. post-operative catheterisation in most men, and a their experience was not compromised during the Once the procedure is finished, the patient is taken to hospital stay of 2–3 days. Catheterised patients also period of service adjustment. Subsequent patients the recovery bay (often the patient walks unaided). need to attend a follow-up outpatient appointment a underwent PUL with local anaesthetic unless they few days after discharge for a trial without catheter. After he has voided twice, is comfortable (pain is requested (or they were deemed unsuitable for) Long-term complications of TURP can include stress measured on a VAS scale), and has been reviewed by general anaesthetic when treatment options were urinary incontinence and impaired sexual function, the operating surgeon, he is discharged. An being discussed. which are felt to be bothersome by many patients3. appointment is made for the patient to attend a These risks can delay men from seeking treatment, but An audit of the records of the first 42 men treated with nurse-led follow-up clinic 3–4 months after surgery. when they do, waiting lists for non-urgent TURP can be PUL indicated good outcomes 3 months after surgery long. We found that having TURP as the only surgical Since September 2017, we have treated 61 men with (Table). Three-quarters of men underwent the option in Fife placed considerable burden not only on procedure with local anaesthetic and, on average, were PUL instead of TURP, saving an estimated 61 theatrepatients, but also on health-care resources. hours and 122 inpatient bed-days. During the discharged within 3 hours. 2 patients had urinary consenting process, a very small number of men (six) retention post-operatively (4.7%), but the subsequent In 2015, the UK National Institute for Health and Care have requested a general anaesthetic and were added trial without a catheter was successful, Excellence (NICE) recommended the Urolift® System as 2 patients had a mild urinary tract infection (4.7%) to the waiting list for a main theatre slot. Only one a minimally invasive alternative to TURP for the treated with oral antibiotics, 6 reported temporary patient was found to be unsuitable for PUL under local treatment of urinary obstruction due to BPH4. Accessing urinary urgency (14.2%) and 2 patients required anaesthesia due to other co-morbidities, and he the prostate via the urethra, the device places irrigation postoperatively due to haematuria but did not underwent the procedure under elective general require an overnight stay. It quickly became clear that permanent implants that lift and secure the enlarged anaesthetic. prostate tissue away from the obstructed urethra. It PUL could be offered not only as a day-case procedure, takes less than 20 mins, can be performed under a but that with use of a local anaesthetic protocol and Conclusions local anaesthetic, and patients can go home after a few rapid discharge, the service could be moved entirely to Performing PUL (Urolift® System) in an outpatient hours, typically without a catheter. Adverse events, an outpatient setting. In December 2019, we moved the setting with local anaesthesia is now part of NHS Fife’s which include haematuria, dysuria, micturition urgency, PUL service to the Day Treatment Unit, an outpatient standard operating procedures. With a workable local pelvic pain, and urge incontinence, are typically mild to clinic in Queen Margaret Hospital, Fife. anaesthetic protocol that does not require an moderate in severity and resolve within 2-4 weeks2,5. PUL also preserves sexual function2. Table: Audit of first 42 PUL patients As NHS Scotland has a vision for person-centred care Measure Local anaesthetic General anaesthetic p-value that includes managed patient risk profiles and Baseline innovation to improve outcomes, we seized the Number of patients 32 10 opportunity to include PUL as one of the treatment 64.5 ± 10.8 60.5 ± 11.3 0.3 options that we offer patients with obstructive LUTS. We Age (years) Prostate volume (mL) 37 ± 9.2 40 ± 9.1 0.5 also wanted to explore whether treating patients under a local anaesthetic would enable us to move the Implants per patient 3.1 ± 1.3 3.2 ± 1.0 0.9 procedure to an outpatient setting. Not only were these Theater time (min) 17 ± 5.2 17 ± 6.0 0.9 changes anticipated to improve patients’ access to Pain score (VAS) 2 ± 1.4 2 ± 2.0 0.9 treatment with good outcomes but also reduce the Qmax 10.1±2.5 10.7±0.6 0.2 burden on the BPH care pathway. IPSS score 19 ± 6.2 23 ± 6.9 0.1 Implementation of PUL QoL score 5 ± 0.8 5 ± 1.3 0.4 To transform our BPH treatment pathway, we first 3-month outcomes needed to establish PUL as a treatment option. A local Number with impaired IPSS 18 9 business case was submitted and approved by the NHS Qmax 13.7±2.0 13.8±0.6 0.7 Fife Health Board, and funding was provided by the Qmax change from baseline 3.6±0.5 3.1±0.0 Scottish Government. The business case described the IPSS at follow-up 9 ± 4.3 10 ± 1.8 0.6 current pathway and the opportunity for change, particularly the burdens on inpatient bed capacity, IPSS change from baseline -12 ± 7.3 -12 ± 6.0 0.9 theatre time, and waiting lists for TURP. We estimated Paired p-value <0.0001 <0.001 the potential benefits to patients and the care pathway Number with QoL scores 32 10 of introducing PUL, which we expected would release QoL at follow-up 2 ± 1.3 2 ± 1.0 0.8 bed and theatre capacity through effective treatment QoL change from baseline –3 ± 1.6 –3 ± 1.1 0.4 Paired p-value <0.0001 <0.0001 EAU Section for Urologists in Office (ESUO)

European Urology Today

Data are number or mean ± SD. IPSS = International Prostate Symptom score. VAS = visual analogue scale. QoL = quality of life.

Figure 2: The preparation room

Figure 3: The procedure room

anaesthetist and with rapid discharge, we found it was possible to switch almost entirely to ambulatory outpatient PUL procedures while maintaining high-quality care, outcomes, and treatment experience. PUL can be offered early in the disease course as the primary treatment or secondary to other treatments. Not only are patients’ urinary symptoms improved but longer-term quality of life is maintained or enhanced. For the NHS Fife Urology service, substantial savings in time and resources have been realised. Key learning points • PUL (Urolift® System) is easily performed in an outpatient setting, under local anaesthetic with no need for an anaesthetist, while maintaining good clinical outcomes and patient experience. This realisation open the way for more procedures to be performed in an out-patient setting. Further research is required, though. • Eligible patients can be recruited from the BPH clinic or the urology waiting list. • Average procedure time is 17 mins; we treat around 6–8 patients per session. • The BPH treatment pathway has been dramatically simplified, with significant savings in terms of staff time, theatre time, and inpatient bed-days. • The keys to success are selection of patients, allowing time to discuss all bothersome symptoms with the patient, and establishing practical expectations6. • BPH treatment aims to improve symptoms to increase quality of life, which needs to be clarified from the very beginning. • PUL may be offered as a primary treatment or secondary to medication. • Further data is required to standardise Urolift® as an out-patient procedure. Disclosure: Mr. Petros Tsafrakidis is a Teleflex UK mentor References 1. Benign prostatic hyperplasia: an overview. C. G. Roehrborn Reviews in Urology volume 7 (Suppl 9), pages S3–S14 (2005). 2. The prostatic urethral lift for the treatment of lower urinary tract symptoms associated with prostate enlargement due to benign prostatic hyperplasia: the L.I.F.T. study. C.G. Roehrborn. S. N. Gange, N. D. Shore, et al. Journal of Urology, volume 190, issue 6, pages 2161–2167 (2013). 3. Sexual function after transurethral resection of the prostate (TURP): results of an independent prospective multicentre assessment of outcome. M. Muntener et al. European Urology. volume 52, issue 2, pages 510–516 (2007) 4. Urolift® for treating lower urinary tract symptoms of benign prostatic hyperplasia: medical technologies guidance [MTG26]. National Institutes for Health and Care Excellence. 16 September 2015 [Internet]. Available from https://www.nice.org.uk/guidance/mtg26 (accessed July 13, 2020). 5. Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12-month results from the BPH6 study. J. Sønksen. N. J. Barber, N. J. Speakman, et al. European Urology volume 68, issue 4, pages 643–652 (2015). 6. Treatment options for benign prostatic hyperplasia in older men. R. Miano, C. De Nunzio, A. D. Asimakopoulos, S. Germani, A. Tubaro Medical Science Monitor. Volume 14 (7), pages RA94-RA102 (2008).

August/September 2020

The evolution of urology volunteerism in Haiti Streamlining volunteer efforts in order to maximise the positive impact to urology training and practice For more than 25 years, volunteer urologists have independently provided direct patient care in Haiti or conducted educational seminars to share their expertise with fellow Haitian colleagues. In general, these activities operated independently without cross-coordination and thus had failed to achieve their full potential. In 2014, the AUA began to work with Dr. Angelo Gousse, a Haitian-American academic urologist practising in Miami, on humanitarian efforts in Haiti. Dr. Gousse has been volunteering his services in Haiti to improve urologic education for over two decades and has served as a great liaison between Haitian urology and the AUA. The AUA had already been supporting two Haitian residents to attend the Fundamentals in Urology course each year, and in 2015, increased its outreach to Haiti by holding an Ultrasound Course in Port au Prince. In 2016, Dr. Angelo Gousse co-founded the Global Association for the Support of Haitian Urology (GASHU). The mission of the organisation is to improve academic urologic training in Haiti by working directly with Dr. Angelo Gousse urology residents in Haiti while better coordinating the efforts of non-Haitian urologists contributing to urologic care in Haiti. This effort will also improve access and quality of urological care in Haiti. GASHU also strives to increase awareness with patient education aimed at the Haitian public on the importance of urologic disorders. This mission is fulfilled through various media outlets and activities. GASHU has been able to streamline volunteer efforts in order to maximise the positive impact to urology training, practice and patient care in Haiti. GASHU identified Hospital St. Francois de Salles (Port-auPrince) as one of the premiere hospitals in Haiti which offers great potential for the training of residents and the development of surgical workshops. Once a hospital was chosen for urology residency training in Port au Prince, GASHU members realised that a key to

the success of long-term training in Haiti is to ensure that donated equipment is properly maintained, stored and used. Understanding this, Dr. Gousse requested support from the Global Philanthropic Committee (GPC) to put in place a dedicated urology nurse at Hospital St. Francois to oversee the care of the instruments and help with medical staff training and coordination of educational workshops. The Global Philanthropic Committee (GPC) is a partnership between the American Urological Association (AUA), European Association of Urology (EAU), International Continence Society (ICS) and the Société Internationale d’Urologie (SIU), with the goal of supporting proposals for worthy projects to improve urologic care throughout the world. The primary goal of the GPC is to help build the infrastructure for a sustainable and self-sufficient educational hub in areas of need; using a “train the trainer” model. The GPC has supported the annual salary of Ms. Japhare Joseph for several years now and she has done an outstanding job. Dr. Franks Burks, a reconstructive urologist who travels to Haiti to volunteer on a regular basis, noted Dr. Gousse performs surgery with a Haitian colleague that based on his observations he believes “Nurse Japhare’s presence has been the single biggest advancement in urology in Haiti in recent years.” received. The Haitian residents and urologists are still eager to learn and continue to improve their skills GASHU’s efforts to change the landscape of urologic despite extreme challenges and obstacles. Their care in Haiti is supported by several influential global perseverance in the face of adversity is a great example urology organisations and international leaders in the to all of us during this time. field of urology. In addition the GPC, the following organisations have contributed to this effort over the The continued humanitarian effort in Haiti to improve years: IVUmed, Association des Medecins Haitiens a l’Etranger (AMHE), Societe Haitienne D'Urologie (SHU), urologic care is a testament to what can be accomplished by a truly coordinated global effort Genito-Urinary Reconstructive Surgeons (GURS), among urologists and urology organisations. At the Project Haiti, Endourological Society, Notre Dame 2019 AUA Annual Meeting, Dr. Gousse presented an Filariasis Project, and Konbit Sante. This list is not abstract entitled, “Creation of a Systematic Approach to inclusive and there are many other groups and Improve Urologic Care in Resource Poor Countries: The individuals that have supported this effort. Haiti Experience”, showing the tangible and positive results that can occur through such a coordinated effort While the COVID-19 pandemic and civil unrest in Haiti among volunteer physicians. Let’s hope this initiative has put on hold in-person visits for now, Dr. Henri continues well into the future and can serve as a Nurse Japhare serves a critical role in continuing urologic Lanctin, a urologist who has volunteered in Haiti for a blueprint for others to follow. training in Haiti decade and is an active member of GASHU, has organised online workshops to continue urologic education in Haiti. In January, a teleconference on “E-Learning in Urology” was held and was well

Education Online e-learning at your own convenience

EAU Education Online course

Advanced Prostate Cancer: Metastatic Hormone-Sensitive Prostate Cancer Participants in the AUA Ultrasound Course present their certificates of course completion

The Third course in the Advanced Prostate Cancer series The new Advanced Prosate Cancer series is comprised of 5 courses which offer clinicians a

Global Philanthropic Fund The Global Philanthropic Committee (GPC) consists of multi-national urology organisations including the American Urological Association (AUA), European Urology Association (EAU), International Continence Society (ICS) and the Société Internationale d’Urologie (SIU), with the goal of supporting proposals for worthy projects to improve urologic care throughout the world. The GPC allows organisations to pool their resources to fund larger scale philanthropic projects as a collaborative effort. Urology organisations can support a project through monetary funds and/or in-kind donations, including volunteer time. The GPC’s mission is to provide philanthropic support to improve urological education in the developing world. The GPC strives to provide funding mainly for education and generally will not provide funds for purchasing expensive equipment. The GPC will selectively provide funds for educators to travel for the purpose of providing training in various regions of the world, within the parameters of an approved funding request.

complete view on clinical aspects, diagnosis and treatments of prostate cancer.

Learning chapters in mHSPC: Chapter 1: Definition and classification Chapter 2: Clinical evaluation Chapter 3: Treatment Chapter 4: Follow-up and surveillance strategies Prof. Nicolas Mottet Main Coordinator CHU St Etienne, Department of Urology, Saint-Étienne (France)

2 CME c

redits

Free access with MyEAU account

This course is in line with the EAU Guidelines 2020. This course is supported by an independent educational grant from Janssen, the Pharmaceutical Companies of Johnson & Johnson.

Each course will be individually accredited by EACCME

uroweb.org/education August/September 2020

European Urology Today

EAU21 to feature EAU’s first Patient Poster Track Patient-physician disconnect will be one of the themes at the Annual EAU Congress in Milan this March Ms. Esther Robijn EAU Patient Information Sr. Coordinator Arnhem (NL)

encourage interaction between the patient presenter and medical experts, which allows for a patient perspective to be injected into the conversation. It provides educational opportunities for patients, patient advocates and HCPs, intending to close the gap by improving communication and exchanging perceptions on both sides. This will ultimately lead to better treatments and adherence through shared decision-making as well as improved outcomes.

e.robijn@uroweb.org When discussing urological care, some might say that there is often a patient-physician disconnect. Studies have shown there is often a gap between what the physician recommends, based on scientific evidence combined with experience, and what a patient expects or prefers in terms of outcome, side effects and maintaining a good quality of life1,2. A patient’s personal values and opinions may not be compatible with the recommended treatment. When this hasn’t been taken into consideration, healthcare professionals (HCPs) may appear to be out of sync with health-related quality-of-life matters that a patient wants to discuss.

“The Patient Poster presentations bring together HCPs and patients in the best possible way.” The patient-physician disconnect will be one of the themes at the Annual EAU Congress in Milan, which is taking place from 19 to 23 March 2021. The EAU offers patient advocates the opportunity to present their research into diagnostics, treatments and follow-ups that could cast a fresh light on health-related quality-of-life issues and addresses presumptions that exist regarding these issues. Patient Poster Track activities The Expert-guided Patient Poster tour aims to

“The EAU offers patient advocates the opportunity to present their research that could cast a fresh light on health-related quality-of-life issues.” The Top-5 Patient Poster presentations will take place during the EAU Patient Information sessions. In addition to receiving a prize for best poster, each presenter will be given the opportunity to take the stage and present their research. The Patient Poster presentations bring together HCPs and patients in the best possible way. By bringing the patient perspective into the discussion, it provides a good balance and will clearly showcase any disconnects between what patients think and want and the view of clinicians. A better communication and understanding of expectations on both sides will benefit all. Posters will be electronically accessible at a designated kiosk located in a high-traffic walkway, well away from commercial areas. Advisory Board The patient group representatives from the EAU Patient Advocacy Group (EPAG) will act as the Advisory Board, responsible for the selection of abstracts that will be presented during the Patient Poster Track presentations session, the Expert-

guided Patient Poster tour and the Top-5 Patient Posters session. The EAU Scientific Congress Office The EAU Scientific Congress Office (SCO) is responsible for the selection of one to two abstracts that will be presented to an audience of HCPs at a preselected thematic or poster session of the EAU21 Scientific Programme. This will ensure that the session is compatible with the poster presentation and that the perspectives of both the experts and the patient are presented and discussed.

We encourage you to promote and share the EAU Patient Poster Track!

Or contact us at info.patientinformation@uroweb.org.

This project is brought to you by the European Association of Urology (EAU), with programme development support from Pfizer. References

Join us at the first EAU Patient Poster Track in Milan! For more information about the project, please visit

https://patients.uroweb.org/eau21/.

1. George Miaoulis Jr., Jonathan Gutman & Margaret M. Snow (2009) Closing the Gap: The Patient-Physician Disconnect, Health Marketing Quarterly, 26:1, 56-68, DOI: 10.1080/07359680802473547 2. Canzona MR, Love D, Barrett R, et al. "Operating in the dark": Nurses' attempts to help patients and families manage the transition from oncology to comfort care. J Clin Nurs. 2018;27(21-22):4158-4167. doi:10.1111/jocn.14603

21 Cutting-edge Science at Europe’s largest Urology Congress

Call for Patient Poster Abstracts

1 Nov. Your research

Submission deadline

Selection by reviewers

Outcome abstracts

Your presentation

EAU Update on Prostate Cancer

Virtual meeting Saturday, 17 October 2020

EAU onco-urology series

www.pca20.org

EAU Update on Bladder Cancer and Renal Cell Cancer

20-22 May 2021 Frankfurt, Germany

EAU onco-urology series

www.bca-rcc21.org

European Urology Today

August/September 2020

Getting a tattoo is no longer taboo... But talking about erectile dysfunction still is. Letâ&#x20AC;&#x2122;s break the silence. #UROLOGYWEEK

urologyweek.org August/September 2020

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European Urology Today

August/September 2020

Donâ&#x20AC;&#x2122;t let anything stop you.

Erectile dysfunction (ED) can affect many aspects of your life. Talk to your urologist about ED and ask about the best treatment for you.

European Urology Today

August/September 2020

Turn it the right way up again! Sexual health is an important part of the quality of your life. Donâ&#x20AC;&#x2122;t keep it to yourself. #UROLOGYWEEK

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Scientific

August/September 2020

The EAU RF’s “start-up package” for beginning researchers New research into causal mechanisms and novel therapeutic targets in CRPC after AR blockade failure By Loek Keizer Dr. Alvaro Aytes (Barcelona, ES) was finishing his postdoc in the United States when he started exploring funding opportunities for a new research project. “I was an associate research scientist at Columbia University in New York, and after seven years I wasn’t that well connected to European funding opportunities anymore. I think it was through friends and colleagues that someone pointed out the EAU Research Foundation’s Career Development Programme.” The programme was started by the EAU Research Foundation in 2012, in order to help researchers in urology start projects and prove their viability, thereby attracting new funding. The three-year programme helps promising researchers make a jump from a mentored position to leading their own projects and in turn employ others. “The development programme has been instrumental in helping me develop my own ideas,” says Dr. Aytes. “The most important thing when you transition from a postdoc position to a non-mentor position is that you might have a contract with an institute, but that doesn’t mean you have funding to move your projects forward. This programme acted as a start-up package. Its funds allowed me to hire the first postdoc in my lab, the first technician, and basically start running a lab: ordering supplies and getting things started.” Dr. Aytes is the principal investigator for this project, which falls under the Programme Against Cancer Therapeutic Resistance (ProCURE). It explores causal mechanisms and novel therapeutic targets in castration-resistant prostate cancer after the failure of androgen receptor blockers. It is a joint project between the Catalan Institute of Oncology (ICO) and the Bellvitge Institute for Biomedical Research (IDIBELL). The project recently finished its third year and yielded the first promising results, important new publications for the team and secured new streams of funding to continue the research. Selection process The selection process for the programme took place in 2015 and involved several rounds of interviews and presentations. Dr. Aytes found the process “very interesting. I would say it’s a fine example of how you would recruit people if you’re going to spend a substantial amount of money to launch their careers.” After a round of reviews of the submitted projects, there is a second round that involves a face-to-face interview with the EAU Research Foundation’s committee with every candidate who makes it onto a shortlist. These interviews take place at the EAU’s Annual Congress, in the case of this project in Madrid in 2015. “The face-to-face interview was not unusual but I found that the committee was a nice mix of clinicians and basic scientists who posed interesting questions and comments in a positive way. They weren’t out to tear the proposals apart and select the one that survives. I felt they were looking for interesting ideas that could help move forward the organisation’s strategic plan. It was a pleasant but also demanding process.” The Project Dr. Aytes’s research focuses on advanced prostate cancer and mechanisms of resistance to standard of care treatments. His team is trying to identify new targets or vulnerabilities that emerge from treatment on PCa patients, offering new opportunities for intervention. This includes new targets but also new biomarkers to better stratify patients based on risk or to predict whether treatment may work better or worse in a particular subset of patients. “We do a lot of work with mouse models,” says Dr. Aytes. “We’re basic researchers with a translational point of view so we try to use experimental models, which includes cell-based models or animal models. We model the disease as it progresses from androgen receptor-responsive phases of the disease to androgen receptor, castration-resistant PCa, or even androgen-independent disease where there is a great need for better treatment and the ability to predict who’s going to respond to the treatment available.”

