European Urology Today Vol. 33 No.4 - August/September 2021

European Urology Today Official newsletter of the European Association of Urology Cherish life’s special moments Stress incontinence causes urine leaks during activities such as exercising, laughing or even just coughing.

Talk to your urologist about the treatment best suited for you.

New faces in key EAU positions

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Profiles of new board members on pages 5, 9, 15, 21 and 27

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Vol. 33 No.4 - August/September 2021

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EAU21 Annual Congress attracts global audience Innovative hybrid approach made for an attractive and engaging congress

By Erika De Groot, Loek Keizer and Juul Seesing The European Association of Urology held its 36th Annual Congress, EAU21, on 8-12 July. The global pandemic required the organisers to hold EAU21 virtually, with a small number of session chairs and moderators travelling to the Netherlands to host sessions in a studio setting. (Fig 1) The congress attracted over 6200 unique participants from 120 countries. During the congress days, 52,000 live views were logged for the 180 sessions. The five-day EAU21 Scientific Programme featured 1600 faculty members and speakers, discussing all the latest developments in urology. The European School of Urology hosted special courses during congress hours, and a special programme for urology patients was also introduced this year. The European Association of Urology Nurses will hold its own virtual meeting in September.

What follows is an extremely condensed overview of some of the highlights of EAU21. For the most complete coverage of the Congress, you can read the reports by the EAU’s editorial team and by some of the speakers on www.eau2021.org Full day of semi-live surgery “Technology development never ends!” was the catch-all title for the nearly eight-hour flagship semi-live surgical session at EAU21. The session, or more accurately, the Meeting of the EAU Sections of Uro-Technology (ESUT), Robotic Urology (ERUS) and Urolithiasis (EULIS) was designed to take up most of the first day of EAU21, lasting from 10:15 to 19:00 with an hour-long break at noon. Profs. Gözen (DE) and Walz (FR) chaired the day’s sessions.

session on Friday morning, which was about early detection of prostate cancer. Dr. Roderick Van Den Bergh (NL), Assoc. Prof. Isabel Heidegger (AT), and Dr. Armando Stabile (IT) each gave a case presentation, which was discussed and then cross-examined by medical lawyer Mr. Bertie Leigh (GB) after. Besides Mr. Leigh, the session was chaired by Prof. Chris Bangma (NL) and Dr. Jochen Walz (FR).

Dr. Van Den Bergh described his case as a situation that “started as a fairy tale and ended as a nightmare.” He alluded to it as a perfect case of active surveillance that ended in a “possible metastatic lesion.” Mr. Leigh said, “There is nothing wrong with active surveillance. It is a great advance in modern urology. It is about the way you do it and that is what went wrong in this case.”

Later in the session, the focus shifted to low-grade cancers. “The frequent problem of overtreatment,” as Dr. Walz put it. The overtreatment case presented was quite unique as the patient had put pressure on his urologist to perform a radical prostatectomy, which raised the question: what if a patient keeps pushing for surgery? Mr. Leigh: “When your patient asks you to do something that you think will do him harm and will not do him any good, you should rarely comply with his wishes.”

Management of incontinence Centred on the optimal management of incontinence in elderly patients, Plenary session 2, which took place on Friday, also covered what drug interactions to be aware of when using pharmacotherapy for

Figure 1: The EAU21 studio set in Hilversum, the Netherlands. Some moderators and sessions chairs were able to travel to “host” the congress and lead discussions

Prof. Morgan Rouprêt (FR), and Prof. Arnulf Stenzl (DE), the session went into technical advances and personalised and targeted therapeutical strategies.

Prof. James Catto (GB) kicked off the session with his state-of-the-art lecture “Safe and optimal

Renal cancer Plenary session 4 addressed updates on localised and metastatic renal cancer. Prof. W. Marston Linehan (US) kickstarted the session with his Society of Urologic Oncology (SUO) lecture on the discovery, oxygen sensing and therapy using the von Hippel-Lindau (VHL) kidney cancer gene.

“Dr. Olivares highlighted the system’s modular nature, its flexible upgradeability, the advantages of its open console and the support for standard surgical tools.”

The first of five blocks of presentations covered a wide range of innovations in urological technology, including flexible ureteroscopy with thulium fibre laser, several new kinds of laser technology (including a demonstration of mini-PCNL with MOSES 2.0) and the demonstration of a new kind of ureteral stent, the JFil, by Dr. Andrea Bosio (IT). The JFil led to a lot of questions from the audience, who were clearly interested in the potential of the innovative “pigtail” Figure 2: The pros and cons of radical cystectomy versus radical radiotherapy in light of COVID-19 stent and its potential for reducing stent-related symptoms.

A real scoop in this first series of talks was the participation of Dr. Ruben Olivares (CL) who was the first to use the Medtronic Hugo RAS system to perform a prostatectomy on June 19th at the Clinica Santa Maria in Chile. Dr. Olivares highlighted the system’s modular nature, its flexible upgradeability, the advantages of its open console and the support for standard surgical tools. This historic first procedure would mark the start of a registry and data collection on the performance of the system.

Nightmare session The first Plenary session of EAU21 was the Nightmare

urgency urinary incontinence. According to Prof.

Martin Michel (DE), complete medication history is key to the prevention, detection, and management of drug-drug interactions.

EAU Secretary General Prof. Chris Chapple (GB) discussed that new mesh materials need to be more like fascia-mimetic material made of three layers of polyurethane (PU) electrospun fibres. PU material copes well with repeated distension and is well tolerated in animals, inducing little inflammation.

Mrs. Mary Lynne Van Poelgeest-Pomfret (NL) underscored the importance of listening to patients with regard to treatment goals and evaluation tools.

Advanced bladder cancer in 2021 “Plenary session 3 – Advanced bladder cancer in 2021: Going forward?” on Saturday morning looked into the future of advanced bladder cancer treatment. Chaired

by Prof. Maria De Santis (DE), Prof. Joan Palou (ES),

August/September 2021

The final state-of-the-art lecture of the session was Dr. Enrique Grande’s (ES) “Does every metastatic patient need immunotherapy in a first-line setting?” pertaining to metastatic urothelial carcinoma. Dr. Grande started his lecture answering his central question with a “probably not”; he ended with a “definitely not.”

To find the gene for clear cell renal cell carcinoma (ccRCC), Prof. Linehan and his team conducted genetic linkage in families affected with VHL disease. They localised the gene to the short arm of chromosome 3 and with physical mapping, identified the VHL gene which is a two-hit, loss-of-function, tumoursuppressor gene. Prof. Linehan also cited the relevance of the findings of the Nobel Prize-winning study on how cells can sense and adapt to changing oxygen availability.

Covering immunotherapy-based management of metastatic clear-cell and variant RCC, Dr. Ignacio Duran (ES) stated that immunotherapy-based combinations can provide a long-term benefit in a management of muscle-invasive bladder cancer substantial percentage of patients with metastatic (MIBC) in the time of SARS-COV-2.” He said, “In terms ccRCC. of cure [for MIBC], we have two choices: surgery or radiotherapy.” He went on to present the pros and Moderated live from the EAU21 studio, Dr. Umberto cons of each of these approaches in light of COVID-19. Capitanio (IT), Prof. Marc-Oliver Grimm (DE), and Prof.

(Fig. 2) Peter Mulders (NL) chaired Plenary session 4.

“When your patient asks you to do something that you think will do him harm and will not do him any good, you should rarely comply with his wishes.”

The second state-of-the-art lecture was given by Prof. Lars Dyrskjøt (DK), who answered the question of whether we can use molecular markers to decide treatment for MIBC. One of his conclusions was that “ctDNA has many opportunities across the patient disease course to inform clinical practice.”

Metastatic PCa On Sunday, Plenary session 5 commenced and focused on the treatment for metastatic hormonesensitive prostate cancer (mHSPCa). The session was led by Prof. Alberto Briganti (IT), Prof. Karim Fizazi (FR), Prof. Silke Gillessen Sommer (CH), and Prof.

Arnauld Villers (FR).

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Congress days

Faculty

During his state-of-the-art lecture, Prof. Declan Murphy (AU) emphasised that in the de novo setting, the accuracy of PSMA PET/CT is superior to conventional imaging.

Later in the session, Prof. Christopher Sweeney (US) said that there is evidence to support the hypothesis that men with mHSPCa have a wide array of prognoses, which can be easily defined by clinical variables.

In discussions on the role of imaging-guided treatments such as radiotherapy, Assoc. Prof. Pierre Blanchard (FR) stated there is low level of evidence for metastases-directed therapy (MDT) in oligometastatic recurrent PCa setting, although MDT is widely used.

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) Assoc. Prof. 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) EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680 F +31 (0)26 389 0674 EUT@uroweb.org Disclaimer No part of European Urology Today (EUT) may be reproduced without written permission from the Communication Office of the European Association of Urology (EAU). The comments of the reviewers are their own and not necessarily endorsed by the EAU or the Editorial Board. The EAU does not accept liability for the consequences of inaccurate statements or data. Despite of utmost care the EAU and their Communication Office cannot accept responsibility for errors or omissions.

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Sessions

Ever-increasing applications for robotic surgery in urology Robotic urology is a rapidly evolving field with many studies underway and results coming in the next few years, but some careful conclusions were already drawn by the speakers at EAU21 on Sunday. Plenary Session 6, chaired by Profs. Mottrie (BE), Albersen (BE) and O’Brien (GB), examined if the surgical robot is starting to take over reconstructive surgery, traditionally the field for open or laparoscopic techniques, and all signs are pointing to a shift to robotic-assisted surgery.

“While robotic training is becoming increasingly standardised thanks to ERUS, its curriculum and the work of training centres like ORSI, how much of current robotic training is based on a single robotic system, and how useful will it be as the market becomes more diverse?”

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does, but in terms of surgical technique and approach, it’s all basically the same. It’s work in progress on our part.”

The prospects of surgical remote learning The final of seven plenary sessions at EAU21 took place on Day 5 of the virtual congress, bringing together stone experts from across the continent for an interesting live session. The session was chaired from the studio by Prof. Thomas Knoll (DE) and Prof.

Selçuk Silay (TR), joined by Prof. Evangelos Liatsikos (GR) remotely.

admit that there is a certain amount of bias there.”

“International societies like the EAU and the European School of Urology perhaps did the most to replace physical meetings, creating evidence-based webinars and learning tracks. This year’s Annual Congress (EAU21) is an excellent example of what we are now able to do, to teach surgical theory. Things like stone composition recognition can easily be done from home.”

“The fact remains however that we are surgeons and we have so far not been able to replace in-person, hands-on teaching. We need feeling and feedback from our tools. While this is so far irreplaceable, a mix of hands-on and remote training is certainly a future for us.”

“The fact remains however that we are surgeons and we have so far not been able to replace in-person, Profs.largest Knoll and Liatsikos joinedCongress in discussing these hands-on teaching.”Science at Europe’s Cutting-edge Urology Amid case discussions that weighed the benefits and drawbacks of ESWL, PNL or flexible URS was an update on technique and training. Prof. Olivier Traxer (FR) summarised his personal experiences of remote training over the past fifteen months.

realities with Prof. Traxer. Perhaps remote “coaching” of more experienced surgeons with a live feed of the procedure (similar to moderation during live surgery sessions) is an option, but only if the surgeon already has a degree of skill. There are also many legal ramifications that need to be examined for this to be considered.

“With the events of 2020, we have had to rethink education,” said Traxer. “Social media has allowed us to get in touch and spread information, but of course there is little in the way of quality control.

The industry has started developing webinars and educational platforms, but we must, of course,

Although the congress might have ended, registration remains open for people who would like to watch all of the content on demand. The EAU21 scientific content remains accredited until 12 October, earning participants up to 40 CMEs. For more details, see www.eau2021.org

Join us!

Watch the On Demand sessions until 12 October 19.30 CEST and earn CME credits

As departing chairman of the EAU’s Robotic Urology Section Prof. Mottrie is, understandably, extremely enthusiastic about the potential of robotic surgery and advanced surgical technology in general: “This session proves that everything is becoming robotised. We started with prostate, prostatectomy, then kidney, and bladder, but now everything that we do with our bare hands is going more and more towards robotics. There are new robotic systems coming to market, microsurgery and so on. This will very probably soon include urethral reconstruction and whatever else. As the expenses come down, also due to increased competition, there are very few drawbacks left.”

While robotic training is becoming increasingly standardised thanks to ERUS, its curriculum and the work of training centres like ORSI, how much of current robotic training is based on a single robotic system, and how useful will it be as the market becomes more diverse?

Prof. Mottrie: “As it currently stands, we only have one system. Our current training protocols are, let’s say, a ‘monorobot training.’ But we will in the coming years come to a new era where we will have robot-agnostic training. When you buy a car, sure, there are differences between brands but the driver’s license is the same. You might need the company to tell you what each button and switch

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August/September 2021

EAU Guidelines Office: The year in review Expansion of guidelines activities despite COVID-19 pandemic By the previous Chair and Vice-Chair of the Guidelines Office Board Over the course of the past year and a half, we have faced a truly unprecedented healthcare crisis. The COVID-19 pandemic has tested the resources and capacity of health systems around the world and our normal working patterns have been radically altered.

Despite these challenges, the EAU Guidelines Office has continued to function and in April we were honoured to present the 2021 edition of the European Association of Urology (EAU) Guidelines. We would like to take this opportunity to thank all members of the Guidelines Office who have worked tirelessly during this period to make this update possible.

New Chair of the Guidelines Office Prof. Maria Ribal It is with great pleasure that we announce that the appointment of Professor Maria Ribal as the new Chair of the Guidelines Office Board was confirmed at the General Assembly of the EAU21 Virtual Congress.

We wish her all the very best with her appointment and future as the Chair of the Guidelines Office!

New EAU Urethral Strictures Panel

By Prof. Nicolaas Lumen, Chair of the panel

Last year an additional burden was placed on panel members over and above the yearly update of the EAU Guidelines. In response to the COVID-19 pandemic, a Guidelines Office Rapid Reaction Group (GORRG) composed of highly experienced Board and panel members was established. The GORRG groups’ initial remit was to provide rapid guidance, underpinned by the best knowledge available, on adapting EAU Guidelines recommendations to the COVID-19 pandemic. Thanks to the efforts of all panel members, the publication of the “EAU Adapted Guidelines for the COVID-19 Era” was achieved in a very short period and published in April 2020. Moving forward, the GORRG will expand on their initial remit to address a wider range of important topics directly impacting urological practice.

For the 2021 edition of the EAU Guidelines, we were proud to present two new EAU Guidelines: one addressing Non-Neurogenic Female Lower Urinary Tract Symptoms (LUTS) and one addressing Urethral Strictures. The Guidelines on Non-Neurogenic Female LUTS provide a concise overview of the evidence-base related to assessment and treatment of female LUTS as reflected in clinical practice and expands on the previous EAU Incontinence Guideline. The Guidelines on Urethral Strictures aim to provide a comprehensive overview of urethral strictures management in male, female and transgender patients. In addition, a number of Guidelines have added new sections for 2021 including: • Sexual and Reproductive Health – new section on Priapism • Urological Infections – new section on the Management of HPV in Males • Paediatric Urology – new sections on Testicular Tumours in prepubertal boys and Rare Conditions covering urachal remnants, papillary tumours of the bladder and penile rare conditions

Although a common pathology in urologic practice, it took until 2021 before urethral stricture disease (USD) was introduced as a stand-alone guidelines topic within the EAU guidelines. The Strictures Panel (a mix of clinical experts, methodologists and promising urologists with specific interest in USD) aimed to handle all aspects of urethral strictures. Therefore, it contains not only recommendations on treatment of USD, but also on prevention, diagnosis, peri-operative care and follow-up. In addition, included are recommendations on male USD, female USD and strictures in transgender patients. Therefore, to the best of our knowledge, these guidelines are the most comprehensive currently available. The guidelines are based on a structured literature search ranging from 2008-2018 with selection of articles based on well-defined inclusion and exclusion criteria. To strengthen recommendations, two systematic reviews have been performed and one is ongoing by our team of associates. Although level of evidence in the field of USD is low, trials are running or have been recently performed to improve the quality of available data, an effort fully encouraged by the Urethral Strictures panel. Within the EAU Urethral Strictures Guideline you will find the necessary clinical practice guidelines to optimise the treatment of the individual patient with USD in urologic practice.

Call to action: PIONEER Patient-Reported Outcome Measures Prostate Cancer (PCa) is characterised by a relatively long natural history, where a substantial proportion of PCa patients die from causes other than the disease itself. As a result of this there is an increasing awareness of the importance of measuring treatmentrelated side effects as well as Health-Related Quality of Life (HRQoL) using Patient-Reported Outcome Measures (PROMs). This is essential when considering that cancer patients have the possibility of trading HRQoL for length of life.

Patient-reported outcome measures ask patients to assess elements of their own health, quality of life, and functioning. The resulting data can be used to show how healthcare interventions and treatments affect these aspects of a person’s day-to-day life.

In the first 4 weeks after publication more than 300,000 Guidelines website sessions were generated on Uroweb with 28,000 downloads of the Guidelines pdfs in the first 7 days! Top 6 downloads to date: Prostate Cancer; Renal Cell Carcinoma; Urological Infections; Urolithiasis; Muscle-invasive Bladder Cancer; and Non-neurogenic Male LUTS.

“In the first 4 weeks after publication more than 300,000 guidelines website sessions were generated on Uroweb.org with 28,000 downloads of the Guidelines PDFs in the first 7 days!”

Within PIONEER we are actively working to assess the validity of PROMs currently used for assessing different domains (i.e., urinary, sexual, and bowel function) and quality of life in patients with PCa. One of PIONEER’s overarching goals is to develop both standard core outcome sets (COSs) and PROMs, to guide the selection of the most appropriate COSs and PROMs to use for assessment of outcomes in patients with PCa in routine care and research.

We are excited to announce a new ASCO-EAU Penile Cancer Guidelines Panel. A fully collaborative multi-disciplinary panel has been set up, led by two co-chairs Prof. S.T. Tagawa (ASCO) and Dr. O. Brouwer (EAU). The aim of the panel is to develop a completely new guideline, fully engaging patients in this process.

The first systematic review is under way and the new Guidelines will be published in the 2022 edition of the Guidelines.

On behalf of the EAU Guidelines Office Board, we would like to take this opportunity to thank the wider EAU membership for your support and inspiration. We hope you are enjoying using the 2021 update of the EAU Guidelines and we look forward to a brighter 2022.

Guidelines Office

August/September 2021

audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 EAU Guidelines Office: The year in review. . . . 3 Practical answers to testicular microlithiasis mysteries. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Green light for the EAU Policy Office. . . . . . . . 6

Evidence to support the use of PROMs to improve the quality of care received by patients is growing, supported by the realisation that patients are the best judges of the impact of their treatment on their pain, daily functioning, symptoms and quality of life. For clinicians PROMs are a valuable support tool for shared decision making with a patient-centred focus.

However, it is important to use valid, reliable and appropriate instruments when selecting PROMs that also minimise the burden placed on patients and healthcare workers for data collection.

The “Summaries of changes” sections detail the updates achieved for the various guidelines.

EAU21 Annual Congress attracts global

To achieve this goal we would like to begin by identifying which PROMs are used in daily clinical practice, and to identify potential new data holders and collaborators. Do you have PCa PROMs data?

Are you interested in joining the PIONEER initiative?

Then please take our short 3-minute survey: https://bit.ly/3ytvwLS. Big Data 4 Better Outcomes: Recommendations for the European Health Data Space Coordinated by PIONEER the five Big Data 4 Better Outcomes (BD4BO) projects of the Innovative Medicines Initiative have joined forces to develop a number of joint recommendations to inform EU decision makers in order to respond to the public consultation on the European Health Data Space (EHDS). Read the full set of BD4BO recommendations on the EHDS website.

ERN eUROGEN: Update from the Network for Rare Urology. . . . . . . . . . . . . . . . . . . . . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . 10-13 ESU section: Impressions of the popular masterclasses. . . 16 ESU-ESUT Virtual Masterclass on Urolithiasis. . . . . . . . . . . . . . . . . . . . . . . . . . 17 UUA congress and the virtual ESU course. . . 17 Refresh and test your EAU Guidelines knowledge. . . . . . . . . . . . . . . . . . . . . . . . . . 18

PIONEER welcomes new consortium partner The Centre for Advanced Systems Understanding (CASUS) at the Helmholtz-Zentrum Dresden-Rossendorf (HZDR) and PIONEER ally in the fight against prostate cancer. CASUS takes over the task of providing a new centralised data and analytics platform for PIONEER. The cloud-based platform will provide data access and machine learning analytics capabilities for both academia and industry researchers.

ESUI: Selecting imaging modality to

Besides providing the PIONEER Big Data Platform cloud infrastructure, CASUS will also set up and support federated data analysis for all members of the consortium. For Dr. Michael Bussmann, Scientific Head of the Görlitz (Germany)-based research centre, this aspect is of paramount importance: “By developing advanced machine learning algorithms, we expect to come up with better predictive models of patient outcomes and disease progression. The focus is on established and new clinical and biological indicators, so-called biomarkers. We will try to find out if and how recording such biomarkers improves predictions throughout a prostate cancer patient’s care pathway”.

ESUT: Ablative therapy for renal masses:

follow up drug response. . . . . . . . . . . . . . . . 22 EAU RF section: MARS: Management of priapism and impact on outcomes. . . . . . . . . . . . . . . . . . . 29 ROGUE-1: Multicentric, prospective T1 BCa registry. . . . . . . . . . . . . . . . . . . . . . . 29

Present and future. . . . . . . . . . . . . . . . . . . . 31 European Urological Scholarship Programme (EUSP). . . . . . . . . . . . . . . . . . . . 32 A new glimpse into urology in the 16th century. . . . . . . . . . . . . . . . . . . . . . . . . 33 ESGURS: Controversies in early post-op imaging after urethroplasty . . . . . . . . . . . . . 35 The latest news from the YAU Office. . . . . . . 37 New YAU working group kidney

For any questions, please contact e.smith@uroweb.org

transplantation. . . . . . . . . . . . . . . . . . . . . . . 37 “Long-term and sustained improvements is the goal”. . . . . . . . . . . . . . . . . . . . . . . . . . 43

The EAU Podcast is coming soon!

ESTU: Recipient selection for kidney transplantation. . . . . . . . . . . . . . . . . . . . . . . 44

Looking for informative podcasts on urology?

The EAU presents its new series of podcasts covering a wide range of topics. From Guidelines updates to practical tips in daily practice, we aim to cover it all!

Listen whenever, wherever

Obituary Prof. Louis Denis. . . . . . . . . . . . . . 45 Book review. . . . . . . . . . . . . . . . . . . . . . . . . 45 EAUN section: Provision of advanced uro-oncological care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 EAUN: Latest developments . . . . . . . . . . . . . 48

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Practical answers to testicular microlithiasis mysteries Condition does not always represent increased risk of malignant neoplasm Dr. Athanasios Zachariou ESUO Board Member Dept. of Urology University of Ioannina Ioannina (GR) zahariou@otenet.gr Testicular microlithiasis (TM) was reported for the first time in autopsy specimens by Oliye in 1928 and

by Blumensaat in 1929. Doherty et al. [1] described the sonographic appearance of TM as “innumerable tiny bright echoes diffusely and uniformly scattered throughout in the substance of testes”. Since then, numerous publications have addressed the unmet need of office and outpatient urologists for an agreed TM surveillance protocol.

What is testicular microlithiasis?

TM is defined as multiple similar small-sized echogenic non-shadowing with > 5 foci per testis.

Clustering of the microliths is an essential aspect because five microliths per field may be more problematic than ten disseminated throughout the testis. The European Society of Urogenital Radiology showed a preference for a more detailed definition, describing TM as five or more microliths per field of view. [2]

“There is evidence that TM is a feature of the testicular dysgenesis syndrome (TDS).”

What is the prevalence of TM? Several studies are dealing with the prevalence of TM in both asymptomatic and symptomatic men. In a US army study, Peterson et al. (3) detected TM in 5.6% of asymptomatic males, while in another study of a similar population, the prevalence was 2.4%. [4] TM varies in asymptomatic males from 0.6 to 9.0%.

In symptomatic males, the prevalence generally is higher, reaching from 8.7 to 18.1%. [5] Clinical scenarios 1. TM as incidental finding at scrotal ultrasound The current recommendations are that incidental TM is not an indication for a regular scrotal ultrasound (US) follow-up in the absence of other risk factors.

Furthermore, TM is not an indication for biopsy or further US screening. Patients should be monitored with a scrotal self-examination every month. In a patient with TM, office urologists should ascertain that there are no risk factors for developing Germ Cell Tumour (GCT).

Table 1: Risk factors in TM requiring follow-up or referral Risk Factor

> 5 TM per field of Diffuse TM view

History of maldescent

Annual ultrasound Annual ultrasound

History of orchidopexy

Annual ultrasound Annual ultrasound

GCT history

Annual ultrasound Annual ultrasound

Genetic diseases

Annual or 6-month Referral ultrasound

Family history of GCT

Discussion for open access

Atrophic testis

Annual ultrasound Annual ultrasound

Discussion for open access

2. Family history of GCT TM is significantly more common among men who have family members with GCT than in the general population. [6] Also according to Corde et al., TM was more prevalent among males in families with GCT than in the general population and was more common among familial GCT cases versus unaffected blood relatives. These findings suggest that TM may appear to cluster in certain families. Furthermore, variants of specific genes essential for testicular GCT are more common in TM patients than in fertile men. [7] 3. Association of TM with testicular cancer In recent years, several studies have described a relationship between TM and the risk of testicular cancer. According to Wang et al., the meta-analysis EAU Section for Urologists in Office (ESUO)

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European Urology Today

results describe a possible harmful outcome of TM for developing testicular cancer. [8] The authors found that compared with non-TM individuals or the general population, TM men may have more than a 12-fold higher incidence of testicular cancer. On the other hand, data published as part of follow-up programmes showed controversial results. Studies describing observation of men presenting TM for up to 14 years reported a 1.6% higher chance of developing testicular cancer. [9,10] When the relationship between TM and the histologic subtypes of GCT is evaluated, there is evidence of a positive association between seminomas and a negative association between embryonal cell carcinomas. [11] Furthermore, there are reports that a higher TM count corresponds to a lower initial cancer stage at diagnosis, suggesting that TM may be associated with less aggressive tumours.

Nearly 20% of males with a history of GCT have TM in their contralateral testes. Those patients have an increased risk ratio of 8.9 for concurrent CIS compared with patients who do not have TM. [12] The preceding studies have produced ambiguous results and did not establish elevated tumour markers in males with incidental TM; hence monitoring serum tumour markers in follow-up is inappropriate.

Radiology 2015;25(2):323-30 3. Peterson AC, Bauman JM, Light DE et al. The prevalence of testicular microlithiasis in an asymptomatic population of men 18 to 35 years old. J Urol 2001;166:2061–2064 4. Serter S, Gümüs¸ B, Unlü M et al. Prevalence of testicular microlithiasis in an asymptomatic population. Scand J Urol Nephrol 2006;40:212–214 5. Deganello A, Svasti-Salee D, Allen P et al. Scrotal calcification in a symptomatic paediatric population: prevalence, location, and appearance in a cohort of 516 patients. Clin Radiol 2012;67:862–867 6. Tan, MH., Eng, C. Testicular microlithiasis: recent advances in understanding and management. Nat Rev Urol 2011;8:153–163 7. Korde LA, Premkumar A, Mueller C, et al. Increased prevalence of testicular microlithiasis in men with familial testicular cancer and their relatives. Br J Cancer 2008;99(10):1748–1753 8. Wang T, Liu LH, Luo JT, et al. A meta-analysis of the relationship between testicular microlithiasis and incidence of testicular cancer. Urol J. 2015;12:2057–2064 9. DeCastro BJ, Peterson AC, Costabile RA. A 5-Year Followup Study of Asymptomatic Men With Testicular Microlithiasis. J Urol. 2008;179:1420–1423 10. Patel K V, Navaratne S, Bartlett E, et al. Testicular Microlithiasis: Is Sonographic Surveillance Necessary?

Single Centre 14 Year Experience in 442 Patients with Testicular Microlithiasis. Ultraschall der Medizin.

2016;37:68–73

11. Sharmeen F, Rosenthal MH, Wood MJ, Tirumani SH, Sweeney C, Howard SA. Relationship between the pathologic subtype/initial stage and microliths in testicular germ cell tumors. J Ultrasound Med. 2015;34:1977–1982 12. Tan IB, Ang KK, Ching BC, et al. Testicular microlithiasis predicts concurrent testicular germ cell tumors and intratubular germ cell neoplasia of unclassified type in adults:A meta-analysis and systematic review. Cancer 2010;116:4520-32 13. Thomas K, Wood SJ, Thompson AJM, Pilling D, Lewis-Jones DI. The incidence and significance of testicular microlithiasis in a subfertile population. Br J Radiol. 2000;73:494–497.