EAU Research Foundation

August/September 2020

“That was the main goal of the career track programme: identify new targets and biomarkers in the realm of epigenetics. Epigenetic markers and targets that could predict or could be used as epigenetic targets.” “The project emerged from earlier data during my postdoc. I conceived it and wrote about it during my postdoc period in New York. When the project was accepted, I took the know-how and some animal and cellular models that I had developed during the postdoc years in NYC back to my home institution in Barcelona.” “I should point out that another important aspect of the career track is that it was very flexible with dates, with budget allocation. Typically in science, and especially when starting a project, this is an important factor. The organisations that are funding your work need to understand that you need a certain level of flexibility to allocate funds to either the agent, or hiring personnel, in this case shipping mice across the Atlantic. The EAU-RF understands that. That’s why I think that the career track programme is an excellent programme for essentially what it’s meant to be: launching careers in research.” Response One of the major conclusions following the three years of research is that collectively, the preliminary data strongly points at nuclear receptor binding SET Domain Protein 2 (NSD2) as a potential biomarker for lethal prostate cancer that is functionally linked to metastasis and whose inhibition with small molecules may provide a therapeutic opportunity in advanced prostate cancer. The project has generated several publications (see references below), drumming up interest in the research, and ultimately more funding. Most notably in Nature Communications in December 2018. Work is currently underway on an article for European Urology. “Being published in such a prestigious and widely-cited journal will be the icing on the cake for this project and for the Career Development Programme as a whole,” Dr. Aytes reflected.

References 1. Aytes, A*., Giacobbe, A., Mitrofanova, A., Ruggero, K., Cyrta, J., Arriaga, J., Palomero, L., Farran-Matas, S., Rubin, M.A., Shen, M.M., et al. (2018). NSD2 is a conserved driver of metastatic prostate cancer progression. Nat Commun 9, 5201. https://www.nature. com/articles/s41467-018-07511-4 2. Costas, L., Frias-Gomez, J., Guardiola, M., Benavente, Y., Pineda, M., Pavon, M.A., Martinez, J.M., Climent, M., Barahona, M., Canet, J., Paytubi, S., Salinas, M., Palomero, L., Bianchi, I., Reventos, J., Capella, G., Diaz, M., Vidal, A., Piulats, J. M., Aytes, A., Ponce, J., Brunet, J., Bosch, F. X., Matias-Guiu, X., Alemany, L., de Sanjose, S. and Screenwide, Team (2019a). New perspectives on screening and early detection of endometrial cancer. Int J Cancer 145, 3194-3206. 3. Costas, L., Palomero, L., Benavente, Y., Guardiola, M., Frias-Gomez, J., Pavon, M.A., Climent, M., Martinez, J.M., Barahona, M., Salinas, M., Pineda, M., Bianchi, I., Reventos, J., Capella, G., Diaz, M., Vidal, A., Piulats, J. M., Ponce, J., Brunet, J., Bosch, F. X., Matias-Guiu, X., Alemany, L. de Sanjose, S., Aytes, A*. and Screenwide Team. (2019b). Defining a mutational signature for endometrial cancer screening and early detection. Cancer Epidemiol 61, 129-132. 4. Nombela, P., Lozano, R., Aytes, A., Mateo, J., Olmos, D., and Castro, E. (2019). BRCA2 and Other DDR Genes in Prostate Cancer. Cancers (Basel) 11. 5. Piulats, J.M., Vidal, A., Garcia-Rodriguez, F.J., Munoz, C., Nadal, M., Moutinho, C., Martinez-Iniesta, M., Mora, J., Figueras, A., Guino, E., Padulles, L., Aytes, A., Mollevi, D. G., Puertas, S., Martinez-Fernandez, C., Castillo, W., Juliachs, M., Moreno, V., Munoz, P., Stefanovic, M., Pujana, M. A., Condom, E., Esteller, M., Germa, J. R.,

Prostate cancer metastasis in the mouse lung. Cancer cells (green) are lineage traced and double labelled with CKB (red)

Capella, G.,Farre, L., Morales, A., Vinals, F., Garcia-DelMuro, X., Ceron, J., Villanueva, A. (2018). Orthoxenografts of Testicular Germ Cell Tumors Demonstrate Genomic Changes Associated with Cisplatin Resistance and Identify PDMP as a Resensitizing Agent. Clin Cancer Res 24, 3755-3766. 6. Ruggero, K., Farran-Matas, S., Martinez-Tebar, A., and Aytes, A*. (2018). Epigenetic Regulation in Prostate Cancer Progression. Curr Mol Biol Rep 4, 101-115.

Dr. Alvaro Aytes with his team: Katia Ruggero, Sonia Farran Matas, Xiang Chen, Arián Martínez Tebar, Barcelona, Spain

“It can be difficult to get visibility sometimes, especially coming from a small institution, but I can’t complain. Papers published so far have been highly cited. As a result of these papers I’ve been invited to the French Association for Prostate Cancer, and to conferences and congresses throughout Europe. Invited to participate in research consortiums for European funding. This is the result of the work that the career programme has allowed me to do.” As the cooperation with the EAU Research Foundation winds down, the project has generated promising data that is attracting new interest. “We’re a relatively young lab, but if this new paper gets accepted there will be a lot more to come. I’m very excited about this other follow-up work, on the role of epigenetics program in advanced disease. It will open up new strategies for stratifying patients. There is some know-how, intellectual property that can be derived that will come out from that paper. In terms of new targets for intervention, likely. Obviously there’s confidentialities there. But I think these next two papers in the pipeline are going to be great.” Summarising the role of the Career Development Programme in the project’s success, Dr. Aytes points to the “start-up package” nature of the funding. “Unquestionably, the programme’s funding gave me the ability to hire a postdoc right away, and a technician. It also gave me the possibility to immediately start generating results and attracting further funding.” “Looking around me at other young private investigators, it’s difficult to submit an application for funding by saying that you have a brilliant idea but you don’t have any funds yet. I’ve been able to say, “I have a brilliant idea, but this important association [the EAU] already trusts us.” “We are now up and running, and that was thanks to the Career Development Programme.” At the moment the EAU Research Foundation is focussed on supporting clinical research by young urology researchers through its Seeding Grant Programme. Find out more on: www.uroweb.org/research/seeding-grant-application/.

12th European Multidisciplinary Congress on Urological Cancers

Implementing multidisciplinary strategies in genito-urinary cancers

VIRTUAL 13-14 NOVEMBER 2020 www.emuc20.org European Urology Today

ESU Updates

The legacy and future of the ESU The School’s achievements, milestones and its next Chair Education and postgraduate training were and still remain as fundamental undertakings of the European Association of Urology (EAU). The EAU always believed that urological education and programmes should be accessible to all urologists and urologists in training. In 1994, an official announcement was made during the General Assembly of the 11th EAU Annual Congress held in Berlin, Germany: the EAU Management Committee approved the creation and establishment of the European School of Urology (ESU). The ESU was founded to develop, organise, and oversee EAU education. In 1996, the esteemed Prof. Frits Schröder (NL) was named ESU’s first Chairman. Prof. Schröder was succeeded by fellow key opinion leaders such as Prof. Chris Chapple (GB) and Prof. Paolo Puppo (IT) who led the ESU from 2000 to 2004; followed by Prof. Prof. Hein Van Poppel (BE) from 2004 to 2012; and then by the current ESU Chair, Prof. Joan Palou (ES). For more than two decades, the ESU has dedicated its manpower and resources to offer first-rate education to young and seasoned urologists. The ESU believes that prime urological education is the product of resolute dedication, evidence-based information, and guidance of knowledgeable mentors. Read on for an overview of ESU’s growth through the years and a glimpse of what’s to come.

Prof. Palou passes the torch after years of service For eight fruitful years, the ESU was led by its distinguished Chair, Prof. Joan Palou (ES). Under his leadership, the ESU flourished: activities have increased, ESU’s reach broadened, innovative programmes were developed, more talented and enthusiastic urologists joined the ESU. The ESU also formed close collaborations with all the sections of the EAU and the Guidelines Office. Prof. Palou encapsulated ESU’s greatest achievements into teamwork, credibility and standardisation. “Teamwork facilitated the evolution of the ESU because with clear objectives in mind, we

Prof. Palou at EUREP back in 2012 brainstormed and executed plans as a solid team. On credibility, we are forthcoming with our activities and how we create and maintain relationships. We deliver what we pledged to do. What we offer was and continues to be tried and tested. The pathways of ESU activities have promoted efficiency, consistency and reliability which contributed to standardisation,” he explained. The ESU puts great importance on the well-being of urologists which is linked to education. Prof. Palou cited the results of the 2019 study ‘Prevalence of and Predictive Factors for Burnout Among French Urologists in Training’ by Dr. Jérôme Gas, et al. The study stated that in addition to a well-balanced lifestyle, the feeling of being well-trained is a strong protective factor against burnout. “Good urological education also improves how they manage the stress and the demands that this profession entails. Consequently, good education positively affects their performance and the welfare of their patients,” said Prof. Palou. Urology is his calling What inspired Prof. Palou to choose urology as his specialty? How did all begin? “It was clear from the start. I always knew I wanted to focus on a surgical specialty. The pivotal moment was during my third year at medical school when my grandfather had undergone prostatic surgery. Dr. Francisco Bedós was the surgeon and his performance of the procedure impressed me. That singular event motivated me to pursue urology as my own specialty. In the years to come, Dr. Bedós and I became good friends until his recent passing at age 94. He was an excellent clinician and surgeon, and a remarkable human being.”

Profs. Liatsikos and Palou with the rest of the expert faculty of the ESU-ESUT lasers masterclass in 2014 24

European Urology Today

Prof. Palou initially offered his expertise and service to the ESU in 2010 as an ESU Board member. In 2012, he was designated as Chair of the ESU during the Annual EAU Congress, which took place in Paris, France. In the same year, he became a faculty member of the European Urology Residents Education Programme (EUREP), one of ESU’s highly-regarded teaching programmes for final-year residents. Prof. Palou pioneered e-learning at the EAU. He proposed and determined the format of the EAU Guidelines courses, and supported specialisation courses which included the e-courses. Together with two members of the ESU board whose responsibilities included e-learning, Prof. Palou oversaw the projects and plans of ESU’s online education.

With fellow experts at ESU’s NMIBC masterclass in 2018

The hands-on trainings (HOT) increased with more activities and areas of expertise in urology. The creation of the training group of the ESU has led to a standardised methodology in training education and evaluation of the skills and learning process. A “teach the teacher programme” was also launched to improve the aptitude of the trainers. Prof. Palou also represented the EAU at the Confederación Americana de Urología Residents Education Programme (CAUREP), a prestigious programme formed years ago as a joint initiative of the EAU and the CAU. The CAUREP was modelled after EUREP and continues to offers the Hispanic urological community learning opportunities and updates pertinent to the region. The ESU continues the implementation of the EUREP format to future programmes and adapt it to the needs of a country and/or region such as the new ESU programmes in Asia. Bidding farewell “I always believed that education is a neverending journey. Technologies, information and teaching methodologies will continue to evolve, and the ESU will transform and improve with them. I am confident that the next ESU Chair will be highly capable of pursuing new ventures and upholding the ESU standards,” shared Prof. Palou.

Supporting Urology Week with peers from the Philippine Having a laugh with Prof. Jeroen Van Moorselaar at Urological Association dinner after an ESU event

Prof. Liatsikos stated some of his goals for the ESU, which include: 1. Raise funds from EU grants through standardisation of teaching and surgical education 2. Use online activities to reach out to colleagues who are not part of the ESU family yet 3. Continue with collaborations with national societies “Through different national societies, we can disseminate information about ESU’s structured training, which is designed for urologists at various levels. In addition, when national societies adopt these programmes at a local level, this will further enhance the visibility of the EAU undergraduate platform and ESU activities such as ART in Flexible, EUREP, UROBESTT, masterclasses, and many more,” said Prof. Liatsikos. 4. Maintain and strengthen cooperation with various EAU sections 5. Train the trainers According to Prof. Liatsikos, training the trainers is a programme that the ESU will continue to expand by training an intercontinental group of experts , who will also be ESU’s ambassadors in their respective countries. “My impetus has always been: keep an eye on the goal, work hard and deliver. My objectives will centre on helping to raise the level of urological care, carry out the goals of the EAU and the ESU, and prepare the young promising urologists because they’re the next in line,” Prof. Liatsikos concluded.

“It has been a pleasure to have served the ESU and collaborated with skilled and dedicated colleagues. It’s fulfilling to know that ESU’s impact is evident; participants go back to their countries and to their clinical practice with updated knowledge and renewed vigour. In consequence, this impact improves patient care, encourages new research, and further pushes the progress of the field. These are ESU’s legacy and it’s been an honour to be part of it.” Aspirations for the ESU “I’ve been in close collaboration with Prof. Palou for years and under his guidance, we’ve achieved a standardisation of education for urologists of all levels of experience,” shared ESU Chair Elect and Chief of the Department of Urology at the University Hospital of Patras in Greece, Prof. Evangelos Liatsikos (GR). He continued, “Since its inception, the ESU demonstrated hard work and unwavering commitment for its aims which are evident in its successes. It wouldn’t be easy to find what significant changes are still needed, just minor realignments that could further enhance the dynamics of the school.”

At a 2016 board meeting held in Noordwijk, the Netherlands August/September 2020

ESU Updates

New ESU Board members

Important ESU stats

The ESU welcomes esteemed experts Prof. Prokar Dasgupta (GB) of St. Thomas Hospital and Prof. George Kasyan (RU) of the Moscow State University of Medicine and Dentistry as new members of the ESU Board.

Throughout the years, the ESU has grown; its events and activities expanded and its reached broadened across the globe. Here are some of ESU’s impressive stats and fast facts:

“My aspirations include expansion of ESU’s educational platform with new editorial board members and modernise its digital interface. We will standardise the content and delivery of ESU courses and add new elements such as ‘meet-the-experts’ and webinars,” stated Prof. Dasgupta. Prof. Kasyan said, “I believe that the ESU brings knowledge to urologists, benefits to patients and vision to urological science. In my new role, I aim to devote my expertise and efforts, as well as, further develop and expand my know-how and skills, to better serve the ESU’s endeavours for urology in Europe and beyond.” The current Board members of the ESU include: • Prof. Joan Palou (ESU Chair) • Prof. Evangelos Liatsikos (ESU Chair Elect) • Members: Dr. Juan Gómez Rivas, Prof. Andrea Minervini, Dr. Ben Van Cleynenbreugel

• Consultants: Dr. Henk Van Der Poel and Prof. Jeroen Van Moorselaar • Ex-Officio: Prof. Hein Van Poppel, Prof. James N’Dow, Prof. Jens Rassweiler and Prof. Alex Mottrie

• 42,766 participants at ESU courses at EAU Annual Congresses from 1998 to 2019 • 9,088 participants completed the e-courses • 5,689 participants attended EUREP from 2003 to 2019 • Around 600 Hands-on Training (HOT) courses from 2007 until March 2020 • 321 courses held onsite at non-EAU events from 2002 to 2020 • A total of 91 experts as EUREP faculty members From 2003 to 2020 • 55 courses at EAU congress • 47 webinars at present + 5 upcoming webinars • 28 e-courses • More than 25 HOT courses • Masterclasses dedicated to 11 specific fields in urology

Milestones of the ESU

1999

2003

2005

2007

ESU became the official education office of the EAU

1st EUREP took place in Prague

1st masterclasses held (ESU-Weill Cornell Masterclass in General Urology and ESU-ESFFU Masterclass on Functional Urology)

1st HOT course took place at EUREP

2019

2018

2016

2014

1st UROBESTT commenced

1st ART in Flexible and SET-UP programme held in Spain and Singapore, respectively

1st ESU webinar live-streamed

1st CAUREP commenced in Uruguay; 1st e-course published online (Risk profile-oriented management of BPE/LUTS)

2020

UROwebinars were held; Train-the-Trainer programme launched; 1st masterclasses went virtual (ESU-ESUT Masterclass on Urolithiasis and the OMInar/ESU-Weill Cornell Masterclass in General Urology)

Your future in the EAU and the ESU One of the major aims of the EAU and the ESU is to guide young promising urologists and help pave the paths to their professional careers. Many internationally-known experts who are part of the EAU and ESU family were previous participants of activities and events. They are now Board members, faculty members, Chairs or editors-in-chief of scientific journals, section chairs and members, Young Urologists Office (YUO) Chairs and members, EUREP tutors, Hands-On Training tutors, Scientific Congress Office (SCO) members, and EAU Video Congress Committee members, to name a few. ESU does not only provide valuable educational resources and professional opportunities, but also organises activities and events which are a pool of talent and expertise. Enrich your know-how and bolster your career by participating in the following ESU activities: • Masterclasses (www.esu-masterclasses.org) • Webinars • Educational programmes (e.g. EUREP, ART in Flexible, SET-UP Programme) • Onsite and online courses For more information about the ESU’s activities, please visit www.uroweb.org/education/

August/September 2020

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First virtual masterclass premieres ESU and ESUT pursue prime education during pandemic Prof. Evangelos Liatsikos Course Director, Masterclass Head, Dept. of Urology University Hospital of Patras (GR) liatsikos@yahoo.com

Dr. Arman Tsaturyan Fellow of Endourology University Hospital of Patras (GR)

tsaturyanarman@ yahoo.com Extraordinary times sometimes require extraordinary decisions. To adapt to challenges brought about by COVID-19, the European School of Urology (ESU) and the EAU Section of Uro-Technology (ESUT) transformed ESU-ESUT Masterclass on Urolithiasis into a digital event. With an impressive tally of almost 206,000 impressions on Twitter, the recently-concluded masterclass was not only as successful as its in-person counterpart, but it was also a pioneering event as it was ESU’s first digital event. One of the major advantages of a digital event is the capacity to connect to a massive audience. Virtual events such as the masterclass take away the restrictions a physical venue can impose. The masterclass was still able to offer high-end education to participants through streamed live surgeries, presentations and lively discussions. It is evident that applications of online events are vast which makes going digital a viable alternative. Programme overview Spearheaded by other Course Directors Prof. Joan Palou (ES) and Prof. Andreas Skolarikos (GR), the digital masterclass kick-started in the morning of 19 June 2020. Preparations and the first day A central control office was established to moderate the whole process of live-sessions. Prior to the commencement of the masterclass, the online platform was tested several times to guarantee efficient time management and identify potential issues. Day one was comprised of pre-recorded surgical video presentations and live-surgeries prepared and performed by renowned specialists. The pre-recorded videos included a mini- percutaneous nephrolithotomy (PNL) performed by Prof. Thomas Knoll (DE); a supine endoscopic combined intrarenal surgery (ECIRS) with ultrasound guidance performed by Dr. Cesare Scoffone (IT); a supine ECIRS with fluoroscopic guidance

One of the many enthusiastic tweets about the masterclass

European Urology Today

OR scene during the live surgery session

Prof. Liatsikos’ setup for the virtual event

Dr. Esteban Emiliani (ES); a single-use ureteroscopic lithotripsy performed by Prof. Bhaskar Somani (GB); a flexible ureteroscopic lithotripsy in a horseshoe kidney performed by Prof. Olivier Traxer (FR); a flexible ureteroscopic lithotripsy for upper ureteral stone performed by Dr. Giorgio Bozzini (IT); and a bladder stone lithotripsy performed by Dr. Iason Kyriazis (GR). Particular attention was allocated to the broadcasting of live-surgeries which were performed at the endo-suite operating room at the University Hospital of Patras. Masterclass participants had the opportunity to view a live surgery in various angles on one screen simultaneously. The surgeries included a prone percutaneous nephrolithotomy and an insertion of a filament ureteral stent by Dr. Panagiotis Kallidonis (GR), flexible ureteroscopic lithotripsy with high power laser by Dr. Achilles Ploumidis (GR), and a prone PNL with antegrade ureteroscopy (URS). All pre-recorded video presentations and live-surgeries were accompanied by pre-surgery set-up discussions facilitating in-depth understanding of essential materials for each surgical procedure. Still sustaining momentum, renowned members of the faculty offered tips and tricks, and detailed step-bystep procedures on the masterclass’ day two and final day. They presented expert insights through a pre-recorded surgery illustrating optimal bladder stone lithotripsy, and lively lectures on URS for demanding cases, optimal laser settings, why pressures and temperatures during endourological procedures are the real threat, and more. Participants posed their questions either by pressing a button then raising their hands or by typing their questions in the masterclass chat. These questions were addressed either by a presenter or by the moderators. At the end of the masterclass, panel experts shared their experiences, and provided advice and insights in the management of specific patient cases. Impressions Promising and enthusiastic participants Dr. Marius Anglickis (LT), Dr. Adrian Czekaj (PL) and Dr. Dimitris

Dr. Anglickis shared, “Although it is a pleasure to Siatos (GR) also shared their experiences, feedback and opinions on how the masterclass will impact their participate in various courses and conferences in person, I prefer not to experience the stress in waking daily clinical practice. up very early to head to the airport, searching for a According to Dr. Czekaj, the masterclass covered almost venue at an unfamiliar place, and making it on time. all the aspects of urinary stones management Virtual events not only help reduce the chances in including the metabolic evaluation of urolithiasis. getting infected with COVID-19, but also save time and “Every step and every instrument needed in ease some worries. We have good internet connection procedures such as prone and supine PCNL, URS, here in Lithuania, so participating in the masterclass retrograde intrarenal surgery (RIRS), extracorporeal was easy and convenient. ” shock wave lithotripsy (ESWL), and endoscopic combined intrarenal surgery (ECIRS) were identified Considering the advantages of the virtual events such and explained in detail. I was surprised by the large as the possibility to welcome a greater amount of amount of information on lasers: safe and optimal attendees, cost-reduction, eco-friendliness, usage, set-up, and new technologies.” convenience/accessibility, and positive experience with the organisers of the masterclass, digital events will be “In my clinical practice, we have many patients with more utilized in the near future. kidney stones who show no metabolic or genetic changes in their medical tests. Prevention for kidney Interest in other ESU masterclasses stones is ineffective because quite often, patients have The participants have expressed a huge interest in recurring kidney colic attacks or coral stones. The joining other ESU masterclasses. According to Dr. Anglickis, masterclasses are highly-recommended masterclass is unique; I was able to learn from and and incredibly useful. He had invitations to join courses interact with the best specialists in Europe albeit in Germany but these were postponed due to the digitally, and solve difficult clinical cases with them. Expanding my knowledge through the masterclass will pandemic. Dr. Anglickis stated that he still plans to participate in courses and ESU masterclasses in the help me help my patients more,” said Dr. Anglickis. future. Viewpoints on the format The ESU-ESUT Masterclass on Urolithiasis is the third The overall feedback and evaluation of the ESU-ESUT that Dr. Czekaj has participated in. “The other virtual masterclass by the participants were highly highly-recommended masterclasses I’ve previously positive. Although the virtual format limited the social interaction of participants and the faculty among each joined were the ESU-ESAU-ESGURS Masterclass on other, it did not affect the quality of knowledge shared. Erectile restoration and Peyronie's disease and the ESU-ESUT Masterclass on Operative management of Dr. Czekaj admitted to being curious as to what extent benign prostatic obstruction. I will definitely apply for the digital format affect the realisation of its objectives. the ESU-ESOU Masterclass on Muscle-invasive bladder cancer and the ESU-Weill Cornell Masterclass in General “Honestly, the virtual masterclass met all of my urology.” expectations. It still showed the exceptional moderation of the faculty and commitment of the Dr. Siatos said he plans to attend more ESU medical staff involved in the live surgeries. The only masterclasses such as the ESU-ESUT Masterclass on minor drawback was the lack of opportunity to Lasers in urology and the ESU-ESUT Masterclass on personally meet the experts and fellow participants.” Operative management of benign prostatic obstruction. “The virtual format was efficient and I didn’t encounter For the complete list of ESU masterclasses, please any issues at all. I enjoyed the exchange of opinions visit www.esu-masterclasses.org. The information and insights, and knowing about what other about the masterclasses are updated regularly and colleagues practise in their own departments. What I’ve learned from the masterclass will help me improve adjusted if necessary due to the current COVID-19 situation. my techniques in stone treatment,” stated Dr. Siatos.

The masterclass from the perspective of a participant

August/September 2020

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UROwebinars: "Stellar lectures on a plethora of topics" ESU redesigns courses into equally popular webinars This year, the European School of Urology (ESU) transformed its popular courses typically held onsite during EAU’s annual congresses into 10 UROwebinars.

attendees and where they were from; some were from the Middle East, South Africa and Asia. The enthusiasm and amount of questions asked by the attendees reflected their great interest in the topic.”

A precursor to the EAU20 Virtual Congress and EAU20 Theme Week, each UROwebinar was dedicated to a urological topic relevant to current and future clinical practice. The UROwebinars garnered huge interest and popularity with an impressive 5,000 online participants, with recordings still accumulating views until present.

On 7 July, Prof. Palle Osther (DK) and Prof. Olivier Traxer (FR) presented notable developments during the UROwebinar “Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips, tricks and indications” to 664 attendees. The webinar’s recording was viewed 955 times since late June.

“Brilliant presenters gave stellar and up-to-date presentations which generated a lot of ideas and helped clarify key points on a plethora of urological topics. These are, I believe, the reasons behind the success of the UROwebinars,” stated participant Dr. Peter Beniac (CZ).

“In my opinion, the webinar went very well and technical support was excellent. I think the online format should be kept as a feasible alternative, even after the situation with the pandemic is over,” stated Prof. Florian Wagenlehner (DE) as he described the UROwebinar “Dealing with the challenge of infection in

Locations of the faculty members (red) and online participants (blue) during the UROwebinars

Prof. Malavaud added that webinars are a potent lever to increase the footprint of the EAU and could play a significant role to attract more members as well. “As Chairman of the Membership Office, it is a prospect that I readily embrace and support.”

A UROwebinar's timely coverage of COVID-19 matters

The UROwebinars The first UROwebinar “Prostate cancer imaging: When and how to use it?” took place on 18 June wherein 496 attendees watched internationally-known Dr. Jochen Walz (FR), Dr. Ivo Schoots (NL) and Dr. Geert Villeirs (BE) deliver expert updates. “There were lively discussions, good attendance and plenty of interaction with the audience. We were able to reach urologists from all over the world and not only those who can join us on-site during meetings and courses. I am convinced that the online format will be used more and will be further developed in the future. Technological improvements might enhance the interaction aspect of an online event, which is a drawback relative to face-to-face meetings,” stated Dr. Walz. This was followed by the UROwebinar “Office management of male sexual dysfunction” held on 23 June wherein 335 attendees learned and interacted with the esteemed Mr. Ian Eardley (GB), Prof. David Ralph (GB) and Dr. Julian Marcon (DE). Currently, the recording of the webinar was viewed 613 times since end of June. On 25 June, Prof. Francesco Montorsi (IT) and Prof. Markus Graefen (DE) shared vital insights and developments during their UROwebinar “Prostate cancer update: 2019-2020” to 457 online participants. From late June until the present, the webinar’s recording was viewed 637 times.

urology in the COVID era”, which he co-presented with Dr. Béla Köves (HU) and Dr. Zafer Tandogdu (GB) to 271 attendees on 9 July. On 14 July, Ms. Jo Cresswell (GB) and Mr. Hasan Qazi (GB) presented the UROwebinar “Surgical anatomy for laparoscopic and robotic-assisted radical prostatectomy and cystectomy” to 661 online participants. Ms. Cresswell shared, “I enjoyed the session and I hope that colleagues found it helpful. The webinar was a ‘whistle-stop’ tour of pelvic anatomy as we usually present this as a three-hour course. The online format is a viable alternative when necessary. However, I feel that for this type of interactive session, we lose some of the value when we shorten the session and the presenters have less opportunities to engage the participants in discussions.” Held on 16 July, the UROwebinar “Practical management of bladder cancer”, was presented by respected experts Prof. Fred Witjes (NL) and Prof. Bernard Malavaud (FR) to 525 attendees. “Through the online format, our reach increased at least tenfold and our audience demographics were also quite diverse. Admittedly, it was challenging for Prof. Witjes and I to compress two ESU courses into a one-hour UROwebinar. Nonetheless, I was fortunate to present with Prof. Witjes who set the pace of the webinar and together, we successfully addressed questions and comments from the audience.”

an EAU member this year and have been receiving great opportunities such as interacting and consulting with the best urologic professors in online events and activities. Last year I went to the EAU congress in Barcelona and I loved it. Although it didn’t take place in Amsterdam this year, I appreciate the virtual On 27 July, Mr. Vijay Ramani (GB), Prof. Sascha Ahyai congress as well because lectures of high-quality (DE) and Prof. Thomas Herrmann (CH) delivered scientific content were still accessible thanks to must-know developments to 385 attendees during the technology.” UROwebinar “Management of BPO: from medical to surgical treatment, incl. setbacks and operative “All the UROwebinars were astounding. There were solutions”. The webinar’s recording was viewed 366 stunning images used to illustrate procedures; more times since late June. it made me feel as if I was in the operating theatre together with the presenter. The use of virtual reality Thoughts, impressions and favourites has the potential to add more value to this type of The overall feedback from junior and seasoned webinar in the near future,” said Dr. Beniac. He attendees was positive. added that the webinars addressing the EAU Guidelines and clinical decision-making were Renowned Prof. Mustafa Hiroš (BA) shared his explained in a clear and organised way with evidence thoughts on the UROwebinars, “The programme, supporting the recommendations. If he was not on delivery and technological support for the webinars call, he would have attended all of the webinars. were perfect. Important urological topics were covered from various aspects by prominent Dr. Fauriski Prapiska (ID) shared that he enjoyed specialists; from urologists, radiologists, to molecular the webinars that covered oncology, functional biologists and more. I enjoyed the webinars, urology, and COVID-19 matters. He stated, “I signed especially the ones on prostate cancer (PCa), PCa up to so many UROwebinars because I prefer to imaging and biopsy, and BCa management. I signed increase my knowledge in my free time. up for almost all of the UROwebinars because of Fortunately, healthcare workers in my country get professional, medical and scientific interests. Also, home sooner at the moment. We, urologists, are the ESU courses have always been very high quality. their back-up during the pandemic so I decided to This I observed first-hand when I attended the ESU fill my time with learning.” course held at the congress of the Turkish Urological Association last October.” Dr. Nicolae Cristian Manea (FR) shared, “The webinars were a real-time update of a large volume He added, “COVID-19 has transformed everyone’s life of valuable information. The webinars also provided and working conditions. Joining the webinars was a opportunities to discuss cases faced in daily practice, practical and beneficial means of adapting to the with leading experts in various pathologies who have current situation, and where one can also learn and dealt with thousands of cases. The webinars are also relax at the same time.” excellent resources in preparing for the EBU exam. I want to thank the EAU and the ESU for organising According to Dr. Luis Gabriel Vázquez Lavista (MX), the the UROwebinars during these challenging times.” UROwebinars were well structured and comprised of informative material delivered by knowledgeable A broader reach, accessibility, and convenience are professors. “I enjoyed the webinar on flexible some of the major advantages of the webinars’ digital ureterorenoscopy and retrograde intrarenal surgery; format, making it a viable alternative during the COVID-19 related webinar; and the webinar on extraordinary times such as the current situation bladder cancer (BCa) management because BCa is brought about by the pandemic. Even though the one of my favorite subjects and also because I admire format had a few disadvantages such as a more Prof. Witjes. I think he’s one of the worldwide condensed content with no face-to-face interaction, authorities on the subject.” both faculty and participants have weighed in and concluded that the UROwebinars still delivered He added, “We’re in quarantine here in Mexico and essential updates as designed. I think the situation will remain this way for quite some time. Even though I go out to attend to Access all previous and upcoming UROwebinars via emergencies, I do a lot of consultations from home https://uroweb.org/education/online-education/ (and homeschooling my sons). Fortunately, I became webinars/.

Prof. Ignacio Iribarren Moncada (ES), Dr. Maarten Albersen (BE), and Rn. Mariet Lenaers (BE) shared their expertise to 221 attendees during the UROwebinar “Penile prosthesis” which took place 29 June. This UROwebinar was also organised for the European Association of Urology Nurses (EAUN), a solid association with over 3000 members globally. Currently, the webinar’s recording was viewed 492 times. Prof. Rien Nijman (NL), Prof. Serdar Tekgül (TR) and Mr. Dan Wood (GB) spearheaded the UROwebinar “Practical approach to paediatric urology” which commenced on 2 July and was attended by 404 online participants. According to Prof. Nijman, it was the first time that they delivered a webinar to an audience that size at one time. “It was a great experience. Our reach was more extensive via the UROwebinar. A slide from Profs. Osther and Traxer’s webinar on fURS and RIRS We were pleasantly surprised about the number of August/September 2020

Key points in MRI for PCa diagnosis from PCa-imaging webinar

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OMInar delivers suite of resources in general urology

ESU Event Calendar Date

ESU-Weill Cornell masterclass goes virtual this year Prioritising the safety and well-being of the faculty, organisers and participants, this year’s ESU-Weill Cornell Masterclass in General Urology was redesigned as the virtual event Open Medical Institute webinar (OMInar).

two formats in the future. We aim to continually fine-tune our strategies and find better ways to connect with our students. We’ve entered a new era and these platforms allow us to adapt to varying teaching and learning needs.”

The OMInar took place on 9 July 2020 wherein 25 participants from 19 countries received expert insights and relevant developments on the surgical management of urethral disorders; early detection and treatment of prostate cancer (PCa); and management of non-muscle invasive bladder cancer (NMIBC).

Reaction and impact on attendees Young and promising attendees, Dr. Daria Chernysheva (RU) and Dr. Senjin Djozic (RS) share their OMInar experiences and their opinions on how the meeting will contribute to their practice.

This report encapsulates feedback from the faculty and impressions of the attendees, who also evaluated whether the online format is a viable alternative in the future. The OMInar was spearheaded by fellow renowned experts: EAU Secretary General Prof. Chris Chapple (GB), ESU Chair Prof. Joan Palou (ES), Prof. Douglas Scherr (US), Prof. Gero Kramer (AT), Prof. Shahrokh Shariat (AT) and Prof. Wolfgang Aulitzky (AT).

“I applied to the OMInar because the ESU-Weill Cornell Masterclass in General urology is ‘legendary’ among young urologists. The experts I admire who participated in this masterclass ranked it very high. And I was not disappointed! I enjoyed the lectures dedicated to NMIBC and the early detection of PCa, and the Q&A session was also great,” said Dr. Chernysheva.

She added, “From what I’ve learned during the OMInar, my clinical practice will benefit, particularly with BCa matters. I’ll become more “When most of the world are unable to gather in attentive to the high-grade T1 (T1HG) patients and person, the OMInar was created to offer the urological more confident in the conversations with clinical community a full suite of resources with a broader oncologists concerning treatment strategies for my reach,” stated Prof. Shariat. patients.” “The OMInar was well-received. The motivation behind pursuing the online format instead of postponement was to continue to support the initiative of delivering timely novel updates. Although face-to-face interaction and onsite presence are important components for events, the online format is a feasible option during extraordinary times like these,” stated Prof. Chapple. Prof. Palou agreed, “The virtual meeting went very well, indeed. Participation was good in terms of attendance and the amount of interaction between the attendees and the faculty. The transmission of information was excellent; overall, we received positive feedback. Although the OMInar programme was more compact and there was no hands-on training, the audience received vital key points and opportunities to deliberate.” According to Prof. Aulitzky, the evaluation of the OMInar by the fellows was highly favourable. “We decided to continue to stay in touch with our alumni, albeit online, and assess how they’ll receive this format. We consider this as a model in the future which can be used as a hybrid seminar.” “Both face-to-face and virtual events have their pros and cons. We always observe how the format – inperson or online – resonates with attendees/students. Does it meet their needs? Are there aspects of it that we need to improve? We always take their feedback very seriously,” stated Prof. Shariat. “As Prof. Aulitzky mentioned, we’re planning to combine the best of the

Prof. Aulitzky addresses the OMInar participants

European Urology Today

Dr. Djozic shared, “After my great EUREP experience, I was very excited to take part in the OMInar because it was a great opportunity to interact with experts. The meeting provided information on new studies from around the world and what is currently being researched. The OMInar also helped resolve dilemmas I encounter during its Q&A session. The meeting definitely gave me a sense what was important and what to focus on. “ When asked if they would be interested in participating in other masterclasses of the European School of Urology (ESU), Drs. Chernysheva and Djozic both said “yes”. “I hope to get the chance to attend masterclasses on BCa (NMIBC and MIBC), prostate biopsy and focal therapy,” said Dr. Chernysheva. According to Dr. Djozic, masterclasses are the “best meetings for learning due to smaller groups, more interaction with the faculty and fellow participants in a more relaxed atmosphere, while receiving the first-rate information from top experts in the field.” He concluded, “I don’t know what the situation with the pandemic will be, but I’d definitely like to attend some other masterclasses focusing on the bladder, kidney and prostate cancers, as well as, urolithiasis.”

Event name

Location

OCTOBER 2020 3 7-9 13 22 22 26 28-29 29

Virtual ESU course on New challenges and unmet needs in the surgical treatment of renal tumour: Lights and shadows for a tailored approach in patients with advanced/metastatic renal cancer during the national congress of the Hellenic Urological Association Virtual training ESU MRI Reading UROwebinar on BCG unresponsive disease Virtual 7th Confederación Americana de Urologia Residents Education Programme (CAUREP) Virtual ESU course on Dealing with the challenge of infections in urology during the national congress of the Tunisian Urological Society UROwebinar on An update on fluorescence guided surgery Virtual ESU-ESFFU Masterclass on Functional urology ESU course on Urinary incontinence in children and adults during the national congress of the Polish Urological Association

Hammamet (TN)

Poznan (PL)

NOVEMBER 2020 5 19 19-20 24 26-27

UROwebinar on Bladder pain UROwebinar on New trends in minimal invasive surgery Virtual ESU-ESUT Masterclass on Lasers in urology UROwebinar on Limits of flexible ureteroscopy Virtual ESU-ESUI Masterclass on Prostate biopsy

DECEMBER 2020 Tbd Tbd

UROwebinar on The use of PROMS in the evaluation of RARP UROwebinar on Pelvic pain

JANUARY 2021 30

ESU course on Prostate cancer: Treatment for biochemical recurrence (BCR) after local therapy and for oligometastatic disease during the CEM meeting

Vienna (AT)

FEBRUARY 2021 4-5

ESU-ESOU Masterclass on Non-muscle-invasive bladder cancer

Prague (CZ)

APRIL 2021 8-9 15-17

ESU-ESOU Masterclass on Muscle-invasive bladder cancer URO Berlin Skills Teaching and Training (UROBESTT)

Amsterdam (NL) Berlin (DE)

Please note that all events are subject to change pending updates regarding COVID-19. Visit the Urocalendar at https://uroweb.org/events/calendar/ for the latest schedule.

For more information on all ESU masterclasses, please visit www.esu-masterclasses.org.

Prof. Aulitzky, AAF Medical Director collaborates with EAU and initiates the OMInar

August/September 2020

The battle for EU health funds has begun Amount of EU funding for programmes such as Horizon Europe will be agreed on this autumn Mrs. Sarah Collen EAU Policy Coordinator Brussels (BE)

s.collen@uroweb.org The COVID-19 crisis has highlighted the need for a coordinated European approach to tackling shared health challenges. To answer to this need, the European Commission proposed a massive funding increase for a new standalone EU4Health Programme for the 2021-2027 period. However, this ambition was not shared by member state governments during their marathon four-day summit in July. Despite successfully agreeing on a historic financial recovery plan for Europe, this was achieved at the expense of EU programmes such as Erasmus, Horizon Europe and the EU4Health programme. Member states proposed 1.7 billion for this new EU4Health Programme. Although this is still more than the previous programme, which received under 500 million for the seven-year period, it is far short of the 9.4 billion originally proposed by the Commission. However, the European Parliament has not accepted these cuts and Euro-MPs have requested increased and earmarked funds for these and other EU programmes. As the European Parliament has a veto power over the EU’s multi-annual budget, we should be prepared for some interesting political discussions over the autumn period.