14. Rassam Y, Grommol J, Kliesch S et al. Testicular microlithiasis is associated with impaired spermatogenesis in patients with unexplained infertility.

Urologia Internationalis 2020;104:610-6.

15. Xu C, Liu M, Zhang FF, et al. The association between testicular microlithiasis and semen parameters in Chinese adult men with fertility intention: Experience of 226 cases. Urology 2014;84:815–820 16. Leblanc L, Lagrange F, Lecoanet P et al. Testicular microlithiasisand testicular tumor: a review in the literature. Basic and Clinical Andrology, 2018;28:8 17. De Gouveia Brazao CA, Pierik FH, Oosterhuis JW, et al.

Bilateral testicular microlithiasis predicts the presence of the precursor of testicular germ cell tumors in subfertile men. J Urol. 2004;171:158–160

4. Association of TM with infertility In infertility, the TM prevalence varied between 0.9 to 20.1%, although the association of TM with male infertility is still under discussion. [13] There is evidence that TM is a feature of the testicular dysgenesis syndrome (TDS). TDS is assumed to reinforce disorders of male reproduction such as subfertility, testicular atrophy or cryptorchidism. [14] TM-related obstruction of seminiferous tubules is a potential etiological factor for reducing sperm count and sperm motility in 30 to 60% of TM patients. The obstruction of seminiferous tubules, possibly formed by sloughing degenerative tubular epithelium, may create secondary inflammation, increased intraseminiferous pressure and alterations in the blood supply of testicles. Inflammation and calcification in the seminiferous tubules produce deterioration in sperm quality and cause subfertility. [15] Fertility potential may be further decreased by atrophy of uninvolved tubules with spermatogenic arrest or a combination of previously reported factors. It was advocated that microliths and infertility may have a mutual undisclosed etiological factor.

Subfertility is reported to be a risk factor for a testicular tumour. Data analysis revealed that GCT prevalence was 22.6% in infertile members of the TM group versus 1.7% in the infertile TM-free group. [16] Bilateral testicular microlithiasis is indicative of CIS (carcinoma in situ) in subfertile men. Therefore, the prevalence of CIS in subfertile men with bilateral testicular microlithiasis is significantly higher than in patients without testicular microlithiasis (0.5%) and with unilateral testicular microlithiasis (0%). [17] Thus, men with CIS are at particular risk of developing invasive GCT.

Fig. 1a and b: TM in the right testis of an infertile 37-year-old adult with a history of left orchidopexy

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“Men with risk factors and TM should be counselled about the potential increased risk of GCT, perform periodic self-examination and be followed by a medical professional.”

Conclusions Men with incidentally detected microlithiasis should not undergo further evaluation or screening. TM in the absence of solid mass and risk factors for developing a GCT does not represent an increased risk of malignant neoplasm and does not require further evaluation. Men with risk factors and TM should be counselled about the potential increased risk of GCT, perform periodic self-examination and be followed by a medical professional.

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References 1. Doherty FJ, Mullins TL, Sant GR, et al. Testicular microlithiasis: a unique sonographic appearance. J Ultrasound Med 1987; 6:389–392 2. Richenberg J, Belfield J, Ramchandani P et al. Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee. European

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August/September 2021

Profiles

A year after: An interview with Prof. N’Dow Updates from the EAU Adjunct Secretary General – Education As of EAU21, Prof. James N'Dow (GB) is succeeding Prof. Van Poppel (BE) as Adjunct Secretary General - Education. In this exclusive interview, the former Chair of the EAU Guidelines Office Prof. N’Dow talked about his current role and his vision, updates on his PIONEER programme, and the people who inspired him.

With the EAU’s support in partnership with its Research Foundation, the Guidelines Office put together a strong consortium to secure €12M-funding from the European Commission’s Innovative Medicines Initiative to collate the best and largest PCa datasets from within and beyond Europe. We feel fortunate to have had the privilege of working with patients, PCa specialists, scientists, epidemiologists, big-data analytics experts, ethicists, and Health Technology Assessment (HTA) experts.

What does your position entail and what are your aspirations in this role?

It is an incredible honour to be entrusted with the EAU Adjunct Secretary General – Education position. The core mission of the EAU is to improve the quality of urological care. To provide our 19,000 EAU members with exceptional resources that help them in their daily clinical practice, education is a fundamental aspect in achieving this goal.

In June 2021, we received confirmation of a €21.3M-funding from the European Commission’s Innovative Medicines for another Big Data project called OPTIMA, this time focussing on prostate, breast and lung cancers whereby Clinical Practice Guidelines are interfaced with Electronic Health Records and real-world data powered by Artificial Intelligence, if necessary. The OPTIMA consortium is also coordinated by the EAU.

My team and I aim to truly understand the individual and collective endeavours of the many talented people involved in education within and beyond the EAU. Together, we will evaluate and see how our aspirations align with the expectations of the EAU members and the patients we all serve.

My role involves ensuring connectivity and collaborations across the EAU and its different Offices in terms of activities relating to education to harness diverse, complementary expertise across within and beyond the organisation; to limit unnecessary duplication of effort; and most importantly, to ensure that we are able to demonstrate the impact of educational activities on patient outcomes and healthcare efficiency over time.

Achieving these objectives will help fulfil the hopes of patients and meet their needs, as well as, help realise the aspirations of urologists wherever they may be in the world.

Your other notable initiative is Horizons, which was created to increase the capacity and standard of healthcare through provision of education and training in your home country. What are Horizons’ latest developments?

You initiated the PIONEER programme, which is a project aimed to harness the potential of big data analytics as a means to ensure optimal care for European prostate cancer patients. Please tell us more about it.

A key ambition of the Guidelines Office has always been to use the best evidence available to underpin guideline recommendations. It soon became clear that the quality of the majority of published evidence is unsatisfactory as the basis for recommendations.

We needed to look for innovative ways to fill the gap.

The use of big data was one such option. However, to do so would require significant funding.

surgeon, John Steyn, who encouraged me to always do better.

Even though I was the most junior doctor in the department at that time, John Steyn didn’t treat me differently. Along with other senior hospital specialists, he welcomed me to his home.

I admired John. He had amazing qualities as a surgeon and as a human being. He was an inspiration that cultivated my interest in the field of urology.

Who are your biggest inspirations and why?

Aside from John Steyn, I was blessed with the guidance of other exemplary mentors, two of them no longer with us sadly. Prof. Adrian Grant, who was co-Chair of the Cochrane Collaboration, trained me in a breadth of research methods which helped secure numerous research grants. Prof. Robert Pickard, an academic urologist who trained me in Newcastle. He was an outstanding academic surgeon and a kind-hearted person.

And last but definitely not least, my parents.

My father was an inspirational physician and philanthropist who taught me all I know about medicine as a vocation. He taught me that curing Horizons now supports six childbirth facilities in disease was not enough; that we must commit to The Gambia and has trained hundreds of mothers and supporting our patients and their families to regain midwives on maintaining clean, safe and infectiontheir quality of life. free childbirth environments. The Horizons Charitable Trust installed solar-power facilities, renovated My mother, whom I loved dearly and think of every rundown infrastructure, guaranteed clean safe water day, was a brilliant educator. She was an supplies and safe disposal of clinical waste. empowered, strong woman who taught my siblings and I that with hard work, determination, When did you know that you wanted to be a integrity and humility, we could reach and touch urologist? the stars. She always told us that the only limits I always wanted to be a doctor but I didn’t know were the limits of our imagination. which speciality. My first surgical job was an attachment with the urology ward in Aberdeen.

Converse with and follow Prof. N’Dow on Twitter I was incredibly fortunate to work for an exceptional via his handle @NDowJames.

Profiles

Prof. Sønksen succeeds Prof. Wirth as EAU treasurer “I have learned a lot from him, and I’ll do my best to bring that experience with me” Prof. Jens Sønksen (DK) has a long history at the EAU. A member since 1996, he was part of the Scientific Congress Office from 2012 to 2017 and has served as Adjunct Secretary General - Clinical Practice since 2017. When the executive board, in the absence of Prof. Sønksen, discussed whom to suggest for the upcoming vacancy for treasurer, they decided to recommend a reliable force.

Bring in Prof. Sønksen. “I was very honoured and proud, and I felt deep respect,” the newly appointed treasurer shared. “I hope to do it as well as my predecessor Prof. Manfred Wirth (DE) did.

I will do whatever I can to be a treasurer that the EAU members are pleased with.”

Having been the president of the Danish Association of Urology and the chairman of the EU-financed collaboration between Denmark and Sweden named ReproUnion, which aims to manage and prevent fertility problems, Prof. Sønksen has gained relevant experience which prepared him for his new role. “Although I have never held the title of treasurer before, I have a lot of experience, both nationally and internationally. And as professor of urology at the University of Copenhagen, I also have to manage finances,” he stated.

“In my view, being a treasurer of an organisation such as the EAU is slightly different from, let’s say, a private company. The EAU is an organisation where a considerable part of the funds comes from paying members living all around the world. You should have a deep respect for that, and consequently employ a much more cautious investment strategy.”

What can you say about the position of the EAU at present?

Prof. Sønksen: “We are still in a strong position despite the challenges we are facing due to the

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COVID-19 pandemic. Once again, things changed almost overnight just like they did back in 2008. The EAU proved that it was able to handle the financial crisis back then and I believe we shall be able to handle the current challenges, too.”

“However, COVID is changing the world, so including the medical world and not least its financial aspects. Before COVID, we already noticed a trend of decreasing sponsorships for the national societies and also for the EAU itself. It has not become easier to obtain sponsorships and other types of funding during the pandemic. And yet we are still in good financial shape. In respect of that, I have to mention Prof. Wirth, who has held this position for seventeen years. His time as a treasurer has been hugely successful. Sitting with him in the executive board for five years now, I have learned a lot from him, and I’ll do my best to bring that experience with me.”

“The EAU is an organisation where a considerable part of our funds comes from paying members living all around the world. You should have a deep respect for that.”

“I see a lot of opportunities for the EAU to expand.

One of them is to strengthen our political profile in a European context and I feel we have taken a great step towards that with the establishment of the EAU Policy Office. Another development concerns patient-directed information. We want to extend our guidelines with evidence-based materials suitable for patients. EAU Patient Information is going to be a huge factor within the EAU and an EAU Patient Office has already been established.”

Roots The roots of Prof. Sønksen’s involvement in the EAU go back to the urologist’s eagerness to educate himself and others. “I first learned about the EAU because of educational development,” he recalled. I took some courses and was involved in symposia.

After I had become an associate professor at the University of Copenhagen in 2003, I created a platform in my department for the development of more clinical science. I had many young colleagues who were very active in the EAU. They suggested that I should apply for a position at the scientific office. That’s how this was set in motion.”

Prof. Sønksen’s roots as urologist are in his home country Denmark, where he learned the importance of international collaboration. “Countries such as Denmark, Sweden, the Netherlands, and Belgium

are relatively small countries in comparison with Germany, France, and Italy. You see that those smaller countries work together in terms of patient mobility. Take the Øresund Bridge between Denmark and Sweden, which brought Southern Sweden and the greater Copenhagen area much closer in terms of traveling time. We should utilise the expertise of, for example, a Swedish hospital highly specialised in a certain area as opposed to specialising in that same area at a Danish hospital nearby. And vice versa.”

These Danish influences contribute to who Prof.

Sønksen is as an executive board member of the EAU. “I want to help build up international collaborations. When we facilitate collaboration between different countries, we will gain much more knowledge, knowledge which will be useful for patients in all countries under the umbrella of the EAU.”

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Green light for the EAU Policy Office Prof. Hein Van Poppel appointed first chair to guide EAU’s policy activities in the EU Mrs. Sarah Collen EAU Policy Coordinator Brussels (BE)

s.collen@uroweb.org

Prof. Hein Van Poppel, first Chairman of the EAU Policy Office

During the General Assembly 2021 the EAU members formally approved, with 94% of the General Assembly's votes, the establishment of a new EAU Policy Office to make sure that the interests of European urologists and urological patients are taken into account on a European level. Prof. Hein Van Poppel is assigned as the Office’s first Chair.

Prof. Van Poppel will take the helm as the first Chairman of this new Office as he is ideally located near the headquarters of the European Union (EU) institutions in Brussels, and has significant experience of working with EU decision makers. In 2007, the EAU Executive Committee asked him to take the lead on their behalf on representing EAU interests to the EU.

Why the need for an EAU Policy Office?

Over the past years, the EAU has been increasing its influence over European Union (EU) policies that are of relevance to urological health care. At this moment the policy activities are at a critical time with the EAU being a major stakeholder in a number of matters that will have a lasting impact on the profession and the patients we care for. So the inauguration of the Policy Office comes at a perfect time to contribute to these issues to the best interest of our professions, but mostly our patients.

Initially the focus was on Prostate Cancer, including a strong campaign which has recently led to for the likely uptake in Europe’s Beating Cancer Plan.

The work of the Policy Office will, however, not only be focused on uro-oncological issues, and in fact one of the first tasks will be to appoint a Vice-Chair from outside of oncology. These chairs will be supported by the EU Policy Manager, Sarah Collen, who implements the strategy of the Policy Office and makes sure we target the right policies and networks at the right time to have an impact on policies.

What are the priorities?

For the first two years, the objectives and deliverables are outlined in the strategic document, which includes 6 priorities: 1. Inclusion of Early Detection of Prostate Cancer in Europe’s Beating Cancer Plan.

2. Facilitating EAU led research through EU funds.

3. Contributing to and taking advantage of digitalisation of health care and data driven research and technologies.

4. Promoting a supportive policy and funding environment for developing quality care for rare and complex urological conditions; 5. Facilitating a conducive regulatory environment for the regulation of medicines and medical devices; 6. Promoting patients’ advocacy for urological conditions.

This plan therefore ties in activities and programmes from across the EAU and helps to build on the excellent scientific knowledge from across the organisation. Our next phase will be to ensure that each theme has an active network of working group members to ensure we are getting insights from across the EAU membership.

Who do we work with?

Patient outcomes are at the heart of our lobbying effort in Brussels and we will work with the Patient

Office and its EAU Patient Advocacy Group (EPAG) to ensure initiatives that work together effectively.

It is really important too to work in partnership with our National Societies to ensure that the policies that are made in Brussels make sense to different nations and are useful and implementable.

“Our next phase will be to ensure that each theme has an active network of working group members to ensure we are getting insights from across the EAU membership.”

We will also work in partnership with other networks of researchers, health care professionals, patients, industry representatives and regulators to raise shared concerns, but our voice is independent.

The EAU is a member of the European Cancer Organisation (ECO), the Biomed Alliance and the European Alliance on Personalised Medicine (EAPM), among others.

Although our focus is the EU, we also work beyond its border and have strategic links with the WHO and in particular the WHO Europe Region Office to ensure our knowledge and expertise are relevant beyond the 27 EU member states.

ERN eUROGEN: Update from the Network for Rare Urology “The Future Looks Bright” Ms. Jen Tidman ERN eUROGEN Business Support Manager Nijmegen (NL)

Jen.Tidman@ radboudumc.nl The European Reference Networks (ERNs) are the largest healthcare innovation in Europe involving 30 million patients with a rare disease or complex condition.

ERN eUROGEN (www.eurogen-ern.eu) is the ERN for uro-recto-genital rare diseases and complex conditions and is one of 24 ERNs approved and funded by the European Commission (EC).

ERN eUROGEN aims to improve diagnosis, create more equitable access to high-quality treatment and care for patients with these rare diseases and conditions, and covers the whole spectrum from congenital anomalies to transitional and lifelong care, complex functional urology, and rare urogenital tumours.

Strategic Board Meeting We held our annual Strategic Board meeting virtually on 4 June 2021. The full report is available on our website with links to the presentations, which covered the status of ERN eUROGEN, network management and enlargement, registry development, training and education, the Clinical Patient Management System, and guidelines development.

The annual Strategic Board Meeting of ERN eUROGEN took place virtually on 4 June 2021

They also confirmed 100% EC funding for the next ERN grants, removing the co-financing principle; a major bonus for the ERN coordination teams and the coordinating healthcare providers.

The EC have recently sent the ERNs a vision paper for a new version of CPMS with a simpler, more intuitive, and customisable desktop interface. ERN eUROGEN has provided feedback to further facilitate its development.

Guidelines & Clinical Decision Support Tools The ERN Guidelines initiative has begun, training is Education & training underway, and in September we will hold the first The ERN Exchange Programme facilitating short term meeting of the ERN eUROGEN Guidelines Expert Panel. visits is now running. Exchanges will allow trainees and We are liaising closely with the EAU Guidelines Office, fellows to gain expertise or carry out research as well particularly on new guidelines relating to paediatric Representatives from our Healthcare Providers (HCP), as visits from MDT members, ePAG representatives, or urology and penile cancer and the ways existing Affiliated Partners (Associated National Centre and The EC has released the final version of the procedure experts to carry out surgery following requests from guidelines can be endorsed by the ERN. National Coordination Hub), ERN Patient Advocacy for disease expansion within the ERNs. ERN eUROGEN treating clinicians. The applications from the first call Group (ePAG) and Supporting Partners were invited to hopes to include paediatric kidney transplant surgery, are in progress and another call will be launched later ERN eUROGEN is leading on a new ‘Global Penile attend. The EAU was represented by Prof. Hendrik Van male infertility, and paediatric oncological urology as this year.

Cancer Collaboration’ between experts from our Poppel (BE), EAU Adjunct Secretary General, and Sarah new disease areas. network, the EAU, the Confederación Americana de Collen (BE), EAU EU Policy Manager.

We are on summer break from our educational webinar Urología (CAU), and the Global Society of Rare Registry Development programme, but all past webinars are available to Genitourinary Tumours (GSRGT). This group will The ERN registries will be forming a crucial part of the watch via links on our website, where you can also continue to collaborate relating to guidelines and In summary, as the ERNs move toward their five-year registries. anniversary in 2022, Prof. Wout Feitz (NL), ERN eUROGEN EC’s EU4Health programme as they will be linked to the keep an eye out for our upcoming programme.

Network Coordinator stated: “We have achieved progress European Health Data Space. in all areas and the future looks bright!”

Clinical Patient Management System The aim of the ERN eUROGEN Registry is to set up a ERN eUROGEN delivers virtual highly specialised advice large patient registry collecting individual data from to European healthcare professionals using an EC Funding In July, the EC outlined their commitment to the ERNs patients suffering from rare urogenital diseases or innovative IT platform, the Clinical Patient Management through EU4Health 2021-2027, with €5.3 billion complex conditions, to gather data on disease System (CPMS), provided by the EC. As a guest user, you available to improve health in the EU and ensure a demographics, study disease outcome and treatment can refer a case to us and our expert MDTs are able to high level of health protection in all EU policies and efficacy into adulthood, and develop new guidelines for diagnose, suggest treatment or surgery, and provide activities.

EU standard care. advice for post-operative and transitional support.

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Expansion of the Network We will hold another strategic board meeting in early 2022 once new healthcare provider (HCP) members from the 2019 call join ERN eUROGEN: a potential expansion of 30 members, leading to a total of 58 HCPs from 20 Member States.

Following surveys and after discussion with the ERN eUROGEN Registry Advisory Board (including Dr. Wim Witjes (NL) from the EAU Research Foundation), we are already starting work on the final registry. We are working hard to get everything ready for our HCPs to begin work and input data.

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

Oliver.Hakenberg@ med.uni-rostock.de

The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem.

Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org

Case study No. 69 A 35-year-old man suffered a straddle injury to the urethra without pelvic fracture. A few weeks later, he complained of dysuria and a urethrogram showed a stricture which was treated by direct vision internal urethrotomy (DVIU). Already three weeks later, a recurrence occurred. During the following two years, the patient underwent eight endoscopic procedures, either dilatation or DVIU. Eventually, a urethroplasty was performed. One year later, the patient is still complaining of dysuria

and was referred to our centre without any detailed reports of the previous procedures.

A new urethrogram was done (Fig. 1).

Case study No. 70 This 61-year-old woman was referred with an incrustated ureteral stent on the left side for further management (fig.1). The stent had been in situ for almost four years and had been inserted because of symptomatic lower calyx stones.

The patient suffers from severe cardiac insufficiency (NYHA 3-4) due to coronary artery disease, rheumatoid arthritis with prednisolone medication and COPD (Gold 4) requiring permanent oxygen treatment. For those reasons the symptoms of left stone disease were at the time treated just by stent insertion.

Somehow, the stent was “forgotten”. A urologist now tried to take the stent out but was unsuccessful.

Therefore the patient was referred to us.

Case provided by Dr. Amin Bouker, Clinique Taoufik, Tunis, Tunesia.

E-mail: aminbouker@gmail.com

Figure 1

Discussion point • Which treatment is advisable?

Traumatic strictures need open urethroplasty up-front Comments by Dr. Marco Bandini Pune, Maharastra (IN)

Dr. Pankaj Joshi Pune, Maharastra (IN)

Dr. Sanjay Kulkarni Pune, Maharastra (IN)

The initial etiology of the stricture was traumatic.

Thus, it must be criticized that DVIU was done as the first management and it is quite wrong that

this treatment was repeated thereafter. Indeed, DVIU is useless in strictures due to trauma where a complete spongiofibrosis is present and the success of DVIU is unlikely. We do not offer DVIU in patients with post-traumatic stricture as initial treatment!

According to the urethrogram provided, the patient presents multiple bulbar and peno-bulbar urethral strictures with the most significant in the proximal bulbar urethra with a nearly obliterated segment of approximately 3-4 cm. Based on our experience, we believe that the urethra may end up in such a condition precisely because of multiple DVIU/ dilatations and previously failed urethroplasty.

Although the details are not given, we believe that an anastomotic urethroplasty was attempted, but unfortunately it failed leaving a long ischemic tract of distal bulbar urethra.

Thus, based on the fragmented history, the previous failed urethroplasty and the present situation shown on the urethrogram, we believe that a graft-plusflap urethroplasty may represent a good solution for this case.

Accordingly, we start with intra-operative endoscopy with a small caliber endoscope to assess the entire urethra. We prefer a complete perineal approach with penile invagination and unilateral dissection of the urethra with dorsal urethrotomy. An oral mucosa graft would be fixed to the corpora to create the dorsal wall of the neourethra. Then, a preputial or distal penile skin flap would be harvested and transposed to the perineum with its vascular pedicle. The flap will create the ventral wall of the neourethra from the proximal bulbar end up to the distal end of the stricture. The residual corpus spongiosum will be sutured back to the cavernosa covering the flap to prevent sacculation.

Clearly, such difficult cases should be referred to high-volume centres.

I would like to stress the following points for cases such as this one: 1. Avoid DVIU in traumatic stricture, go directly for anastomotic urethroplasty.

Fig. 1

Discussion point • Which management and treatment is advisable?

Case provided by Oliver Hakenberg, Rostock, Germany. email: oliver.hakenberg@med.uni-rostock.de

2. Use a small caliber endoscope (ureteroscope) to assess the entire urethra.

3. Perineal incision, penile invagination and dorsal approach is best suited.

4. Aim for a single stage reconstruction.

5. Obliterative stricture segment may need the addition of a ventral flap.

Double graft technique or graft + flap augmentation required Comments by Prof. Jalil Hosseini Tehran (IR)

Ass. Prof. Farzin Soleimanzadeh Tabriz (IR)

Based on the history and looking at the urethrogram, this seems to be a rather complex case. At least four abnormal / questionable points can be detected in this urethrogram: 1) there is a long segment severe mid-bulbar urethral stricture, 2) there is a shorter segment of penile urethral stricture, 3) there is a proximal bulbar urethral filling

Case study No. 69 continued The patient underwent endoscopic assessment which showed that the two distal short strictures allowed easy passage of an 18 Fr. cystoscope and were then dilated to 24 Fr. A guidewire was passed through the proximal stricture (fig. 1) and a perineal incision was made. Palpation showed a thick bulbar urethra which allowed for a ventral approach. Surprisingly, there was a scrotal tube anastomosed to the native urethra just below the sphincter together with a dorsal

August/September 2021

defect (maybe the remnant of a urethroplasty), and 4) there is a notch in the penobulbar junction (which can be clinically important if the view angle changes slightly).

The first and the second strictures appear straight forward but the third and fourth ones need further evaluation. Number 3 – if significant - looks like a growth rather than a stricture or, indeed, the remnant of a previous urethroplasty. More importantly, we know little about the proximal urethra and a voiding cystourethrogram might be helpful.

If all of the above-mentioned findings are recognizable, this is indeed a penobulbar multi-stricture case. A long augmentation urethroplasty would be necessary, keeping in mind that the main bulbar stricture is quite narrow and may need a double graft (inlay – onlay) technique or graft + flap augmentation. If areas number 3 and 4 prove to be insignificant findings, one may treat this patient by two separate short graft

Important notes • It is a pity that this patient has undergone several endoscopic procedures.

• Endoscopic treatment for this patient was an absolute mistake at least for the last seven times. Even some parts of the strictures may be the result of the repeated procedures.

• Unfortunately, multiple procedures may negatively affect the graft take process as well, depending on the degree of resultant Figure 1 spongiofibrosis.

• If VCUG graphs are inconclusive, we routinely perform an intra-operative flexible cystoprocedures for bulbar and penile strictures, again with urethroscopy, especially in this patient whose an inlay – onlay graft for the proximal one by a perineal proximal stricture may not allow the passage approach. A perineal incision may be appropriate to of even a fine urethroscope without a new treat bulbar stricture and can be extended to the trauma. scrotum for the distal one. Alternatively, a circumcision- • Anastomotic urethroplasty is not an option in like incision and degloving of penile skin can be used. this patient.

However, the patient should be treated in a highvolume centre.

graft (fig.2). Diseased tissue was excised and a skin to skin dorsal anastomosis was done. Then, the dorsal aspect of the urethra was incised (fig.3) and

grafted with buccal mucosa (fig. 4). Then, the urethra was closed with another ventral buccal

mucosa graft (fig.5) and the spongiosum was closed over that. (fig6).

Figure 1

Figure 3

Figure 5

Figure 2

Figure 4

Figure 6

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European Urology Today

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Profiles

“The ESU train is on the right track” Incoming Education Office Chairman hails strength and reputation of School Prof. Evangelos Liatsikos (Patras, GR) has succeeded Prof. Joan Palou (Barcelona, ES) as Chairman of the EAU’s Education Office following EAU21. We asked him about his previous experience and his plans for the European School of Urology in the coming years.

Evangelos Liatsikos is currently Professor and Chairman of the Department of Urology at the University Hospital of Patras in Greece. He serves as visiting professor in Leipzig and until recently in Vienna. He is specialised in endourologic, laparoscopic and robotic urological surgery, including single-port surgery.

Liatsikos has previously served as Chairman of the EAU Section of Uro-Technology (ESUT) since 2016 and has also served as a board member of the European School of Urology (ESU) for eight years.

great ambassador for the EAU. We hold courses all around Europe and beyond, we’ve standardised a lot of the training, and our standardisation procedures have been adopted by many international societies.

Working for the ESU is rewarding because you see you have such a big audience, and the potential to reach so many people.”

The chairman’s shoes Prof. Palou stepped down after nine successful years, leaving big shoes to fill. As to what the ESU Chairman’s primary tasks are, Prof. Liatsikos puts emphasis on assembling a good team around him. “The chairman’s job is to choose a good board! This is not one person’s job. You need to select people who have vision, are motivated and prepared to work hard.”

Around half of the ESU board members are currently at the end of their term and Prof. Liatsikos has been looking for new members to join the ESU after the A powerful tool congress. “We take a lot of things into account when “I finished my eight-year term at our last board selecting board members. We’ve found people from meeting,” Liatsikos says. “They were nice years. My all around Europe with different backgrounds. It is responsibilities centred mainly on laparoscopic and important to find people who not only seek the endourological training. I assisted and advised the glory of being board members but who are also board in that regard, helping devise new surgical prepared to do the work.” Prof. Liatsikos feels that training programmes. My experience as ESUT his work as ESUT chairman, in addition to his Chairman for the past four years has also helped in day-to-day duties has prepared him for finding a this regard, though I only represented the ESUT balance between his responsibilities in this new informally on the ESU Board.” position.

Having observed the inner workings of the European School of Urology over the past eight years, Liatsikos has a deep respect for its status and the achievements of his predecessor. “The School is a powerful tool for the EAU. Urological education really makes a difference.”

“The school is well-structured and Joan Palou did an excellent job during his tenure. He has really improved the school, it’s now world-famous and a

“Also, as chairman you need to be able to work in harmony with the people behind the scenes: the people at the EAU Central Office who work for the School but also specifically for online platforms and training programmes. The same goes for urologists who work for the EAU in the Guidelines Office, the Sections, the Young Academic Urologists and all other Offices. You need to coordinate everyone’s efforts, listen to everyone’s input and decide how to proceed.

It’s not an easy job: you have to foresee what is

Prof. Liatsikos in his previous guise as ESUT Chairman, leading discussion at ESUT18 in Modena, Italy

interesting and what new developments in education are worth pursuing.”

Goals Prof. Liatsikos feels that the school is “on the right track”, going in generally the right direction.

“Clearly, we will be seeing some minor corrections to make the track a bit more straight, but it’s already a great effort to keep the train going. With new board members come new collaborations and a new dynamic within the School. Together we will look at expanding our activities, especially beyond Europe.”

Personally and, as former ESUT Chairman, understandably, the new Chairman would like to see the ESU embrace technology in its methods. “During the pandemic we adapted to new online training

activities that were really appreciated by our audience. After the end of this unpleasant worldwide experience our online platforms will play a key role in the educational process. After all, we are educating young urologists, those who are always engaged with their phones and tablets.”

“Finally, as incoming chair I would like to encourage the readers of European Urology Today that they need to familiarise themselves with the ESU’s activities, and ideally participate in them. We have so many great things to offer young urologists and they need to get to know our portfolio.”

All of the EAU’s educational activities, including workshops, online education, exchange programmes and scholarships can be found on: www.uroweb.org/education

Profiles

EAU welcomes new Chair of the Guidelines Office An exclusive interview with Prof. Ribal Prof. Maria Jose Ribal Caparros (ES) is the • Facilitate dialogue among the members of the newly-appointed Chair of the EAU Guidelines EAU GO Office. In this exclusive interview, she expounds on • Assist the group that the Guidelines represent to what her new role entails, her aims and maintain and improve their production as the aspirations, and the pivotal moment she knew she EAU Guidelines are now considered among the wanted to be a urologist. best (if not the best) in the field and endorsed by 75 countries.

Congratulations on your new appointment!

Thank you. It is an immense honour to lead the What are your aims and aspirations for the EAU EAU Guidelines Office (GO). The previous Guidelines Office? leadership under Prof. James N’Dow was a very My first objective will be to consolidate and improve fruitful period; the way our EAU Guidelines are the current structure in the elaboration of the conceived underwent a profound transformation.

Guidelines by developing areas such as prevention in His example will be my motivation. Preserving the urological diseases, treatment of complications, the excellence achieved in recent years is an important inclusion of patient-reported outcomes, and directives challenge and a great responsibility. for the follow-up of patients.

Could tell us about your tasks and responsibilities in this role?

My main responsibilities include leading the GO and ensuring that everything is facilitated to the EAU Panels. These tasks require reaching a consensus on the basis for producing the Guidelines, managing logistical tasks, and promoting the EAU GO and EAU activities.

My role also involves working together with EAU Offices on a regular basis and participating in the EAU organisation since as Guidelines Chair, I am also an EAU Board member. I will also liaise with different societies and organisations involved in the Guidelines production to promote collaborations and joint-venture projects which will: • Ensure transparency in both production and composition of our Guidelines • Aid in the integration of the patients’ voice to our Guidelines • Develop research projects to produce recommendations based on real-world evidence

August/September 2021

and devoting time to research have been very satisfying. I always liked the process of learning.

Cultivating facets beyond your own speciality opens your mind.

How was it like for you as a recipient of the coveted Crystal Matula Award?

For me, the Matula was the award. Not only did I take it as a recognition but also, a welcomed challenge. It has brought me great joy and it has opened many doors. I have it in my office. The award has always been a source of motivation.

When did you know that you wanted to be a urologist?

Without a doubt, I always wanted to become a surgeon ever since I was 3 years old! I don’t know why this was so apparent to me because there aren’t any doctors nor surgeons in my family.

The second objective is to ensure that patients in Europe receive standardised treatment in order to improve the quality of and the homogenization of care.

“Looking ahead, we must focus our attention on having our Guidelines as a reference for establishing health policies in urology as well.”

As medicine progresses towards a more patientcentred model, it is crucial to maintain the existing initiative and to take the patients’ perspective into account with regard to our Guidelines recommendations. Additionally, we are undergoing a great evolution in data management and the integration of massive data analysis. Therefore, our Guidelines must be pioneers in the incorporation of real-world data and evidence into the structure, methodology, and production of the recommendations.

Looking ahead, we must focus our attention on having our Guidelines as a reference for establishing health policies in urology as well.

You have many urological interests. What fascinates you about these fields?

I feel passionate about my work. I’ve been dedicated to uro-oncology for more than 20 years now, and I couldn’t have chosen a better subspecialty. Major oncology surgery is exciting. I’ve been fortunate to know open surgery, as well as, laparoscopy and robotics which have revolutionized the world of cancer surgery.

I like the operating room a lot and being with patients; talking to them and participating in their stories. In addition, developing an academic career

In medical school, I was already impressed with urology because of its comprehensive reach. A urologist diagnoses, operates, and follows up.

There are research opportunities, too. I am proud of this field and of myself for making the right choice. I’m convinced that urology is the best speciality in the world.

Who or what inspires you, and why?

Inspiration is a complex thing. I admire many, who during my career, have supported me and helped me. I have so many names in mind and I wouldn’t dare to leave any of them forgotten. They know how grateful I am to them because no road is truly travelled alone.

I am inspired by honesty, courage, commitment, enthusiasm, and loyalty. I am inspired by the values that have been instilled in me by my family, as well as, by the love, strength and support of all those who believe in me.

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Key articles from international medical journals Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

Source: Biomarkers and clinical scores to aid the identification of disease severity and intensive care requirement following activation of an in-hospital sepsis code.

Jaume Baldirà, Juan Carlos Ruiz‑Rodriguez, Darius Cameron Wilson, Adolf Ruiz‑Sanmartin, Alejandro Cortes, Luis Chiscano, Roser Ferrer‑Costa, Inma Comas, Nieves Larrosa, Anna Fàbrega, Juan José Gonzalez‑Lopez and Ricard Ferrer.

extreme caution should be used when considering treatment shifts based upon unvalidated surrogate endpoints.

Assoc. Prof.

Francesco Sanguedolce Section editor Barcelona (ES)

Source: Intermediate clinical endpoints for surrogacy in localised prostate cancer: an aggregate meta-analysis. Gharzai LA, Jjang R, Wallington D et al.

Lancet Oncol 2021; 22: 402-10.

fsangue@ hotmail.com

Ann Intensive Care 2020; 10:7. https://doi. org/10.1186/s13613-020-0625-5

Evaluation of biomarkers and clinical scores to aid the identification of disease severity and intensive care requirement for suspected sepsis Early diagnosis and treatment are mandatory for a successful outcome in sepsis. Few validated biomarkers or clinical score combinations exist which can discriminate between cases of infection and other non-infectious conditions following activation of an in-hospital sepsis code, as well as provide an accurate severity assessment of the corresponding host response. This study aimed to identify suitable blood biomarkers (MR-proADM (mid-regional proadrenomedullin), PCT (prolactin), CRP and lactate) or clinical score (SOFA and APACHE II) combinations to address this unmet clinical need.

A prospective, observational study of patients activating the Vall d’Hebron University Hospital sepsis code (ISC) within the emergency department (ED), hospital wards and intensive care unit (ICU). Area under the receiver operating characteristic (AUROC) curves, logistic and Cox regression analysis were used to assess performance.

One hundred and forty-eight patients met the Vall d’Hebron ISC criteria, of which 130 (87.8%) were retrospectively found to have a confirmed diagnosis of infection. Both PCT and MR-proADM had a moderate-to-high performance in discriminating between infected and non-infected patients following ISC activation, although the optimal PCT cut-off varied significantly across departments.

Similarly, MR-proADM and SOFA performed well in predicting 28 and 90-day mortality within the total infected patient population, as well as within patients presenting with a community-acquired infection or following a medical emergency or prior surgical procedure. Importantly, MR-proADM also showed a high association with the requirement for ICU admission after ED presentation [OR (95% CI) 8.18 (1.75–28.33)] or during treatment on the ward [OR (95% CI) 3.64 (1.43–9.29)], although the predictive performance of all biomarkers and clinical scores diminished between both settings.

Investigators conclude that the individual use of PCT and MRproADM might help to accurately identify patients with infection and assess the overall severity of the host response…

Investigators conclude that the individual use of PCT and MR-proADM might help to accurately identify patients with infection and assess the overall severity of the host response, respectively.

In addition, the use of MR-proADM could accurately identify patients requiring admission to the ICU, irrespective of whether patients presented to the ED or were undergoing treatment on the ward.

Initial measurement of both biomarkers might therefore facilitate early treatment strategies following activation of an in-hospital sepsis code.

Finding the optimal biomarkers and clinical scores is an important research field also in urosepsis.

Key articles

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New consensus-report on research priorities in sepsis Identification of intermediate clinical endpoints in localised prostate cancer The long natural history of localised prostate cancer poses challenges in clinical trials design to improve overall survival. In order to overcome this the international Intermediate Clinical Endpoints in Cancer of the Prostate (ICECaP) working group established metastasis-free survival as a surrogate endpoint for overall survival for men with localised prostate cancer. However, 90% of the patients enrolled in the trials evaluated were treated with radiotherapy meaning the validity of this endpoint in surgical trials in unknown. This paper used a broader set of inclusion criteria to identify potential intermediate clinical endpoints for individual patient-level validation.

In this meta-analysis eligible trials had to be randomised, therapeutic, reporting overall survival and at least one intermediate clinical endpoint, and with a sample size of at least 70 participants.

Trials of metastatic disease were excluded.

Intermediate clinical endpoints included biochemical failure, local failure, distant metastases, biochemical failure-free survival, progression-free survival, and metastasis-free survival.

… they showed that local failure did not correlate with overall survival in any of the subgroups examined.

Having identified 4,221 studies, 75 randomised trials published between March 1986 and January 2020 were included. (53,631 patients) Median trial level follow-up was 9.1 years (IQR 5.7-10.6), medium age was 68.7 years (66.6-70.5) and median baseline PSA was 12.1 ng/ml (10.0-15.9 ng/ ml). Intermediate clinical endpoints that included biochemical failure had poor correlation of the treatment effect with overall survival. Correlation with local failure was also poor. Correlation of progression-free survival was moderate (R2 0.46 [95% CI 0.22-0.67]) and metastasis-free survival had the strongest correlation (R2 0.78 [95% CI 0.59-0.89]). Interestingly this held true in subgroup analysis irrespective of primary radical treatment. The same result was also seen when including only high-risk trials.

More controversially they showed metastasis-free survival might not be a surrogate endpoint for radiotherapy-specific trials testing dose escalation, nodal irradiation, or hypofractionation. The goal of dose escalation is primarily to reduce local failure, and they showed that local failure did not correlate with overall survival in any of the subgroups examined. This finding could account for why dose-escalation trials to date, even those powered for overall survival, have not improved overall survival.

For men with biochemical recurrence, it remains true that non-prostate cancer deaths are more frequent than dying from the disease. As a consequence, it may be true that intensification of treatment for biochemical recurrence may worsen other cause mortality and as a result obscure any correlation between biochemical recurrence and overall survival. This is especially likely to be true for treatments aimed at local control. As a result,

Urosepsis is a feared situation in urology and its prevention and treatment is of utmost importance.

The objective of this report was to identify priorities for administrative, epidemiological and diagnostic research in sepsis. The report is a follow-up to a previous consensus statement about sepsis research by members of the Surviving Sepsis Campaign Research Committee, representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine. They addressed six questions regarding care delivery, epidemiology, organ dysfunction, screening, identification of septic shock, and information that can predict outcomes in sepsis.

The document provides a framework for priorities in research to address the 6 most important questions…

Six questions from the Scoring/Identification and Administration sections of the original Research Priorities publication were explored in greater detail to better examine the knowledge gaps and rationales for questions that were previously identified.

The document provides a framework for priorities in research to address the following questions: (1) What is the optimal model of delivering sepsis care?

(2) What is the epidemiology of sepsis susceptibility and response to treatment?

(3) What information identifies organ dysfunction?

(4) How can we screen for sepsis in various settings?

(5) How do we identify septic shock?

(6) What in-hospital clinical information is associated with important outcomes in patients with sepsis?

The group concludes that there is substantial knowledge of sepsis epidemiology and ways to identify and treat sepsis patients, but many gaps remain. Areas of uncertainty identified in this manuscript can help prioritise initiatives to improve understanding of individual patients and demographic heterogeneity with sepsis and septic shock, biomarkers and accurate patient identification, organ dysfunction, and ways to improve sepsis care. The present report provides guidance also for research on urosepsis.

Source: The Surviving Sepsis Campaign: research priorities for the administration, epidemiology, scoring and identification of sepsis. Nunnally ME, Ferrer R, Martin GS, Martin-Loeches I, Machado FR, De Backer D, et al.

Intensive care medicine experimental. 2021;9(1):34 https://doi.org/10.1186/s40635-021-00400-z

Can we develop further bespoke treatments for men with mCRPC? Metastatic castration-resistant prostate cancer (mCRPC) is a heterogeneous lethal disease characterised by variable sensitivity to androgenreceptor signalling pathway therapy. All patients ultimately develop treatment-resistant, lifethreatening disease. One mechanism of resistance to androgen deprivation is activation of the PI3K/

AKT pathway Furthermore, the PTEN tumour suppressor is functionally lost in approximately 40–50% of patients with mCRPC. PTEN loss activates AKT signalling, leading to tumour growth and cell proliferation, worse outcomes, and reduced benefit from androgen-receptor pathway blockade.

Ipatasertib is a selective ATP-competitive small-molecule inhibitor of all three isoforms of AKT. It has been evaluated both as a single agent and in combination studies using dual AKT and androgen-receptor pathway blockade with ipatasertib and abiraterone and was shown to be feasible with manageable side-effects. This study assesses whether the combination is more effective than abiraterone alone.

Patients with previously untreated asymptomatic or mildly symptomatic mCRPC were recruited.

Previous chemotherapy for metastatic hormonesensitive prostate cancer was permitted, provided it was initiated no more than 6 months after the time of first castration treatment, and that the patient had not progressed during chemotherapy or within 3 months after completion of chemotherapy. All patients were required to have a valid prostate cancer tumour PTEN immunohistochemistry result, using archival or newly collected tumour samples.

Next-generation sequencing to detect PTEN status or PIK3CA/AKT1/PTEN alteration was also done using the FoundationOne CDx next-generation sequencing assay.

1,611 patients were screened and 1,101 (68%) were enrolled and assigned 1:1 to placebo-abiraterone versus ipatasertib-abiraterone. 521 patients had PTEN loss by immunohistochemistry and were equally split between the groups. In the intention to treat analysis median progression free survival was 16.6 months in the placebo-abiraterone group and 19.2 months in the ipatasertib-abiraterone group (HR 0.84 [95% CI 0.71-0.99] p = 0.043; ns at a = 0.01). In the patients with PTEN loss, median progression-free survival was 16.5 months in the placebo-abiraterone group and 18.5 months in the ipatasertib-abiraterone group (HR 0.77 [95% CI 0.61-0.98] p = 0.034; significant at a = 0.04).

Adverse events leading to discontinuation of treatment occurred in 5% of the placeboabiraterone group and 21% of the ipatasertibabiraterone group, suggesting there is a balance between clinical benefit and quality of life.

… it is the first randomised phase III trial in this setting to report a combination treatment suggesting there may be a benefit for other combinations.

This study is significant in two ways. Firstly, it demonstrates that targeting the AKT pathway may have a role in mCRPC for men with PTEN loss, although further follow-up is required to demonstrate if this results in improved overall survival. It is also not clear what is the best test to determine what is clinically significant PTEN loss.

In addition, it is the first randomised phase III trial in this setting to report a combination treatment suggesting there may be a benefit for other combinations.

Source: Ipatasertib plus abiraterone and prednisolone in metastatic castrationresistant prostate cancer (IPATential150): a multicentre, randomised, double-blind, phase 3 trial. Sweeney C, Bracarda S, Sternberg CN, et al.

Lancet 2021; 398: 131-42.

EAU EU-ACME Office

European Urology Today

August/September 2021

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com

Stringent anemia correction prolongs graft survival Anemia and vitamin D deficiency are common among renal transplant recipients and are associated with allograft failure. Therefore, both are potential therapeutic targets among kidney transplant recipients. In this Japanese multicentre, two-by-two factorial, open-label, randomised clinical trial the aim was to examine the effects of anemia correction and vitamin D supplementation on 2-year change in eGFR among kidney transplant recipients.

153 patients with anemia and > 1-year history of transplantation were recruited among 23 hospitals in Japan, and randomly assigned to either a high or low hemoglobin target (> 12.5 vs. < 10.5 g/dl) and to either cholecalciferol 1,000 IU/ day or control. The trial was terminated early based on the planned interim intention-to-treat analyses (α = 0.034).

2-year decline in eGFR was smaller in the high vs. low hemoglobin group …, but did not differ between the cholecalciferol and control groups.

Among 125 patients who completed the study, 2-year decline in eGFR was smaller in the high vs. low hemoglobin group (-1.6 ± 4.5 vs. -4.0 ± 6.9 ml/min/1.73 m2; p < 0.022), but did not differ between the cholecalciferol and control groups.

These findings were supported by the fully adjusted mixed effects model evaluating the rate of eGFR decline among all 153 participants. There were no significant between-group differences in all-cause death or the renal composite outcome in either arm. The authors conclude that ‘aggressive’ anemia correction shows a potential to preserve allograft kidney function.

Source: Correcting anemia and native vitamin D supplementation in kidney transplant recipients: a multicenter, 2 × 2 factorial, open-label, randomized clinical trial. Obi Y, Ichimaru N, Sakaguchi Y, Iwadoh K, et al. CANDLE-KIT Trial Investigators.

Transpl Int 2021;34(7):1212-1225.

New role for adjuvant chemotherapy after cystectomy?

Although adjuvant cisplatin-based chemotherapy has been shown to prolong disease-free survival in patients with locally advanced upper tract urothelial carcinoma, the role of adjuvant chemotherapy after cystectomy is less clear. In addition, despite a high risk of metastatic recurrence, no standard adjuvant systemic therapies have been shown to improve outcomes in patients with pathological evidence of residual disease after neoadjuvant cisplatin-based chemotherapy. Nivolumab is a monoclonal antibody against programmed death 1 and has been shown to be effective after cisplatin chemotherapy in patients with metastatic urothelial carcinoma. This study evaluates its role compared with placebo, in patients with muscle-invasive urothelial carcinoma after radical surgery (with or without previous neoadjuvant cisplatin-based combination chemotherapy).

CheckMate 274 was a phase 3, multicentre, double-blind, randomised, controlled trial, in patients with muscle-invasive urothelial carcinoma who had undergone radical surgery Key articles

August/September 2021

who received, either 240 mg nivolumab intravenously (353) or placebo (356) every 2 weeks for up to 1 year. (79% cystectomy, 21% upper tract tumours).

Neoadjuvant cisplatin-based chemotherapy before trial entry was allowed and occurred in approximate 43% of patients equally distributed between the groups. The primary endpoints were disease-free survival among all the patients (intention-to-treat population) and among patients with a tumour programmed death ligand 1 (PD-L1) expression level of 1% or more. Survival free from recurrence outside the urothelial tract was a secondary endpoint.

However, in this group adjuvant immunotherapy showed a significant and clinically meaningful benefit regardless of PD-L1 expression.

The median disease-free survival in the intentionto-treat population was 20.8 months (95% CI, 16.5 to 27.6) with nivolumab and 10.8 months (95% CI, 8.3 to 13.9) with placebo. The percentage of patients who were alive and disease-free at 6 months was 74.9% with nivolumab and 60.3% with placebo (hazard ratio for disease recurrence or death, 0.70; 98.22% CI, 0.55 to 0.90; p < 0.001).

There were 282 patients with a PD-L1 expression level of 1% or more, 140 in the nivolumab group and 142 in the placebo group.

Among these the percentage alive at 6 months was 74.5% and 55.7%, respectively (hazard ratio, 0.55; 98.72% CI, 0.35 to 0.85; p < 0.001). However, treatment-related adverse events of grade 3 or higher were more common in the nivolumab group (17.2%) than the placebo group (7.2%). Two treatment-related deaths due to pneumonitis and one treatment-related death due to bowel perforation were noted in the nivolumab group.

The patients included in this study had a very high risk of recurrence, 47% had node positive disease whilst just over 74% of patients has pT3/4 disease on final histology. However, in this group adjuvant immunotherapy showed a significant and clinically meaningful benefit regardless of PD-L1 expression. Data for overall survival is awaited but patients will want to know about these results

Source: Adjuvant nivolumab versus placebo in muscle-invasive urothelial carcinoma.

Bajorin DF, Witjes JA, Gschwend JE, et al.

N Engl J Med 2021; 384: 2102-14.

Searching for better longterm immunosuppressive regimens Withdrawal of either steroids or calcineurin inhibitors are two strategies to reduce treatmentrelated side effects of long-term immunosuppression after kidney transplantation and to improve long-term graft survival. This study aimed to evaluate the efficacy and safety of these two strategies. In a multicentre randomised controlled trial, 151 incipient kidney transplant recipients received cyclosporine (CsA), mycophenolic acid (MPA), and steroids for three months, then followed by either steroid withdrawal (CsA/MPA) or replacement of cyclosporine with everolimus (EVL) (EVL/MPA/ steroids).

While the EVL/MPA/steroids regimen is an attractive strategy, it does lead to more rejection and secondary morbidity.

5-year patient survival (89% vs. 86%; p = n.s.) and death-censored graft survival (95% vs. 96%; p = n.s.) were comparable in the CsA/MPA and EVL/ MPA/steroids arm, respectively. 51 CrEDTA clearance was comparable between both groups in the intention-to-treat analysis, but in the treatment-received analysis the EVL/MPA/steroids

arm showed a superior 51 CrEDTA clearance at 1 and 5 years after transplantation (61.6 vs. 52.4, p = 0.05 and 59.1 vs. 46.2ml/min/1.73 m2 , p < 0.043).

Prof. Serdar Tekgül Section Editor Ankara (TR)

Numerically, there were more and more severe rejections in the EVL/MPA/steroids arm, which also showed a higher incidence of post-transplant diabetes (26% vs. 6%, p < 0.002) and infections.

No significant differences were observed in cardiovascular outcomes and malignancy.

serdartekgul@ gmail.com

The authors conclude that both regimens provide good long-term patient survival and graft survival.

While the EVL/MPA/steroids regimen is an attractive strategy, it does lead to more rejection and secondary morbidity. (ClinicalTrials.gov number: NCT00903188; EudraCT Number 2007-005844-26).

Source: 5-Year outcomes of the prospective and randomized CISTCERT study comparing steroid withdrawal to replacement of cyclosporine with everolimus in de novo kidney transplant patients. CISTCERT study group. Pipeleers L, Abramowicz D, Broeders N, Lemoine A, et al.

Transpl Int 2021;34(2):313-326

Tumour volume increase of index MRI visible lesions during PCA active surveillance: Monitor annually?

Modern active surveillance (AS) of prostate cancer (PCa) implies surveillance of visible lesions on MRI, and the assessment of any change based on the PRECISE score. MRI progression leads to targeted biopsies aiming to look for potential histological progression and tumour grade change. However, the characteristics of MRI changes of visible lesions are currently not well evaluated, and no data exist to compare such modifications according to the initial tumour grade of the disease.

The most useful implication of this work for routine practice may be that, …, annual MRI scans may be too frequent to detect meaningful change…

In the present study, the authors followed MRI visible lesions in 160 patients under active surveillance, and compared the lesion volume evolution over time between ISUP grade 1 (low-risk) and grade 2 (intermediate-risk) cancers.

The index lesion was measured by planimetry on the sequence best showing the tumour by an expert radiologist blinded to all clinical and pathological data. All lesions were scored using PI-RADS v2.1 recommendations.

The percentage change per year was calculated between two serial scans. From a dataset of active surveillance patients, only those undergoing targeted biopsies for visible lesion were included. Median follow-up was 38 months.

There was no significant difference in the percentage change per year between ISUP grade 1 (n = 84; 18% change) and grade 2 (n = 76; 23% change) lesions. This corresponded to annual increases in mean tumour diameter of 6% and 7%, respectively. The findings remain unchanged in patients having more than 10% of Gleason pattern 4 on targeted biopsies.

Thus, radiological evolution of visible cancers on AS was not markedly different between low- and intermediate-risk prostate cancers when considering the key parameter of tumour volume.

However, the authors highlighted that MRI could overestimate volume as small lesions are often surrounded by areas of inflammation or atrophy that can mimic low grade areas. Conversely, imaging may underestimate low grade disease extension. The most useful implication of this work for routine practice may be that, given the low annual increase in size of MRI visible lesion, annual MRI scans may be too frequent to detect clinically meaningful tumour change in most patients.

Source: Tumour growth rates of prostate cancer during active surveillance: is there a difference between MRI-visible low and intermediate-risk disease? Giganti F, Allen C, Stavrinides V, Stabile A, Haider A, Freeman A, Pashayan N, Punwani S, Emberton M, Moore CM, Kirkham A. Br J Radiol. 2021 Jul 8:20210321. doi: 10.1259/ bjr.20210321.

Lateral pedicle control during RARP: Clips or bipolar energy? Does it matter?

The initially described technique for lateral prostatic pedicles ligation during robotic radical prostatectomy is based on the use of surgical clips. Indeed, monopolar or bipolar energy have been suggested to increase the risk of nerve injury. In this retrospective study, the authors have evaluated the alternative use of bipolar energy, in a prospectively collected cohort of 338 patients. A total of 144 (43%) and 194 (57%) men underwent clipless surgery with bipolar energy (RARP-bi), and surgery with clips (RARP-c). The RARP-bi technique involves cauterisation of the pedicle with the Maryland bipolar forceps on both the specimen and the stay side at the location where the clips would otherwise be placed. Then, cold section is performed. The primary objective was to compare both techniques for differences in functional and oncological outcomes.

Both groups were comparable regarding baseline data. Nerve-sparing procedures were performed in 95% of patients. Complication (only grade 1-2) and bladder neck contracture rates were similar in both groups. No difference was reported in terms of lymphoceles. Pathological and oncological outcomes were also comparable in RARP-bi and RARP-c groups. RARP-bi was not associated with impaired outcomes in terms of positive surgical margin rates. Urinary and sexual function scores were not significantly different according to the technique, even on a multivariable linear regression model. There was a significant trend towards better zero daily pads rates in the RARP-bi groups (68% versus 52%, p = 0.005).

This analysis suggests that bipolar energy can be used safely for pedicle ligation during RARP without compromising functional and oncological outcomes.

This analysis suggests that bipolar energy can be used safely for pedicle ligation during RARP without compromising functional and oncological outcomes. It could also be cost-effective by decreasing operative time and instruments use.

The main limitation of the present study is its retrospective nature and the lack of randomisation. Moreover, patients undergoing RARP-bi were operated in a later period than those undergoing RARP-c. The experience accumulated between these two periods of the single surgeon involved in this study may have introduced an expertise bias when evaluating study endpoints.

Source: Robotic-assisted Radical Prostatectomy and Impact on Outcomes.

Basourakos SP, Lewicki PJ, Ramaswamy A, Cheng E, Dudley V, Yu M, Karir B, Hung AJ, Khani F, Hu JC. Clipless.

Eur Urol Focus. 2021 Jul 7:S2405-4569(21)00175-9.

EAU EU-ACME Office

European Urology Today

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Prof. Oliver Hakenberg Section Editor Rostock (DE)

Sexual dysfunction in young adult survivors of childhood cancer

Oliver.Hakenberg@ med.uni-rostock.de

The authors sought to determine the prevalence of sexual dysfunction and to identify the factors associated with sexual dysfunction in young adult survivors of childhood cancer.

Multicentre phase II trial: High-dose salvage radiotherapy and shortterm hormone therapy for oligorecurrent nodal disease in PCa patients The era of metastasis-directed therapy is open.

However, a high number of evidence data is still missing. In this French multicentre and openlabel phase II trial, patients experiencing oligorecurrent pelvic node relapse after primary treatment for prostate cancer have received high-dose intensity-modulated radiotherapy combined with a six-month hormone therapy.

Radiotherapy was directed to node positive spots detected by fluorocholine PET-CT. The maximum number of pelvic positive nodes on imaging was five for inclusion. Pelvic disease was defined by nodes located below the aortic bifurcation.