What will the EU4Health programme look like? Obviously, much depends on the funding the European Commission will have at their fingertips and that will depend on the outcome of the discussion on the budget. However, it is clear there will be a strong focus on health security and coordination between EU member states to manage a health crisis, on strengthening the European Centre for Disease Prevention and Control (ECDC), on developing capacity to prepare and fight a health crisis, and on investing in health systems to make sure they are best prepared. The EU4Health has three general objectives: 1. To protect people in the EU from serious cross-border health threats and improve crisis-management capacity; 2. To make medicines, medical devices, and other crisis-relevant products available and affordable plus support their innovation; 3. To strengthen health systems and the health care workforce by investing in public health, for instance through health promotion and disease prevention programmes for diseases such as cancer. The EU4Health Programme will also address inequalities in health and improve access to affordable, preventive and curative health care. The EAU will be supporting initiatives to keep EU funding for health and research high on the European Agenda. Whatever happens to the final budget, the EAU is active in lobbying for these funds to include sufficient support for prostate cancer, the most common male cancer in the EU, which to date has not received the profile and support of other common cancers such as breast cancer. This is in line with the recommendations of our recently published White Paper on Prostate Cancer (see https://uroweb.org/

eu-must-do-more-on-prostate-cancer/). Prof Hein van Poppel (BE) and the EU Policy Coordinator, Mrs. Sarah Collen (BE), recently intervened in an online event with the European Parliament’s spokesperson on this funding programme, MEP Cristian Busoi from Romania, to promote the case for increased EU investment in early detection of Prostate Cancer. Recommendations to guide EU cancer research In July, the board of experts for new ‘research missions’ to be supported by the EU research and innovation programme Horizon Europe made their recommendations on what the Cancer Mission should look like. There are plans for the funds to be allocated in line with the EU Cancer Plan, addressing the whole spectrum of cancer care: from prevention and early detection, treatment and care, to survivorship and quality of life. The overall aim of the cancer mission is that three million lives will be saved by 2030; three million people that will live longer and better. The foundation for this should be a better understanding of cancer, with an overarching theme of addressing inequalities.

“As the European Parliament has a veto power over the EU’s multi-annual budget, we should be prepared for some interesting political discussions over the autumn period.” There are thirteen recommendations overall, including an important call to optimise existing screening programmes and develop novel approaches for screening and early detection. This

brings a promise of a strengthened approach to prostate cancer and early detection. A core group of experts in the EAU has been working hard to develop the best algorithm on the basis of current evidence and this will be submitted soon to European Urology. We believe a common standard for early detection of prostate cancer will be an important milestone to achieve cancer health equity across the EU. Another important recommendation suggests increasing the quality of cancer research and the set-up of UNCan.eu, a Europe-wide platform to provide better understanding of cancer. Some of these initiatives will be aligned with the big data platform on Prostate Cancer called PIONEER, which Prof. James N'Dow (GB) is the project coordinator of on behalf of the EAU. The EAU will be following the developments of the negotiations on the EU multi-annual budget over the coming weeks and months. Keep an eye on the policy pages in the upcoming EUTs for further updates as the amount of EU funding is agreed on this autumn. For any further questions on this or other EU funding programmes, please contact s.collen@uroweb.org.

Affordable medicines and innovation top EU priority The EU Commission will publish its proposal for a European pharmaceutical strategy later this year Later in 2020, the European Commission will publish its proposal for a European pharmaceutical strategy which will address the challenges related to affordability and access to medicines and innovation across the EU. The use of digital technologies such as AI and real world data open up new opportunities for understanding medicines and how they are developed and used in clinical practice. The coronavirus pandemic has shown how important it is to have systems that can ensure availability of medicines at all times. It has also highlighted how dependent Europe is on outside countries for importing active pharmaceutical ingredients and medicines. The Pharmaceutical strategy for Europe aims to address these issues. It aims to examine legislative and non-legislative actions to achieve four specific objectives: • To ensure that patients across Europe have access to new medicines and therapies in their countries;

• To make medicines more affordable; • To reduce direct dependence on raw materials sourced from non-EU countries; • To influence other countries to harmonise international standards of quality and safety of medicines.

“The EAU calls for urgent actions to diminish bureaucratic burdens...” The EU has opened up a Consultation with EU citizens and stakeholders to gather views on how these objectives may be best achieved. The role of the European Medicines Agency will be crucial and it is likely that the regulations on paediatric and orphan medicinal products will be revised. The EAU has provided a response to the Commission’s consultation in writing. During a workshop organized by the European Commission

on 14-15 July, Mrs. Sarah Collen (GB), the EU Policy Coordinator, represented the EAU and highlighted a number of important issues: • We called for urgent actions to diminish bureaucratic burdens and move towards more patient-centred, independent (investigator-led), risk-based, pragmatic, efficient and cheaper clinical trials. • We highlighted the need for EU funding for monitoring the uptake of treatment postmarketing-authorization for clinical optimization and the management of treatments available on the market. • We noted the need for maintenance of both the individual registries as well as the integrated data platforms (i.e. www.prostate-pioneer.eu) to enable continued accessibility for researchers and clinicians. Artificial Intelligence legislation at EU level will also need to be fit for its purpose in the health sector.

• We promoted the huge capacity and educational value of European medical societies in bringing new treatments and technologies to patients. Clinical practice guidelines, congresses and education work conducted by the EAU and other medical societies are key enablers of bringing innovation into clinical practice and of establishing clear working arrangements for a multi-disciplinary team around a patient, including training in the appropriate application of medicinal products. • We welcomed the European Commission’s commitment to the Health Technology Assessment regulation and believe that finding a way through the political impasse can play a crucial role in promoting joint scientific assessments and in addressing some of the inequalities across the EU. The proposal for the strategy will be out later this year and we will keep you up to date with what changes are in store.

1,2,3, GO! Cancer a top priority in the European Parliament Three parliamentary groups now follow cancer activities Cancer has been given a high profile by this current European Parliament, with none less than three parliamentary groups now following cancer activities in its chambers. MEPs Against Cancer (MAC) is an informal group of interested MEPs, hosted by the European Cancer Leagues. Who are the leading lights of this group? The co chairs and vice chairs are Veronique TrilletLenoir, a member of the RENEW Europe group from France and an oncologist, Loucas Fourlas, a Cypriot from the European People’s Party (EPP), Miriam Dalli, a Maltese representative from the Socialists and Democrats (S&D) group, and Petra de Sutter, who is a Belgian gynaecologist, member of the Green party, and a supporter of our campaign on Prostate Cancer (also see www.europeancancerleagues.org/ meps-against-cancer-mac-meps/). There is also a new official parliamentary intergroup on cancer, which will be part of the official fabric of the European parliament, called Challenge Cancer. August/September 2020

This group is chaired by the Romanian MEP Cristian Busoi from the EPP. The secretariat for this group is the European Cancer Patient Coalition (EAU’s close colleagues and collaborators). Co –chairs are Frederique Reis from Belgium, and Aldo and Patriciello and Alessandra Moretti from Italy.

“We are confident that action on cancer will not be overlooked.”

have signed up for the group and will elect chairs in their first meeting. So, with three groups now following and promoting EU action on cancer, we are confident that this issue will not be overlooked, even though the COVID-19 response will understandably be the priority for some time to come.

the names of MEPs from your country and are willing to contact these Euro-MPs to join in our joint advocacy campaign on Prostate Cancer, please do let us know via s.collen@uroweb.org.

Prof. Hein van Poppel (BE) and Mrs. Sarah Collen (GB) attended the first virtual meeting of this group on behalf of the EAU and were able to highlight the need The EAU will be closely for more EU action on prostate cancer (see www.ecpc. following the activities of org/intergroup/). all groups and will be in regular contact with On top of these groups, the European Parliament also members of these voted for the creation of a special parliamentary groups. We will be committee on cancer which will be set up over the keeping you informed of summer for a twelve-month period to contribute to all EU activities on cancer. Representatives of the EAU attended the first virtual meeting of the new official parliamentary If you recognize any of the development of the EU Cancer Plan. 33 Euro-MPs intergroup on cancer called Challenge Cancer European Urology Today

˘ Prof. Sedat Tellaloglu Universal visionair with great academic skills

1935-2020

Sedat Tellaloglu was born on 27 March 1935 in northern Cyprus. He came to Turkey to study at the medical school after he completed his high school education. He graduated from Istanbul University, Cerrahpasa School of Medicine, in 1961 and became a specialist in urology in 1966, Assistant Professor in 1974 and Professor in 1979. He served as a chair for Istanbul University, Istanbul School of Medicine, Urology Department for 15 years. He played an important part as precursor in the field of andrology, paediatric urology and renal transplantation in his department and in Turkey as a whole. He educated countless urologists who contributed to the academy of Turkish urology over the last 30 years. Sadly, he died on 17 April 2020 because of COVID-19. Universal vision He was disciplined and had a great deal of authority. He always had a universal vision which led his department and Turkish urology to increase their scientific standards. He was a very good diplomat, which he learnt from the English

after his retirement. The Andrology Congress 2002 and the Turkish Urology Congress 2020 are devoted to his name. people he used to live with in Cyprus. He was the founder of andrology, paediatric urology and transplantation departments as subspecialties of the department of urology of the Istanbul University Medical School. He also made a large contribution to the development of other subspecialties, such as uro-oncology and endourology. He was the first urologist who applied transrectal prostate biopsy and intravesical therapy in Turkey and he was one of the surgeons who brought renal transplantation surgery to Turkey.

was a pioneer in knowledge generation and in promoting the TAU in the healthcare field and industry as a professional organisation. In 2005 he served as Congress President for the Annual EAU Congress in Istanbul. Later in his life, despite his advanced age, he always remained part of academic and social life in urology. He continued to serve as a moderator and speaker in international and national congresses as an Honorary Chairman of TAU, even

He was one of the giant names in European Urology as well. He had a very good academic and social dialogue with the well-known urologists of his era. He will be dearly missed by both Turkish and European urologists. Ates Kadıoglu,MD Professor of Urology Vice President of Turkish Association of Urology

Knowledge generation I knew him for 33 years. First as a medical student, then as urology resident in the Department of Urology and later as lecturer in the same department. He contributed enormously to the Turkish Association of Urology (TAU), especially regarding institutional structure and infrastructure. During his 20 year term as chairman of the TAU he

Prof. José Manuel Reis Santos Curious expert in the epidemiology of stones

1946-2020

Jose was born in Aguas, a small village in the district of Beira Baixa in Portugal. His secondary education was in Castelo Branco, the main town in that district. He entered Lisbon University Medical School in 1965 and graduated in 1971 at the age of 24. Urology training Subsequently, he did 2 years of training in general surgery and went on to training in urology in the Curry Cabral Hospital urology unit in Lisbon and finished in 1978. In December 1978, he passed the final examination in urology with honours. He then became a consultant in urology at the Hospitais Civis de Lisboa. He passed the European Board of Urology examination with a score of 86% and was assistant lecturer in urology at the New University of Lisbon from 1978 until 2002. He was then appointed professor at the Portuguese Catholic University from 2002. He is survived by his wife Sandra, two children Katya and Patrick and 2 grandchildren. Stones Prof. Santos had extensive experience in all fields of urology, but especially in the area of urinary stone disease. He greatly contributed to research as well as to management of stones with all his abilities, as he did with all scientific activities, meeting organisations and relevant

European Urology Today

urology, in order to use them in his department. He was very internationally oriented. As one of the few urologists in his country he tried to introduce new treatment modalities, after getting the necessary training, since he had a truly inquisitive mind. His ultimate aim was to raise the standards of urological care in all its aspects in his country.

publications. He has been involved in the foundation of research groups and sections for urolithiasis from the beginning of these activities in Europe. For example, he became a member of the “urolithiasis research group” formed by Prof. H.G. Tiselius in 1998 and was also on the board of the organising committee of the European Symposium on Urolithiasis. Furthermore, he was chairman of the 12th European Symposium on Urolithiasis which was organised in Cascais/Portugal in 2007 with excellent participation. Later, when the EAU section of Urolithiasis ( EULIS) was formed under the chairmanship of Prof. H.G. Tiselius, he continued to be a board member of this section until 2017.

published articles. He was a member of 15 scientific societies. EULIS, the International Alliance of Urolithiasis (IAU) and the South-Eastern European Group for Urolithiasis Research (SEGUR) were the main societies involved with stone disease. He participated in all main activities of EULIS and gave many lectures regarding various aspects of stone management and research. Thanks to his pleasant personality and excellent relationships with the relevant societies, groups, as well as organising companies, he was willing and able to support everyone eager to pursue scientific activities in the field of stone disease, while never losing the smile on his face and passion in his field.

Epidemiology In addition to the minimal invasive management of stones he was mainly involved in the epidemiology of stones, on which he gave various lectures and

Inquisitive He worked at the Portuguese Catholic University for a long period of time and was always ready to learn all new developments and techniques in the field of

Prof. Santos was an excellent tutor with great passion and young urologists working with him learnt a lot from his techniques regarding all contemporary modalities, particularly in the minimal invasive management of stones. He was also an excellent tutor because of his unlimited patience and extremely serene personality. Published articles He was the author of more than 100 published articles and worked on the editorial board of the Urolithiasis journal (formerly Urological Research) for a long period of time. His main contributions to the field of urolithiasis were in epidemiology. He even funded urolithiasisrelated research activities with his own financial sources. Additionally, he was a medical adviser for 4 industries at various times. On behalf of EULIS Prof. K. Sarica and Dr. P.N. Rao

August/September 2020

Treatment of visible lymph nodes in prostate cancer A report from the session at the EAU20 Virtual Congress Prof. Chris Bangma Erasmus MC Dept. of Urology Rotterdam (NL)

c.h.bangma@ erasmusmc.nl

Prof. Jeroen Van Moorselaar AmsterdamUMC Dept. of Urology Amsterdam (NL)

rja.vanmoorselaar@ vumc.nl Visual lymph nodes The increased sensitivity of PSMA-PET compared to MRI has resulted in PSMA-PET becoming the standard in the evaluation of biochemical recurrence after primary treatment of prostate cancer. In the staging at the time of first diagnosis, PSMA-PET appears to be the procedure of choice in men diagnosed with cancers that have an increased risk of nodal metastases1. We can see more pathological lymph nodes, which introduces various clinical dilemmas about their treatment since we still lack validated guidelines. Traditional prognostic algorithms for the decision to perform lymph node dissections at the time of radical prostatectomy are becoming outdated, as the new imaging information is not incorporated and validated into prognostic tools. The value of nodal treatment for the cure of early metastatic disease is being revisited, and so the indication and extent of the nodal therapy are issues of debate in the multidisciplinary setting. When are we overtreating visible nodal disease and when do we undertreat the patient by neglecting a realistic chance of cure? Primary disease In the session on nodal treatment, it was stressed by Alberto Briganti (IT) that PSMA-PET is altering our management already2, but that we do not know whether this also translates into improved patient outcome. The evidence on the efficacy of systemic treatment in oligo-metastatic patients and hormone-sensitive patients is still based on conventional imaging only. We gradually are encouraged to treat low volume lymph node metastases with curative intent by removing or irradiating these. Nick Van As (GB), radiotherapist, argued that based on recent trials irradiation cleans the pelvis better than surgery, and that the pelvis is free of recurrences after 5 years in 71% in a phase 1-2 trial3, while in the data shown by the urologist Karim Touijer (US) this is around 30% in comparable patient groups when nodes are surgically removed by extended dissection4. It is likely that any systemic intervention such as ADT added to a regional treatment will show at least some improved disease-free survival, as about one third of metastases is found outside the pelvis at the time of a PSMA-PET scan1. It is therefore also important to know when to stop treating locally/ regionally, to prevent unnecessary morbidity of surgery and irradiation. Jeroen Van Moorselaar demonstrated this dashed line between cN1 (nodes in the pelvis) and M1a (nodes outside the pelvis). There might be incidental patients that do well in terms of disease-free survival by treatment of the sole metastasis outside the pelvis, but we are unable to identify those patients upfront. For the outcome of systemic treatment we have to rely on the results of the studies made with old imaging technology. Whether ADT should start early or later is still not decided yet. With the new PSMA-PET scan, the definition of low-volume disease has become uncertain and might be redefined. The clinical dilemma between the treatment of M1a with curative intent and the initiation of palliative systemic treatment by androgen deprivation still remains. To combine systemic treatment with treatment of the primary tumour makes sense clinically and biologically: the STAMPEDE5 and HORRAD6 study supported the finding of survival benefit. The Nature study 2015 by Liu highlighted that August/September 2020

distant metastases are clonally related to the primary and the pelvic lymph nodes7 and therefore it is better to remove this primary source of spread. We await the results of three trials (TROMBONE [ISRCTN 15704862], g-RAMPP [NCT02454543], and SIMCAP [NCT03456843]) to see if surgical removal of the primary tumour is applicable in this situation, just like radiotherapy in the above mentioned studies. Recurrent disease In case of recurrent disease, Piet Van Ost (BE, radiation oncologist) and Steven Joniau (BE, urologist) discussed the use of curative treatment options for visible lymph nodes. Radiotherapy performs better than surgery, and 50% of patients remain biochemically free from disease at 14 months. It is a high risk group, as 10 year cancer specific survival is only 66%8. Surgery might only be competitive if its side effects are less compared to the radiation toxicity. The surgical template used in case of a sole visible node is unilateral, and bilateral in case of several nodes. In the STORM RCT trial the combination therapy of surgery, radiotherapy, and short courses adjuvant ADT will be analysed. The alternative to regional nodal therapy is systemic treatment. While in the recurrent setting an extra radiation related Grade 2 toxicity of 10% might be in balance with a delay of recurrent disease, it is still unknown if systemic treatment is better than nodal treatment with regard to survival, and which of the various sequences or combinations of ADT therapies has the best net effect for the patient. Or, to speak with Chris Sweeney about this clinical dilemma: ‘it needs a multidisciplinary team to advise the optimal personalised treatment for the 50-year-old as well as the 75-year-old patient…’

“In disease recurrent cases, nodal treatment showed that only little can be gained at the time nodes are visible.” When: early or late? Intuitively, one would argue to initiate nodal therapy ‘the sooner, the better’9 as in men with negative PSMA PET scans the application of salvage radiation for biochemical recurrence gives better survival compared to those with a positive scan. Also, due to the fact that the PSMA-PET cannot visualise all microscopic metastases, one might state that ‘the larger the treatment field, the better’10,11. These concepts have been illustrated in the above mentioned studies. In any setting one needs to consider whether treatment of nodes is curative or palliative and delays symptoms or initiation of systemic therapy, or whether it becomes useless because it hardly produces a better quality of life and no survival benefit. The NCT 04269512 study (Predict-Study) will determine the value of immediate nodal dissection in intermediate risk patients in the primary setting. In disease recurrent cases, nodal treatment showed that only little can be gained at the time nodes are visible.

Local treatment: red Nodal treatment: blue Systemic treatment: grey Total effect: green

Net benefit

time

‘Net benefit’ of treatment for a patient

systemic treatment possibilities. Maybe imaging is an obvious, but not the most important, prognostic risk factor. Is it genetics, is it the immune system? For imaging does not see biology, it sees anatomy. Nevertheless, PSMA-PET is the better NM-staging instrument, especially in recurrent disease. References 1. Hofman, M.S., et al., Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. Lancet, 2020. 395(10231): p. 1208-1216. 2. Han, S., et al., Impact of (68)Ga-PSMA PET on the Management of Patients with Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol, 2018. 74(2): p. 179-190. 3. Ferreira, M.R., et al., Dosimetry and Gastrointestinal Toxicity Relationships in a Phase II Trial of Pelvic Lymph Node Radiotherapy in Advanced Localised Prostate Cancer. Clin Oncol (R Coll Radiol), 2019. 31(6): p. 374-384. 4. Touijer, K.A., et al., Long-term outcomes of patients with lymph node metastasis treated with radical prostatectomy without adjuvant androgen-deprivation therapy. Eur Urol, 2014. 65(1): p. 20-5. 5. Parker, C.C., et al., Radiotherapy to the primary tumour for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial.

Lancet, 2018. 392(10162): p. 2353-2366. 6. Boeve, L.M.S., et al., Effect on Survival of Androgen Deprivation Therapy Alone Compared to Androgen Deprivation Therapy Combined with Concurrent Radiation Therapy to the Prostate in Patients with Primary Bone Metastatic Prostate Cancer in a Prospective Randomised Clinical Trial: Data from the HORRAD Trial. Eur Urol, 2019. 75(3): p. 410-418. 7. Liu, W., et al., Copy number analysis indicates monoclonal origin of lethal metastatic prostate cancer. Nat Med, 2009. 15(5): p. 559-65. 8. Bravi, C.A., et al., Androgen deprivation therapy in men with node-positive prostate cancer treated with postoperative radiotherapy. Urol Oncol, 2020. 38(4): p. 204-209. 9. Emmett, L., et al., Treatment Outcomes from (68) Ga-PSMA PET/CT-Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET. J Nucl Med, 2017. 58(12): p. 1972-1976. 10. Fossati, N., et al., The emerging role of PET-CT scan after radical prostatectomy: still a long way to go. Lancet Oncol, 2019. 20(9): p. 1193-1195. 11. De Bleser, E., et al., Metastasis-directed Therapy in Treating Nodal Oligorecurrent Prostate Cancer: A Multi-institutional Analysis Comparing the Outcome and Toxicity of Stereotactic Body Radiotherapy and Elective Nodal Radiotherapy. Eur Urol, 2019. 76(6): p. 732-739.

BALTIC21 7th Baltic Meeting in conjunction with the EAU 28-29 May 2021, Minsk, Belarus www.baltic21.org

To treat or not to treat? Obviously, lymph node dissection, radiotherapy, and any adjuvant systemic medical therapy all bear side effects, and the most important factor to predict their occurrence and bother is the condition and age of the patient. If we would be able to define a ‘net benefit’ for a patient as a result of all factors concerning survival and quality of life, it might look like the figure in the graph below. It shows that early on in localised cancer, nodal treatment might add little, but when nodes are visualised later on it might add to the patients’ benefit and curation. In even later stages, it might temporarily prevent clonal metastases to occur, but in the high-volume metastatic stage the tumour will expand from the bone metastatic lesions anyway, so no benefit is to be expected. We are anxious not to miss a window of cure by undertreatment of the pelvis at the time of low-volume visible nodes. We observe that the disease burden for the patient can be diminished by knocking out lethal clones in the regional area. But what is the net gain? Does a 10% increase in toxicity balance a 6-month delay of start of systemic medication in one third of the patients? Long-term survival is difficult to predict because there are many unrecognised confounders and many

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

European Urology Today

European Urological Scholarship Programme (EUSP) Worthwhile clinical visit in brand new state-of-the-art facilities in Krakow, Poland Dr. Kostas Chondros University General Hospital of Heraklion Dept. of Urology Heraklion (GR)

k.chondros@ med.uoc.gr The ever-evolving field of urology and urological surgery creates the need for continuous training and knowledge expansion for every urologist. Visiting different departments of excellence, tertiary hospitals and large academic facilities is mandatory in order to gain new skills and experience. EUSP supports this effort by providing economical funds and stimulating clinical or experimental research between European centres. Thanks to EUSP, I had the opportunity to visit one of the largest academic centres in Krakow (PL) for a programme focused on laparoscopic urologic surgery. The city of Krakow Krakow is one of the oldest and largest cities in Poland located in the south of the country. The city is of huge historical and cultural interest and is thus a major tourist attraction. Krakow has a lot of UNESCOprotected monuments, such as Wieliczka Salt mines, Auschwitz concentration camp and the historical centre of the city. The city’s main square is the largest medieval square in Europe and ends at the impressive Wawel Castle near the Vistula River. Several areas and sights around the city refer to WWII history of the place (old Jewish quarter-Kazimierz, Jewish Ghetto, Schindler’s factory). Poland is also famous for its excellent cuisine and beer crafting, while the nightlife is intense because of the many visitors and the large number of university students.

European Urological Scholarship Programme Office

The university Krakow has one of the most historical universities of Europe and one of the oldest (14th century) of the world, the Jangellonian University. The campus of the university consists of 15 faculties, including humanities, law, natural and social sciences, and medicine. Famous scientists, among whom Nikolaus Copernicus, attended this facility in the past. The urology department was located in a separate building from 1928 until January 2020. It was then transferred to a brand new facility: the new University Hospital, which coincided with my arrival for a Clinical Visit on 8 January. The Urology Department Poland’s largest and most modern hospital was inaugurated in October 2019. The Urology Department moved there at the begging of January 2020, to a brand new building. The new University Hospital offers a highly equipped operation block with 19 OR’s and 1,000 beds. The Urology Department has 44 beds and an additional 2 in-house OR’s for everyday operation lists. The unit is run by Prof. Piotr Chłosta and his team which consists of 10 specialist Urologists, 12 residents and 2 dedicated anaesthesiologists. The Department represents an academic centre of excellence and a reference centre for cancer patients in Poland, which is also EBU certified. The programme The daily schedule consisted of: a) Morning briefing with case discussions, todays OR programme review and literature update or presentation by a resident b) Ward visit c) Outpatient’s consultation clinics d) Cystoscopy/UDS outpatient lists e) Daily 3 or 4 OR’s lists.

Images from the main operating block during an LRP using the Olympus-Sony 4K system

Medical staff • • • • • • • • • • • •

Prof. Piotr Chłosta, Head of the Department Dr. Tomasz Wiatr Dr. Przemysław Dudek Dr. Michał Zembrzuski Dr. Wacław Lipczynski Dr. Anna Czech Dr. Wojciech Habrat Dr. Katarzyna Gronostaj Dr. Małgorzata Rapacz-Tomasik Dr. Anna Wołek (anaesthesiologist) Dr. Łukasz Curyło Dr. Wojciech Wegrzyn (anaesthesiologist)

B-TURP, Laser URS, fURS and PCNL are simultaneously performed daily. Urethral surgery is also taking place, such as urethral stenosis reconstruction, artificial sphincter implantation and stent insertion.

• Laparoscopic partial nephrectomy (3) • Laparoscopic inguinal lymphadenectomy (1) • Laparoscopic pyelolithotomy (1) And in several other cases: • Open radical nephrectomy with VC thrombectomy (2) • Open retroperitoneal lymphadenectomy (1) • AUS implantation (2) • PCNL (2) I was really amazed by the work of this team and the high quality of service they provide to their patients. Both attendees and residents kindly accept me as a member of their team. I would like to thank Prof. Chłosta for giving me this opportunity to work with him and his team and upgrade my surgical skills. Finally, I would like to acknowledge the EUSP office for assisting me in this visit to Poland and to applaud its effort to train young urologists.

My experience During my 2-month fellowship I had the opportunity to be exposed to major laparoscopic surgery (in total 28): • Laparoscopic extraperitoneal radical prostatectomy (7) The department is specialised in treating cancer patient • Laparoscopic transperitoneal radical prostatectomy who underwent the latest minimally invasive with eLND (4) techniques. Major cancer surgeries are performed • Laparoscopic radical cystectomy with ileal laparoscopically, using modern laparoscopic equipment conduit (6) such as Thunderbeat® energy forceps and Olympus-Sony • Laparoscopic radical cystectomy with Studer's 4K viewing system. At least one OR list/day is dedicated neobladder (1) Urological surgeon Dr. Łukasz Curyło (left), Professor Piotr to laparoscopic surgery while normal cases of TURB, • Laparoscopic radical nephrectomy (5) Chłosta (middle) and me (right)

European experience in robotic kidney transplantation Study of the ERUS RAKT Working Group earns the ESTU René Küss Prize 2020 Dr. Andrea Gallioli Fundaciò Puigvert Dept. of Urology Autonomous University of Barcelona (ES) andrea.gallioli@ gmail.com Co-authors: Dr. Angelo Territo, Dr. Alberto Breda After the historical surgical experiments carried out by René Küss in 1951 and the first successful cadaveric kidney transplantation by Joseph Murray in 1962, kidney transplantation has been considered the best renal replacement treatment. At present, open kidney transplantation is the preferred technique. However, technological advancements have led to experiments with minimally invasive kidney transplantation. ERUS RAKT Working Group Robot-assisted kidney transplantation (RAKT) has only recently been introduced in Europe1. The technique was initially standardised by Menon et al2. An EAU Robotic Urology Section (ERUS RAKT) Working Group was constituted to draw together early European experiences at the highest volume centres using this minimally invasive technique. In 2017, the data provided by the eight centres of the ERUS RAKT Working Group demonstrated the safety and feasibility of the technique in 120 patients3. One of the potential limitations of RAKT is represented by the learning curve, as the procedure requires vascular skills to be translated into a robotic approach. On the other hand, the use of the robot might improve the EAU Section of Transplantation Urology (ESTU)

European Urology Today

accuracy of the anastomoses and shorten the learning curve in robotic surgeons. To investigate this, a study was designed, coordinated by the pilot centre (Fundaciò Puigvert, Barcelona) under the guidance of Dr. Alberto Breda, to assess the learning curve of RAKT. The study was assigned to me, when I was visiting the Fundaciò Puigvert (Director: Dr. Joan Palou) as part of a six-month fellowship during my residency at the University of Milan (Director: Prof. Emanuele Montanari (IT)). All consecutive RAKTs performed in the five highest volume centres represented in the ERUS RAKT Group, i.e. Fundaciò Puigvert (Barcelona), Hospital Clinic (Dr. Antonio Alcaraz; Barcelona), Careggi Hospital (Prof. Sergio Serni; Florence (IT)), Ghent University Hospital (Dr. Karel Decaestecker; Ghent (BE)), and Bakirkoy Research Hospital (Dr. Volkan Tugcu; Istanbul (TR)), were reviewed. Shewhart control charts were used to analyse whether the process was in control, taking as referral values the cases reported by Breda et al.3 with a rewarming time < 48 minutes (+2SD = alert line, +3SD = alarm line). The rewarming time is critical, as it represents the time between the peritoneal insertion of the graft in the abdominal cavity and the start of kidney reperfusion. Learning curve Cumulative summation graphs were generated to assess the learning curve according to surgical timings and renal graft function (glomerular filtration rate) at days 7, 30 and at 1 year. Linear regressions were performed to compare the learning curves of each surgeon. Our results demonstrated that the vascular anastomoses time was generally under control. In fact, the arterial anastomosis time was below the alarm/alert line in 93.3%/88.9% of RAKTs, while venous anastomosis time was below the alarm/ alert line in 88.9%/73.9%. Moreover, the ureteroneocystostomy time was below +2 and +3SD in 87.9% and 90.2% of cases, respectively.

Plateau Conversely, the rewarming time was below the alert line in only 46% of cases. Accordingly, the time spent during rewarming time without performing the vascular anastomoses exceeded +3SD in 24.7% of procedures and +2SD in 37.1%. Cumulative summation graphs showed that the learning curve for arterial anastomosis required up to 35 (mean = 16) cases. A similar conclusion was reached for venous anastomosis, which may need more than 40 procedures (mean = 24). The plateau in the ureteroneocystostomy curve was reached within 30 RAKTs in 4/5 centres (mean = 17). The plateau for rewarming time was reached at a mean of 35 cases. Interestingly, the curves for non-anastomotic time during rewarming time resemble those for rewarming time. Complications and delayed graft function rates decreased significantly and reached a plateau after the first 20 cases. On the linear regression model, all the anastomotic times were comparable. The slopes with respect to nonanastomotic time during rewarming time were slightly different (p = 0.0006), which was also true for rewarming time itself (p = 0.007). The importance of teamwork We concluded that a minimum of 35 cases is necessary to reach reproducibility in anastomosis time, rewarming time and functional results. Therefore, the study demonstrated a short learning curve to achieve optimal results among expert surgeons. It also underlined the importance of the synergic work between the robotic surgeon and the bedside assistant. Actually, the teamwork influences the rewarming time as well as the anastomotic time. Consequently, the initial steps of the technique should be taken by a dedicated team under supervision. The definitive results of the study were published in European Urology4 while the abstract was accepted at the EAU Virtual Congress 2020. The abstract was awarded the René Küss Prize 2020 for the best

abstract of the section by the EAU Section of Transplantation Urology (ESTU). The grant was dedicated to data management expenses for the ERUS RAKT Working Group. Acknowledgments The authors would like to thank ESTU Chairman, Prof. Enrique Lledó García, for this valuable achievement and all the collaborators that helped us complete the study. We believe that this work proved the importance of collaboration at different levels. It is the result of a multicentric database set up by a group of European surgeons from tertiary referral centres, which was analysed by a resident who took part in an exchange programme established between a Spanish (Fundaciò Puigvert) and an Italian (University of Milan) institution. References 1. Breda A, Gausa L, Territo A, López-Martínez JM, Rodríguez-Faba O, Caffaratti J, et al. Robotic-assisted kidney transplantation: our first case. World J Urol 2016;34:443–7. https://doi.org/10.1007/s00345-015-16736. 2. Menon M, Sood A, Bhandari M, Kher V, Ghosh P, Abaza R, et al. Robotic kidney transplantation with regional hypothermia: a step-by-step description of the Vattikuti Urology Institute-Medanta technique (IDEAL phase 2a). Eur Urol 2014;65:991–1000. https://doi.org/10.1016/j. eururo.2013.12.006. 3. Breda A, Territo A, Gausa L, Tugcu V, Alcaraz A, Musquera M, et al. Robot-assisted Kidney Transplantation: The European Experience. Eur Urol 2018;73:273–81. https://doi.org/10.1016/j. eururo.2017.08.028. 4. Gallioli A, Territo A, Boissier R, Campi R, Vignolini G, Musquera M, et al. Learning Curve in Robot-assisted Kidney Transplantation: Results from the European Robotic Urological Society Working Group. Eur Urol 2020. https://doi.org/10.1016/j.eururo.2019.12.008.

August/September 2020

Urological emergency visits during COVID-19 outbreak Tertiary care referral centre in Northern Italy shows altered Emergency Department visits pattern Dr. Luca Villa Eugenio Ventimiglia Division of Experim. Oncology/Unit of Urology IRCCS Hospital San Raffaele Milan (IT)

graphically explored on a weekly basis. Further sub-analyses were performed to assess and compare the urological reasons for ED visits among the aforementioned periods. Overall reduction of ED visits On 26 May 2020, 941 patients had a laboratoryconfirmed diagnosis of COVID-19; of those, 762 (80.9%) were hospitalised.

l.villa@hotmail.it

Dr. Eugenio Ventimiglia Dept. of Urology IRCCS Hospital San Raffaele Milan (IT) eugenio. ventimiglia@ gmail.com

Prof. Kemal Sarica EULIS Chairman Dept. of Urology Medicana Bahcelievler Hospital Istanbul (TR) saricakemal@ gmail.com It took a few weeks between the first report of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 [COVID-19]) and its worldwide spread, that led the World Health Organisation to declare the pandemic status on 11 March 20201. In Italy, the alleged ‘patient number one’ was diagnosed on 21 February 2020, kicking off the COVID-19 outbreak with a nearly-exponential growth of the number of cases in a few days. It had several dramatic consequences on the healthcare system, which was close to collapse. Lockdown Shortly after, the Italian government declared the lockdown of the country, on 8 March 2020. Hence, health infrastructures were forced to reshape their functioning in order to admit and assist as many COVID-19 patients as possible, thus postponing elective and non-urgent cases2,3. As for urgent or emerging genitourinary conditions, our academic hospital continued to take care of emergencies and non-deferrable cancer cases, as recommended by international societies4,5. This meant that our emergency department (ED) was rapidly clogged with patients presenting with fever and dyspnoea and the surgical departments were forced to reduce the allotted operating theatre slots. In this context, we explored the impact of the COVID-19 outbreak on the rate of ED visits at a tertiary care referral centre – IRCCS Ospedale San Raffaele, Milan (IT) - either for any reason or for urgent urologic conditions. Study set-up All cases admitted to the ED of a single tertiary care referral centre between 1 January, 2019 and 26 May 2020 were retrospectively analysed. We graphically evaluated the total number of cases on a timeline by selecting two time intervals:

During the study period, an overall reduction of ED visits was observed compared to the control period (see Figure 1A). A total of 8,640 accesses was recorded at our ED (vs. 18,971 in the 2019 control period), with a mean admission rate of 91 patients/ day (vs. 201.9 in the 2019 control period). A consistent reduction was observed compared to the 2019 control period (IRR [95% CIs] 0.45 [0.44-0.46]), with a nadir reached on 30 March 2020 (number of ED visits = 46); subsequently, a slight constant increase of ED visits was observed (see Figure 1A).

Fig. 1A: Daily cases admitted at our emergency department

Nevertheless, the number of urological visits at ED was clearly affected by the COVID-19 outbreak. In total, we recorded 398 urological patients during the COVID-19 period (vs. 916 in the 2019 control period), with a mean admission rate of 4.2 patients/ day (vs. 9.9 in the 2019 control period). A consistent reduction was observed as compared with the 2019 control period (IRR [95%CIs] 0.43 [0.38-0.49]), with the nadir reached in the fifth week (n = 12 cases); thereafter, a slight constant recovery was observed (see Figure 1B). Urological reasons As far as the urological reasons that lead the patients to go to the ED are concerned, we found that the number of visits for each condition was lower in the COVID-19 period compared to the 2019 control period, especially for genito-urinary infections and testicular/ penile issues (72 and 74% reduction, respectively) (see Supplementary Table 1). Similarly, fewer urological patients were hospitalised in the COVID-19 period compared to the 2019 control period (100 vs. 137 patients, respectively). However, when adjusting for the number of ED urological visits, we found that the proportion of urological patients hospitalised (number of urological patients hospitalised/number of urological ED visits) was clearly higher in the COVID-19 period compared to the 2019 control period (25.1% vs. 14.3%, respectively). Our findings suggest that COVID-19 considerably altered the pattern of ED visits in our tertiary care referral hospital. A high number of COVID-19 patients was accepted and hospitalised in the context of an unexpected overall large ED visits reduction, which is also reflected by a significant decrease of urological

Fig. 1B: Weekly urological cases during the study and control period

cases compared to the corresponding period of the previous year. Fear of infection? We were relatively surprised by the current pattern of ED admissions in our hospital, being a similar trend as that reported by De Filippo et al. with regard to hospital admissions for acute coronary syndrome (ACS) at 15 centres in Northern Italy, with a significant decrease in ACS-related hospitalisation during the first weeks of the COVID-19 outbreak6. Firstly, we may speculate that the main reason for this phenomenon was the fear of being infected with

Table 1: Number of cases, mean daily admissions, and incidence rate ratios (IRR) for all and urological cases at our emergency department

All cases N. of patients Mean daily admissions IRR (95% CIs); p-value Urological cases N. of patients Mean daily admissions IRR (95% CIs); p-value COVID-19 cases N. of patients Mean daily admissions

Study period

Control period - 2019

8640 91

18,971 201.9 0.45 (0.44-0.46); p<0.001

398 4.2

916 9.7 0.43 (0.38-0.49); p<0.001

References

1. the study period, defined as the time between the day after the first COVID-19 case was officially 941 NA recorded in our country (i.e. 22 February 2020) 9.9 NA and 26 May 2020 (the day of data extraction); 2. a control period in 2019, defined as the CI: confidence interval; IRR: incidence rate ratio Study period: February 21, 2020 to May 26, 2020 corresponding time interval of the previous year Control period 2019: February 21, 2019 to May 26, 2019 (i.e. from 22 February 2019 to 26 May 2019). Supplementary Table: Number of urological cases during the study and the control period classified by main urological complaint Subsequently, we relied on descriptive analyses to define and compare the number of both overall and Study period Control period - 2019 Decrease (%) urological patients admitted to our ED in the two Urological complaint different periods by calculating incidence rates (as Hematuria 57 103 45 mean daily admissions, by dividing the number of cumulative admissions by the number of days for Renal/ureteric colic 183 332 45 each time period) and incidence rate ratio (IRR), as Genito-urinary infection 82 297 72 previously described6. The difference between urological visits to the ED in the COVID-19 period and the 2019 control period was EAU Section of Urolithiasis (EULIS)

August/September 2020

Acute urinary retention Testicular/penile Other

Study period: February 21, 2020 to May 26, 2020 Control period 2019: February 21, 2019 to May 26, 2019

57 23 9

123 89 23

COVID-19 in the hospital. This may have discouraged people with other conditions to visit the ED and led them to attempt self-treatment on the basis of general practitioner advice, as the authorities recommended. Secondly, current findings may be useful to highlight that a significant proportion of ED visits in the pre-COVID-19 period were not lifethreatening and might be managed outside the hospital, as indirectly shown by the higher proportion of urological patients hospitalised in the COVID-19 period. However, we cannot rule out that social distancing and lockdown may have caused a reduction in the incidence of some health problems. Finally, we may argue that the gradual overall reduction in new daily cases of COVID-19, occurring in Italy from April 20207,8, could justify the consistent gradual recovery of ED visits observed in our centre - the nadir was reached on 30 March 2020 - thus leading urological patients to refer again to the ED in case of need. Further analyses will be helpful to improve the comprehension of such an apparently counterintuitive phenomenon.