The primary endpoint was the two-year progression-free survival defined by two consecutive PSA levels above the level at inclusion (and/or clinical recurrence and/or death). Overall, 67 patients were recruited in 15 centres. Only four patients had a concurrent local relapse in the prostate or at the prostatic bed. The median age was 68 years. The median number of positive spots was one (61% patients with only one positive spot on PET-CT). At two years, grade 2 or more toxicity was 10% for genitourinary symptoms and 2% for gastrointestinal ones. No significant alteration of urinary or intestinal quality of life was reported.

The present study demonstrated high rates of biochemical progression after metastasisdirected therapy and short-term hormone therapy for nodal relapse.

The two-year progression-free survival was 81% but decreased to 58% after three years of follow-up. Interestingly, in patients with only radical prostatectomy as primary treatment, the two-year survival rate (97%) was significantly higher than that reported in patients who had undergone surgery plus salvage radiotherapy to the surgical bed.

The present study demonstrated high rates of biochemical progression after metastasis-directed therapy and short-term hormone therapy for nodal relapse. Nearly half of patients are in complete remission after three years. This trial adds initial evidence of benefit.

However, a randomised controlled trial remains necessary. Moreover, the question of intensified therapy by adding new generation hormone therapies still remains, as overall survival benefit from these regimens have been recently demonstrated in phase III trials for patients with oligometastases or relapse after primary prostate cancer treatment.

Source: OLIGOPELVIS GETUG P07, a Multicentre Phase II Trial of Combined High-dose Salvage Radiotherapy and Hormone Therapy in Oligorecurrent Pelvic Node Relapses in Prostate Cancer. Supiot S, Vaugier L, Pasquier D, Buthaud X, Magné N, Peiffert D, Sargos P, Crehange G, Pommier P, Loos G, Hasbini A, Latorzeff I, Silva M, Denis F, Lagrange JL, Morvan C, Campion L, Blanc-Lapierre A. Eur Urol. 2021 Jul 8:S0302-2838(21)01816-9.

Key articles

12

All survivors of childhood cancer (aged 19-40 years) in Sweden were invited to this populationbased study, wherein 2,546 men and women (59%) participated. Sexual function was examined with the PROMIS Sexual Function and Satisfaction Measure. Logistic regression was used to assess the differences between survivors and a general population sample (n = 819) and to identify the factors associated with sexual dysfunction in survivors.

The findings underscore the need for routine assessment of sexual health in follow-up care of childhood cancer survivors…

Sexual dysfunction in at least one domain was reported by 57% of female and 35% of male survivors. Among females, dysfunction was most common for Sexual interest (36%), Orgasm ability (32%) and Vulvar discomfort - labial (19%).

Among males, dysfunction was most common for the domains Satisfaction with sex life (20%), Sexual interest (14%) and Erectile function (9%).

Compared with the general population, male survivors more frequently reported sexual dysfunction in ≥ 2 domains (OR = 1.67, 95% CI: 1.03-2.71), with an increased likelihood of dysfunction regarding Orgasm - ability (OR = 1.82; 95% CI: 1.01-3.28) and Erectile function (OR = 2.30; 95% CI: 1.18-4.49). Female survivors reported more dysfunction regarding Orgasm - pleasure (9% versus 5%, OR = 1.86; 95% CI: 1.11-3.13). A more intensive cancer treatment, emotional distress and body image disturbance were associated with sexual dysfunction in survivors.

The findings underscore the need for routine assessment of sexual health in follow-up care of childhood cancer survivors, and highlight that those treated with more intensive cancer treatment and experience concurrent psychological concerns may benefit from targeted screening and interventions.

Source: Sexual dysfunction in young adult survivors of childhood cancer - A population-based study. Emma Hovén, Kristina Fagerkvist, Kirsi Jahnukainen, Lisa Ljungman, Päivi M Lähteenmäki, Ove Axelsson, Claudia Lampic, Lena Wettergren.

Eur J Cancer. 2021 Jul 14;154:147-156. doi: 10.1016/j. ejca.2021.06.014. Online ahead of print.

Outcomes of European male ageing study on rapid ejaculation Few data have looked at the occurrence and clinical correlates of self-reported shorter than desired ejaculation latency (rapid ejaculation, RE) and its related distress in the general population.

Thus, the investigators tried to determine the prevalence and clinical correlates of self-reported RE and RE-related distress in middle age and older European men.

The reported limited RErelated distress may explain the relatively low number of medical consultations for RE. Subjects were recruited from population samples of men aged 40-79 years across eight European centres. Self-reported RE and its related distress were derived from the European Male Aging Study (EMAS) sexual function questionnaire (EMAS-SFQ). Beck's depression Inventory (BDI) was used for the quantification of depressive symptoms, the Short Form 36 health survey

(SF-36) for the assessment of the quality of life, the International Prostate Symptom Score (IPSS) for the evaluation of lower urinary tract symptoms.

About 2,888 community-dwelling men aged 40-79 years old (mean 58.9 ± 10.8 years) were included in the analysis. Among the subjects included, 889 (30.8%) self-reported RE. Among them, 211 (7.3%) claimed to be distressed (5.9% and 1.4% reported mild or moderate-severe distress, respectively).

Increasing levels of RE-related distress were associated with progressively worse sexual functioning, higher risk of ED and with couple impairment, along with a higher prevalence of depressive symptoms (all p < 0.05). Furthermore, a worse quality of life and higher IPSS score were associated with RE-related distress (all p < 0.05).

Self-reported RE is relatively common in European men aged more than 40 years. The reported limited RE-related distress may explain the relatively low number of medical consultations for RE. RE-related distress is associated with worse sexual function, couple impairment, and more LUTS resulting in a worse quality of life and mood disturbances.

Source: Self-reported shorter than desired ejaculation latency and related distressprevalence and clinical correlates: Results from the European male ageing study.

Giovanni Corona, Giulia Rastrelli, Gyorgy Bartfai, Felipe F Casanueva, Aleksander Giwercman, Leen Antonio, Jolanta Slowikowska, Jos Tournoy, Margus Punab, Ilpo T Huhtaniemi, Dirk Vanderschueren, Terence W O'Neill, Frederick C W Wu, Mario Maggi.

J Sex Med. 2021 May;18(5):908-919. doi: 10.1016/j. jsxm.2021.01.187. Epub 2021 Apr 2.

Opioids after ureteroscopy for urinary stones? No, thank you Pain control after surgery is an issue that may affect the patient’s treatment journey in terms of worsening quality of life and return to normal life.

Usually, medications that are prescribed include non-steroidal anti-inflammatory drugs (NSAID) and opioids. Nevertheless, all these drugs may provoke side effects, among which NSAID-induced peptic ulcer and opiate dependence and/or overdose.

Nevertheless, the NSAID group of patients experienced a significantly lower number of days spent in bed (p = 0.022), as well as a reduced number of drug side-effects (p = 0.025).

Unfortunately, the abuse of opioids is quite common in some countries, especially in the US, where a drastic reduction of their use has been warranted by the relevant authorities. Regardless, the opioids are still very common for pain control during colic pain in stone disease as well as after endo-urological minimally invasive surgery for their treatment.

In the last years, evidence has been mounting to show that NSAID are as effective as opioids for the short term control of colic pain. Recently, a randomised controlled trial has been developed to test the non-inferiority of NSAID vs opioids as first-line treatment option for pain control after ureteroscopic lithotripsy of urinary stones.

According to the study sample size calculated, 81 patients were enrolled in the span of the 2-year recruitment period, 38 randomised in the ketorolac (10 mg) arm and 43 in the oxycodone (5 mg) one. It is worth mentioning that most of the patients screened were not eligible, as more than 500 patients did not fulfil entry criteria and/or refused to participate.

Medications were provided blinded in the same presentation and were taken on demand every 6 hours maximum for 5 post-operative days. All patients were provided with a further 3 non-blinded 5 mg oxycodone pills as rescue medication, if no

pain relief was obtained with the relevant drug assigned.

Primary end-point included difference in pain control from day 1 to 5 post-op according to the visual analogues scale pain score. Secondary end-points included differences in the Ureteric Stent Symptom Questionnaire (USSQ) at the same time points, differences in medication patterns, and access to medical assistance.

The baseline groups’ characteristics were comparable, and no difference was recorded in the number of either protocol (overall mean of 7.2) or rescue medications (39%); 9% of patients did not require any medication, equally distributed in both arms.

No differences were found in terms of VAS and USSQ scores at the different time points; most of the medication drugs were taken at the recovery unit, and their use progressively decreased after post-operative day 1.

Nevertheless, the NSAID group of patients experienced a significantly lower number of days spent in bed (p = 0.022), as well as a reduced number of drug side-effects (p = 0.025).

Overall, this RCT provides robust evidence that NSAID for post-operative pain control is as effective as opioids. Given the risk that the latter conveys in terms of higher side effects and dependence, NSAID should be used as first line drug after ureteroscopy for stone fragmentation.

Source: SKOPE-Study of ketorolac vs opioid for pain after endoscopy: a double-blinded randomized control trial in patients undergoing ureteroscopy. Donald Fedrigon, Anna Faris, Naveen Kachroo, Rajat Jain, Marlie Elia, Lamont Wilkins, Jianbo Li, Smita De, Mark Noble, Manoj Monga, Sri Sivalingam.

J Urol. 2021 Aug;206(2):373-381. doi: 10.1097/ JU.0000000000001772. Epub 2021 Apr 5.

Avoiding urosepsis after ureteroscopy for stone disease Ureteroscopy for the treatment of urinary stone disease is a very common surgical treatment worldwide. It has gained huge popularity in the last two decades thanks to the achieved high stone-free rates with a low risk for complications.

Nevertheless, severe complications may occur, even when surgery is performed by experienced surgeons. Infectious complications are among the most common, with a wide spectrum of severity, from urinary tract infection to sepsis; the latter is potentially fatal.

Multiple factors have been investigated to predict urosepsis, in order to eventually lead to preventive measures. The available data are mostly based on retrospective cohort series and the reported outcomes are not consistent.

In order to shed some light on this topic, a systematic review has been undertaken recently.

According to the search terms chosen, 251 articles were screened from Medline, Embase, and the Cochrane Central Register of Controlled Trials databases. After reviewing for the eligibility criteria, 13 papers reporting data on the association between at least one clinical factor and postoperative urosepsis were finally selected and included in the analysis.

In these patient groups, a urine sample for urine culture should be collected at the very beginning of an ureteroscopy.

There were 8 retrospective and 5 prospective studies selected, with an overall number of 5,597 patients; pooled rate of urosepsis was 5% (95% CI: 2.4-8.2). Notably, criteria used to define urosepsis varied among the studies, but – as by inclusion criteria - they met at least two of the following criteria: high fever (> 380), high pulse rate, high respiration rate or PcCO2, altered white blood cell count, and a few others.

EAU EU-ACME Office

European Urology Today

August/September 2021

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk

The authors evaluated 13 risk factors and found a statistical association with urosepsis in 6 of them: pre-operative stent placement, positive preoperative urine culture, older age, diabetes mellitus, ischaemic heart disease and longer procedure time. Nevertheless, these latter two factor outcomes resulted from pooled analysis of only 2 and 1 studies.

Overall, these outcomes are consistent with previous reports on the association between clinical factors and generalised infectious complications, especially for pre-operative stent placement and positive pre-operative urine culture.

These results are easily explained, as stent placement may result in bacterial colonisation, which is a factor directly associated with the time a stent is left in place. Positive pre-operative urine culture should be treated before any manipulation of the upper urinary tract. Patients may be re-tested to confirm urine sterilisation.

Nevertheless, several conditions may jeopardise the efficacy of an antibiotic treatment - especially in the case of stone formation with recurrent UTIs – such as antibiotic resistance, presence of infected urine proximal to the obstruction or spread of pathogenic bacteria during fragmentation of infectious stones.

In these patient groups, a urine sample for urine culture should be collected at the very beginning of an ureteroscopy. Furthermore, antibiotic treatment should be continued post-operatively instead of being limited to a one shot preoperative prophylaxis.

Source: Risk Factors for Urosepsis After Ureteroscopy for Stone Disease: A Systematic Review with Meta-Analysis. Naeem Bhojani, Larry E Miller, Samir Bhattacharyya, Ben Cutone, Ben H Chew.

After reviewing patient records, the authors were able to include the data of 1,214 patients treated in 21 centres over a 17-year span (2000-2017). Full data for all the variables in observation were available for 458 patients (37%). Missing data varied from 0 to 24%, with tumour architecture (papillary vs sessile) and estimated lesion size being among the most affected variables.

Regardless of this limitation, the authors were able to conduct their main analysis on the overall population by applying relevant statistical methods.

Out of 18 eligible studies, nine retrospective studies comprised of 2,564 patients (532 transferred and 2,032 direct) were suitable for quantitative analysis.

At the multivariable logistic regression, the authors found age, high-grade biopsy, cT1+ at biopsy, pre-operative hydronephrosis, tumour size, ≥ cT3 at imaging, and sessile architecture as the variables associated with ≥ pT2/pN+ disease at the subsequent RNU.

This meta-analysis of 2,564 patients for nine published studies demonstrates hospital transfer does not seem to significantly affect overall testicular torsion outcomes. Quantitative analysis suggests patients who are transferred for treatment of testicular torsion are not at increased risk of orchiectomy (641/2,032, 31.5%) compared to patients who undergo treatment at the initial, presenting institution (196/532, 36.8%; RR 0.96 [95% CI 0.78-1.17].

Regardless of the fact that other variables - among which high-grade cytology, tumour multifocality, cT stage at biopsy - were not statistically significant at the multivariable analysis, they were included in the final nomogram, as the authors found that they provided a clinical net benefit in a decision-curve analysis.

When comparing predictive accuracy, the authors’ nomogram outperformed the EAU and NCCN nomograms with an Area Under the Curve of 75% vs. 71%, respectively.

Clinical T3 at imaging was the strongest predictor (odds ratio 5.10, 95% CI:3.32–7.81, p = < 0.001), which was consistent with the EAU and NCCN algorithms. Tumour size was also an important predictive factor, but - conversely to the EAU and NCCN algorithms - no cut-off was provided, as the variable was found to work better when used continuously in the context of the nomogram.

Regardless of the biases introduced (especially those related to the retrospective nature of the study and the amount of missing data), the manuscript provides further evidence to support patient selection for endoscopic management of UTUC.

Source: Pretreatment Risk Stratification for Endoscopic Kidney-sparing Surgery in Upper Tract Urothelial Carcinoma: An International Collaborative Study. Beat Foerster, Mohammad Abufaraj, Surena F Matin, et al.

The appropriate selection of patients for conservative management of upper urinary tract tumours (UTUC) guarantees the best oncologic and functional outcomes. Mounting evidence shows that patients harbouring low-risk UTUC may preserve their kidneys without compromising the neoplastic control. In such patients, radical nephroureterectomy (RNU) –the standard of care - may result in overtreatment.

Clinical T3 at imaging was the strongest predictor …, which was consistent with the EAU and NCCN algorithms.

Several algorithms have been proposed in the last years to help practitioners in their decisionmaking process, among which those in the EAU and the NCCN guidelines, which included clinical and pathological factors based on evidence available and expert opinions.

Recently, a multicentre study has been undertaken to retrospectively identify clinical factors and endoscopic characteristics of patients who underwent ureterorenoscopy (URS) + biopsy that may associated with ≥ pT2/pN+ disease at the subsequent RNU. Key articles

August/September 2021

However, subgroup analysis for torsion patients presenting within 24 hours of symptom onset shows patients who are transferred to another facility for management are more likely to undergo orchiectomy than those treated at their presenting institution. Pooled data for torsion patients presenting 24 hours of symptom onset also suggests that patients who are transferred for treatment of acute testicular torsion are more likely to undergo orchiectomy (41/66, 62.1%) than those patients treated at the initial, presenting institution (32/155, 20.6%; RR 0.35 [95% CI 0.24-0.51]; In this meta-analysis, hospital transfer does not affect orchiectomy rate in paediatric patients with testicular torsion when pooling data from all presentation time frames. Subgroup analysis of patients presenting with testicular torsion in an acute setting (< 24 hours of symptom onset) suggests the delay associated with hospital transfer has a deleterious effect on testicular viability.

Source: Impact of hospital transfer on testicular torsion outcomes: A systematic review and meta-analysis. Kwenda EP, Locke RA, DeMarco RT, Bayne CE. J Pediatr Urol. 2021 Jun;17(3):293-8.

Eur Urol. 2021 May 19;S0302-2838(21)00328-6. doi: 10.1016/j.eururo.2021.05.004. Online ahead of print.

J Endourol. 2021 Jul;35(7):991-1000. doi: 10.1089/ end.2020.1133. Epub 2021 Mar 15.

Appropriate selection of patients for endoscopic management of upper tract urothelial cancer

…within 24 hours of the onset of symptoms, orchiectomy rates increase significantly with hospital transfer.

Does hospital transfer increase orchiectomy rate in children with testicular torsion?

Testicular torsion is a urological emergency which must be differentiated from other complaints of testicular pain, because a delay in diagnosis and management can lead to loss of a testicle.

Orchiectomy rates after torsion range from 32% to 64% and may be the result of a series of medical and logistical factors that delay both diagnosis and management. It has been established that detorsion within the first six hours increases the chances of salvage before significant ischemia has occurred.

The authors aim to elucidate the effect of hospital transfer on paediatric testicular torsion outcomes through a systematic review and meta-analysis. In paediatric patients with testicular torsion, hospital transfer does not affect orchiectomy rate when data from all presentation time frames are analysed. However, within 24 hours of the onset of symptoms, orchiectomy rates increase significantly with hospital transfer.

The authors included prospective and retrospective studies investigating outcomes for testicular torsion in patients < 18 years who underwent treatment at their presenting institution, as well as, those who were transferred from one institution to another for treatment. Studies must have reported the primary outcomes as orchiectomy for testicular detorsion (attempted salvage) for confirmed torsion.

Therapeutic intervention for foetal LUTO: Evidence and strategies Children with posterior urethral valves diagnosed shortly after birth are at higher risk for renal failure than children diagnosed later in life. Based on this finding, one would assume prenatal diagnosis and even prenatal intervention would bring better clinical outcomes to the patients.

Studies have shown that although in-utero vesica-amniotic shunting for foetal lower urinary obstruction (LUTO) is known to improve perinatal survival, its impact on renal outcome is limited.

More recently, studies including centres performing foetal cystoscopy (FC) have suggested benefit on longer-term survival and renal outcome, with limitations of small numbers and limited follow-up.

The authors aim to report the current evidence on the role of therapeutic intervention for foetal LUTO, discuss and propose the concepts stated below.

Prenatal USG has a 23% rate of false positive diagnosis with variations according to timing of investigation and criteria being used. Improvement of diagnostic accuracy can be achieved by using strict criteria on USG findings. The imaging fusion of real-time ultrasound and MRI is feasible and may improve the foetal diagnosis of LUTO. FC, although technically challenging, will allow direct visualisation to increase accuracy and treatment at the same time.

The prediction of foetal renal function is currently based on ultrasound appearances of the foetal renal cortex, amniotic fluid volume, and foetal urine biochemistry. The effectiveness of foetal urinary biochemical markers to predict renal function remains controversial. Urinary peptidome

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

tebj@medisin.uio.no

analysis is promising as a helpful tool for the discovery and validation of biomarkers of renal disease.

A prenatal staging system which classifies LUTO based on amniotic fluid volume, echogenicity, renal structure, and urine biochemistry may be helpful in selecting foetuses which may benefit from intervention.

The interventions with FC or vesicoamniotic shunting improve perinatal survival and have limited long-term benefit on renal outcome. They carry significant risks, and therefore patient selection and optimum timing are key factors.

The interventions with foetal cystoscopy or vesicoamniotic shunting improve perinatal survival and have limited long term benefit on renal outcome.

They carry significant risks, and therefore patient selection, and optimum timing, are key factors.

Identifying risk factors for foetal and postnatal renal failure is helpful. Multivariate analysis showed that foetal intervention, absence of anhydramnios or renal cortical cysts, and favourable foetal urine biochemistry were the best predictors of survival.

Foetal intervention is not a risk-free endeavour.

There is about 30% risk of losing pregnancies.

There is a high complication rate of 74 - 92% consecutively for FC and vesicoamniotic shunt (VAS). The main maternal complication was premature rupture of membranes (25% with FC, 33% with VAS). Foetal complications occurred in 54% of procedures: shunt migration (38% of VAS cases), omentum or bowel herniation (25% in both VAS and FC cases), urinoma with urethralperineal fistula (25% of FC cases).

The ideal timing for renal functional preservation is difficult to determine. Based on fatal lamb models, the only recommendation that can be given is to intervene before signs of cystic renal dysplasia and foetal renal failure ensue.

FC with flexible fetoscope has been employed for both diagnosis and treatment of LUTO. The development of a customised foetal cystoscope should help overcome the current technical challenges of FC. There is considerable scope for improving VAS technology to minimise complications of shunt dislodgement and blockage occurring in approximately 20% of cases.

Foetal intervention for LUTO improves perinatal survival, with the potential of longer-term survival and renal functional preservation. The underlying challenges include the accurate antenatal diagnosis of the cause of obstruction, patient selection, and mode and timing of intervention.

Smaller studies show a possible benefit of FC cystoscopy over VAS, but the procedure is technically demanding and has a high complication rate. Improved accuracy of prenatal diagnosis, and better patient selection with the aim of intervention before renal failure ensues, may result in better outcomes.

Source: Therapeutic intervention for fetal lower urinary tract obstruction: Current evidence and future strategies. Farrugia MK, Kilby MD. J Pediatr Urol. 2021 Apr;17(2):193-199. doi: 10.1016/j. jpurol.2021.01.034. Epub 2021 Jan 31.

PMID:33583743.

EAU EU-ACME Office

European Urology Today

13

In men with moderate to severe LUTS/BPH at risk of disease progression1,2

20

YEARS

LONG-TERM EVIDENCE

RICH EXPERIENCE

11,868 patients studied in landmark trials, with 6,909 patients on dutasteride as monotherapy or in combination with tamsulosin*3-8

of >20 years in building the science behind dutasteride9

*The overall number of patients studied in landmark trials is 11,868 with Phase III: 4325; EPICS: 1630; SMART: 327; CombAT: 4844; CONDUCT: 742. The number of patients studied in landmark trials with dutasteride as monotherapy or in combination with tamsulosin is 6,909 with Phase III: 2167; EPICS: 813; SMART: 327; CombAT: 3233; CONDUCT: 369.

References: 1. Duodart EU Summary of Product Characteristics (SmPC) effective 17 November 2017. 2. Avodart EU Summary of Product Characteristics (SmPC) effective 17 November 2017. 3. Roehrborn CG, et al. BJU Int 2015;116:450–459. 4. Roehrborn CG, et al. Eur Urol 2010;57:123–131. 5. Roehrborn CG, et al. Urology 2002;60:434–441. 6. Barkin J, et al. Eur Urol 2003;44:461–466. 7. Debruyne F, et al. Eur Urol 2004;46(4):488–494. 8. Nickel JC, et al. BJU Int 2011;108:388–394. 9. Bramson HN, et al. J Pharmacol Exp Ther 1997;282:1496–1502.

Abbreviations: LUTS/BPH, lower urinary tract symptoms secondary to benign prostatic hyperplasia.

In the Netherlands the registered trade name for dutasteride is Avodart and for dutasteride-tamsulosin is Combodart.

Abbreviated Product Information – Avodart (dutasteride)

Abbreviated Product Information – Combodart/Duodart (dutasteride + tamsulosin)

Indication: Treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH).

Reduction in the risk of acute urinary retention (AUR) and surgery in patients with moderate to severe symptoms of BPH. Dosage, adults: Avodart can be administered alone or in combination with the alpha-blocker tamsulosin (0.4mg) Adults: 1 capsule (0.5mg dutasteride) daily. The capsule should be swallowed whole and not be chewed or opened. Contraindications: Women, children and adolescents. Hypersensitivity to dutasteride, other 5-alpha reductase inhibitors, soya, peanut or any of the other excipients. Patients with severe hepatic impairment. Precautions: Combination therapy should be prescribed after careful benefit risk assessment. A study (REDUCE) has shown an increased incidence of Gleason 8-10 prostate cancer compared to placebo. A regular evaluation for prostate cancer must be performed. The mean serum prostate-specific antigen (PSA) concentration during treatment is reduced by 50% after 6 months of treatment. After 6 months of treatment, a new PSA baseline should be established. Digital rectal examinations for prostate cancer prior to initiating treatment and periodically thereafter. In two 4-year clinical studies, the incidence of cardiac failure was marginally higher among subjects taking the combination however data from trials and other sources do not support a conclusion on increased cardiovascular risks with combination. Caution in mild to moderate hepatic impairment. Patients should be instructed to promptly report any changes in their breast tissue such as lumps or nipple discharge. Dutasteride is absorbed through the skin, therefore contact with cracked and leaking capsules should be avoided. Interactions: Verapamil, diltiazem, ritonavir, indinavir, nefazodone, itraconazole, ketoconazole administered orally. Pregnancy and lactation: Contraindicated. Using a condom is recommended if the partner is or may become pregnant. Reduced male fertility cannot be excluded. Side effects: Common: Dizziness, impotence, altered (decreased) libido, ejaculation disorders, breast disorders. Uncommon: Heart failure (collective term). Overdosage: In volunteer studies, single daily dose of 40 mg/day for 7 days had no significant safety concerns. There is no specific antidote for dutasteride, symptomatic and supportive treatment should be given as appropriate. Please refer to the Avodart SmPC for full information (Based on Avodart UK SmPC effective May 2020)

Indication: Treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH). Reduction in the risk of acute urinary retention (AUR) and surgery in patients with moderate to severe symptoms of BPH. Dosage, adults: Adults: 1 capsule (0.5mg dutasteride/0.4mg tamsulosin) daily. May be used to substitute concomitant dutasteride and tamsulosin hydrochloride in existing dual therapy to simplify treatment. The capsule should be swallowed whole approximately 30 minutes after the same meal each day.

Should not be chewed or opened. Contraindications: Women, children and adolescents. Hypersensitivity to dutasteride, other 5-alpha reductase inhibitors, tamsulosin (including tamsulosin-induced angio-edema), soya, peanut or any of the other excipients. A history of orthostatic hypotension or severe hepatic impairment. Precautions: Combination therapy should be prescribed after careful benefit risk assessment. A study (REDUCE) has shown an increased incidence of Gleason 8-10 prostate cancer compared to placebo. A regular evaluation for prostate cancer must be performed. The mean serum prostate-specific antigen (PSA) concentration during treatment is reduced by 50% after 6 months of treatment. After 6 months of treatment, a new PSA baseline should be established.

Digital rectal examinations must be performed for detection of prostate cancer prior to initiating treatment and periodically thereafter.

In two 4-year clinical studies, the incidence of cardiac failure was marginally higher among subjects taking the combination however data from trials and other sources do not support a conclusion on increased cardiovascular risks with combination. Caution should be used in severe renal impairment and mild to moderate hepatic impairment. Patients should be instructed to promptly report any changes in their breast tissue such as lumps or nipple discharge. Orthostatic hypotension may occur during treatment, caution should be exercised when given concomitantly with drugs causing hypotension. Discontinue treatment 1-2 weeks prior to surgery for cataract due to risk of intraoperative floppy iris syndrome (IFIS). Dutasteride is absorbed through the skin, therefore contact with cracked and leaking capsules should be avoided. Contains Sunset Yellow (E110), which may cause allergic reactions. Interactions: Verapamil, diltiazem, ritonavir, indinavir, nefazodone, itraconazole, ketoconazole administered orally, warfarin, anesthetic agents, PDE5 inhibitors and other alpha1- adrenoceptor antagonists, paroxetine, cimetidine, diclofenac, warfarin, furosemide. Pregnancy and lactation: Contraindicated. Using a condom is recommended if the partner is or may become pregnant. Reduced male fertility cannot be excluded. Side effects: Common: Dizziness, impotence, altered (decreased) libido, difficulty with ejaculation, breast disorders.

Uncommon: Headache, Heart failure (collective term), palpitations, orthostatic hypotension, rhinitis, constipation, diarrhea, nausea, vomiting, urticaria, rash, pruritus, asthenia. Overdosage: Acute overdosage with 5mg tamsulosin hydrochloride has been reported.