54 74 61

1. WHO Timeline – COVID-19. World Health Organization https://www.who.int/news-room/detail/08-04-2020who-timeline---covid-19 Accessed April 25, 2020 2. Zangrillo A, Luigi Beretta L, Paolo Silvani P, et al. Fast Reshaping of Intensive Care Unit Facilities in a Large Metropolitan Hospital in Milan, Italy: Facing the COVID-19 Pandemic Emergency Crit Care Resus. 2020 Apr 1. Online ahead of print. 3. Nacoti M, Ciocca A, Giupponi A, et al. At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. NEJM Catalyst Innovations in Care Delivery. NEJM Catal. 2020 Mar 21 [Epub ahead of print]. Accessed April 25, 2020 4. European Association of Urology COVID19 Resources for Urologists. https://uroweb.org/covid19-resources-forurologists/ Accessed April 25, 2020. 5. American Urological Association COVID-19 Info Center. https://www.auanet.org/covid-19-info-center/ covid-19-info-center Accessed May 1, 2020. 6. De Filippo O, D'Ascenzo F, Angelini F, Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy. N Engl J Med. 2020 Apr 28. doi: 10.1056/ NEJMc2009166. [Epub ahead of print] 7. Covid-19, situation in Italy - Ministero della Salute. https://www.salute.gov.it Accessed June 6, 2020. 8. New Cases of COVID-19 In World Countries - Johns Hopkins University & Medicine. https://coronavirus.jhu. edu/data/new-cases Accessed June 6, 2020.

European Urology Today

ESOU opens borders between disciplines Underpinning the new course with strong and successful partnerships Dr. Gianluca Giannarini Associate Editor, European Urology Oncology ESOU Board Member Udine (IT) gianluca.giannarini@ hotmail.it I had the fortune to join the ESOU Board in early fall 2019, and to be involved in several scientific sessions and projects during the latest ESOU meeting in January 2020 in Dublin (IE) under the new lead of Prof. Morgan Rouprêt. I am also one of the Associate Editors of European Urology Oncology, the new sister journal of European Urology. The journal – which is produced under the EAU umbrella - is fully devoted to the study of genitourinary malignancies and has become the official journal of ESOU.

meeting, which will take place in Gothenburg (SE) in February 2021, and the ESOU meeting to be held during the next Annual EAU Meeting in Milan (IT) in March 2021. Key opinion leaders representing several European and transatlantic societies, such as the American Society of Clinical Oncology (ASCO), the Society of Urologic Oncology (SUO), the European CanCer Organisation (ECCO), the European SocieTy for Radiotherapy and Oncology (ESTRO) and the European Society for Medical Oncology (ESMO), will be participating in the scientific sessions to discuss common problems and controversies in onco-urology. We are certain it will be a conference with high scientific quality and impact, It covers the entire spectrum of genitourinary malignancies, with a special focus on the latest advances in the field presented at recent meetings, such as ASCO Genitourinary Cancers Symposium, ASCO or American Urological Association (AUA), which could not be attended by many of us due to the known public health emergency.

New developments The new course of ESOU is thrilling in many ways, and this enthusiasm was apparent among the several hundreds of attendees and faculty members in Dublin. Two main avenues of development in our EAU Section are particularly exciting: promoting strategic alliances with other scientific societies renowned and active in oncology and onco-urology in particular, and delivering high-quality editorial products. By doing this, multidisciplinary collaborations with no boundaries among urologists, medical and radiation oncologists, and other specialists in genitourinary cancers will be reinforced, with the ultimate goal of enhancing and individualising patient care. Expansion highlights The Board is now devotedly working to design the scientific programmes of the next stand-alone ESOU EAU Section of Oncological Urology (ESOU)

European Urology Oncology is the official journal of ESOU

Meeting in Dublin During the meeting in Dublin, I had the pleasure of presenting the mission, contents and format of European Urology Oncology on behalf of the Editor-in-Chief, Prof. Alberto Briganti (IT). The journal is relatively young: the first issue was published in May 2018. It has already been accepted for indexing in MEDLINE and will likely receive an impact factor in June 2021. It is published bimonthly, and features mainly original articles and collaborative reviews focused on clinical, basic and translational research in onco-urology. Attendees were eager to ask and know how a brand-new journal can progress so fast and how much work is done behind the scenes.

“... promoting strategic alliances with other scientific societies in oncology and onco-urology, and delivering high-quality editorial products...” The European Urology Oncology lecture was delivered by Prof. Nicolas Mottet (FR), representing the EAU Guidelines panellists, who brilliantly tackled the topic of the evolving management of hormone sensitive metastatic prostate cancer, and was then challenged in a lively questions-andanswers discussion. The European Urology Oncology Best Paper Award for 2019 was presented to Dr. Pieter De Visschere, a radiologist from Ghent (BE), for the article entitled “A systematic review on the role of imaging in early recurrent prostate cancer”, which continues to be the most cited article of the journal. The liaison with European Urology Oncology materialised further with the recent publication of three articles generated by case-based debates held during the scientific sessions and written by the young case presenters together with the debating panellists.

European Urology Oncology Award ceremony in Dublin, January 2020

Rich array Thus, it is an inspiring time for ESOU with a rich array of ideas and initiatives. We hope the next meeting will be a great opportunity to further augment the interest in our section, reinforce partnership with other subjects and societies, and establish new clinical and scientific cooperation among the representatives of the large, diverse and ever growing onco-urological community.

Prof. Djoko Rahardjo Founding member of Indonesian Urological Association, talented leader

1940-2020 It is with great sadness that we announce the demise of Dr. Djoko Rahardjo on 21 February 2020 at the Academic Hospital Dr. Cipto Mangunkusumo in Jakarta (ID). He is survived by his wife, son, daughter, and grandchildren. Education Dr. Rahardjo was born in Solo (ID) on 3 March 1940. After receiving his medical degree from the University of Indonesia, Jakarta in 1964, he voluntarily served as an army doctor in West Borneo (ID) for one year. He then went back to his alma mater for specialisation training in the department of surgery. Upon completion, he was chosen to be a staff member in the division of urology and was sent to West Berlin where he spent two years (1970-1972) at Freie Universität (Westend Hospital and Neuköllner Krankenhaus) for further training in Urology. invasive procedures. Nowadays these procedures are standard competences among Indonesian urologists. During the eighties, he was sent abroad to take various short courses in North America, Europe, Djoko, as his friends used to call him, had deep Japan, and Australia in order to help broaden the respect of basic research and future vision. In the urological services in Indonesia. At the same early nineties he started to think about the time, he encouraged young urologists to go importance of having scientific-clinician urologists in abroad, mainly to Europe, to help develop and Indonesia. Two of his best friends in Europe, Professor improve the urological care in Indonesia, which Udo Jonas and Professor Frans Debruyne, helped him at that time was still in its infancy. fulfil his dream, and the networking collaboration which followed still exists and has grown enormously. Pioneer In the mid-eighties, Dr. Rahardjo was armed with Post-graduate programme information from meetings, courses and visits to Dr. Rahardjo gave a lot of attention to education, several centres in Europe. He learned how to use especially post-graduate programmes. He was the instruments from abroad himself and became actively involved in the development of the universityone of the pioneers in upper tract endo-urology based training programme for urology in our country procedure (URS and PCNL) in Indonesia. It was a that officially started in 1983. turning point in the treatment of renal and ureteral stones, an abundant urological problem In 1986, he was appointed chairman of the division of in our country: from open surgery to minimal urology, department of surgery at “Dr. Cipto

European Urology Today

international delegates in 1990 during a meeting in Fukuoka (JP). As a graduate from one of the German universities and because of his close collaboration with other centres, he was awarded honorary member of the Deutsche Gesellschaft für Urologie (DGU) in 1995.

Mangunkusumo” Academic Hospital Jakarta as well as chairman of the Urology Training Programme at the University of Indonesia. As a thoughtful mentor, he built a solid clinical programme including various aspects of urology. Later on, he urged to start with basic research amid the limited facilities. He was appointed professor of urology in 2001, and he held a position as vice dean of the Faculty of Medicine, University of Indonesia between 1997 and 2007. Founding member He was a founding member of the Indonesian Urological Association in 1973 and was elected President in the year 1987-1990 and 1993-1996. Following this, he became the Chairman of the Indonesian College of Urology from 1997 to 2009. With his continuous involvement in the urological community activities of the region, he became one of the founding members of Urological Association of Asia by signing the document together with other

Medal of honour Apart from his activities as clinician and academician, Dr. Rahardjo was admired for his broad-minded, talented leadership, a very outgoing and sociable personality and management experience, and the Indonesian Government appointed him coordinating Chairman of the presidential doctors team of the Republic of Indonesia between 1994 and 2009. In recognition of his work and responsibilities, he was awarded a medal of honour by the government. Over a forty-year period, Dr. Rahardjo made significant contributions not only in urological care but also in research, education, and other activities beyond his formal training. Such an accomplishment can only be achieved with hard work and consistency, which has hopefully inspired the next generation of urologists to follow his example. On behalf of the Indonesian Urological Association (www.iaui.or.id) Prof. Rainy Umbas Dept. of Urology, Faculty of Medicine University of Indonesia E-mail: penguruspusatiaui@gmail.com

August/September 2020

Young Urologists/Residents Corner RESECT: Help improve the quality of TURBT surgery The new BURST collaborative study around the world Dr. Nikita Bhatt Urology resident East of England Deanery Cambridge (GB)

nikitarb89@gmail.com

Co-authors: Dr. Kevin Gallagher (GB) and Dr. Veeru Kasivisvanathan (GB) CALLING ALL RESIDENTS Don’t miss your chance to be part of a global effort to improve the quality of TURBT.

matter? Does striving for these quality indicators lead to better outcomes? Questions such as these will be answered in this study. Who can take part? Anybody anywhere in the world who works in a centre performing TURBT can take part. Background There is strong evidence which guides the optimal management of non-muscle invasive bladder cancer (NMIBC), particularly in how the initial resection should be performed and in the use of single-dose postoperative intravesical chemotherapy. We know that “good quality” NMIBC surgery results in improved accuracy of diagnosis and reduced recurrence rates. The European Association of Urology (EAU) guidelines include clear and easily measurable recommendations related to transurethral resection of bladder tumour (TURBT) and IV-chemo use, based on the best available evidence. Despite this, evidence shows that practice varies widely and this may have an impact on oncological outcomes. There are no international datasets assessing practice of TURBT surgery.

Who are we? The British Urology Researchers in Surgical Training (BURST) research collaborative is a UK-based, international collaborative. We have an ethos of teamwork and shared creative effort. BURST aims to include and engage trainees from different countries and backgrounds to create practice-changing studies Benefits of getting involved that can have a significant impact on the improvement 1. Registration is simple and should avoid formal of patient care. ethical approvals. 2. You will be part of what could potentially be the What do we do? largest prospective study of TURBT surgery ever Collaborative research is fast becoming a novel performed. alternative research model in all surgical disciplines. 3. Improve your own practice; use the database to Traditional research models pose major challenges, record and track your own and your hospital’s including a risk of producing underpowered studies. TURBT training, performance, and outcomes and Collaborative research has a unique ability of measure these against the world! delivering large-scale, multi-centre studies. 4. Get published and present; all contributors will receive Pubmed indexed collaborator authorship. We provide the opportunity and expertise for trainees The individuals who recruit the most patients will to collaborate and conduct multi-centre research with be invited on the writing committee. The more a quick turnover that has the potential to be practice patients recruited, the higher up on the changing and produce major publications. All BURST collaborative list that individual will be. Plus, you studies are subject to a robust peer review process. will be given preference to present the study findings at conferences. The model implemented by BURST1, has been able to deliver fast, high-quality research providing definitive 5. Returns on this will be fast; our previous studies MIMIC and IDENTIFY are proof of this. answers. This is embodied by the success of our recent MIMIC and IDENTIFY studies2,3. More information about BURST and the RESECT study The MIMIC (A Multi-centre cohort study evaluating the is available on our website. Further questions and queries can be sent to bursturology@gmail.com. We role of Inflammatory Markers In patient’s presenting look forward to working with you; with your help, this with acute ureteric Colic) study is an example of a study has the potential to have significant impact on large-scale, definitive, trainee-led research collaborative project. It launched in October 2016, improving the quality of TURBT surgery around the world. Don’t miss out on your chance to be a part of recruiting over 4100 patients from 71 sites and 7 countries within 4 months. MIMIC showed that white this study. cell count was not associated with the likelihood of stone passage in patients initially treated References conservatively for acute ureteric colic. The results of 1. Kasivisvanathan V, Ahmed H, Cashman S et al (2017). The the study are now being used to develop a risk British Urology Researchers in Surgical Training (BURST) calculator for stone passage. We believe this is the Research Collaborative: an alternative research model for largest contemporary cohort study in stone research. carrying out large scale multi-centre urological studies The MIMIC study has been published in BJUI2. BJU Int doi:10.1111/bju.14040 The IDENTIFY study (Investigation and DEtection of Neoplasia in paTIents reFerred with suspected urinarY tract cancer: a multi-centre analysis) is the largest study of haematuria in secondary care ever performed. This global prospective study aims to individualise examinations for haematuria using over 11,000 patient records from 110 year. Preliminary results were discussed and shared at EAU19. IDENTIFY won the award for Best Abstract by Resident-in-Urology. One year later, at EAU20, another abstract of the study won the second prize in the same category. All collaborators will be recognised with PubMed indexed collaborator authorship for any publication that results from this study. Key contributors will also be invited on the writing committee for publications. The first IDENTIFY paper has been submitted. There will be more. RESECT (transurethral REsection and Single instillation intravesical chemotherapy Evaluation in bladder Cancer Treatment) is the latest BURST project, which aims to improve TURBT quality. This study is designed to understand and measure variation in operative practice, TURBT quality, single instillation intravesical chemotherapy usage and early recurrence rates in patients having undergone TURBT surgery. These standards will be measured against international guidelines. What factors are associated with quality? What hospital, surgeon and service features are associated with higher quality? Does it August/September 2020

2. Factors associated with spontaneous stone passage in a contemporary cohort of patients presenting with acute ureteric colic. Results from the MIMIC Study (A Multi-centre cohort study evaluating the role of Inflammatory Markers In patients presenting with acute ureteric Colic). Shah, Taimur T et al. BJU Int. 2019 Apr 18. 3. Lee MJ, Banghu A, Blencowe NS et al. Academic requirements for Certificate of Completion of Training in surgical training: Consensus recommendations from the Association of Surgeons in Training/National Research Collaborative Consensus Group. Int J Surg 2016; 36 (1): S24-30. Appendix A -RESECT Study Team

Lead trainees: Mr. Kevin Gallagher and Miss Nikita Bhatt Chief Investigator: Mr. Veeru Kasivisvanathan (BURST Chair, Academic Clinical Lecturer in Uro-Oncology, University College London, London) Core team members: Mr. Keiran Clement, Miss Eleanor Zimmermann, Mr. Taimur Shah, Mr. Sinan Khadhouri, Miss Meghana Kulkarni, Dr. Chuanyu Gao, Dr. Chon Meng Lam, Dr. Alexander Light, Miss Keerthanaa Jayaraajan, Miss Aqua Asif, Dr. Thineskrishna Anbarasan, Mr Vinson Chan

Transurethral REsection and Single instillation intra-vesical chemotherapy Evaluation in bladder Cancer Treatment (RESECT) improving quality in TURBT surgery.

How do I get involved? 1. Register your interest

Using this link: https://is.gd/resect

2. Complete your site’s registration

We will notify you of updates and provide the necessary documentation for registration and data collection. Updates will also be tweeted on our Twitter account @BURSTurology.

3. Begin uploading data

You will be given an individual logon for our online, live, electronic database that holds the standardised data entry instruments (REDCap database). The REDCap database tool was successfully used in our previous studies: MIMIC and IDENTIFY.

4. Reach your patient recruitment target

We will be asking you to collect a certain number of patients over a period of time to reach your target to become a Pubmed Indexed collaborator. The individuals who recruit most patients will also receive an invitation on the writing committee. Though this is a trainee-led project, we ask for a named supervising consultant or an attending as well.

5. Become a national coordinator

If you would like to increase your level of involvement with RESECT and chances of presenting data yourself, the position of National Coordinator is available in each country. The National Coordinator will work closely with the BURST committee, helping to recruit centres and facilitate communication in the respective country. He, she, or they will also receive access to their country-specific data and have the opportunity to present this work nationally.

How many people have already registered? Global Registration Overview (17/07/20) Total Number of Registered Collaborators: 487 Total number of Registered Hospitals outside UK: 172

Overview of Registrations in Europe (Excluding UK) Total Number of Registered European Collaborators: 97 Total number of Registered European Hospitals: 72 Top 10 countries:

Steering group members: Dr. Steven MacClennan (Research Fellow, University of Aberdeen), Mr. Param Mariappan (Consultant Urologist, Western General Hospital, Edinburgh), Mr. Tim O’Brien (Consultant Urologist, Guy’s and St Thomas’, London) Patient and Public involvement: Jacqueline Emkes, Rachel Jury European Urology Today

Urologists prepared to fight rising antimicrobial resistance Stronger arguments than ever for participation in the GPIU study Prof. Truls E. Bjerklund Johansen Oslo University Hospital Dept. of Urology Oslo (NO)

and the findings have great impact on our daily antibiotic use practices. The severity of healthcareassociated urinary tract infections is also increasing, with 25% being urosepsis in recent years. Healthcareassociated infections in urology are seen in around 11%, with one-third being severe infections. There are also significant differences between regions and types of hospitals1,2.

tebj@medisin.uio.no

GPIU is an international internet web-based study. All patient information is reported anonymously to the central study file. The study is sponsored by the EAU RF and the Merian-Iselin Foundation. Since 2018, the GPIU is also available in Spanish and Russian, which makes it even more attractive for investigators from these countries to join the study.

Dr. Zafer Tandogdu University College London (UK)

drzafer@gmail.com z.tandogdu@ ucl.ac.uk

Prof. Florian Wagenlehner Justus Liebig University Giessen Dept. of Urology Paediatric Urology and Andrology Giessen (DE) florian.wagenlehner@ chiru.med.uni-giessen.de

Co-authors: R. Bartoletti, G. Bonkat, F. Bruyere, T. Cai, J. Medina-Polo, B. Koves, E. Kulchavenya, T. Perepanova, A. Pilatz The Global Prevalence of Infections in Urology (GPIU) study is a worldwide point prevalence study intended to create surveillance data on antibiotic resistance, type of urogenital infections, risk factors and data on antibiotic consumption. The GPIU study has been performed annually since 2003. Due to the tremendous and enthusiastic participation of more than 1000 hospitals / centres from 70 countries, more than 30,000 thousand urological patients have been screened, yielding important information about infection-related issues of urological patients. The collected detailed information about urology patients is unique and is not available in any other sources.

Collating key intelligence information The studies have shown that the bacterial spectrum is comprised of pathogens Escherichia coli (31%), followed by species of Pseudomonas (13%), Enterococcus (10%), Klebsiella (10%), Enterobacter (6%) and Proteus (6%). Candida spp. and Pseudomonas spp. occur significantly and more frequently as causative agents in urosepsis than in other types of infections.

European Urology Today

7. You are also cordially invited to fill in the additional questionnaire on TRUS-Bx of the prostate. 8. You will be able to compare your own results with the total mean results by January 2021.

Join the GPIU research network! Resistance to antibiotics is continuously increasing, which is the strongest argument ever for taking part in the GPIU-study. With few new antibiotics against gram negative pathogens in the pipeline, it is crucial that we use those we have in a prudent way. The GPIU-study is the only worldwide study in urological infections. Investigators are very welcome to publish their regional results when compiling with investigators of their region. Recently, 10-year Asian GPIU data was published8.

Box 5: Important modifications of the CDC/NHSN criteria which will be used in the GPIU 2020

The GPIU is an altruistic initiative by urologists. The study has become a unique instrument to monitor and meet the expected increase in antibiotic resistance on The resistance rates of all antibiotics tested, other than an international level. Furthermore, severe urinary tract carbapenems, against the total bacterial spectrum is a infections is of particular interest for pharmaceutical cause of concern in most regions although the companies that want to study the effect of new resistance of E. coli, Klebsiella and Proteus spp. was antibiotics. The reason is that it is easier to identify and below 45% for the most commonly used antibiotics. verify the eradication of causative pathogens in UTI Enterococcus spp. and Pseudomonas spp. however, had than in other severe infections. As has been seen in the resistance rates above 70% to most antibiotics3. SEPENS study, a strong research network of urologists is also attractive for companies who want to explore The resistance rates of most of the uropathogens new principles for prophylaxis and treatment such as against the antibiotics tested have not shown significant vaccines and peptides in preparation of the posttrends of increase or decrease, but were already high antibiotic era. during the first study years. Resistance to almost all pathogens was lowest in North Europe and highest in National coordinators Asia4. To facilitate the running of the GPIU, strengthen the organisation and prepare for future side studies the GPIU study group recently announced positions as Providing evidence for guidelines recommendations As antibiotic prophylaxis is an important part of national coordinators. Urologists from nine countries have been scheduled for interviews this autumn. antibiotic consumption, data on routine antibiotic prophylaxis have been evaluated showing that use of antibiotic prophylaxis in urological patients was highest Box 1: Benefits for GPIU-Investigators in Latin America (84%), followed by Asia (86%), Africa 3,5 • Online certificate of infection control (85%), and Europe (67%) . The antibiotics most frequently used for prophylaxis were second-generation • Online statistics cephalosporins, ciprofloxacin, cefotaxime, and • Recognition in GPIU publications amoxicillin plus beta-lactamase inhibitor.