In volunteer studies, single daily dose of 40 mg/day for 7 days had no significant safety concerns. There is no specific antidote for dutasteride, symptomatic and supportive treatment should be given as appropriate. Please refer to EU SmPC for Combodart for full information. (Based on Combodart UK SmPC effective May 2020)

Full SmPC of AVODART (19 May 2020) for UK is available at - https://mhraproducts4853.blob. core.windows.net/docs/e8e6e7b1e175d5b1ca7f030251fc2a815037290f

Full SmPC of COMBODART (19 May 2020) for UK is available at - https://mhraproducts4853.blob.core.windows.net/docs/ 4dc3ac1b3936bccac9a2e55226931f98eb4f17ae

Full SmPC of AVODART (16 April 2020) for Netherlands is available at - https://www. geneesmiddeleninformatiebank.nl/smpc/h28317_smpc.pdf

Full SmPC of COMBODART (16 April 2020) for Netherlands is available at - https://www.geneesmiddeleninformatiebank.nl/smpc/ h104130_smpc.pdf

For medical questions about this product, please contact the operating company in the country of your residence or call +31 (0)33-2081100 or email to nl.medischevraag@gsk.com for the Netherlands. Please report adverse events to the operating company in the country of your residence or call +31 (0)33-2081100 or email to nl.bijwerking@gsk.com for the Netherlands For the use of registered medical practitioner or a Hospital or a Laboratory only. Avodart/Duodart is for use in men only. Avodart/Duodart trade marks are owned by or licensed to the GSK group of companies.

PM-GBL-UR-ADVT-210002 Date of preparation: June 2021. GlaxoSmithKline BV, Van Asch van Wijckstraat 55H, 3811 LP Amersfoort, The Netherlands

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European Urology Today

August/September 2021

Profiles

Prof. Albers: “Intention is to enhance the scientific quality” New SCO chair aims to develop the EAU into one of the most influential scientific societies in the world Since 2003, he has been a member of the EAU Guidelines Panel on Testicular Cancer. “Here, I gathered most of my experience concerning the workings of the EAU,” Prof. Peter Albers (DE), the newly elected chair of the EAU Scientific Congress Office (SCO), says.

achieved the largest number of sessions for and composed by patients at a major scientific meeting.”

What are your goals for the SCO? “The SCO should be a lively and flexible group of excellent researchers and clinicians. Ideally, the SCO should reflect urology in its whole and be a pacemaker by stimulating optimal presentation of cutting-edge scientific achievements. Furthermore, we need to improve our gender balance and look out for young, brilliant urologists to join us in the future.”

“Here, I learned about this outstanding quality of scientific discussion, often in a multidisciplinary setting. Here, I learned about extraordinary friendship even if there are controversies on certain topics. The way of delivering education and conducting research, thereby developing the highest standard for our specialty, impressed me from my very first day at the EAU. To this day, I have admired the EAU for this scientific culture as well as for the way of communicating scientific achievements all over the world. Now, I want to give back to the EAU.” Prof. Albers alludes to his new position as chair of the SCO, a position he took up in 2020, after which he immediately had to lead the SCO in the unprecedented conversion from a physical into a virtual EAU20. He had been a member of the SCO since 2012, after having served on the Video Committee of the EAU Scientific Office for several years before.

The aim of the SCO is to maintain the highest scientific level for the Annual EAU Congresses.

What are the most important factors in achieving this goal?

Prof. Albers: “Most importantly, we need to continue stimulating colleagues from all over the world to submit their research results for the Annual EAU Congress. As SCO, we then select about thirty percent of the abstracts based on a rigorous review process.

The SCO is strongly dependent on the well-selected reviewers; there are at least four to five of them per topic. Only rarely, the SCO overrules the reviewers’ ratings, for example in the case of interesting but conflicting research. The responsibility of the SCO is

What do you think you will add to the SCO? “First of all, we have to properly select the reviewers of abstracts based on their publication records and replace them when necessary. Secondly, I am going to try to focus the Annual EAU Congress on a clear quality-based presentation of abstracts. For instance, we have introduced best-of-the-best abstract sessions, including prizes, with comments from experts of the SCO or from outside the EAU to put things into perspective.”

to look for the best and most appealing presentation of interesting topics. As part of that, we introduced the Game-Changing Sessions under the guidance of my predecessor Prof. Arnulf Stenzl (DE) a few years ago.

These sessions include presentations of large phase-III trials and other important news of the year followed by expert comments.”

“I will have succeeded in my job when all members of the SCO are motivated to work for the team as hard as they did in the past.”

Has it been a personal goal of you to become the chair of the SCO? “No. I have enjoyed working in this prestigious group since 2012; I was just more or less lucky to be promoted. The SCO’s foundation is teamwork, and one of us has to coordinate this. So, my personal goal is to improve the work of the group. I was thrilled to notice the congress office’s expertise and flexibility during the preparations for EAU20 and EAU21.

“Another important issue is patient participation. With It wasn’t easy to convert EAU20 from a physical into a the EAU Patient Day at EAU21, we have already virtual congress first, and then having to deal with the Do you expect major changes happening for the SCO during your term?

“It has already become clear that audio-visual education is getting more and more popular. The video committee will certainly need more members in order to properly select the best of the best. By and large, we are ready to adopt changes the audience wants."

uncertainties regarding EAU21. In my previous positions outside the EAU, I have never witnessed such kind of support.”

“My main intention to accept this function was to enhance the scientific quality in a mainly surgicallydominated field such as urology. We treat 25 percent of all cancers, but in the past we had deficits to perform large comparative trials to provide level-I evidence for our surgical approaches. Urology will change in the upcoming years; perioperative systematic therapy including IO treatments will emerge, and we, as onco-urologists, need to apply our knowledge to this development. As for non-oncology topics, we are faced with an elderly population which needs multidisciplinary care. We also need comparative trials in oncology and non-oncology for new drug developments and methods to sustain quality of life. The Annual EAU Congress should be the place where major developments are presented first and then professionally distributed to the community after.

This is a major challenge for the SCO, and thus this position is very challenging and interesting for me.”

You work at the Heinrich Heine University Düsseldorf. What kind of experience that you have gained in Germany do you bring to the EAU? “Sometimes it is not so easy to be a German SCO member. Germans have a questionable reputation of being organisers and streamliners – and not necessarily team players. I am not saying this is all wrong. I myself have learned a lot as an EAU member, balancing European cultures and improving international connections. I still can improve at diplomacy! I will have succeeded in my job when all members of the SCO are motivated to work for the team as hard as they did in the past.

If we continue to work at this level of transparency and confidence with the reliable support of the Executive Committee, we will certainly manage to further develop the EAU into one of the most influential scientific societies in the world.”

Profiles

Prof. Merseburger takes on role as EUSP Chair His vision for the scholars and knowledge exchange Bolstering the next frontrunners and stimulating research in urology are the core objectives of the European Urological Scholarship Programme (EUSP). Through year-long scholarships, clinical visits, and fellowships, the EUSP encourages knowledge exchange and provides valuable experience to young, promising participants.

These commendable goals parallel the enthusiasm and drive of renowned expert, Prof. Axel Merseburger (DE), who was recently appointed as the new EUSP Chair. He stated, “Knowing that we can help engage young doctors in urology is exhilarating. Through the EUSP, we can motivate and enable them to pursue their future careers in this field.”

Due to the emergence and impact of the COVID-19 pandemic, the announcement of Prof.

Merseburger’s new role was postponed to 2021. He said, “The pandemic may have delayed my appointment, but it gave me the opportunity to start the transition, a ‘soft-opening’ as you may call it, with Prof. Vincenzo Mirone who still led the EUSP at that time, and me learning from him.”

Vision and perspectives of the new EUSP Chair Prof. Merseburger’s vision for the programme is built upon the following pillars: Disruptive technologies “Through the EUSP, we aim to stimulate that new type of innovative clinical and experimental research. Digital innovation is reshaping the way we function. Robotics, augmented/virtual reality sensor technology, the Internet of Things, data information modelling systems, and other disruptive technologies transformed the healthcare industry, and will continue to do so. Novel ways of data collection and analysis are becoming more

August/September 2021

important in the development of new treatment options,” said Prof. Merseburger.

Prof. Merseburger underlined the importance of encouraging institutes to apply for an EBU-EAU certification. Such institutes, that specialise in percutaneous nephrolithotomy, high-intensity focused ultrasound, radiofrequency ablation, and open surgery can be host centres for clinical visits and scholarships in the future.

Cultivating long-term commitments Prof. Merseburger stated that by creating long-term scholarship programmes and topic-based curricula, the EAU can further train young urologists in various fields of urology, leadership and research possibilities, medical IT and other areas.

Additionally, since the COVID-19 travel restrictions are still enforced in many countries, Prof.

Merseburger encourages scholars to reach out to certified host centres in their home countries to continue their learning, gain experience and boost their knowledge.

Dedicated programmes Development of dedicated programmes for urological subspecialties is possible through the joint efforts with the Young Urologists Office, the European School of Urology (ESU), the Guidelines Office and the EAU Research Foundation (EAU RF). According to Prof.

Merseburger, the current fellowship programmes are a good start and can be enhanced by combining them with ESU courses, masterclasses, and the Guidelines Associates programme.

One of the requirements in the application for EUSP one-year scholarship is submission of a project proposal. According to Prof. Merseburger, some reports lack a proper structure which make them difficult to review. “We are currently designing a format to guide applicants on how to successfully create a project proposal.”

“Knowing that we can help engage young doctors in urology is exhilarating.”

Enriching participation To foster engagement, Prof. Merseburger advised to give the scholars a podium to share their experiences, which in turn, could inspire medical students to become urologists, and mentor those groups. He added that building strong relations with national representatives of urological residents will help establish a solid platform that will aid in stimulating more research, and in consequence lead to further progress in urological science and medical care.

Prof. Merseburger mentioned the application of new EU funding possibilities (e.g. as Horizon Europe and EU4Health) for what strategic direction the EAU/EUSP should take. “As Chair of an EAU Office, I’m planning to propose research ideas that the Office and the Board believe should be some of the priorities considered by the EAU. These will include research proposals as collaborative projects with other Offices (e.g. the Young Academic Urologists, the ESU),” said Prof. Merseburger.

Plans and initiatives When asked what he has in mind for the future,

In terms of certification, accreditation or recognition of centres for open (onco or non-onco) surgery,

Another notable aim of Prof. Merseburger is the integration of the EUSP and EAU RF clinical trials/ registries for knowledge sharing. This is to give EUSP scholars the opportunity to access ongoing EAU-supported projects and/or clinical trials.

“Opportunities abound and ambitions are high at the EUSP. I look forward to working with the EUSP team in the years to come,” concluded Prof. Merseburger.

For more EUSP updates, please use the hashtags #eauscholars and #EUSP. Connect, converse and read some of his professional and personal insights on Twitter via his handle @amerseburger and @uroweb.

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Report

Impressions of the popular masterclasses ESU highlights benign prostatic obstruction, focal therapy, prostate biopsy and partial nephrectomy

By Erika De Groot The European School of Urology (ESU) together with the EAU Sections of Uro-Technology (ESUT), Urological Imaging (ESUI), and EAU Robotic Urology Section (ERUS) redesigned their popular masterclasses to continue elevating knowledge and skills in the time of the COVID-19 pandemic. In this article we bring you impressions and an overview of the four ESU masterclasses which took place early this year.

Vital BPO techniques and technologies Review of the current EAU Guidelines for indications for benign prostatic obstruction (BPO) surgery, introduction to different training models, semi-live demonstration of enucleation techniques, new technologies for surgical BPO therapy, and minimallyinvasive therapy options are some of the topics covered by the Virtual ESU-ESUT Masterclass on Operative management of benign prostatic obstruction which took place in April. The scientific programme was interspersed with clinical cases and lively panel discussions.

The masterclass was led by internationally-known experts ESU Chairman Prof. Evangelos Liatsikos (GR), Course Directors Dr. Marcel Fiedler (DE) and ESUT Chairman Prof. Ali Serdar Gözen (DE).

When asked about his masterclass impressions, participant Dr. Lucca Brizzi (IT) shared, “The BPO masterclass gave me the desire to experiment new techniques that I don't know. I appreciate the clarity and the perfect synthesis of the speakers and the scientific content."

Fellow participant Dr. Mehrdad Mazdak (DE) described his masterclass experience as “immense”.

He said, “Not only did I gain more confidence to put what I’ve learned into practice, but also received knowledge directly from the experts. One can improve one’s clinical dexterity through the ESU masterclasses, which I think are the best gateway and output of the Guidelines.”

According to participant Dr. Deimantas Šukys (LT), the knowledge he gained during the masterclass was useful in his daily practice and that he enjoyed interacting with the faculty of experts. He disclosed, “I applied for this masterclass because in my practice, I treat BPH with TURP or laparoscopic prostatectomy, and prepare for TUREP.” Focal therapy masterclass impressions Following the BPO masterclass was the Virtual ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer, which took place in May. With the support of the ESU board, Course Director Dr. Eric Barret (FR), together with ESUT Chairman Prof. Ali Serdar Gözen (DE) and ESUI Chairman Prof. Georg Salomon (DE), have successfully lead this masterclass.

The masterclass was comprised of highly informative lectures on the rationale for focal therapy, diagnostic tools for patient selection (e.g. ultrasound and MRI), treatment modalities, energy sources (e.g. cryotherapy, laser ablation, brachytherapy, etc), and focal therapy for PCa recurrence, to name a few.

Faculty member and Chairman of the Young Academic Urologists, Dr. Juan Gómez Rivas (ES) shared some of the key messages of the masterclass: 1. Use mpMRI to select target within the prostate for targeted biopsy.

2. Define a clinical cohort of patients whose tumours harbour low- to intermediate-risk characteristics without indication for surveillance and lower than those bounded for radical therapy.

3. Select energies suitable to treat and accomplish an oncologically safe organ-sparing ablation with minimum toxicity. Match the patients with energies based on tumours characteristics and location.

Participant Dr. Georgios Tsampoukas (GB) stated the benefits he attained from attending the masterclass: “The masterclass broadened my knowledge and clarified the indications regarding the applicability of the modality. It helped improve my daily practice as I can now communicate more confidently to my patients that focal therapy is an option (i.e. advantages and limitations) and find the most suitable option for them.”

Fellow participant Dr. Peter Ka-Fung Chiu (HK) applied for the masterclass to learn more about focal therapy. He said, “I have some early experience in using HIFU and I would like to learn more tips and tricks and the standard recommendations on this topic.” He added that he enjoyed the case discussions and the live Q&A wherein participants were divided into small groups and supervised by top experts.

Dr. Chiu said that the masterclass reminded him of proper case selection, as well as, the pros and cons of each treatment option.

A focus on prostate biopsy The Virtual ESU-ESUI Masterclass on Prostate biopsy commenced in June providing participants relevant and comprehensive updates on innovations in transrectal ultrasonography, MRI (e.g. standardised reading, reporting and quality control), biomarkers in the PCa diagnosis, transperineal or transrectal approaches, fusion biopsy and more. The masterclass was led by Course Directors Prof. Lars Budäus (DE), Prof. Salomon and Dr. Jochen Walz.

European Urology Today

Whether on-site or online, ESU masterclasses are attended by enthusiastic and eager participants

Another participant, Dr. Ioannis Efthimiou (GR), also enjoyed the MRI-reading course. He stated that it was The scientific programme included breakout sessions “a valuable and enjoyable experience albeit too for the MRI reading course using the MIM software short.” Dr. Efthimiou added that the reason he where participants were divided into 8 groups and applied to the masterclass was to improve his received expert feedback on cases provided. Each knowledge and skills on the diagnosis of PCa using group was supervised by a faculty member. The MRI. He stated that unfortunately, he cannot apply masterclass also offered video demonstrations on tools some of the strategies and techniques due to a lack of such as electromagnetic, image-based, mechanical equipment at his hospital. and robotic navigation, and MRI-guided in-bore biopsy, to name a few.

“My clinical practice will benefit from what I’ve learned from masterclass because it has enabled me “The impact of the masterclass to my clinical practice to read prostate MRI and to make MRI a key is this: I will be able to put into practice the assessment in the diagnosis of prostate cancer,” information I acquired about MRI and biopsy stated participant Dr. Gilles Natchagande (BJ). He said (indication, preparation, performance and antibiotic that he enjoyed the breakout sessions, as well as, the prophylaxis), and begin the implementation of fusion presentations on biopsy practices on the different biopsy in my country, the Dominican Republic,” types of fusion. shared participant Dr. Geraldini Castillo (DO). She added that she applied for the masterclass because it Participant Dr. Ivo Vujicik (MK) said, “I was intrigued offered a complete updated programme on prostate when I heard about the masterclass from a biopsy. “My favourite part was the MRI-reading colleague. I wanted to participate because I would course, which I found very interesting. I learned a lot,” like to learn more about the new techniques used for targeting prostate biopsy as I try to keep myself said Dr. Castillo. updated with the latest technologies as much as possible. The challenge now is how to integrate them into my clinical practice. I hope the lessons I’ve learned about accurate reading and interpretation of mp-MRI images using the MIM software will be useful in my practice.” He added that he was especially interested in the basics of fusion biopsy and the use of electromagnetic navigation. “The masterclass met my expectations because I learned a lot about the use of MRI in PCa diagnosis, the indications and the current techniques of prostate biopsy,” concluded Dr. Vujicik.

During the prostate biopsy masterclass, Prof. Salomon shows assigning a risk score according to prostate regions

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PN masterclass demonstrates resection techniques

PN matters Commencing a week after the prostate biopsy masterclass is the Virtual ESU-ESUT-ERUS Masterclass on Partial nephrectomy. Spearheaded by Course Directors Dr. Alberto Breda (ES), Prof. Liatsikos and Prof. Francesco Porpiglia (IT), the masterclass tackled topics such as milestones of partial nephrectomy (PN), PN in T2 tumours, indications for open surgery, standard laparoscopy, robot-assisted laparoscopy, retro and transperitoneal approaches, and more. The programme included video sessions on maximising

nephron-sparing, performing perfect enucleation, and predicting the extension of regions undergoing ischemia.

Participant Dr. Adrian Czekaj (PL) shared, “This masterclass will definitely encourage me to offer nephron-sparing and minimally-invasive treatment to patients with diagnosed kidney tumours.

Unfortunately, in many countries such as Poland, the main obstacle might be the lack of universal access to the surgical robot, which facilitates the implementation of new technologies, provides a shorter learning curve and allows for the more frequent decision of using minimally-invasive technique.”

Dr. Czekaj stated that he was impressed by the presentation on the implementation of 3D-augmented virtual reality. He said, “It seems that the use of robotic surgery is an integral part of implementing new technologies and optimising oncological and functional results. I will certainly remember one of Prof. Alex Mottrie's most important principles for kidney surgery: ‘Exposure, exposure, exposure’ and the statement of another participant, who said that in laparoscopy you sew as you can, while in robotic surgery you sew as you like.”

When asked which topic/presentation made a lasting impression on him, participant Dr. Artur de Oliveira Paludo (BR) stated, “The 3D virtual models and augmented reality caught my attention because in the era of precision medicine, these tools are essential to deliver better results to our patients. For me, radiology and surgery must go together.”

According to participant Dr. Pankaj Pankaj (IN), the masterclass has provided him with new knowledge on current PN practices which he claimed will improve outcomes for this complex surgery at his centre. He said that the robot-assisted PN techniques, 3D imaging and reconstruction, and use of technology in PN were the most useful to him as these are aspects that he and his peers seek to improve at their centre.

Interested in applying for a masterclass? Please visit www.esu-masterclasses.org for more information.

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Report

ESU-ESUT Virtual Masterclass on Urolithiasis Highlights on pathophysiology, diagnosis and conservative treatment Dr. Arman Tsaturyan Fellow of Endourology University Hospital of Patras Patras (GR) tsaturyanarman@ yahoo.com

Prof. Evangelos Liatsikos Head of the Dept. of Urology University Hospital of Patras Patras (GR)

Even when held online, the masterclass shows a relaxed atmosphere

The masterclass was the second of its edition held in digital format. Using the experience gained from last year’s virtual masterclass and analysing the possible pitfalls and limitations in terms of attendance, together with the organisers, we created a unique platform which enabled easier communication and interaction between the faculty members and participants. We believe we reached our main goals: to share and deliver knowledge.

3.

4.

5.

6.

Communicating with the OR

Dr. Kasra Saeb-Parsy (GB), Dr. Esteban Emiliani (ES) and Prof. Oriol Angerri Feu (ES) Mini-PCNL with SuperPulsed Thulium Fiber Laser SOLTIVE and suction-evacuation sheath by Dr. Marcin Popiolek (SE) A pre-recorded surgery on percutaneous nephrolithotripsy by Dr. Janak Desai (IN) Robotic ureteroscopy by Prof. Jens Rassweiler (DE) Bladder stone lithotripsy by Dr. Iason Kyriazis (GR).

liatsikos@yahoo.com From June 18 to 19 of this year, through the collaboration of the European School of Urology (ESU) and the EAU Section of Uro-Technology (ESUT), the virtual ESU-ESUT Masterclass took place at the University Hospital of Patras in Greece.

Leading experts in Europe shared recent advancements and hot topics in the field of urolithiasis, as well as, their practical experiences to 53 participants from all over the world in an intensive two-day programme.

The faculty held interactive discussions on pathophysiology, diagnosis, and conservative treatment. They highlighted the advantages, limitations, and potential threats of minimally-invasive modalities and presented essential tips and tricks of their practised techniques during the presentations and surgeries (pre-recorded and live).

Despite the virtual format, the masterclass’s programme was comprised of three live surgeries and 15 pre-recorded surgical video presentations performed by renowned specialists. Compared to last year’s programme, the number of pre-recorded surgeries this year has increased significantly and the faculty was able to cover most of the endourological procedures.

The pre-recorded videos included: 1. Flexible ureteroscopic lithotripsy using most recent laser energy devices showing different laser settings performed by Prof. Thomas Knoll (DE), Dr. Armin Secker (DE), Assoc. Prof. Øyvind Ulvik (NO), Dr. Guido Giusti (IT), Prof. Bhaskar Somani (GB), Prof. Olivier (FR) 2. Mini endoscopic combined supine PNL by Dr. Cesare Marco Scoffone (IT), Prof. Daniel Adolfo Pérez Fentes (ES), Dr. Oliver Wiseman (GB),

Particular attention was given to the broadcasting of the live surgeries which were performed at the dedicated endo-suite operating room at the University Hospital of Patras. With the help of several cameras, the participants were able to examine all the aspects of the surgeries, including endoscopic, radiologic, and other images shown simultaneously on one screen.

The live surgeries were comprised of: 1. Prone combined percutaneous nephrolithotomy performed by Dr. Panagiotis Kallidonis (GR) and Prof. Liatsikos 2. Mini-combined percutaneous nephrolithotripsy by Prof. Andreas Skolarikos (GR) and Dr. Kallidonis 3. Flexible ureteroscopic lithotripsy with high power laser by Dr. Kallidonis All pre-recorded video presentations and live surgeries were accompanied by pre-surgery set-up discussions

to facilitate an in-depth understanding of essential materials needed for each surgical procedure.

The second day was dedicated to the presentation of hot topics, tips and tricks, complications, and troubleshooting. To encourage more interaction during the sessions, each presentation was followed by a short discussion. All participants were free to ask their questions either with a special button or typing the questions in a common chat area throughout the whole masterclass. The questions were addressed either by the presenter or by the moderators with additional discussion of important points. At the end of the masterclass, panel experts shared their experiences with specific advice for the management of different particular cases.

Encouragingly for us, the feedback received from participants and their evaluation of the virtual masterclass were highly positive. Although the virtual format limited the social interaction of participants amongst each other and the faculty, it did not affect the delivery of the knowledge and quality of the scientific content. Considering the advantages of the virtual events, such as greater participation of attendees, cost-reduction, eco-friendly, and accessibility as well as our positive experience with the organisation of the masterclass, we strongly believe that these kind of events will be more utilised in the near future.

Report

UUA congress and the virtual ESU course Hybrid collaboration focuses on tactics, treatment and challenges Academy of Medical Sciences (NAMS) of Ukraine welcomed the delegates on behalf of the NAMS President, Prof. Tsymbalyuk Vitaly Ivanovich (UA).

The plenary session "UTI and Urolithiasis" was chaired by Prof.

Sergey Vozianov and Prof. Victor Stus. During this session, they The rank of "Honorary Member of the Association of discussed the pathogenetic Urologists of Ukraine" was awarded to Prof. Lisovyi features of acute pyelonephritis Volodymyr Mykolayovych (UA), who is Chairman of and the principles of herbal the Academic Council of Kharkiv National Medical medicine for urinary tract University and Corresponding Member of the NAMS of infection. They also underscored avshulyak@ Ukraine. the rules for choosing the tactics hotmail.com in treating ureteral stones.

The thematic sessions centred on key issues and The three-day congress of the of the Ukrainian challenges in urology, and explored contemporary A group of Ukrainian scientists Urological Association (UUA) kicked off in Kiev, research. led by Prof. O.V. Romashchenko, Deliberations among the ESU and local faculty Ukraine on 17 June 2021. During this well-attended who established an annual event, the virtual course “Kidney cancer” organised During the symposium "Modern features of treatment course dedicated to female by the European School of Urology (ESU) commenced of lower urinary tract symptoms/benign prostatic sexology and sexopathology, on 18 June wherein 283 delegates onsite and 1,630 hyperplasia", Prof. Sergey Vozianov, Dr. Sergey Volkov held informative discussions on erectile dysfunction, livestreamed lectures went smoothly and there were online participants viewed the course.

(UA), Dr. Stepan Gusakovsky (UA) and I disseminated erogenous zones in women, and the diagnosis of plenty of fruitful discussions. It was truly a pleasure to information about mathematical models in the study be part of this experience.” female sexual dysfunction.

Preparing and coordinating the congress was difficult of the results of combined treatment of LUTS in BPH. due to the COVID-19 pandemic. The organising We emphasised that combination therapy affects Discussions on the following topics were especially Popular virtual ESU course committee complied with all the rules of urination, sexual function, especially in terms of important and interesting during the congress: Spearheaded by Prof. Alberto Breda (ES), Prof. T. epidemiological safety according to the ejaculation. The main recommendation was the early O’Brien, London (GB), Asst. Prof. Maria Carmen Mir 1. Treatment tactics in the presence of a positive recommendations of the World Health Organization appointment of combination therapy and caution with Maresma (ES), the virtual ESU course covered topics surgical edge and the Ministry of Health of Ukraine. Thankfully, combination therapy.

2. When nephrectomy is mandatory and when it is on kidney cancer. From the UUA, the interactive case COVID-19-related morbidity in the country has dropped possible to limit resection discussions was conducted by Prof. Sergey Vozianov, by the time the congress took place and the 3. Techniques and indications for kidney biopsy Dr. Volkov, and myself. restrictions were minimised. Thanks to ESU’s help, the 4. Results of robot-assisted techniques congress was organised, and the course was Presentations and insights such as the tactics and 5. Indications for enucleation restructured into a virtual event. methods of treatment of kidney cancer were shared, 6. Target-therapy options and their indications and the discussions that followed were enlightening.

The presentations were either delivered pre-recorded Of course, everyone misses the urology meetings; the The role of embolisation of renal vessels in the in online format or live at the congress. This adapted treatment of patients in the severe category of was large crowds that they attract, conversing with friends setup made it possible to ensure quarantine clearly defined. and peers in person. However, there is no reason to measures, maintain live communication, and carry out wait until things get back to the way they were; there a scientific programme packed with essential updates. are just too many important developments in urology Impressions we need to talk about now. Rest assured, we will The interaction, participation, and overall Congress coverage organisation of the congress and ESU course were continue to find innovative ways to share and deliver On day one, Prof. Sergey Vozianov (UA), President of During Prof. Carme Mir Maresma’s lecture on clamping outstanding, according to Prof. Sergey Vozianov. He the newest, most relevant urological updates whether UUA and Corresponding Member of the National approaches during partial nephrectomy said, “The UUA and the ESU did an excellent job; the on-site or virtually.

Prof. Alexander Shulyak Dept. of Urology Institute of Urology of the National Academy of Sciences of Ukraine (UA)

August/September 2021

European Urology Today

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ESU Updates

Refresh and test your EAU Guidelines knowledge Take the ESU e-courses and collect your CME credits The European School of Urology (ESU) offers you 16 free e-courses dedicated to the EAU Guidelines.

Every year, when the new edition of the EAU Guidelines is released, renowned experts meticulously select vital points in the new Guidelines and integrate them in the ESU e-courses.

This guarantees that you update your knowledge with the latest information available, and receive European CME credits (ECMEC®). Through these e-courses, the ESU provides urologists and residents with essential and contemporary information on a global scale.

The ESU courses for EAU Guidelines At present, there are 16 ESU e-courses in total which covers a myriad of topics. These e-courses are dedicated to the following EAU Guidelines: • • • • • • • • • • • • • • • •

EAU Guidelines on Neuro-urology EAU Guidelines on Testicular Cancer EAU Guidelines on Bladder Stones EAU Guidelines on Paediatric Urology EAU Guidelines on Renal Transplantation EAU Guidelines on Chronic Pelvic Pain EAU Guidelines on Urinary Incontinence EAU Guidelines on Urological Infections EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer EAU Guidelines on Primary Urethral Carcinoma EAU Guidelines on Non-muscle-invasive Bladder Cancer EAU Guidelines on Men's Health EAU Guidelines on Thromboprophylaxis EAU Guidelines on Urolithiasis EAU Guidelines on Renal Cell Carcinoma EAU Guidelines on Prostate Cancer

E-courses format and CME credits To take the e-courses, here are the steps: 1. Please go to www.uroweb.org/education/ online-education/e-courses/ 2. Click on the e-course of your choice.

3. Click on the 'Log in' button then and log in with your MyEAU account.

4. If you do not have a MyEAU account yet, you can sign up for one for free in a matter of minutes via https://myeau.uroweb.org/myeau/signup. An EAU membership is not mandatory.

5. Once you have a MyEAU account, please do steps 1 to 3.

Each ESU course on the EAU Guidelines is divided into multiple learning modules. Each module is made up of multiple-choice questions. To choose the right answer per question, you are encouraged to navigate to corresponding chapters in the EAU Guidelines.

This way, you will review the most recent Guidelines, test your knowledge, and earn CME credits..

The e-courses are available in English. Each e-course will take approximately 60 to 90 minutes for you to complete. It is mandatory that you answer the questions in the final assessment. A passing grade of 80% and above will guarantee you your CME credits.

Welcome screen of one of the newest ESU e-courses

You can stop anytime during the course if needed. To pick up where you left off, simply log in again to proceed with the remaining questions.

Meet the team The team is comprised of internationally-known experts which include:

A question from the ESU course for EAU Guidelines on Prostate Cancer

Dr. Henk Van Der Poel, Chair Netherlands Cancer Institute (NL)

Dr. Tom Marcelissen Maastricht UMC+ (NL)

Dr. Nikolaos Grivas General Hospital of Ioannina G. Hatzikosta (GR)

Dr. Panagiotis Kallidonis University Hospital of Patras (GR)

The ESU courses on the EAU Guidelines are developed advanced prostate cancer, non-muscle-invasive by the aforementioned experts, reviewed and bladder cancer, urolithiasis and more! approved by the EAU Guidelines Panel, and supported by e-learning specialists of the EAU such as ESU “Through these e-courses, the ESU E-course Manager, Dr. Nan Li (NL).

If you have any questions and/or suggestions for the current e-courses and future topics, please contact us at educationonline@uroweb.org.

provides urologists and residents with essential and contemporary information on a global scale.”

More ESU e-courses for you Interested in enriching your knowledge further and accumulate CME credits? The ESU offers other highly informative e-courses with topics ranging from

Visit the ESU e-courses webpage www.uroweb.org/ education/online-education/e-courses/ for more information.

Join us on the EAU Educational Platforms: The online learning platform for functional urology

The online learning platform for GU cancers (Prostate, Bladder and Kidney Cancers)

uroonco.uroweb.org With access to

uroluts.uroweb.org

:

Webcasts • Articles with expert comments • Surgical videos

Video interviews with key opinion leaders • Webinars on hot topics

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European Urology Today

August/September 2021

Masterclasses in Urology Broaden your knowledge and enhance your skills Let leading experts guide you with: • In-depth lectures

• Case presentations

• Live and semi-live surgeries

• Practical hands-on training

ESU-ESAU-ESGURS Masterclass on Erectile restoration and Peyronie’s disease

ESU-ESTU Masterclass on Kidney transplant

ESU-ESFFU Masterclass on Functional urology

28-29 October 2021, Madrid, Spain

3-4 November 2021 Nijmegen, The Netherlands

Virtual

www.esukidneytransplant.org

www.esufunctional.org

6-7 October 2021 www.esuerectile.org

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

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

ESU-ESUT Masterclass on Lasers in urology 18-19 November 2021, Barcelona, Spain www.esulasers.org

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

ESU-ESOU Masterclass on Non-muscle-invasive bladder cancer 24-25 February 2022, Prague, Czech Republic

www.esunmibc.org

Sign up for an ESU Masterclass!

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

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

esu-masterclasses.uroweb.org August/September 2021

European Urology Today

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European Urology Today

August/September 2021

Profiles

“Cannot talk to patients unless we speak their language” Prof. Eamonn Rogers is the first chair of the newly formed EAU Patient Office Back in 2012, EAU Patient Information (EAU PI) was established to better involve patients and their families in the EAU’s mission of raising the level of urological care in Europe. As well-informed patients are better equipped to talk about their conditions and treatments, this would foster a more meaningful dialogue between the doctor and the patient, which would lead to better care.

pressured to see more patients and reduce waiting times. Urologists cannot be expected to address the additional needs of patients by themselves. With the impending regulatory bureaucracy, it is imperative that my office, in cooperation with EAU colleagues, challenges healthcare providers to develop facilities to support patients psychosocially and financially.”

With its focus on product development, such as translations of the EAU Guidelines into lay language, EAU PI grew significantly over the years that followed. In 2019, this resulted in the creation of the EAU Patient Advocacy Group (EPAG).

“EPAG was established to involve patients and their advocates in every aspect of our product development,” Prof. Eamonn Rogers (IE), chair of EAU PI, explains, “but also, perhaps more importantly, to give them a platform from which they could voice their perspectives and needs.

In EPAG, they can collaborate with the EAU to bring matters to the attention of Members of the European Parliament in Brussels.”

As a result, EAU PI had grown into an impactful part of the EAU, a part that required a seat at the EAU Board table. During the virtual General Assembly on the last day of EAU21, the EAU members approved of the EAU Patient Office being added to the board, with Prof. Rogers as its first chair.

Pillars “I accepted this role because I want to build on PI’s growth and develop further alliances with patient advocacy stakeholders,” Prof. Rogers says.

“I believe two of the pillars we must build on are dedicated patient education and the additional needs identified by patients on Patient Day during EAU21. These needs included more information on the financial burden of urological cancers, ensuring that the needs of loved ones are addressed in care

plans as well, digital literacy, and finding support in patient peer support groups.”

“I want to particularly emphasise the importance of translating our patient materials into our patients’ native languages as we cannot talk to patients about their needs unless we speak their language. I hope my new role as chairman of the EAU Patient Office will allow me to work with national urological societies, who are best placed to know the needs of their citizens.”

Challenges “There will be considerable challenges. While evidence shows patient outcomes are enhanced by patient involvement, urologists are constantly

Prof. Rogers, who started as EAU PI chairman in 2020 with decades of experience as urologist in his home country Ireland, believes he has acquired the know-how to handle these challenges. “In 2016, Ireland’s Health Services appointed me as National Adviser in Urology,” he expounds. “Working with the Royal College of Surgeons, we published a blueprint for urological services in Ireland. ‘A Model of Care for Urology’ incorporated a policy of improved patient access and treatment with an integrated value-based healthcare management strategy to adopt it. A key component was to modify the urological healthcare to optimise the interaction between the hospitals and the community. We worked with multidisciplinary stakeholders and patients to achieve this.

Furthermore, we developed patient-centred strategies on the most prevalent chronic urological conditions Irish urologists had to treat.”

“This unique experience of working simultaneously with patients and healthcare professionals gave me the opportunity to influence and lobby politicians to raise patient issues and seek critical resources. I was left in no doubt of the influence of patient participation in improving urological healthcare services while patient participation enhanced me professionally.”

“Prior to this experience, I had also worked on the Irish national accreditation of patient support groups.”

Partner with patients With his term as chair of the EAU Patient Office just underway, Prof. Rogers directs his words at his fellow

urologists and EAU members. “EAU members have a proud tradition of caring for patients. However, there is an increasing demand from patients for greater control over the decisions that affect their urological health, especially post-COVID. This is driven by demographic changes where patients increasingly seek healthcare advice using internet-based health technology.”

“I hope my new role as chairman of the EAU Patient Office will allow me to work with national urological societies, who are best placed to know the needs of their citizens.”

“I believe it is critically important for urologists to partner with patients as we manage, and patients increasingly live with, highly prevalent and often co-morbid chronic health conditions such as prostate cancer, urinary incontinence, sexual dysfunction, male LUTS, and urinary tract infections. Also, we must advocate for patients with a urological disease so that they receive better support from healthcare providers. In this regard, patients and their advocates are crucial allies as the EAU lobbies for improved urological healthcare.”

“Simultaneously, I hope to educate patients on the importance of participation in clinical research and self-managing general and urological wellness.”

“As I chair this new office, I realise I will be standing on the shoulders of visionary giants.

I want to thank the EAU for the honour of appointing me to this new role.”

Profiles

“A lot that I achieved in life was thanks to the EAU” New EU-ACME chair Prof. Marek Babjuk gives back by contributing to urological education It is a pivotal instrument for European urologists.

The EU-ACME programme keeps track of urologists’ educational activities irrespective of the country they practise in or where they have participated in accredited Continuing Medical Education (CME) or Continuing Professional Development (CPD) activities. “CME and CPD are critical for the quality level of urology in Europe and for the careers of individual urologists,” says Prof. Marek Babjuk (CZ), who has been appointed to new chair of EU-ACME, succeeding Prof. Rien Nijman (NL).

“The quality of education and the level of acquired knowledge have to be checked. EU-ACME is thus tightly connected with all educational activities, including the European School of Urology (ESU) and its scholarship programme (EUSP).”

I will do my best to improve all EU-ACME activites and the flow of information to EAU members.”

What are your goals for EU-ACME? “In the future, it is going to be necessary to improve the communication with individual countries and to try to find a way to boost local acceptance of the legal consequences of European education. Above all, it is paramount to continue with all that was built by Prof. Nijman and his team. Prof. Nijman is a distinguished European expert. He devoted a great deal of effort to EAU’s interests in EU-ACME and to the success of EU-ACME itself. He is deeply respected by the urological community, and it will not be easy to substitute his experience and knowledge. I hope we will stay in touch, at least for the initial few months.”

Has it been a personal goal of you to become chair of EU-ACME? “My goal has been to participate in EAU activities in the area of education. Nearly my entire professional life has been connected with the EAU. The EAU has supported me throughout my career, gave me the opportunity to meet the most distinguished European experts, and allowed me to learn a lot about education, research principles, and activities.

What do you think you will add to the EU-ACME EU-ACME and CME/CPD are non-detachable parts of office?

Prof. Babjuk: “This is not an easy question, because education, so my decision was not difficult. I hope I can contribute to the success of the EAU as the I am just getting started and will need to acquaint myself with many details. I will do my best to bring chairman of the EU-ACME office.” all my experience gained from my academic position at the Charles University in Prague, my work for the “A milestone in my career was my Czech Urological Society, and my participation in several EAU activities to this position. There is no participation in the first surgical doubt that CME/CPD are very important tools to training course of ESU back in 1998.” improve the level of urology within all European countries. For instance, we are currently updating the criteria for the EAU-EBU Host Centre Certification You are also chairman of the EAU Guidelines Programme, which should improve the international Working Panel on Non-Muscle Invasive Bladder recognition of individual European training centres Cancer (NMIBC). Could you tell something about and provide transparent information to scholars. how you started out at the EAU?

“I hope there is still room for improvement at EU-ACME and in the flow of information to EAU members.”

August/September 2021

“I have been an EAU member since 1994. That was the year I participated in the annual meeting in Paris.

This was the era of building a large society with a lot of enthusiasm. The meeting was simply great, and it persuaded me to become a member of the EAU. A milestone in my career was my participation in the ESU course in Ukraine back in 1998, which was the first surgical training course in the history of ESU.” “This was my first direct experience with ESU and the education offered here. As my main scientific interest was bladder cancer, I was invited to contribute to the creation of the EAU Guidelines on NMIBC, which brought me to the centre of the activities of the association. Owing to my activities in this area of education, I became a member of the ESU board. So, apparently, a lot that I achieved in life was thanks to the EAU.”

You work in the Department of Urology at the 2nd Medical Faculty of the Charles University in Prague and have been president of the Czech Urological Society since 2011. What kind of experience you have gained in the Czech Republic do you think you bring to EU-ACME? “All these positions are related to urological education and to generating interest in our specialisation. Moreover, I come from one of the central European countries, which has a different kind of history and, even today, has a specificity to it in comparison with western countries. I hope I will be able to contribute the benefits of all these experiences to the success of EU-ACME and to the enhancement of urology in the whole of Europe.”

For more information on EU-ACME, please visit www.eu-acme.org.

European Urology Today

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Selecting imaging modality to follow up drug response PERCIST criteria developed to define progressive disease not commonly used Prof. Francesco Sanguedolce ESUI Board Member Fundació Puigvert Barcelona (ES) University of Sassari (IT) fsangue@ hotmail.com Guidelines on how to assess systemic treatment response to solid tumours are based on the RECIST version 1.1 criteria, which define how to report measurable and non-measurable lesions by using conventional imaging. They also define how to assess treatment response on the basis of unidimensional changes of target and non-target lesions, as well as in the case of appearance of new lesions. [1] Systemic disease treatment changed In the last 10-15 years, the paradigm of treatment of systemic disease has changed for all the main urological cancers: in renal cell carcinoma (RCC) with the introduction of tyrosine-kinase inhibitors and inhibitors of angiogenesis, in urothelial cancer (UC) with the immune checkpoint inhibitors, and in prostate cancer (PCa) with the new generation of antiandrogens.

These new treatment modalities can induce necrosis/ oedema, inflammatory reaction and/or flare-up at the targeted lesions, which can result in an increase in size at the anatomical unidimensional evaluation – defined as progressive disease by RECIST 1.1. Such a circumstance is called pseudo-progression.

“In the last 10-15 years, the paradigm of treatment of systemic disease has changed for all the main urological cancers. As a result, there is an urgent need to switch from a unidimensional to a metabolic assessment of drug response.”

Cytostatic agents Cytostatic agents are known to cause this phenomenon, which is not contemplated on the RECIST criteria as they are based on the response assessment to cytotoxic agents. This may especially happen when using the latest generation of systemic immune treatments for RCC and UC. In order to avoid this issue, a modified version of the RECIST criteria has been introduced in systemic immunotherapy. A new response category has been added called Immune-Unconfirmed Progressive Disease, which is defined as an increase in size at the EAU Section of Urological Imaging (ESUI)

Fig. 1: Standard imaging fails to identify changes in response to treatment in bone metastases

anatomical unidimensional evaluation in the presence of a clinical/laboratory response that it is not confirmed at the subsequent re-assessment within 4 or 8 weeks.

[2] As a result, there is an urgent need to switch from a unidimensional to a metabolic assessment of drug response, especially in the setting of systemic treatments.

European Urology Today

”Which type of imaging test should

PERCIST criteria In an attempt to adapt the RECIST criteria to a be used to stage systemic disease and metabolic assessment with 18F- Fluorodeoxyglucose monitor treatment response?"

(FDG) PET/CT, the PERCIST criteria [3] have been developed, which define progressive disease (PD) in the case of: How should NGI be reported? The METastasis Reporting and Data System for Prostate Cancer (METRADS – P) • more than 30% increase in standard uptake value has been published to standardise imaging acquisition corrected for lean body mass (SULpeak); and response assessment by means of WBMRI. Bone • new 18F-FDG–avid lesions; and soft tissue lesions are reported separately, and • growth in total lesion glycolysis by more than 75%. each lesion is given a score from 1 to 5 with respect to the likelihood of treatment response. [6] In figures 1 Nevertheless, these criteria have only been applied in and 2 the case of a 60-year old patient with HSPC and the setting of a few trials, as FDG PET/CT is not bone metastasis on enzalutamide is described. routinely performed and some of these criteria are not According to RECIST 1.1 criteria there is a stable disease commonly measured or reported. Furthermore, not all response at conventional imaging, but biochemical and cancers are FDG-avid. Indeed, prostate cancer is not WBMRI findings are showing a complete response.

FDG-avid. This is the reason why several new imaging Recently, another reporting system has been proposed tools have been introduced in the management of for PET PSMA imaging. [7] Nevertheless, all these advanced prostate cancer, which include PET/CT with reporting systems need external validation before they different tracers, PET/MRI and whole-body MRI can be introduced in clinical practice or in trials.

(WBMRI). Next-generation imaging (NGI) can better define PD in Hormone-Sensitive Prostate Cancer (HSPC), Imaging to stage systemic disease can detect micrometastasis in non-metastatic Overall, it is not yet clear which type of imaging test Castration-Resistant Prostate Cancer (CRPC) patients, should be used to stage systemic disease and monitor and can prompt a timely switch of treatment line in the treatment response. The pivotal studies in the different metastatic CRPC setting. clinical scenarios included mostly (if not only)

Fig. 2: Quantitative whole-body MRI with diffusion-weighted imaging (DWI) as a response biomarker

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Reporting next-generation imaging The RADAR III group and the ASCO have recently published guidelines and recommendations on how to use NGI. They should be used as complementary tests as long as they may prompt a change of treatment strategy. [4,5]

conventional imaging (CT and Bone Scan), while there is a progressive increase in the use of NGIs in current clinical practice. Furthermore, the increased cost burden that their employment involves is substantially limiting their diffusion throughout the world.

Finally, there is an urgent need to demonstrate their clinical benefit, as potential stage-migration (or Willy Rogers phenomenon) to an earlier detection of progressive disease may provide a false perception of survival improvement. Also, earlier sequencing of systemic drugs may facilitate selection of more aggressive tumour variants.

References 1. Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, Dancey J, Arbuck S, Gwyther S, Mooney M, Rubinstein L, Shankar L, Dodd L, Kaplan R, Lacombe D, Verweij J (2009) New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). European journal of cancer 45 (2):228-247. doi:10.1016/j. ejca.2008.10.026 2. Seymour L, Bogaerts J, Perrone A, Ford R, Schwartz LH, Mandrekar S, Lin NU, Litiere S, Dancey J, Chen A, Hodi FS, Therasse P, Hoekstra OS, Shankar LK, Wolchok JD, Ballinger M, Caramella C, de Vries EGE, group Rw (2017) iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics. The Lancet Oncology 18 (3):e143-e152. doi:10.1016/S1470-2045(17)30074-8 3. Wahl RL, Jacene H, Kasamon Y, Lodge MA (2009) From RECIST to PERCIST: Evolving Considerations for PET response criteria in solid tumors. Journal of nuclear medicine : official publication, Society of Nuclear Medicine 50 Suppl 1:122S-150S. doi:10.2967/jnumed.108.057307 4. Crawford ED, Koo PJ, Shore N, Slovin SF, Concepcion RS, Freedland SJ, Gomella LG, Karsh L, Keane TE, Maroni P, Penson D, Petrylak DP, Ross A, Mouraviev V, Reiter RE, Divgi C, Yu EY, Group RI (2019) A Clinician's Guide to Next Generation Imaging in Patients With Advanced Prostate Cancer (RADAR III). The Journal of urology 201 (4):682-692. doi:10.1016/j.juro.2018.05.164 5. Trabulsi EJ, Rumble RB, Jadvar H, Hope T, Pomper M, Turkbey B, Rosenkrantz AB, Verma S, Margolis DJ, Froemming A, Oto A, Purysko A, Milowsky MI, Schlemmer HP, Eiber M, Morris MJ, Choyke PL, Padhani A, Oldan J, Fanti S, Jain S, Pinto PA, Keegan KA, Porter CR, Coleman JA, Bauman GS, Jani AB, Kamradt JM, Sholes W, Vargas HA (2020) Optimum Imaging Strategies for Advanced Prostate Cancer: ASCO Guideline. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 38 (17):1963-1996. doi:10.1200/JCO.19.02757 6. Padhani AR, Lecouvet FE, Tunariu N, Koh DM, De Keyzer F, Collins DJ, Sala E, Schlemmer HP, Petralia G, Vargas HA, Fanti S, Tombal HB, de Bono J (2017) METastasis Reporting and Data System for Prostate Cancer: Practical Guidelines for Acquisition, Interpretation, and Reporting of Whole-body Magnetic Resonance Imaging-based Evaluations of Multiorgan Involvement in Advanced Prostate Cancer. European urology 71 (1):81-92. doi:10.1016/j.eururo.2016.05.033 7. Fanti S, Hadaschik B, Herrmann K (2020) Proposal for Systemic-Therapy Response-Assessment Criteria at the Time of PSMA PET/CT Imaging: The PSMA PET Progression Criteria. Journal of nuclear medicine : official publication, Society of Nuclear Medicine 61 (5):678-682. doi:10.2967/ jnumed.119.233817

August/September 2021

Cherish life’s special moments

#UROLOGYWEEK

Stress incontinence causes urine leaks during activities such as exercising, laughing or even just coughing.

Talk to your urologist about the treatment best suited for you.

urologyweek.org

August/September 2021

European Urology Today

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Enjoy your golden years Overactive bladder and incontinence shouldn’t stop the fun. Ask your urologist about treatment options so you can focus on living life to the fullest. #UROLOGYWEEK

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urologyweek.org

European Urology Today

August/September 2021

Be unstoppable 60% of incontinence issues are treatable. Consult your urologist about what treatments are best suited for you.

#UROLOGYWEEK

urologyweek.org

August/September 2021

European Urology Today

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You don’t always have to go with the flow 10-20% of Europeans experience frequent urine loss. Consult your urologist about overflow incontinence and the best treatment options for you. #UROLOGYWEEK

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urologyweek.org

European Urology Today

August/September 2021

Profiles

2021 General Assembly paves way for new faces New Chairs for Robotics, Urolithiasis and Uropathology Sections EAU21 was not only a scientific highlight for urology in its own right, but it played an important part for the future of the Association too. At the General Assembly on 12 July 2021, which was the first in over two years, existing EAU Board members could formally retire and be succeeded by their replacements. The same goes for the chairs of the EAU’s Sections.

In 2021, there are three new faces for the EAU Sections for Robotic Urology (ERUS), Urolithiasis (EULIS) and Uropathology (ESUP). We spoke with the incoming chairmen as they start their new terms.

EULIS Prof. Christian Seitz (Vienna, AT) has succeeded Prof.

Kemal Sarica (Istanbul, TR) as chairman of EULIS, the EAU Urolithiasis Section. Prof. Seitz is Head of the Stone Clinic and head of Robotic Surgery at the Urology Department of the Medical University of Vienna, Austria. He has been a EULIS board member since 2013 and has been on the EAU Guidelines panel on Urolithiasis since 2009.

“Prof. Sarica promoted EULIS successfully in all parts of the world,” said Prof. Seitz. “He always steered EULIS in a professional and friendship-driven way, in which collaboration and multidisciplinarity was always a key to success. To say it in his words we were all ‘brothers and sisters in stones’.”

Prof. Alberto Breda

ERUS Prof. Alberto Breda (Barcelona, ES) will succeed Prof. Alexandre Mottrie (Aalst, BE) as chairman of the EAU Robotic Urology Section. Prof. Mottrie was the ERUS Chairman ever since ERUS joined the EAU as a section in 2011, making this a transitional moment for the section.

Uropathology “Uropathology research also focuses on themes of applied pathology, approached in close collaboration with the clinicians, backed up by appropriate epidemiological support, while not neglecting the traditional framework as the basis of a modern gauged characterization of pathological settings.”

ambitions is to give a voice to these societies and to help them get the recognition they deserve by embracing an alliance with the ERUS. Finally, I am committed to entering close collaborations with the major academic centres in the world to give our young robotic urologists an opportunity to apply for exchange programmes that would benefit their careers.”

“Our section works in line with the EAU organisational structure. I see the strength of EULIS in its multidisciplinary approach to urolithiasis, working in close cooperation with paediatricians, nephrologists, nutrition scientists, research dieticians, radiologists and other affiliated medical professionals keeping up with new developments. Therefore, EULIS deals with all aspects of stone disease treatment: from diagnosis, intervention to metabolics, nutrition, metaphylaxis and prevention.”

“Together with our board, associates and affiliate members I want to further promote this multidisciplinarity through our workshops, webinars, congress participation and our biannual meetings. Additionally, we will support fellowship programmes in centres of excellence aiming at that integrated approach.”

Prof. Maurizio Colecchia

He is Chair of the Uropathology Working Group of the European Society of Pathology, Chair of Uropathology Group, Societa’ Italiana di Patologia (SIAPEC) and member of its Scientific Committee.

Prof. Colecchia is a member of several other pathology-related bodies and a widely cited author.

This is his first appointment with the EAU. Asked if being Italian was in some way useful for the chairman of ESUP, Prof. Colecchia explained the important role of uropathologists in urology in Italy: “In Italy many uropathologists have an important role in clinical practice with involvement in guidelines regarding the management of urologic neoplasms, contributing to the activities of the national scientific society of Pathology (SIAPEC), and as expected experts to many chapters of the WHO Classification of Genitourinary Society of Pathology, 5th edition.”

“Nowadays, the increase of molecular tests for diagnostic and prognostic use in daily practice is relevant and EAU members have to be aware of the impact of molecular predictive tests on the response to therapy in GU neoplasms. Prostate cancer risk for male BRCA 1 and BRCA 2 mutation carriers has been introduced in the assessment of personal and familial predisposition to carry PCa, and the role of immunotherapy with protocols requiring PDL 1 evaluation is central both in adjuvant as well as neoadjuvant chemotherapies.”

“My ambitions with ESUP are to have a collaborative role in EAU to work up an update in the field of basic and translational research, regarding the aetiology and pathogenesis of urological diseases.”

Prof. Jens Rassweiler (Heilbronn, DE), Chairman of the EAU Section Office marks the transition of Section Chairs: “On behalf of the EAU, I would like to thank the departing chairmen for many years of duty to their section and the EAU in general. I look forward to working with their successors and wish them all the best in their new positions. We will support their sections in any way we can.”

For more information about the EAU’s Sections, visit www.uroweb.org/sections

Prof. Breda is Chief of the Uro-Oncology Unit at the Fundació Puigvert in Barcelona and well-known within the EAU. Until recently he was chair of the Laparoscopic Group within the EAU Section of Uro-Technology, and he remains a member of the Scientific Congress Office and Chairman of the Renal Transplantation Guidelines Panel. Prof. Breda is specialised in minimally invasive surgery in the field of Uro-Oncology and Kidney transplantation.

“Prof. Mottrie is a role model for many of us,” said Prof. Breda, reflecting on his predecessor. “He has been a pioneer in robotic surgery and many of us learned the way to perform certain robotic surgeries from him.”

“Moreover, he is a talented speaker, a team player and an excellent human being. He is actively involved in training surgeons from all over around the world and possibly this is among his main merits. I am willing to push the ERUS forward and I am happy that I will be able to count on the help of many talented ERUS board members including Prof. Mottrie, who will still be actively involved in education within ERUS and at ORSI, the OLV Robotic Surgery Institute in Belgium.”

Ambitions Prof. Breda is taking over at an interesting point for robotic urology: more and more companies are close to bringing new robotic systems to market, potentially opening doors for new applications for surgical robots and costs coming down. Prof.

Breda: “The ERUS has become a great society and it represents a trade union between robotics and urology. ERUS, as many other societies, have been able to grow thanks to the effort of many talented surgeons and assistants and thanks to a strict collaboration with Intuitive over the past 15 years.”

“Nowadays there are at least three new robotic companies coming in the market, and one major issue will be the way we will be able to provide training to the surgeons with all the new machines.”

“Furthermore, I believe there are still too many national sub-societies that are not able to be represented within Europe. One of my main

August/September 2021

Join us in Amsterdam!

Prof. Christian Seitz

Upcoming developments in urolithiasis Prof. Seitz sees many developments in the coming years for urolithiasis, something that the section will also be dealing with in their meetings and educational efforts. “Innovations in technology like further miniaturisation of instruments, and improved or new lithotripsy and stone removal devices are continuous developments supporting the concept of a ‘personalised stone approach’.”

“Urologists should be aware that genetics, microbiomes and proteomics are developing fields, aiming to unravel urolithiasis disease mechanisms.

Beyond that, machine learning and deep learning applications, both subsets of artificial intelligence, are gaining significant interest in urology and have the potential to revolutionize the decision-making process.”

ESUP The EAU Section of Uropathology, ESUP, welcomes Maurizio Colecchia (Milan, IT) as its new chairman, succeeding Prof. Rodolfo Montironi (Ancona, IT).