There are significant differences between countries/ regions and types of hospitals, both in using prophylaxis for clean procedures and in the types of Aims and characteristics of the GPIU Study The primary aims of the study are to do the following in antibiotics used. Antibiotic prophylaxis was not always consistent with guidelines recommendations5. GPIU urology departments throughout the world: data indicate that in the near future both antimicrobial (1) Evaluate urology practice in terms of hospital prophylaxis and empirical treatment will have to be infection control, which includes: tailored for each patient on the basis of risk factors, a. Control programmes for catheters, contamination category of surgical procedures and antibiotics, etc. availability of effective antibiotics in the region. b. Antibiotic consumption practice (2) Evaluate UTI and surgical site infections (SSI) in Prostate biopsies hospitalised urological patients, which includes: Especially in transrectal prostate biopsy, antibiotic a. Patient baseline characteristics prophylaxis is critical, as infection is a serious adverse b. Pathogens and their antimicrobial resistance effect of this procedure, and recent reports suggest an c. Antimicrobial treatment (3) Determine the prevalence of healthcare-associated increasing incidence of post biopsy infections. For this reason a prostate biopsy side study has been infections (HAI) for: performed since 2010. In the first published report, a. Geographical regions symptomatic urinary tract infections were seen in 5.2% b. Varying hospital settings of men, which were febrile in 3.5% and required c. Study years hospitalisation in 3.1%. The most important risk factor was fluoroquinolone resistance in causative pathogens6. The secondary aims of the study are to offer The GPIU study group is currently analysing data from participating urology departments and urologists: recent years, which show an increase in the rate of (1) an instrument for quality control of healthcareinfectious complications. GPIU is now paying special associated infections within their institution attention to recent recommendations by EMA on (2) acknowledgement of active involvement in an antibiotic prophylaxis and the ongoing switch to infection control program according to European Association of Urology (EAU) /ESIU (EAU Section for transperineal biopsies. Infections in Urology) recommendations Challenging UTI definitions (CDC/NHSN criteria) (3) Certificate for infection control The ESIU has adapted and modified the CDC/NHSN criteria for special usage in urology and especially The results of the study continuously provide national and international data on UTI and SSI for use in further when urologists are taking part in the annual global prevalence study on infections in urology, because the research and allows individual institutions to benchsame criteria have to be used if data from different mark their performance against national and institutions are compared and if the efficacy of any international peers. intervention has to be tested. A proxy for antibiotic consumption is reflected by the Urosepsis application rates used for antibiotic prophylaxis for During recent study years we have seen an increase in urological interventions. Resistance rates of most uropathogens against antibiotics are directly evaluated the reported percentage of urosepsis7. In 2006, the percentage of HAUTI being urosepsis was 9.3%, in 2007 it was 15.4% and in 2008 it was 21.8%. The ESIU EAU Section of Infections in Urology (ESIU) believes this might be due to more blood cultures being 36

taken which is also in accordance with general recommendations. However, in order to avoid a too high registration of urosepsis, investigators are encouraged to stick to the definitions of urosepsis presented in the ESIU/EAU guidelines. Currently, the GPIU study group is analysing the results of the GPIU-SERPENS study which is based on 400 historic cases of urosepsis from the GPIU database and 600 cases from a prospective study. It is expected that this analysis will provide important new information on the severity, clinical course and classification of urosepsis.

• Slides with study results

Box 2: Study days in 2020 The study days are held on the following dates in 2020: November 3-5, 10-12, 17-19, 24-26. Box 3: Online study registration https://gpiu.esiu.org/ Box 4: Practical guide for GPIU investigators 1. Decide on the most desirable study day for your department. 2. Log on to the GPIU’s website and register yourself as an investigator and fill in the fields requested to earn EU-ACME points (http://gpiu.esiu.org/) 3. You may print out PDFs of the report forms to use as reference when making notes. 4. On the chosen single study day, at 08:00 AM local time all patients present on the ward should be included. The presence of urinary tract infections and/or surgical side infections during their entire hospital stay should be documented and audited. Thus the charts and case records of the included patients should be examined both retrospectively and prospectively and patients should be categorized as having or not having a urinary tract infection (UTI) and/or surgical side infection (SSI). 5. Fill in the electronic hospital report form. Submit your data to the study database, or store pending forms in your local computer while awaiting additional data. 6. When the results of cultures etc. are available, complete the electronic patient report forms and submit them to the study database. Remember to connect to the internet for the submission of report forms!

Don’t forget! You should still complete your data entry even if no hospital acquired urinary tract infection is detected in your clinic on the study day.

1. The time interval between the admission of the patient and the diagnosis of HAUTI is no longer a criterion for the definition of a HAUTI. It is sufficient that the patient has a negative urine culture on admission and a careful clinical evaluation suggests that there was no UTI present on admission. 2. An exacerbation from ASB to asymptomatic UTI after any intervention has to be considered healthcare-associated caused by an endogenous source. 3. Any extension of infection already present at admission with a change in pathogen, including emergence of resistance, has to be considered healthcare-associated. 4. Healthcare-associated asymptomatic bacteriuria (HAASB) should be considered as colonisation, probably as risk factor under certain circumstances, but not as infection. However, screening for ASB is always necessary before all the mucosa traumatizing urological interventions of the urinary tract, because treatment of ASB has to be initiated before any such interventions. Therefore screening for HAASB should be included into the upcoming GPIU study, but data on HAASB will be evaluated separately and not included in calculation of the prevalence of HAUTI. 5. For the GPIU, as for all routine surveillance, we recommend that the time interval for diagnosing HAUTI or HAASB should be seven days after the intervention, or in case of on-going antibiotic therapy seven days after the end of antibiotic therapy, or in case of an indwelling urinary catheter, seven days after removal of the catheter. 6. There is a new definition on sepsis, which should be based on the quick SOFA score: Respiratory rate ≥ 22/ min Altered mental function Systolic blood pressure ≤ 100 mmHg References 1. Bjerklund Johansen TE, Cek M, Naber K, Stratchounski L, Svendsen MV, Tenke P, et al. Prevalence of hospitalacquired urinary tract infections in urology departments. Eur Urol 2007;51(4):1100-11; discussion 1112. 2. Wagenlehner F, Tandogdu Z, Bartoletti R, Cai T, Cek M, Kulchavenya E, et al. The Global Prevalence of Infections in Urology Study: A Long-Term, Worldwide Surveillance Study on Urological Infections. Pathogens 2016;5(1). 3. Johansen TE, Cek M, Naber KG, Stratchounski L, et al. Hospital acquired urinary tract infections in urology departments: pathogens, susceptibility and use of antibiotics. Data from the PEP and PEAP-studies. Int J Antimicrob Agents 2006;28 Suppl 1:S91-107. 4. Tandogdu Z, Cek M, Wagenlehner F, Naber K, et al. Resistance patterns of nosocomial urinary tract infections in urology departments: 8-year results of the global prevalence of infections in urology study. World J Urol 2014;32(3):791-801. 5. Cek M, Tandogdu Z, Naber K, Tenke P, Wagenlehner F, van Oostrum E, et al. Antibiotic prophylaxis in urology departments, 2005-2010. Eur Urol 2013;63(2):386-94. 6. Wagenlehner FM, van Oostrum E, Tenke P, et al. Infective Complications After Prostate Biopsy: Outcome of the Global Prevalence Study of Infections in Urology (GPIU) 2010 and 2011, A Prospective Multinational Multicentre Prostate Biopsy Study. Eur Urol 2013;63(3):521-7. 7. Tandogdu Z, Bartoletti R, Cai T, et al. Antimicrobial resistance in urosepsis: outcomes from the multinational, multicenter global prevalence of infections in urology (GPIU) study 2003-2013. World J Urol 2016;34(8):1193-200. 8. Choe HS, Lee SJ, Cho YH, Çek M, Tandogdu Z, Wagenlehner F, Bjerklund-Johansen TE, Naber K; GPIU Asian Investigators. Aspects of urinary tract infections and antimicrobial resistance in hospitalized urology patients in Asia: 10-Year results of the Global Prevalence Study of Infections in Urology (GPIU). J Infect Chemother. 2018;24(4):278-283.

August/September 2020

Networking in the urological office Basic principle of networking: Get to know and trust each other Dr. Horst Brenneis ESUO Board member Urologie im Zentrum Pirmasens (DE)

brenneis-dr@gmx.de

Ass. Prof. Fotios Dimitriadis ESUO Board member ESAU Assoc. Board member G. Gennimatas General Hospital Thessaloniki (GR) helabio@yahoo.gr For many clinically active urologists, working in practice seems to be synonymous with the ‘lone wolf’, alone and out in the open. This is by no means the case. Working in office only works within the framework of good networking. One of the most important things when starting to work is the establishment of a functioning network. It takes place on many different levels. Know each other personally The basic principle of networking is summarised in the slogan "Get to know and trust each other". All people involved should know each other personally and also know each other’s capacities well. Fast and direct communication is also important, e.g. through directly dialable telephonenumbers, emailing and other contact options. It goes without saying that the rules of data protection must be observed. In a functioning network, there must be a possibility of direct contact without long detours via secretaries, etc. Networking is not only of great importance in large cities or central regions. Especially in rural areas, patients can be well cared for, close to home, in a functioning network. As observed by one of the authors who lives and works in a medium-sized city with an extensive rural environment in southwest Germany. Interdisciplinary outpatient medical centre Networking begins in the own practice. In the course of the restructuring and centralisation of the healthcare system, individual practices are increasingly on the retreat. Cooperation in various legal forms, for example with employed doctors, is the future. One of the authors cooperates with another specialist in urology in an interdisciplinary outpatient medical centre. This “Medicenter” also includes two general practitioner's offices, one with a focus on diabetics, a paediatrician, an ophthalmologist's surgical practice, two orthopaedists, a gastroenterological and a nephrological office with outpatient dialysis and a dentist. Furthermore, there is a pharmacy, an orthopaedic shoemaker, a speech therapist, an occupational therapist, a physiotherapeutic practice with gym and last but not least a café. Short and fast ways to treat patients can be realised here thanks to good personal knowledge of the other services offered in the centre. Furthermore, synergies are possible. For example, the urologists and orthopaedists share a fully digital X-ray unit. The image processing is integrated into the practice software. The aim is not only the quality of care but also cost savings. The institution also becomes known through joint appearances and events, such as an annual Men's Health Day. Cooperation with clinics The next level involves cooperation with clinics. In the region of one of the authors there is a municipal hospital with a urological department, a central hospital and a university hospital. Of utmost importance, also at this level, is to get to know each other personally. Direct contact persons and fast direct communication channels are indispensable. An exchange of information about findings from practice, therapeutic options discussed with the patient, but also results of e.g. operations and EAU Section for Urologists in Office (ESUO)

August/September 2020

especially problems and complications are immensely important. The flow of information of e.g. imaging, laboratory values and histology must be guaranteed. Short direct telephone calls of the doctors involved have proven to be particularly useful, which only works when the contact persons know each other well. When people know each other personally through the framework of joint training courses, conferences and also tumour boards, it facilitates the work enormously. One of the authors is also moderator of an interdisciplinary tumour board of which the members regularly meet. The head physicians of the participating clinics meet with office urologists, and also the Department of Radiotherapy, the radiology office, the resident oncologist and, if necessary, family doctors are invited. This way an interdisciplinary concept for the care of oncological patients can be developed by direct exchange. In addition, it also serves to protect the physicians working in office from dealing with costs and insurance companies in case of expensive therapies. Interdisciplinary meetings In addition to the professional cooperation described above, an interdisciplinary network between general practitioners and specialists in the outpatient sector and hospital doctors is also helpful. In Germany, this often takes place in the form of Medical District Associations, in which all doctors working in a city or a district or county are grouped together. It is possible to get to know all doctors of a region personally by means of regular interdisciplinary further training, but also professional general meetings. In addition, a closer interdisciplinary cooperation can take place when structured and defined physician networks are formed, especially in the outpatient care setting. Here, for example, joint quality management systems can be established or coordinated staff training can take place. Regional quality circles Another level is formed by regional quality circles, in which physicians from a region - usually specialists in a certain area- join together to carry out further training or discuss problems specific to their specialism. It is also possible for them to make a joint appearance towards political decision-makers or insurance companies and the like. The next level of cooperation is then provided by regional or national professional associations, such as the southwest German Society of Urology, the German Society of Urology or the Professional Association of Urologists in Germany. The regional societies in particular offer forums that deal specifically with questions of office urologists. It is helpful to see that everyone shares the same problems. Regional and national congresses are also organised by these societies.

in the individual countries represented within the EAU and jointly they hope to be able to solve common problems and answer questions. Regardless of the level, whether local, regional, national or international, good personal relations with the people that form the backbone of any network is essential. As mentioned above: "Get to know and trust each other"

Figure 1: Medicenter Pirmasens/Germany

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Submission deadlines: 1 March - 1 July - 1 November Please check our website for details regarding the eligibility criteria and application procedure: www.uroweb.org/education/young-urologists-office-yuo/yau or contact the office via yau@uroweb.org

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/

EAU Edu Platform The online learning platform for GU cancers

International associations The final level of networking in the field of urology in practice is formed by international associations, such as the EAU. Here, urologists working in the outpatient and office sectors throughout Europe have come together in the "European Section of Outpatient and Office Urology (ESUO)" to develop programmes, further training and ideas especially for this group. They are represented very differently

PROSTATE CANCER

KIDNEY CANCER

BLADDER CANCER

Advantages of networking in office and outpatient urology • Patients remain in the network and are treated in the cooperation • Possibility of coordinated therapy across disciplines and sectors • Sharing of information among medical and healthcare professionals • Providing unlimited opportunities to broaden urologists’ knowledge about the health care industry • Knowledge gained through different educational opportunities may lead to career-advancing opportunities • Creating professional relationships and opportunities for broader collaborations Table 1: Advantages of networking in office and outpatient urology

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Urological passion The driving force behind my application to become an EAUN Board member Franziska Geese, MScN, RN EAUN Board Member Elect Berne (CH)

f.geese@eaun.org Since 2013, EAUN has accompanied me in my professional life with all its evidence-based and educational resources. I realised early that if I wanted to make a difference in the further professionalisation of urological care, I had to change my position from a resource user to a resource developer. After a while, I got the opportunity to serve on the Scientific Committee of EAUN and to participate in the EAU Patient Information initiative. After seven years of experience working for a non-profit organisation, I applied for EAUN Board membership. I was happy when the board approved my application. However, due to the Sars-COVID pandemic, EAUN members had no chance to vote on my Board membership. Therefore, the EAUN Board decided to accept me as EAUN Board Member Elect for one year until the members will be given the opportunity to vote at EAUN21 in Milan. To introduce myself to the EAUN members, I am happy to give a brief personal insight. Originally graduated as a Registered Nurse in Germany, I decided to move to Switzerland in 2010 due to the greater opportunities there to graduate in Advanced Nursing Practice (ANP). After graduation, my first employment in Switzerland was at the University Hospital Bern in the Department of Urology, High Dependency Unit, in 2012. This department was specialised in surgical treatment of people with European Association of Urology Nurses

uro-oncological tumours (e.g. bladder cancer, prostate cancer, kidney cancer, etc.). As a result, I was able to gain experience with these patient groups at an early stage of my career.

co-lead the project next to Rita Willener and to convince stakeholders to support the project. Already at the beginning of the ANP project, considerations were made how the counselling service could be evaluated. By means of a descriptive evaluation, it At the High Dependency Unit, I quickly noticed that was shown at an early stage that the ANP counselling especially men with bladder or prostate cancer had no service had closed a health service gap with the possibilities to express and discuss their worries and provision of psycho-oncological care for men with fears. Unmet needs such as how to cope with the prostate cancer and their partners. This awoke an diagnosis and therapeutic side effects, e.g. sexual increased interest in the innovative ANP counselling dysfunction, incontinence, and communication service, which had been implemented for the first problems in a couple’s relationship came to light. To time in this format in Switzerland. Highlights were meet unmet needs of relatives at the High Dependency when the ANP counselling service was awarded the Unit, a care model to include and empower them with Bernese Care Prize and the Phenomenon Award. An comprehensive information was introduced. invitation to give a lecture at a Symposium by the Swiss National Cancer League, supported by the ANP counselling service national government, was a good opportunity to In addition to my work at the High Dependency Unit, I spread the word about psycho-oncological care for had the opportunity to gain research experience with men with prostate cancer and their partner. the project "Development of a guideline for people with a long-term urinary catheter," led by Rita Boosting the theory-practice transfer Willener, CNS. As a research associate, I was Further experience followed in haemato-oncological responsible for the systematic literature review, critical care, nursing practice development and quality appraisal of studies/guidelines, the organisation and management. At this stage, I realised that if I wanted management of meetings and the development of a to deepen my knowledge about the evaluation of guideline adapted to the Swiss national context. The nursing interventions, I had to become a research project resulted in a recommendation by the Swiss associate. A possibility arose soon and I started Society for Patient Safety and a publication. working in the Academic-Practice-Partnership (APP) of the University of Applied Sciences Bern and the “… it needs more leaders who have University Hospital Bern, in November 2018.

experience in urological nursing and have sufficient research skills to make accomplishments of urological nurses visible…” In August 2013, I was promoted to an ANP position and was commissioned to develop a counselling service for patients with prostate cancer. Fulfilling an ANP role according to the PEPPA framework by Bryant-Lukosius (2004), coupled with the development of a counselling service, required various competencies, in particular leadership to

The APP enables me to use my clinical experience of and knowledge about the implementation/evaluation of ANP roles in various settings. Advanced Practice Nurses often lack time during their clinical work and do not have the necessary methodological skills to evaluate their interventions and the effects of their role. Due to the position in the APP, I am able to support Advanced Practice Nurses in boosting the evaluation of ANP interventions. Projects in which I am currently involved mainly relate to: a) the evaluation of ANP roles for people with

oncological diseases (sarcoma, glioblastoma, etc.); b) the analysis of interface management problems and the potential of interprofessional collaboration in complex patient pathways; c) the application and evaluation of the Swiss interprofessional collaboration tool SIPEI. In addition to my work as a research associate, I have been participating in a PhD programme since spring 2020. This programme will illustrate the contributions of APNs to the care of people with an oncological disease and their job satisfaction, in Switzerland.

"Advanced Practice Nurses often lack time during their clinical work and do not have the necessary methodological skills to evaluate their interventions and the effects of their role." All in all, I would like to say that my passion and fascination for urological nursing has been a constant feature in my career. Also, my various commitments at the EAUN and EAU reflect that urology is the discipline that I support and promote. I remember that when I was working as an Advanced Practice Nurse, I was often frustrated not to have sufficient research skills to evaluate ANP interventions. Nursing-evidence is one of the most important aspects of nursing practice development. From my point of view, it needs more leaders who have experience in urological nursing and have sufficient research skills to make accomplishments of urological nurses visible and show their benefits for patients. I will be very happy when we can finally meet and exchange views in Milan at EAUN21. Until then, I wish all members good health! Yours sincerely, Franziska

"Spot-on" evidence-based nursing care New research and developments Dear EAUN members, The growing evidence in urology nursing care is amazing! With this column, the EAUN SIG Groups want to put the spotlight on recent publications in their field of interest. This month’s articles have been carefully chosen because of the scientific value from PubMed and represent different methods and approaches in research and development in urological nursing care. We hope this initiative will have your attention and continuously provide information on "spot-on" urological nursing care. If you would like to inform us and your colleagues about new initiatives or exiting developments in one of the special interest fields you can contact us using the email addresses below. Best regards

Bente Thoft Jensen, Chair, EAUN Special Interest Group - Bladder Cancer b.thoft@eaun.org

The bladder cancer articles below will give you a sort of overview of what bladder cancer is, the natural history, risk factors treatment etc. Moreover, apart from the actual treatment algorithm, a further article about the family aspect and what is means to undergo treatment for both men and woman.

Selected from PubMed Bladder Cancer • Anderson B. Bladder cancer: overview and disease management. Part 1: non-muscle-invasive bladder cancer. Br J Nurs. 2018;27(9):S27-S37. doi:10.12968/ bjon.2018.27.9.S27. PMID: 29749774. https://pubmed.ncbi.nlm.nih.gov/29749774/ • Anderson B. Bladder cancer: overview and management. Part 2: muscle-invasive and metastatic bladder cancer. Br J Nurs. 2018;27(18):S8-S20. doi:10.12968/ bjon.2018.27.18.S8. PMID: 30281356. https://pubmed.ncbi.nlm.nih.gov/30281356/ • Pozzar RA, Berry DL. Gender Differences in Bladder Cancer Treatment Decision Making. Oncol Nurs Forum. 2017;44(2):204-209. doi:10.1188/17. ONF.204-209. PMID: 28222088. https://pubmed.ncbi.nlm.nih.gov/28222088/

Quantitative results of a national intervention to prevent hospital-acquired catheter-associated urinary tract infection: A pre-post observational study. Ann Intern Med. 2019;171(7_Suppl):S38-S44. doi:10.7326/ M18-3534. https://pubmed.ncbi.nlm.nih.gov/31569231/ • Mitchell BG, Fasugba O, Cheng AC, et al. Chlorhexidine versus saline in reducing the risk of catheter associated urinary tract infection: A cost-effectiveness analysis. Int J Nurs Stud. 2019;97:1-6. doi:10.1016/j. ijnurstu.2019.04.003. https://pubmed.ncbi.nlm.nih.gov/31129443/ • Dubbs SB, Sommerkamp SK. Evaluation and Management of Urinary Tract Infection in the Emergency Department. Emerg Med Clin North Am. 2019;37(4):707723. doi:10.1016/j.emc.2019.07.007. https://pubmed.ncbi.nlm.nih.gov/31563203/ • Clarke K, Hall CL, Wiley Z, et al. Catheter-Associated Urinary Tract Infections in Adults: Diagnosis, Treatment, and Prevention [published online ahead of print, 2019 Sep 18]. J Hosp Med. 2019;14:E1-E5. doi:10.12788/ jhm.3292. https://pubmed.ncbi.nlm.nih.gov/31532742/

Endourology • Robotic versus open ureteroneocystostomy: is there a robotic benefit? Skupin P A, Stoffel J T, Malaeb B S, et al. Published Online:15 Jul 2020. https://doi.org/10.1089/end.2019.0715 • Impact of body mass index on outcomes following anatomic greenlight laser photoselective vaporization of the prostate. Pierce H., Goueli R., Al Hussein Al Awamlh, B., et al. Published Online:15 Jul 2020. https://doi.org/10.1089/end.2020.0077 • Percutaneous microwave ablation of stage t1b renal cell carcinoma: Short-term assessment of technical feasibility, short-term oncologic outcomes, and safety. Guo J and Arellano R.S.. Published Online: 9 Jul 2020 https://doi.org/10.1089/end.2020.0382 • Early outcomes of robot-assisted radical prostatectomy following completion of a structured training curriculum: A single surgeon cohort study. Arjan S Sehmbi A., Sridhar A.N, Sahadevan K, et al. Journal of Clinical Urology 1-9, sage pub.com/ journals-permissions DOI: 10.1177/2051415820938176 https://journals.sagepub.com/doi/abs/10.1177/ 2051415820938176

Continence

Stefano Terzoni, Chair, EAUN Special Interest Group - Continence s.terzoni@eaun.org

Anna Mohammed, Chair, EAUN Special Interest Group - Endourology a.mohammed@eaun.org

European Urology Today

• The relationship between psychological and physical secondary conditions and family caregiver burden in spinal cord injury: A correlational study. Conti A, Clari M, Nolan M, et al. Top Spinal Cord Inj Rehabil. 2019;25(4):271-280. doi:10.1310/sci2504-271. https://pubmed.ncbi.nlm.nih.gov/31844379/ • Majeed A, Sagar F, Latif A, et al. Does antimicrobial coating and impregnation of urinary catheters prevent catheter-associated urinary tract infection? A review of clinical and preclinical studies. Expert Rev Med Devices. 2019;16(9):809-820. doi:10.1080/17434440.2019.1661774. https://pubmed.ncbi.nlm.nih.gov/31478395/ • Meddings J, Manojlovich M, Ameling JM, et al.

Join an EAUN Special Interest Group

www.eaun.org/about-eaun August/September 2020

Spotlight on frailty in bladder cancer Is frailty an underestimated marker in clinical practice?

b.thoft@eaun.org Perioperative and long-term functional and oncological outcomes following radical cystectomy (RC) for bladder cancer remain unchanged, despite advances in technique and perioperative management as well as neoadjuvant therapy. Is there something we overlooked? The article below gives an overview of what we know so far about frailty and RC.

it is estimated that one third of patients undergoing RC is sarcopenic and would benefit from a combined intervention of physical exercises and nutrition with protein supplements to attenuate the loss of lean leg mass and strength and promote the recovery phase10,14. Prehabilitation Today, it is generally accepted that exercises provide the best anabolic stimulus and nutrition potentiates the muscle protein response. Moreover, these two components are synergistically related. Therefore, a combined intervention should be offered in both the perioperative period and post discharge to counteract sarcopenia, maximise recovery and reduce long-term impairments14.

Although prehabilitation is not yet considered as standard treatment or is not offered due to concerns over a delay in cystectomy, this intervention may be a valuable preventive approach to modify well-known High rates risk factors. Attempts to counteract frailty using The RC procedure represents an integral component in multimodal prehabilitation programmes, including the management of advanced bladder cancer. However, physical exercises and nutrition supplementation, have it is associated with high rates of postoperative shown to be feasible, effective and lead to a positive morbidity (up to 90%1) and mortality rates between change in patients’ fitness and functional status12,15,16. 0.8–8.3%2. Patients suitable for RC are usually characterised as elderly and frail. They often suffer Frailty assessment from other urgent medical conditions because of a Both retrospective and prospective studies using a heavy comorbid burden that should mandate preoperative frailty assessment have shown that frailty pre-evaluation before scheduled surgery3. is associated with worse outcomes. Preoperative frailty assessments, based on patients' physiological fitness Frailty is defined as a syndrome of physiologic decline using the Fried Frailty Criteria or psoas muscle volume, and loss of functional reserve across organ systems, have been the best predictors of worse outcomes on leading to vulnerability for disease and death4. Specific prospective cohorts6. Perioperative risk assessment to RC, frailty is associated with higher complication before RC should incorporate objective measures of rates and mortality5. physiologic age, physical function, nutrition, lean muscularity, cognitive age, patient preferences and Useful for clinical practice frailty. Future work is needed to validate the The increased likelihood of pre and postoperative performance of existing metrics (= statistics) to improve frailty calls for increased awareness to inform early risk the ability to predict perioperative complications and assessment and qualify the shared decision process. oncologic outcomes and to define and assess the However, most institutions performing RC do not effectiveness of specific prehabilitation interventions to routinely measure frailty in clinical practice. This could counteract deconditioning in relation to surgery. partly be explained by the absence of consensus on how to define and measure frailty in the urological Key points to consider in radical cystectomy in community, despite a plethora of instruments, tools clinical practice and scales according to the literature6. Finally, there seems to be little agreement on which of those tools • Frailty is associated with worst postoperative are useful for clinical practice. Thus, there is currently outcomes after radical cystectomy. no standard recommendation of the optimum tool for • Frailty can be assessed using a frailty index or measuring frailty in RC. preoperative frailty assessment. Frailty is a dynamic phenomenon and seems to be modifiable while patients - according to most scales • Prospective studies show that preoperative can move between the status of being robust to assessments based on patients’ physiologic fitness pre-frail and frail. One well-known tool is the Fried and nutritional status are likely to be most useful for radical cystectomy. Frailty Phenotype7, which defines frailty by the following criteria: impaired grip strength, gait speed, physical activity, unintentional weight loss and • Further research is needed comparing various self-reported exhaustion. It seems to promote the frailty assessments to determine the best tool for concept of prehabilitation to modify or optimise clinical practice. deficits. • Inclusion of preoperative frailty assessment in guidelines for muscle-invasive bladder cancer is Sarcopenia An important and fundamental component of frailty is warranted to improve implementation in clinical sarcopenia, which is defined by progressive and severe care. loss of skeletal muscle mass. A common method of assessing sarcopenia in RC patients is measuring psoas From: Frailty and preoperative risk assessment before radical cystectomy. Burg, M L et al, Curr Opin Urol muscle volume on preoperative abdominal imaging. 2019, 29:216–219. This is already done prior to surgery to determine disease stage and is thus easy to access for clinical use. However, standard cut-off values of psoas muscle References volume for determining when patients are ‘frail’ (and 1. Elmussareh M, Simonsen PC, Young M, Kingo PS, thus at increased risk for postoperative complications Jakobsen JK, Jensen JB. Correlation between organand/or should change treatment direction) are yet to specific co-morbidities and complications in bladder be established; they are warranted to facilitate early cancer patients undergoing radical cystectomy. prevention of sarcopenia in clinical practice4. Scandinavian Journal of Urology. 2018;52(5-6):395-400. Sarcopenia is, however, accepted as an important preoperative prognostic factor of overall and cancerspecific survival after RC8 and is associated with increased 30-day and 90-day high-grade complications9-11. These findings support the association of certain components of the Fried Frailty Criteria with increased complications and stress the significant impact of preoperative physical fitness and nutritional status on postoperative outcomes of RC. The physical decline including aerobic fitness and nutritional status are significant drivers in sarcopenia. Older patients, such as RC patients, who’s average age peaks around 67, are less able to utilise amino acids for protein synthesis at muscle level, and almost 30% are at nutritional risk ahead of surgery12,13. In addition, European Association of Urology Nurses

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cancer. Urol Oncol. 2020. 7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. 8. Mayr R, Gierth M, Zeman F, Reiffen M, Seeger P, Wezel F, et al. Sarcopenia as a comorbidity-independent predictor of survival following radical cystectomy for bladder cancer. Journal of cachexia, sarcopenia and muscle. 2018;9(3):505-13. 9. Wan F, Zhu Y, Gu C, Yao X, Shen Y, Dai B, et al. Lower skeletal muscle index and early complications in patients undergoing radical cystectomy for bladder cancer. World journal of surgical oncology. 2014;12:14. 10. Mayr R, Fritsche HM, Zeman F, Reiffen M, Siebertz L, Niessen C, et al. Sarcopenia predicts 90-day mortality and postoperative complications after radical cystectomy for bladder cancer. World J Urol. 2018;36(8):12017. 11. Smith AB, Deal AM, Yu H, Boyd B, Matthews J, Wallen EM, et al. Sarcopenia as a predictor of complications and survival following radical cystectomy. The Journal of urology. 2014;191(6):1714-20. 12. Bente Thoft Jensen GD, Jørgen Bjerggaard Jensen, Caitlyn Retinger Mallory Bowker. Implementing a Multimodal Prehabilitation Program Prior to Radical Cystectomy in a Comprehensive Cancer Center: A Pilot Study to Assess Feasibility and Outcomes. Urologic Nursing. 2019;November-December 2019 / Volume 39 / Number 6:303-13. 13. Jensen BT, Laustsen S, Petersen AK, Borre M, Soendergaard I, Ernst-Jensen KM, et al. Preoperative risk factors related to bladder cancer rehabilitation: a registry study. European journal of clinical nutrition. 2013. 14. Gillis C, Buhler K, Bresee L, Carli F, Gramlich L, Culos-Reed N, et al. Effects of Nutritional Prehabilitation, With and Without Exercise, on Outcomes of Patients Who Undergo Colorectal Surgery: A Systematic Review and Meta-analysis. Gastroenterology. 2018;155(2):391-410.e4.

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15. Jensen BT, Laustsen S, Jensen JB, Borre M, Petersen AK. Exercise-based pre-habilitation is feasible and effective in radical cystectomy pathways-secondary results from a randomized controlled trial. Support Care Cancer. 2016;24(8):3325-31. 16. Minnella EM, Awasthi R, Bousquet-Dion G, Ferreira V, Austin B, Audi C, et al. Multimodal Prehabilitation to Enhance Functional Capacity Following Radical Cystectomy: A Randomized Controlled Trial. Eur Urol Focus. 2019.

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Dr. Bente Thoft Jensen, PhD Chair, EAUN SIG Bladder Cancer Aarhus (DK)

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2. Banerjee S, Semper K, Skarparis K, Naisby J, Lewis L, Cucato G, et al. Patient perspectives of vigorous intensity aerobic interval exercise prehabilitation prior to radical cystectomy: a qualitative focus group study. Disabil Rehabil. 2019:1-8. 3. Psutka SP, Barocas DA, Catto JWF, Gore JL, Lee CT, Morgan TM, et al. Staging the Host: Personalizing Risk Assessment for Radical Cystectomy Patients. European urology oncology. 2018;1(4):292-304. 4. Burg ML, Clifford TG, Bazargani ST, Lin-Brande M, Miranda G, Cai J, et al. Frailty as a predictor of complications after radical cystectomy: A prospective study of various preoperative assessments. Urol Oncol. 2019;37(1):40-7. 5. Chappidi MR, Kates M, Patel HD, Tosoian JJ, Kaye DR, Sopko NA, et al. Frailty as a marker of adverse outcomes in patients with bladder cancer undergoing radical cystectomy. Urol Oncol. 2016;34(6):256.e1-6. 6. Grimberg DC, Shah A, Molinger J, Whittle J, Gupta RT, Wischmeyer PE, et al. Assessments of frailty in bladder

European Urology Today

Synopsis of nursing research study Withdrawing from treatment for bladder cancer: Patient experiences with BCG instillations Dr. Jason Alcorn, FHEA, D. Nurse Mid Yorkshire Hospitals NHS Trust Dept. of Urology Wakefield (GB) jason.alcorn@ outlook.com

This is a report of the nursing study ‘Withdrawing from treatment for bladder cancer: patient experiences of BCG instillations’, which is awaiting publication in the International Journal of Urological Nursing. The primary aim of this mixed methods study was to explore how patients’ experience with BacillusCalmette Guerin (BCG) treatment influenced their early withdrawal. We did not set out to investigate which strategies could potentially keep patients on treatment for a longer period, these became apparent as the research progressed. The reason for undertaking this research was the withdrawal rate of up to 86% (Lamm et al., 2000). Mycobacterium bovis bacillus In the UK alone, there are 10,000 new diagnosis annually of bladder cancer. It is recognised as the second most common urological cancer in the UK and USA (Tobias & Hochhauser, 2010). BCG was first discovered at the turn of the 20th century, when Albert Calmette and Camille Guerin isolated an attenuated live strain of Mycobacterium bovis bacillus, a live vaccine against tuberculosis, known as BCG (Crispen, 1989). It was not until the late 1970s that BCG started to be used for bladder cancer following studies by Morales (Morales et al., 1976). So why the high withdrawal rate?

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Cumulative effect? The answer may in part be due to the fact that very little is known about patients’ experience with this intravesical treatment. Some authors have suggested that there is a cumulative effect of the BCG instillations on the patient leading to symptoms such as pain, flu-like symptoms, etc. (Berry et al., 1996; Heiner & Terris, 2008; Orihuela et al., 1987) which lead the patient to withdraw, but this does not take their experience with the treatment into account. A list of side effects can be found in the European Association of Urology Nurses guidelines for the intravesical instillation (Vahr et al., 2015). This study which was conducted in a large National Health Service Hospital Trust serving a metropolitan area in the North of England may offer some insight. The study was undertaken in two parts: firstly a retrospective case note analysis, identifying trends such as symptomology and the ‘natural history’ of BCG treatment. Secondly, a qualitative approach, interviewing patients and identifying themes from the subsequent data analysis. Four themes What is interesting about this study is that it identifies four themes: treatment concerns, withdrawal influencers, unmet needs and treatment bereavement. Participants identified treatment concerns and withdrawal influencers as areas that concerned them most and influenced their decision-making processes. In more detail, these themes were made up of the following underlying factors: • Treatment concerns were made up of influencing factors. These affected the quality or experience of the treatment and the attendant processes, such as physical or psychological distress. What supported these themes were dignity, physical effects, side effects and psychological and emotional distress. • Withdrawal influencers emerged from the factors social impact, experience and effects on daily life. It was found that these factors intertwined to bring the patient to a point of stopping their ‘cancer

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treatment’. • Unmet needs derived from communication, choices and the environment that the treatment is delivered in post treatment. • Treatment bereavement, this is when patients talked about the loss and feelings experienced following their decision to withdraw from treatment. This highlights their personal journey and how they thought about their treatment and how they questioned themselves about their decision-making. This is particularly illuminated with the following quote:

“I used to lie in bed and think, “I am not having this treatment and if that thing starts growing inside me again, I know they have got rid of it and it might not come back again but I am not having the treatment and I needed this treatment and I’m not having it”.

In concluding the study, nursing recommendations were presented such as education, environment, patient support and record keeping. A further recommendation was that healthcare professionals need to work with the patient and their extended support networks in a concerted effort to ensure patients complete their treatment. To read more about this study please see the following articles: Nonmuscle invasive bladder cancer and bacillus CalmetteGuerin treatment: a review of the literature (Alcorn et al., 2014); BCG treatment for bladder cancer, from past to present use (Alcorn et al., 2014); Patterns of patient withdrawal from BCG treatment for bladder cancer: A retrospective time interval analysis (Alcorn et al., 2019); and Withdrawing from treatment for Bladder cancer: Patient experiences of BCG instillations (Alcorn et al. in press). References Alcorn, J., Burton, R., & Topping, A. (2014). Non-muscle invasive bladder cancer and bacillus CalmetteGuerin treatment: a review of the literature. International Journal of Urological Nursing, 9(2), 57–68. Alcorn, J., Burton, R., & Topping, A. (2014). BCG

treatment for bladder cancer, from past to present use. International Journal of Urological Nursing, 9(3), 1–10. Alcorn, J., Burton, R. L., & Topping, A. E. (2019). Patterns of patient withdrawal from BCG treatment for bladder cancer: A retrospective time interval analysis. International Journal of Urological Nursing, 13(2), 63–74. https://doi.org/10.1111/ ijun.12191 Alcorn, J., Burton, R. L., & Topping, A. E. (awaiting publication). Withdrawing from treatment for Bladder cancer: Patient experiences of BCG instillations. International Journal of Urological Nursing Berry, D., Blumenstein, B., Magyary, D., Lamm, D. & Crawford, E. (1996) Local Toxicity Patterns Associated with Intravesical Bacillus Calmette-Guérin: A Southwest Oncology Group Study. International Journal of Urology, 3 (2) March, pp. 98–100. Crispen, R. (1989) History of BCG and Its Substrains. Progress in Clinical and Biological Research, 310, pp. 35–50. Heiner, J. & Terris, M. (2008) Effect of Advanced Age on the Development of Complications from Intravesical Bacillus Calmette-Guérin Therapy. Urologic Oncology, 26 (2), pp. 137–140. Lamm, D., Blumenstein, B., Crissman, J., Montie, J., Gottesman, J., Lowe, B., Sarosdy, M., Bohl, R., Grossman, H., Beck, T., Leimert, J. & Crawford, D. (2000) Maintenance Bacillus Calmette-Guerin Immunotherapy for Recurrent TA, T1 and Carcinoma in Situ Transitional Cell Carcinoma of the Bladder: A Randomized Southwest Oncology Group Study. The Journal of Urology, 163 (4), pp. 1124–1129. Morales, A., Eidinger, D. & Bruce, A. (1976) Intracavitary Bacillus Calmette-Guerin in the Treatment of Superficial Bladder Tumors. The Journal of Urology, 116 (2), pp. 180–183. Orihuela, E., Herr, H., Pinsky, C. & Whitmore, W. (1987) Toxicity of Intravesical BCG and Its Management in Patients with Superficial Bladder Tumors. Cancer, 60 (3), pp. 326–333. Tobias, J. & Hochhauser, D. (2010) Cancer and Its Management. 6th ed. Oxford: Wiley-Blackwell. Vahr S., De Blok W., Love-Retinger N., Intravesical instillation with mitomycin C or bacillus Calmette-Guérin in non-muscle invasive bladder cancer. European Association of Urology 2015. ISBN: 978-90-79754-76-2.

HYPERLINKS

The International Journal of

Urological Nursing

- the official Journal of the BAUN International Journal of

Urological Nursing the journal of the baun

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Volume 10 • Issue 2 • July 2016

Editor Rachel Busuttil Leaver Associate Editor Jerome Marley

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