Abstract submission deadline: 1 November 2021

Maurizio Colecchia is Associate Professor of Pathology at Vita Salute University San Raffaele.

www.eau22.org European Urology Today

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In the first-line treatment of advanced renal cell carcinoma (RCC)

R EACH FOR C ONTROL+ C ONFIDENCE BAVENCIO® (avelumab) in combination with axitinib is an immunotherapy and a tyrosine kinase inhibitor approved by the EMA for patients with advanced RCC, delivering1*: Significant progression-free survival (PFS) vs sunitinib1

A well-characterized safety and tolerability profile • Rate of permanent discontinuations due to treatment-emergent adverse events: 7.6% vs 13.4% with sunitinib2 • Rate of permanent discontinuations due to treatment-related adverse events: 3.5%† vs 8.0% with sunitinib3 – 14.7% of patients permanently discontinued only BAVENCIO due to treatment-related adverse events – 8.1% of patients permanently discontinued only axitinib due to treatment-related adverse events • 11.1% of patients required high-dose corticosteroids for the treatment of immune-related adverse events2 • 56.7% of patients experienced Grade ≥3 treatment-related adverse events vs 55.4% with sunitinib (fatal adverse events occurred in 3 patients treated with BAVENCIO in combination with axitinib and in 1 patient treated with sunitinib)2 – Hepatotoxicity with BAVENCIO in combination with axitinib: Grade ≥3 increased ALT and increased AST occurred in 4.8% and 2.8% of patients, respectively

• 31% reduction in the risk of disease progression or death vs sunitinib (HR: 0.69 [95% CI: 0.57, 0.83]; P<0.0001) • mPFS: 13.3 months vs 8.0 months with sunitinib

Nearly double the objective response rate (ORR) vs sunitinib1 • 52.5% ORR vs 27.3% with sunitinib

*The overall study population in the JAVELIN Renal 101 Trial (N=886) included all patients, regardless of PD-L1 expression.1 Rate represents patients who discontinued both BAVENCIO and axitinib.3

†

ALT=alanine aminotransferase; AST=aspartate aminotransferase; CI=confidence interval; EMA=European Medicines Agency; HR=hazard ratio; mPFS=median progression-free survival; PD-L1=programmed death-ligand 1.

To learn more, please see the EMA-approved SmPC (Summary of Product Characteristics) References: 1. BAVENCIO® (avelumab). European Summary of Product Characteristics. Amsterdam, the Netherlands: Merck Europe B.V.; Jan 2021. 2. Motzer RJ, Penkov K, Haanen J, et al. Avelumab plus axitinib versus sunitinib for advanced renal-cell carcinoma. N Engl J Med. 2019;380(12):1103-1115. 3. European Medicines Agency, Committee for Medicinal Products for Human Use (CHMP). Assessment report: Bavencio. 19 September 2019. Procedure no. EMEA/H/C/004338/II/0009/G.

Copyright © 2021 Merck KGaA, Darmstadt, Germany. All rights reserved.

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GL-AVE-00114

August/September 2021

MARS: Management of priapism and impact on outcomes First international, multicentre, observational study regarding priapism Prof. Giorgio Russo Università Degli Studi Di Catania Department of Urology Catania (IT) giorgioivan1987@ gmail.com We would like to present to our readers the first international, multicentre, observational study regarding priapism: “the MARS study (ManAgement of pRiapiSm and its impact on outcomes: an international register; NCT04932902).” The project is conducted by the YAU Sexual and Reproductive Health Group and the EAU Research Foundation.

The project The principal target of the MARS study is to shed light on what may be the response to medical surgical treatment in patients with priapism. In particular, the MARS study aims to set up a rational data collection that has a solid scientific basis.

EAU Research Foundation

Priapism is a urological emergency that is defined as a prolonged penile erection lasting more than 4 hours despite orgasm and in the absence of sexual stimulation. It causes time-dependent smooth muscle damage that can result in significant morbidity (including permanent erectile dysfunction (ED), penile shortening, penile curvature, and loss of girth) without prompt intervention.

“These data will have a significant impact on current EAU guidelines and recommendations”

outcomes after medical or surgical treatment. The aim of our study is to evaluate the impact of the management of priapism from a sexual and clinical long-term-outcomes point of view.

“Evidence-based treatment strategies for priapism are currently lacking, especially with regard to sexual function”

How does it work?

Our purpose is to create an international register that could be a starting point for the creation of a solid, Evidence-based treatments are lacking scientific, evidence-based approach regarding Despite the very high burden of priapism and its priapism. Taking part is simple. Moreover, you will time-dependent adverse effect on erectile function, become part of what could potentially be the largest few studies have comprehensively defined the clinical prospective study on priapism treatment ever epidemiology of this complication. Nor have any performed. Anybody who works in a centre and treats studies compared sexual dysfunction in men with cases of priapism can quickly and easily enter the sickle cell disease (SCD) with the sexual dysfunction in data into our online secure database (powered by those without it. Evidence-based treatment strategies Castor®). All contributors will receive PubMed for priapism are currently lacking, especially with indexed collaborator authorship. The highest regard to sexual function. Even today, the published recruiting individuals will be invited on the writing studies show considerable bias in terms of sample committee. The more patients you recruit, the higher size, evaluation of reproducible outcomes, use of up the collaborative list you will be. And the more internationally validated questionnaires, well-defined likely it is you will be asked to present the study follow-up evaluation as well as the evaluation of findings at conferences.

Prospects The expectations for the present proposal vary. First, we hope to acquire more knowledge about sexual function in patients with priapism using prospective, multicentre data with objective and reliable variables.

Second, these data will have a significant impact on current EAU guidelines and recommendations. Finally, from a clinical point of view, these data could be useful to establish new treatments for the management of priapism. You will find more information in the section “EAU RF projects” on the EAU website (https://uroweb.org/research/projects) or you can send an email to giorgioivan.russo@unict. it to ask for participation and receive a registration account.

“You will become part of what could potentially be the largest prospective study on priapism treatment ever performed”

ROGUE-1: Multicentric, prospective T1 BCa registry EAU RF supports set-up of extensive database for improved diagnosis and treatment Dr. David D'Andrea Dept. of Urology, Comprehensive Cancer Center Medical University Vienna Vienna (AT) david.dandrea@ meduniwien.ac.at Co-authors: Francesco Soria, Paolo Gontero, Shahrokh F. Shariat Patients with T1 urinary bladder cancer (UBC) are at high risk for recurrence and progression. [1] However, the prognosis depends on several concomitant factors. First and foremost, an accurate diagnosis is imperative to appropriate disease management.

“We believe that this project has the potential of changing the management of patients with T1 UBC.” Under or over-staging Due to conventional transurethral resection techniques resulting in fragmentation and cauterisation of the tissue, the pathological review is often difficult and may result in under- or over-staging. A central pathology review of European Organisation For Research And Treatment Of Cancer (EORTC) trial data found only a 43% concordance in patients with T1 tumours. [2] Moreover, risk factors such as concomitant carcinoma in situ (CIS), variant histology (VH), and lymphovascular invasion (LVI) have been associated with a prognosis of a poor quality in patients with T1 UBC. [3] However, there is a consistent heterogeneity in reporting these features across studies.

Clean prospective dataset There is an unmet need for a clean prospective dataset on T1 UBC to allow an accurate risk stratification in order to aid clinical decision making.

Thanks to the support of the EAU Research Foundation (EAU RF), we could start a project aiming at prospectively collecting data on patients with a primary diagnosis of T1 UBC and creating a platform that will answer relevant clinical questions. Studies originating from this registry can potentially change risk stratification and, therefore, management of patients with T1 UBC. EAU Research Foundation

August/September 2021

Study objectives The primary objectives of the study are: • To investigate the therapy failure rates in patients with primary diagnosis of T1 UBC; • To investigate the association of clinicopathological features such as LVI, VH and CIS, tumour size, and number of tumours with pathological outcomes; • To analyse the accuracy of the local pathologist assessment with regard to the evaluation of pathology features such as tumour stage and grade, sub-staging according to microscopical and extensive invasion, LVI, VH, and CIS; • To investigate the inter-observer variability among different local pathologists comparing these observations with a central pathology revision performed by an expert genitourinary pathologist; • To develop a clinically applicable risk stratification tool which may guide physicians during patient counselling and decision-making regrading adjuvant therapies or early cystectomy.

Patients with a primary diagnosis of UBC and who are scheduled for TURB are prospectively recruited from academic tertiary care centres across Europe, Canada, and the USA. Patients with confirmed diagnosis of T1 UBC are included in the study.

Adjuvant treatments After TURB, patients will receive adjuvant treatments (i.e. intravesical therapy or early cystectomy) and a follow-up according to guidelines and clinical standards. All clinical and pathological data, as well as data regarding adjuvant treatments, will be prospectively collected during the study period or until patient death. We plan to recruit patients over a two-year period and follow them for five years. The duration of the project will therefore be seven years.

Pathological images Another major strength of this project is the prospective collection of pathological images.

The database is designed to accept the upload and storage of scanned pathology slides that will be available for central pathological re-review and further analyses, as required by the projects originating from this database.

“There is an unmet need for a clean prospective dataset on T1 UBC to allow an accurate risk stratification.”

Failure rate Recurrence rates for T1 bladder cancer are estimated to be up to 50%. [4] We plan to include 700 patients in the study. This allows detection of a 50% failure rate with 4% on either side of the 95% Confidence Interval (proportion 0,50 with 95% CI 0.46 - 0.54).

The recruitment of patients has started in August 2021. We are welcoming any partner interested in participating in this great project. We believe that this project has the potential of delivering highquality data and a high level of evidence research that will eventually change the management of patients with T1 UBC.

References 1. Babjuk M, Burger M, Compérat EM, Gontero P, Mostafid AH, Palou J, et al. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update.

Eur Urol 2019;76:639–57. https://doi.org/10.1016/j. eururo.2019.08.016.

2. Meijden Avd, Sylvester R, Collette L, Bono A, Kate Ft. The Role And Impact Of Pathology Review On Stage And Grade Assessment Of Stages Ta And T1 Bladder Tumors: A Combined Analysis Of 5 European Organization For Research And Treatment Of Cancer Trials. J Urology 2000;164:1533–7. Https://Doi. Org/10.1097/00005392-200011000-00017.

3. D'Andrea D, Abufaraj M, Susani M, Ristl R, Foerster B, Kimura S, et al. Accurate prediction of progression to muscle-invasive disease in patients with pT1G3 bladder cancer: A clinical decisionmaking tool. Urologic Oncol Seminars Orig Investigations 2018;36:239.e1-239.e7. https://doi. org/10.1016/j.urolonc.2018.01.018.

4. Cambier S, Sylvester RJ, Collette L, Gontero P, Brausi MA, Andel G van, et al. EORTC Nomograms and Risk Groups for Predicting Recurrence, Progression, and Disease-specific and Overall Survival in Non– Muscle-invasive Stage Ta–T1 Urothelial Bladder Cancer Patients Treated with 1–3 Years of Maintenance Bacillus Calmette-Guérin. Eur Urol 2016;69:60–9. https://doi.org/10.1016/j. eururo.2015.06.045.

“We are welcoming any partner interested in participating in this great project.”

Complex data collection One of the major challenges we faced when we planned this study was how to handle such an extensive and complex data collection. We needed a solution which was reliable, multi-platform and user-friendly. Thanks to the support of EAU RF, we could create an individualised, cloud-based clinical data management database for this project. We used the Castor Electronic Data Capture (www.castoredc. com), a platform developed to capture medical research data in clinical trials. The platform helps to standardise research studies and ultimately creates better treatments and care standards for patients.

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European Urology Today

August/September 2021

Ablative therapy for renal masses: Present and future Current view and plans by the ESUT Ablative Group Prof. Dmitry Enikeev Sechenov University Institute for Urology and Reproductive Health Moscow (RU) dvenikeev@ gmail.com The ongoing quest for less invasive surgery remains one of the primary concerns of the medical community. The combination of trying to reduce the negative impact on the patient’s quality of life and developing precise volumetric imaging has resulted in the creation of image-guided ablative techniques.

In 2006, renal cell carcinoma ablation was mentioned in the EAU guidelines for the first time: an ‘experimental approach with limited applicability’.

Until 2010, a lack of adequate data made the transition to cryoablation and RFA problematic.

Currently, the European guidelines strongly recommend performing tumour ablation (TA) only on patients with small renal masses who are for one reason or another ineligible for surgery. Since then, image-guided ablation procedures have become a feature of urological departments all over the world.

Their safety and efficacy are constantly being verified.

This article aims at keeping the medical community updated on recent developments and highlighting the future potential of ablation techniques.

What is the state of play?

As readers are probably aware, the two main techniques suggested by the European guidelines for the percutaneous ablation of kidney tumours are cryoablation (CRA) and radiofrequency ablation (RFA). The main principle underpinning these procedures is to apply extremely low or high temperatures to the tumour site directly. As you can imagine, this results in cell injury, tumour apoptosis as well as coagulative necrosis. In a BJU International meta-analysis of case studies published by El Dib et al. (2012), it was shown that the CRA and RFA complication and efficacy rates were comparable. [1] The mechanisms Cryoablation refers to the freezing of cancer lesions below -20°C. The technique is based on the JouleThomson effect – the temperature changes due to rapid expansion of gas. The stages of the procedure comprise the freezing of the tumour with argon (cooling probe up to -40 °C), and then rapid thawing with helium. [2] These two consecutive steps lead to cellular death as a result of its rupture with ice crystals. [3]

Despite tumour ablation’s long history, wellperformed RCTs are still hard to find. In fact, most of the available studies deal with comorbid and frail patients and thus there is quite a selection bias. Any future studies should ideally include other cohorts of patients - this would then lead to a more objective outcome. In recent decades, we have gained valuable experience regarding the CRA and RFA of kidney cancer, despite the lack of prospective randomised trials. This means that ablative techniques nowadays comprise a rather well-studied treatment modality, especially in some patient cohorts. Even though it is comparable to PN in terms of outcomes, ablative surgery remains of particular interest for the reason of its specific advantages over conventional partial nephrectomy.

What are the advantages?

One of the main advantages of ablation is that it is possible to carry it out in one day. Previously, Rivero et al. [8] reported a decreased hospital stay for those who were treated with ablation. These data on shorter hospitalisation periods are supported by the meta-analysis of Sanchez et al., which shows a lower complication rate after TA compared to PN [9], despite the shorter hospitalization length.

Moreover, as with tumour biopsy, cryoablation can be performed under local anaesthesia. Kerviler et al. showed that the mean pain levels measured during the procedure were negligibly low. [10] No general anaesthesia means that the hospital stay can be reduced. And let’s not forget that general anaesthesia in elderly patients may cause a number of neurological disorders, including cognitive decline.

Cost effectiveness Moreover, local anaesthesia and low complication rates allow us to treat weak and frail patients. Active surveillance might be an option for this group of people, but lower quality of life and increased anxiety in patients on active surveillance suggest that immediate treatment is advantageous. Another point which cannot be ignored is the cost effectiveness of TA for health care systems. For example, the median total costs were almost 3 times lower for TA than for PN [11] in Castle’s analysis.

However, renal tumour biopsy is always required before the ablative treatment because TA doesn’t allow us to perform a histological evaluation of the treated site. Some prefer to perform a biopsy on the same day as the ablation, but the jury is out on this one. At Sechenov University, we prefer to perform a biopsy several weeks prior to ablation so intraprocedural imaging is not compromised and the risk of complications remains at a minimum.

What can we expect?

What is mostly expected from TA relates to the expansion of the indications. Even now, we may see Radiofrequency ablation, on the other hand, works on studies with favourable oncological outcomes for the basis of temperature increase (> 50°C). This larger tumours (T1b). For example, Andrews et al. method is also based on the Joule effect. It is the found that local recurrence, metastases and deaths process by which the passage of an electric current from RCC were not statistically different between PN through a conductor (tissue) produces heat. [4] The and cryoablation for cT1b patients. [12] Another resulting hyperthermia leads to cellular damage due important issue to be borne in mind is that we can to the immediate protein denaturation and perform ablation in patients without comorbidities – subsequent coagulative necrosis. Delayed changes this data is supported by a growing body of evidence occur several days after heating just as with induction on 5 and 10-year outcomes after TA. We believe that of apoptosis and vascular injury. in the not too distant future ablative surgery will be recommended for use in all patient cohorts.

Bias In the 2021 EAU guidelines, both CRA and RFA for TA’s future not only lies in the enhancement of renal cell carcinoma are recommended in weak and current modalities but also the development of new comorbid T1a patients. [5] Ablation was found to be energy-based techniques. As readers may be aware, safe, resulting in lower complication rates than evidence on percutaneous microwave ablation surgery, and the only uncertainty was long-term (MWA) is rapidly growing. Yu et al. showed no oncological efficacy. High long-term survival rates difference between MWA and PN in their cohort were demonstrated by several large studies. A study study involving 1,955 patients neither in local tumour on cryoablation published in 2015 (Larcher et al.) progression, cancer-specific survival nor in distant showed a 10-year recurrence-free survival rate of metastases. [13] Irreversible electroporation (IRE), 95%, disease relapse-free survival of 81%, cancerfirst used in prostate cancer became a subject of specific mortality-free survival rate of 100% and research in RCC ablation. Currently, the only results all-cause mortality-free survival rate of 61% [6] available are those of short 2-year follow-up by A controlled study by Thompson et al. published in Canvasser et al. in renal tumours: with 83% of local European Urology (2015) showed that 5-year recurrence-free survival [14]. Initial clinical studies on metastatic-free survival rate was better after PN in laser ablation of renal tumours by Kariniemi et al. comparison with RFA (p = 0.005) for T1a tumours. [7] showed preliminary efficacy with no local recurrence The authors explained these differences by during 20 months of follow-up [15], yet this result imperfections in TA and imaging protocols, resulting remains highly questionable in view of inferior in residual cancer. However, these specific studies are outcomes in other trials. Stereotactic ablative of limited use because of their bias in selecting radiotherapy (SABR) has been presented as a viable patients. option for inoperable T1A patients. In their metaanalysis, Correa et al. have shown encouraging results of SABR with local control rate of 97.2%. [16] EAU Section of Uro-Technology (ESUT) However, the absence of high-quality controlled August/September 2021

Fig. 1: Partial nephrectomy and ablative therapies

studies means that we should be careful in promoting these techniques, at least at the moment.

Join the team Tumour ablation is undoubtedly an important treatment modality that is now becoming a feature of clinical practice. Obviously, ongoing and future studies will expand the range of indications for TA and develop this technique further. The ESUT group plans to deepen its work on tumour ablation of the kidneys.

We hope that you will join our team in its efforts to broaden the knowledge of this procedure as more and more surgeons continue to show interest in the universe of ablative techniques.

References 1. El Dib, R., Touma, N. J. & Kapoor, A. Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: A meta-analysis of case series studies. BJU Int. 110, 510–516 (2012).

2. Habash, R. W. Y., Bansal, R., Krewski, D. & Alhafid, H. T. Thermal therapy, Part III: Ablation techniques. Crit.

Rev. Biomed. Eng. 35, 37–121 (2007).

3. Chu, K. F. & Dupuy, D. E. Thermal ablation of tumours: Biological mechanisms and advances in therapy. Nat. Rev. Cancer 14, 199–208 (2014).

4. Ahmed, M., Brace, C. L., Lee, F. T. & Goldberg, S. N. Principles of and advances in percutaneous ablation.

Radiology 258, 351–369 (2011).

5. EAU Guidelines: Renal Cell Carcinoma | Uroweb.

6. Larcher, A. et al. Long-term oncologic outcomes of laparoscopic renal cryoablation as primary treatment for small renal masses. Urol. Oncol. Semin. Orig.

Investig. 33, 22.e1-22.e9 (2015).

7. Thompson, R. H. et al. Comparison of partial

nephrectomy and percutaneous ablation for cT1 renal masses. Eur. Urol. 67, 252–259 (2015).

8. Rivero, J. R. et al. Partial Nephrectomy versus Thermal Ablation for Clinical Stage T1 Renal Masses: Systematic Review and Meta-Analysis of More than 3,900 Patients.

J. Vasc. Interv. Radiol. 29, 18–29 (2018).

9. Sanchez, A., Feldman, A. S. & Ari Hakimi, A. Current management of small renal masses, including patient selection, renal tumor biopsy, active surveillance, and thermal ablation. J. Clin. Oncol. 36, 3591–3600 (2018).

10. de Kerviler, E. et al. The Feasibility of Percutaneous Renal Cryoablation Under Local Anaesthesia.

Cardiovasc. Intervent. Radiol. 38, 672–677 (2015).

11. Castle, S. M. et al. Cost comparison of nephron-sparing treatments for cT1a renal masses. Urol. Oncol. Semin.

Orig. Investig. 31, 1327–1332 (2013).

12. Andrews, J. R. et al. Oncologic Outcomes Following Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses(Figure presented.). Eur. Urol. 76, 244–251 (2019).

13. Yu, J. et al. Percutaneous Microwave Ablation versus Laparoscopic Partial Nephrectomy for cT1a Renal Cell Carcinoma: A Propensity-matched Cohort Study of 1955 Patients. Radiology 294, 698–706 (2020).

14. Canvasser, N. E. et al. Irreversible electroporation of small renal masses: suboptimal oncologic efficacy in an early series. World J. Urol. 35, 1549–1555 (2017).

15. Kariniemi, J., Ojala, R., Hellstrm, P. & Sequeiros, R. B. MRI-guided percutaneous laser ablation of small renal cell carcinoma: Initial clinical experience. Acta radiol.

51, 467–472 (2010).

16. Correa, R. J. M. et al. The Emerging Role of Stereotactic Ablative Radiotherapy for Primary Renal Cell Carcinoma: A Systematic Review and Meta-Analysis.

European Urology Focus vol. 5 958–969 (2019).

Send your application to become member of one of the ten YAU Groups now!

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/

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European Urological Scholarship Programme Focal therapy: Sexual consequences I spent one wonderful year as member of the Focal Therapy team at University College London Hospital (UCLH), under the supervision of Profs Mark Emberton and Caroline Moore.

“It has been an enriching experience to spend one year surrounded by brilliant young researchers...”

Clinical activities and research This year was made possible by the EUSP. The scholarship gave me the freedom to divide my time between clinical activities and research. I had to register beforehand with the General Medical Council and prove my knowledge of English. I could

attend focal therapy clinics and their multidisciplinary meetings and treat patients under supervision. Before the first lockdown, this amounted to 1.5 clinical days each week. This was reduced to one full theatre day after the lockdown, while other clinical activities were conducted remotely.

Qualitative study My research activities focused on detailing sexual outcomes after focal therapy. The aim was to set up a qualitative study to gather in-depth information on the evolution of men’s sexual function after focal therapy using HIFU, cryotherapy and irreversible electroporation. Of course, the study had to be redesigned completely to allow for remote instead of in-person interviews. This gave me the chance to conduct a systematic review and meta-analysis on existing literature. I also had the opportunity to

meet with another team working on ageing and cellular senescence and to work on a review article on the role cellular senescence plays in prostatic diseases. I have been able to establish collaborations that I know will remain even now this scholarship has ended.

One of the highlights This past year has been one of the highlights in my career. It has been an enriching experience to spend one year surrounded by brilliant young researchers and to experience how research is led and organised in the UK. The clinical part of my scholarship has been incredibly useful for my future career. I have gained surgical skills in focal therapy that I will bring back to my home institution, as well as expertise in the selection, management and follow-up of patients treated with focal therapy from various energy sources. I was provided with great

Best Clinical Scholar 2021 Dr. Gaelle Fiard CHU de Grenoble Dept. of Urology Grenoble (FR)

@GaelleFiard

quality scientific guidance and very supportive feedback. It is an experience I would recommend to every young academic urologist. Thank you, EUSP board!

Best Research Scholar 2021 Dr. Ivan Lysenko Military Medical Academy Dept. of Urology St. Petersburg (RU)

ivan_lysenko@ mail.ru

New technique for MIBC studies I will never forget my feelings of great excitement directly after my interview with the EUSP Board Committee in Munich (DE). Ten minutes later, I was filled with hope and expectations for a long-awaited new chapter in my life. Fortunately, there was someone by my side to support me: my special thanks to Angela Terberg for being so supportive and crossing her fingers for me.

After two weeks I received a positive outcome, and three months later I found myself standing in front of the incredible and majestic AKH (Allgemeines Krankenhaus der Stadt Wien (AT)), one of the largest urological teaching centres in Europe - a real city within a city. I was fortunate and honoured to meet an outstanding and multinational team, remarkable people and a real family. Everyone was willing to make my onboarding process smooth and comfortable. The lessons of true leadership, all sorts of scientific ‘cooking recipes’ and, most importantly, how to be a great human being were taught to me by the Chairman of the Department of Urology, Prof. Shahrokh Shariat, who left me with lasting memories.

which may predict response to neoadjuvant therapy (NAC) in muscle-invasive bladder cancer (MIBC) patients. Based on recent findings and our previous studies, we hypothesised that specific mutations in genes involved in DNA repair are associated with response or failure of NAC therapy in MIBC patients.

Dr. Melanie Hassler (AT) and Dr. Andreas Bruchbacher (AT) kindly shared their knowledge and experience with me and assisted me in developing a laboratory research activity which allows us to carry out nearly every study in a modern, high-level fashion.

Further validation After performing these experiments with the help of an NGS sequencing method, we concluded that genomic alterations in DNA repair genes, such as BRCA1, BRCA2, ERCC2 and CDK12, may predict Muscle-invasive bladder cancer response to cisplatin-based NAC in MIBC patients Thanks to the EUSP one-year fellowship programme, (p = 0.001). Results from the current study outlined I’ve experienced great collaboration between laboratory staff and clinicians, which helped us publish future concepts. They are followed by further analysis with much greater external, large-scale validation of our study results. Our main objective was to identify this finding, which is ongoing.

DNA damage repair (DDR) gene alteration patterns,

Fellows posing with Prof. Shariat

endoscopic surgery sessions, mostly based on urinary stones treatment and BPH management, besides laparoscopic procedures. It included collaborating with a research team at the University of Patras under the guidance of Profs. Evangelos Liatsikos and Panagiotis Kallidonis.

surgery. The comments from the experts were extremely useful, and they will be part of my ‘building blocks’ as I continue to practice in this field.

Additionally, the research work was the best way to understand that research is absolutely essential in order to comprehend the diseases we treat, the technology we use and the surgical techniques we employ and perhaps improve.

Endoscopic surgery skills improved Dr. Begoña Ballesta Martínez Royal Perth Hospital Perth (AU)

bballestamartinez@ gmail.com I have recently completed the EAU EULIS EUSP Fellowship in the General University Hospital of Patras (GR) hosted by Prof. Evangelos Liatsikos.

When I applied for this programme, I intended to complete my fellowship working with experts in laparoscopy and endourology.

Research team The programme consisted of observing, assisting in and completing some steps in a large number of

The number of some surgical procedures fell slightly as a result of Covid-19 in Greece. However, the team is surgically, academically and personally outstanding; a game-changing group of experts. We performed between 6 and 10 endoscopic cases per day including PCNLs, ECIRSs, RIRSs and URSs. Procedures During my three months in Patras, I performed the access of 5 PCNLs, 5 RIRS, 2 for the treatment of upper urinary tract tumours, 6 URS and 4 cystolithotripsy of big stones. I assisted in 14 PCNLs, 20 RIRS-5 UTUC-, 12 URS, 1 ECIRS, 1 cystolithotripsy. I observed a great deal of endoscopic procedures of all types. I performed steps in 3 nerve-sparing radical prostatectomies and

With the team at the General University Hospital of Patras

assisted in more than 20 cases. Although these were not the specialisation subjects of the fellowship, I also assisted in 12 open surgery sessions including radical cystectomies + Bricker, radical prostatectomies, radical and partial nephrectomies and 1 ureterectomy. We had research meetings on a monthly basis.

The specialisation in this EAU EULIS EUSP fellowship in Patras will remain present in my clinical practice forever. I learnt how important standardisation is in

Dr. Sanchez Guerrero enjoys challenging fellowship in France Dr. Clara Sanchez Guerrero Hospital Universitario Ramón y Cajal Dept. of Urology Madrid (ES) csguerrero9@ gmail.com L’hôpital de la Pitié Salpetrière in Paris is the largest hospital in France. The first Hôpitaux Général were built in the 17th century. Home to several famous doctors, such as Profs. Charcot and Babinski, the hospital nowadays has 90 buildings and is a reference centre for numerous pathologies. The department of urology, led by Professor Emmanuel Chartier-Kastler, is not only a leading centre in functional urology and neurourology, but also in oncological and robot-assisted surgery.

European Urological Scholarship Programme Office

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European Urology Today

I was incredibly lucky to embark on this challenging journey full of lessons and new discoveries, spend time at the Medical University of Vienna and have access to all its research and clinical facilities. Regardless of how much effort and time it takes, I would definitely encourage applicants to strive for the EUSP fellowship grant at some point in their career.

Timetable My week’s activities at the neurourology and functional urology section were as follows: • Monday: consultation and endoscopies; highly specialised consultations for diagnosis, follow-up and post-operatory visits.

• Tuesday: operating room. At 17.30 hrs, the multidisciplinary meeting for urological cancers was held.

• Wednesday: consultation with Professor Veronique Phé. As on Monday, this was a specialised consultation for the treatment of neurological patients.

• Thursday: robot-assisted surgery.

• Friday: I visited the Raymond Pointcaré handicap hospital. It is a reference centre for neurological disease rehabilitation.

Surgical activity I was able to attend numerous stress urinary incontinence surgery sessions. In addition, I witnessed the use of techniques such as ProAct ® implantation and Bulkamid® injection for the first time. I learned how to perform a supratrigonal augmentation

Another useful aspect was the experience I gained by using the most innovative and high-tech equipment from different manufacturers. However, the most important gift was getting to know Prof. Liatsikos and his team. The way they think and how they tackle surgery and science changed my vision on urology forever. I strongly encourage younger people to work hard, enjoy learning, give their all and be present in as many surgery sessions as they can. I would recommend that they enrol in an internationally recognised fellowship programme in their favourite urological area. I am very thankful to the EAU, the EUSP, the EULIS, Prof. Mirone, Prof. Sarica, Prof. Liatsikos, Prof. Kallidonis and the whole team in Patras for the unique opportunity.

clinic. It is possible to perform physical exploration, endoscopies and flowmetry. The team of nurses was magnificent. They were a great support when diagnostic tests were being performed on patients.

They also taught patients how to do intermittent catheterisation and stoma management.

Covid-19 The Covid-19 pandemic was very present.

Hospitalisation beds were closed and surgical activities were reduced by the end of my visit.

However, I do not think this situation was a handicap; I accomplished all the learning objectives I proposed.

The team with me and Prof. Chartier-Kastler on the right

enterocystoplasty and how to use different techniques of urinary continent diversion. I attended a robotassisted and open promontofixation for the treatment of pelvic organ prolapse.

Outpatient clinic My visit to the outpatient clinic was useful, since one of my main objectives was to learn how to manage urinary tract symptoms in patients with neurological diseases. Consultation is very well organised at the

My clinical stay has changed my view on neurourology and the importance of collaboration between medical departments. I had the opportunity to get to know interns, fellows and urologists from different countries and it was very interesting to share different ways to work.

For the full articles of the summaries on this page, please visit uroweb.org/education/scholarship/reports/ August/September 2021

A new glimpse into urology in the 16th century Newly discovered Vesalius consilium translated and published by EAU History Office

By Loek Keizer

The nature of the consilium The consilium concerns Bernhardus of Augsburg, 32 at the time of writing and married. As a younger man in Milan, he started to have difficulty urinating, with pain and blood. He also regularly discharged pus, which makes us immediately think of gonorrhoea, which was still unknown at the time. It would take another four centuries for the first antibiotics to become available.

Because the disease could not be treated at the root cause, it became a chronic condition that had to be managed. The patient reported recurring strictures and ulcers and episodes of retention.

The latest volume of De Historia Urologiae Europaeae has a world first: an annotated translation of a recently discovered consilium by 16th-century anatomist and physician Andreas Vesalius (15141564). Vesalius, known for his De Humani Corporis Fabrica (1543) anatomical study was consulted by letter in 1538 on the case of a young nobleman from Augsburg and his case of (presumably) chronic gonorrhoea.

The consilium goes into great detail and provides new insights into the state of medicine in the early renaissance. It was discovered by the authors, a trio of Belgian Vesalius experts, in 2019.

Volume 28 of De Historia was published digitally on the occasion of the 36th Annual EAU Congress, the EAU21 Virtual Congress. Congress delegates and EAU members may download their copies using the QR code at the bottom of this page. A print edition will be made available when regular congresses resume.

The authors of the chapter are retired medical doctors Dr. Maurits Biesbrouck (Roeselare, BE), Dr. Theodoor Goddeeris (Kortrijk, BE) and Prof. Omer Steeno (Louvain, BE), who have had a long-running interest in the works of Vesalius, and are considered to be some of the foremost authorities on his oeuvre.

(Figure 1) Dr. Goddeeris can rely on his personal rich medico-historical library and personal experience to support the trio.

Figure 2: Vesalius at age 28. Woodcut print from the 1543 edition of Vesalius’s Fabrica

Discovering the consilium It was Prof. Steeno who first got wind of this new consilium when he was vacationing with his wife in Nuremberg, in Southern Germany in 2019. “We were there for touristic reasons but I also wanted to visit the family grave of Georg Buchner (1536-1598), a jeweller from Nuremberg who accompanied Vesalius on his last trip to Palestine and was with him when he died on Zakynthos.”

“When I returned home, I started looking at the works of Franconian historical societies to see what was available on Buchner and his family. It was in the Mainfrankisches Jahrbuch für Geschichte und Kunst [Mainfranken Annual for History and Art], Vol. 50 from 1998 that I discovered an article from then 77-year-old GP and amateur archaeologist Dr. Hans Hahn from Geldersheim (1921-2001).”

Figure 1: Authors Goddeeris, Steeno and Biesbrouck with Theo Dirix (second from left) at ‘The Spanish Roof’ in Oud-Heverlee, Belgium. Now a restaurant, the venue was a castle inhabited by several generations of Vesalius’s ancestors.

Vesalius “Vesalius was a pioneer of anatomy,” explains Dr. Biesbrouck on behalf of the authors. “He was the first to rely on only his own observations to support his findings and recommendations. He knew of others’ works but distanced himself from their conclusions until he could reproduce or disprove their findings himself. In his writings, he even criticised Galen (129 - ca.210), whose works were still taught at universities at the time.” (Figure 2)

“With the help of Dr. Uwe Müller, historian and archivist of the Schweinfurt city archives and library I received scans of both the article and the manuscript of the oldest known consilium by Vesalius.”

“His article had the promising title (translated): ‘Does the binder of the Bausch Library contain a copy of a previously unknown consilium by Andreas Vesalius from 1538?’ With the help of Dr. Uwe Müller, historian and archivist of the Schweinfurt city archives and library I received scans of both the article and the manuscript of the oldest known consilium by Vesalius.”

“Dr. Hahn’s discovery in 1998 had clearly not been widely picked up after its publication. Dr. Biesbrouck translated the Latin text into Dutch. It was subsequently translated into English for this publication with the help of Dr. Bert Gevaert, Prof.

Van Kerrebroeck and Mr. Jonathan Goddard on behalf of the EAU History Office.”

“Vesalius’s biblio-biography with all his know works was first collected by Dr. Harvey Cushing (1869-1939, known for Cushing’s disease or syndrome) in 1943.

Since then more works of Vesalius have been uncovered, either through research or by chance or serendipity.” In 2005, Dr. Biesbrouck started work independently on making an up-to-date and complete bibliography of Vesalius’s works, which is updated annually and can be found on: www.andreasvesalius.be

“In that sense, his scientific approach mirrored that of Nicolas Copernicus who also based his revolutionary findings about the solar system on his own observations. It is this independent scientific spirit that sets men like Copernicus and Vesalius apart from the slavish reproducing of centuries-old wisdom that marked the Middle Ages.”

August/September 2021

“He is incredibly detailed in his approach, weighing every possibility and offering advice for any eventuality.”

“This fits in with what we know about Vesalius through his Fabrica and other consilia. The Fabrica is of course known for its fine prints but also includes quick sketches to illustrate his thinking and bring his point across so that physicians with less anatomical knowledge could grasp it.”

“Our search for new Vesalius-related materials continues unabated. Prof. Steeno recently unearthed six letters written by Vesalius from the sickbed of Don Carlos (1545-1568), the son of King Philip II of Spain and grandson of Holy Roman Emperor Charles V. It is well known that Vesalius was involved in treating Don Carlos but not yet what his role specifically was. These letters have now been published in In the Shadow of Vesalius by R. Van Hee (Antwerp: Garant, 2020).”

“When searching for materials, a good starting point is the friends, acquaintances and colleagues that Vesalius mentions in his writings. We keep a list of these names on our site. Great work on this subject is also being done by Jacqueline Vons, Stéphane Velut, Vivian Nutton, Theo Dirix, Pascale Pollier and others.”

“Of course Vesalius was still reliant on the medical knowledge of the time. While his anatomical • Read the full, annotated consilium in Latin and observations are revolutionary, his medical knowledge English as well as much more background and therapeutic arsenal are still firmly based in (pre-) information about Vesalius, his established works medieval times and the works of Hippocrates, and this unique discovery in De Historia Urologiae Dioscorides, Galen, Avicenna, and Rhazes. Knowledge Europaeae Vol. 28. had not really evolved in the previous centuries and was based on an understanding of the four elements, • The authors of the chapter maintain a website or the balancing of bodily fluids and humours. with the complete and regularly updated Treatment was herbal, or bloodletting or enemas or in bibliography of their famous countryman: some cases surgery without any real anaesthesia.” www.andreasvesalius.be

Download your copy of Historia Vol. 28 Free for all EAU Members and EAU21 Delegates As every year since 1994, the EAU’s History Office has prepared a new volume of De Historia Urologiae Europaeae to coincide with the Annual Congress. Volume 28, which was made available to EAU21 delegates and EAU members is a digital production for the time being, but will be printed for the next regular EAU congress.

Volume 28 is not only special for its virtual genesis, but also because it breaks the regular editorial format somewhat, making space for two much longer and more in-depth chapters than are usually included. The first extended chapter is an historical overview by world-renowned urethral strictures expert Prof. Tony Mundy, in which he explores centuries of documentation on the subject. The other, the “cover feature” for Volume 28, concerns the chapter on the new Vesalius consilium.

Other chapters in this volume: • Parsifal: The Story of Geoffrey Parker, British Urologist and Surgeon to the French Resistance

by Jasmine Winyard and Jonathan Charles Goddard • St. Cosmas and St. Damian’s Role in Urology by Marcos Cherem-Kibrit and Jorge MorenoPalacios • Michele Troja: Enlightenment Scientist, and the “Urology Chair” at the University of Naples in the 18th Century by Renato Jungano and Gloria Castagnolo • Friedrich August von Haken (1833-1888): His Contribution to the Development of Endoscopy

by Thaddaeus Zajaczkowski

“In the days of Vesalius, it was common for wellknown doctors to be consulted ‘long-distance’ to advise local physicians who were treating a wealthy or otherwise prominent patient. The specialist would receive a written case and typically respond with a three-part written response: a summary of the case, the current knowledge on the problem, and finally the recommended course of action. This mainly occurred in Latin, the language of science in Western Europe at the time. From some physicians of the time, we have hundreds of consilia, in Vesalius’s case we only know of 15 so far.”

EAU History office

Biesbrouck: “The fact that the medical problems of a nobleman from Augsburg reached Vesalius, who was at the time based in Padua, was not uncommon, as mentioned. What is unusual for consilia of the time is the thoroughness with which Vesalius (then 24 but already a professor) approached his advice. It is rare for a consilium to exceed twenty pages. He is incredibly detailed in his approach, weighing every possibility and offering advice for any eventuality.

What is also typical of Vesalius is the fact that he added a few sketches to support his words. (Figure 3) This was also unusual, though Vesalius would go on to do it in later consilia. In this consilium he also backs up his thoughts with his own anatomical observations, which other doctors also did not do.

These observations add to Vesalius’s scientific authority.”

New insights Discovery of a previously unknown consilium of course sheds light on Vesalius as a young anatomist, giving the authors new insights into his knowledge and personality. Biesbrouck: “This consilium reinforces what we already knew about Vesalius. In it, he first of all tries to stick to facts and offers every possible solution at hand. He suggests a variety of herb-based remedies to treat the patient’s symptoms, but also surgical options to treat the urinary blockage.

He would make the fine instruments required for these procedures himself and he sketches their designs on the parchment.”

You can download a complete copy of the 192-page book in PDF format. EAU members can download their copies through UROsource.com or by scanning this QR code to access a special download page.

Figure 3: Details from the copy of the 1538 consilium that was (re-)discovered in 2019

European Urology Today

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Send your nominations today!

EAU Crystal Matula Award 2022 For a young promising European urologist The EAU Crystal Matula Award 2022 is the most prestigious prize given to a young promising European urologist aged 40 or under who has the potential to become one of the future leaders in academic European urology. The award will be presented at the Opening Ceremony of the upcoming 37th Annual EAU Congress in Amsterdam, 18-21 March 2022, during the Opening Ceremony.

The list of previous awardees includes many well-known names: V. Phé (2021), D. Tilki (2020), M. Albersen (2019), S. Silay (2018), C. Gratzke (2017), A. Briganti (2016), M. Rouprêt (2015), S. Shariat (2014), P. Boström (2013), P. Bastian (2012), S. Joniau (2011), J. Catto (2010), M. Ribal (2009), V. Ficarra (2008), M. Michel (2007), A. De La Taille (2006), M. Matikainen (2005), P. Mulders (2004), B. Malavaud (2003), M. Kuczyk (2002), B. Djavan (2001), A. Zlotta (2000), G. Thalmann (1999), F. Montorsi (1998), F. Hamdy (1996).

Nomination Process National Societies can nominate a candidate by supplying the following documents: • Letter of endorsement • Motivation letter

• Complete curriculum vitae • List of publications in the below sequence: 1. Peer reviewed papers (including the impact factors of the journals) • Original articles • Reviews • Case reports 2. Book chapters or editor of books • Overview of grants received from (inter-)national institutions or from the industry • List of received Awards • The deadline for nomination is 1 November 2021.

Please note that eligible candidates can also apply for this award by contacting their national urological society directly. The candidate is then expected to supply his/ her national society with a CV and the above mentioned documents, requesting a letter of endorsement.

How to apply Please send your nominations to the EAU Central Office at m.smink@uroweb.org and mention “EAU Crystal Matula Award 2022” in the subject line of your e-mail.

The EAU Crystal Matula Award is supported by a grant of €10,000 from LABORIE.

Apply now!

LABORIE

EAU Prostate Cancer Research Award 2022 For the best paper published on clinical or experimental studies in prostate cancer With the goal to encourage innovative, high-quality research in prostate cancer, the EAU has launched the EAU Prostate Cancer Research Award. Supported by the Fritz H. Schröder Foundation, an expert jury will select the best paper dealing with clinical or experimental studies in prostate cancer.

The award will be handed over at the 37th Annual EAU Congress in Amsterdam, 18-21 March 2022, during the Opening Ceremony.

• The paper must have been published or accepted for publication in a high-ranking international journal between 1 October 2020 and 30 September 2021, and submitted in English.

• Applicants must be a member of the EAU. • The submitting author must be the first author of the paper or, by exception, the corresponding senior last author.

• Applicants should only submit one paper.

• Deadline for submission by e-mail is 1 November 2021.

Join this competitive search and help boost the quality of prostate cancer research in Europe!

A review committee will screen all entries and an independent jury will select the best paper based on quality and merits.

Rules and Eligibility • The topic of the paper should deal with clinical or experimental prostate cancer research.

How to apply Inquiries and correspondence should be addressed to the EAU Central Office, at m.smink@uroweb.org, with “EAU Prostate Cancer Research Award 2022” in the subject line of your e-mail.

The award is supported by a grant of €5,000 from the FRITZ H. SCHRÖDER FOUNDATION. www.fhsfoundation.eu

34

European Urology Today

August/September 2021

Controversies in early post-op imaging after urethroplasty Trauma and Reconstructive Urology Working Party of YAU gives overview Ass. Prof. Malte Vetterlein University Medical Centre HamburgEppendorf Dept. of Urology Hamburg (DE) m.vetterlein@uke.de

respondents indicating to omit any evaluation at the time of catheter removal. Of the remaining 89% who opted for any kind of postoperative imaging, 47% and 58% stated to perform pcRUG and VCUG, respectively.

[12] Notwithstanding pending surveys from outside the United States, those data suggest that the vast majority of urologists still rely on early postoperative imaging to guide decisions regarding further catheter management, although this practice has been recently challenged.

that extravasation rates were rather low, which is generally used as a core argument to conclude that imaging may be omitted in such patient populations.

[4-6] Terlecki et al. published a series of 110 patients with anterior strictures, of which 59 (54%), 28 (25%), and 23 (21%) underwent EPA, augmented anastomotic repair, and ventral onlay flap or graft, respectively.

There were no extravasations in the EPA cohort and only 1 (3.6%) after augmented anastomotic repair and 1 (4.3%) after ventral onlay. [6]

institutional algorithm for years now with good results and low extravasation rates.[10] Not only do we have the advantage of physiological voiding pressures during VCUG, but we are also able to evaluate early urethral patency, the healing of the graft, and potential residual urethral narrowness, which is simply not possible with pcRUG as such pathologies would be masked by the catheter.

Discussion Early post-urethroplasty imaging is useful to assess Ass. Prof. Roland extravasation, urethral patency, and potential residual Granieri et al. analysed 407 patients, of which 232 Dahlem narrowness. Such practice is reflected by the recently (57%), 150 (37%), and 25 (6.1%) underwent EPA, University Medical published EAU Guidelines on Urethral Stricture augmented anastomotic repair, and ventral onlay graft Centre HamburgDisease, [3] which strongly recommend postoperative urethroplasty, respectively. [4] At early postoperative Eppendorf imaging at the time of catheter removal. The available imaging, 21 patients (5.2%) had extravasation and Dept. of Urology evidence suggests a particular benefit of imaging there was no statistical difference in extravasation Hamburg (DE) after graft augmentation and more complex rates between EPA (5.6%), augmented anastomotic repair (4.7%), and ventral onlay grafts (4.0%; p > 0.9). procedures, given that extravasation rates are commonly higher after BMGU compared to EPA. One However, patients did benefit from extending r.dahlem@uke.de “The rationales for both pcRUG and [4] particular consideration is quite important in this catheterisation for another week in case of extravasation, given that leakage rate decreased from context. Is it highly likely that everything depends on VCUG are sound.”

Over the last couple of years, the information about the appropriate action we take if contrast 5.1% at initial pcRUG to 0.98% at a second optimum surgical strategies in patients with anterior extravasation is detected, or to put it another way: urethrography a week later (p < 0.001). [4] urethral strictures has grown substantially. This has In 2017, Grossgold et al. developed a grading system “Does it even matter if we see a leak?” [5] if we do culminated in the development of well-founded for urethral leakage after buccal mucosal graft not react appropriately? In most cases of Hoy et al. investigated 229 patients, of which 118 treatment guidelines published by renowned urethroplasty (BMGU; grade 0: no leak; grade 1: extravasation, the catheter remains for another 7-14 (52%) and 111 (48%) underwent augmented urological associations and societies. [1-3] Whereas “wisp” leak; grade 2: length of leak >1 .03 cm or anastomotic repair and ventral onlay BMGU, days at the discretion of the individual surgeon but there is more or less consensus on how to treat width of leak > 0.32 cm; grade 3: length of leak > 1.03 respectively. [5] Overall extravasation rate was low determining the severity of extravasation is a very strictures with particular locations, lengths, and cm and width of leak > 0.32 cm). [8] Out of 91 with 3.1% and there were no statistically significant subjective process. We can simply speculate on what aetiologies, short-term post-urethroplasty imaging patients, 31 (34%) had contrast extravasation of any differences in recurrence rates (60% vs. 94%; p = would happen to those patients if we did not know remains controversial. degree on initial postoperative imaging, which 0.0057) and complication rates (29% vs. 7%; p = about the extravasation. It may well be that results translated into 13 (14%), 7 (7.7%), and 11 (12%) 0.087) between patients with versus without after EPA for example are as good as they are, even Guidelines patients with leak grade 1, 2, and 3, respectively. extravasation. [5] However, one could argue that this with extravasation, simply because we know about it There is some evidence promoting the omission of Remarkably, Kaplan-Meier estimates showed a is indeed clinically relevant and statistical and are able to act accordingly by extending the any imaging after urethroplasty. [4-6] On the other significantly lower recurrence-free survival in patients insignificance is probably due to the absolute low catheterisation time. hand, different data indicate the diagnostic benefit with urethral leak grade 3 vs. grade ≤ 2 (p = 0.031). [8] number of urethral leaks in this series. and even prognostic importance of immediate Although the thresholds for length and width of the Inconclusive postoperative urethrography. [7-10] In this regard, the leak to define the grading system were more or less Postoperative urethrography: pcRUG or VCUG? To date, the second question (pcRUG versus VCUG) inaugural European Association of Urology (EAU) arbitrarily calculated by receiver operating Urethral imaging post-urethroplasty can be achieved cannot be answered definitely. Firstly, we would Guidelines on Urethral Stricture Disease were the first characteristic curves, they still suggest a clinically by pcRUG, which is characterised by a feeding tube need a prospective, multi-institutional trial with a lot to strongly recommend “[…] a form of validated relevant impact of the degree of contrast extravasation inserted alongside the catheter and contrast injection of patients to actually compare pcRUG followed by urethrography after urethroplasty to assess for urinary on surgical outcomes after BMGU, which directly under dynamic fluoroscopy. VCUG involves a VCUG versus VCUG followed by pcRUG to allow for a extravasation prior to catheter removal.” [3] The underscores the value of postoperative imaging. technique with the patient voiding under fluoroscopy real comparison of the diagnostic yield of each American Urological Association (AUA) Male Urethral after the bladder has been filled with contrast and the technique. Secondly, the choice of postoperative Stricture Guideline does mention that urethrography Assessment of early urethral patency by VCUG Foley catheter has been removed. imaging modality is directly dependent on catheter is typically performed a couple of weeks following In 2019, we published data from our department on management, which is still highly heterogeneous open urethral reconstruction to avoid inflammation, 513 men who received one-stage BMGU for bulbar among reconstructive referral centres. VCUG in a “Catheter reinsertion may also urinoma, abscess, and fistula formation due to a stricture and underwent a standardised patient with a suprapubic catheter makes sense as persistent urethral leak. However, there is no formal postoperative VCUG. Overall, 54 patients (11%) catheter reinsertion is not required and we can be avoided by using suprapubic recommendation by the AUA that endorses this showed evidence of extravasation, which was, simply uncap the suprapubic catheter. In this context, catheterisation until postoperative practice. [1] however, no predictor of stricture recurrence in the we do not really have any data available to multivariable Cox regression analysis after adjusting determine if catheter reinsertion is really that imaging.” for several stricture characteristics and intraoperative traumatic. Such open research questions call for “Such open research questions call parameters (hazard ratio 1.08; 95% confidence international collaborations that set up prospective comparisons with a focus on catheter management, The rationales for both techniques are sound. for international collaborations that interval = 0.48-2.40; p = 0.9). [10] Interestingly, we found a residual urethral narrowness in nine patients Advocates of pcRUG underline the effort to avoid early postoperative imaging, a standardisation of set up prospective comparisons.”

(1.8%), which was predictive of stricture recurrence traumatic catheter reinsertion in case of extravasation grading urethral leaks, and extravasation. Patientin the multivariable model (hazard ratio 4.60; 95% [13,14] and the greater degree of distension to identify reported outcome measures that give more Controversial questions confidence interval = 2.15-9.85; p < 0.001). incompletely healed areas, which could potentially be information about the quality of treatment and the Evidence is scarce when it comes to the question of missed by VCUG. [15] Furthermore, some patients may catheter-related quality of life should also be used. urethrographic modality. In a nutshell, there are Extravasation rate parallels surgical complexity not be able to void during VCUG, which is not relevant This will help to get a better understanding of the currently two main controversial questions regarding In 2020, Giudice et al. presented similar findings in when performing a pcRUG. On the other hand, VCUG options we have and how they impact our patients in post-urethroplasty imaging that are consistently 630 patients undergoing various types of urethral the early post-urethroplasty setting. allows for physiological voiding pressures and by debated and called into question: reconstruction. Overall, 77 (12%) had extravasation at avoiding direct manual injection of contrast towards early imaging, and intriguingly there were significant the renewed anastomosis, traumatic adverse events References (1) Do we need urethrography after urethroplasty at 1. Wessells H, Angermeier KW, Elliott S, et al. Male Urethral differences when looking at stricture location. after VCUG are very unlikely. all?

Stricture: American Urological Association Guideline. J Extravasation rates were lowest in bulbar strictures (2) If we choose to perform postoperative Urol 2017;197:182-190.

(7.9%), followed by multifocal (18%), and penile POIROT trial urethrography, should we opt for peri-catheter 2. Lumen N, Campos-Juanatey F, Greenwell T, et al.

(20%) strictures. Maybe the most interesting finding The only study which has looked into this clinical retrograde urethrography (pcRUG) or voiding European Association of Urology Guidelines on Urethral from this study was the increasing extravasation rate question prospectively is the POIROT trial from Ghent cystourethrography (VCUG)?

Stricture Disease (Part 1): Management of Male Urethral paralleling the surgical complexity. Extravasation was (Belgium). An interim analysis was published in Stricture Disease. Eur Urol 2021;80:190-200. seen in 6.0% after excision and primary anastomosis 2020.[14] Overall, 25 patients underwent sequential Current practice patterns 3. Campos-Juanatey F, Osman NI, Greenwell T, et al.

(EPA): in 13% after one-stage grafting, in 14% after pcRUG followed by VCUG in case of no extravasation We do not have a lot of data showing if and how European Association of Urology Guidelines on Urethral augmented anastomotic repair, and in 22% after a on pcRUG. Extravasation was detected in 3 patients urologists perform post-urethroplasty imaging on a Stricture Disease (Part 2): Diagnosis, Perioperative combination of flap and graft. [7] (12%) and VCUG did not unfold any new leakages not regular basis, but there is novel evidence from the Management, and Follow-up in Males. Eur Urol previously diagnosed by pcRUG. Interestingly, 20% of United States providing useful information on current High predictive value 2021;80:201-212. patients were not able to void at all during VCUG. practice patterns, at least in North America. Members Finally, in 2020 Patino et al. published a large series 4. Granieri MA, Webster GD, Peterson AC. A Critical Furthermore, radiation exposure was higher after of the Society of Genitourinary Reconstructive Evaluation of the Utility of Imaging After Urethroplasty of 1,101 patients with early post-urethroplasty imaging VCUG compared to pcRUG (203 vs. 122 mGy/cm2; Surgeons (GURS) were surveyed on several questions and found an extravasation rate of 4.9%. Similarly to p < 0.001). [14] While the final results from POIROT for Bulbar Urethral Stricture Disease. Urology regarding perioperative management in patients will be published soon, there are some things to 2016;91:203-207.

Giudice et al., [7] extravasation was more common undergoing urethroplasty. 142 out of 248 urologists deduct from the interim analysis. Indeed, the 5. Hoy NY, Wood HM, Angermeier KW. The Role of after graft urethroplasty (6.1%) compared to EPA responded (response rate 57%) and 68% indicated diagnostic yield of pcRUG regarding contrast Postoperative Imaging after Ventral Onlay Buccal Mucosal (2.2%). [9] Importantly, functional recurrence was they routinely perform urethral imaging at the time of 9.3% with extravasation versus 3.2% without extravasation seems comparable to VCUG and Graft Bulbar Urethroplasty. J Urol 2020;204:1270-1274. catheter removal, whereas 13% and 20% stated to catheter reinsertion can be avoided in some cases.

6. Terlecki RP, Steele MC, Valadez C, Morey AF. Low Yield of extravasation (p = 0.04) and the positive predictive omit imaging completely or only selectively perform The proportion of patients not being able to void Early Postoperative Imaging After Anastomotic value of extravasation for predicting anatomic urethrography, respectively. [11] Such patterns during the examination appears quite high and, in Urethroplasty. Urology 2011;78:450-453. recurrence was high (78%). Furthermore, infectious corroborate the precursor study with a similar study such cases, pcRUG may be the solution at hand. complications were more frequently reported in design from 2013. Overall, 90 of 184 surveyed However, it should be noted that catheter reinsertion patients who had extravasation on early imaging urologists responded (49%). There were 11% of may also be avoided by using suprapubic The full references of this article are available from (p ≤ 0.04). catheterisation until postoperative imaging. [5,7,10] the EUT Editorial Office. Please send an e-mail to: In patients undergoing urethroplasty-naïve, primary EUT@uroweb.org with reference to the article Contrary evidence – overall low number of leaks EAU Section of Genito-Urinary Reconstructive BMGU, we have been using a Foley for 10 days plus “Controversies in early post-op imaging” by There are some studies attesting a low yield of Surgeons (ESGURS) Ass. Prof. Vetterlein, Aug/Sep issue 2021. post-urethroplasty imaging. They all have in common a suprapubic catheter for 21 days as per our Need for urethrography after urethroplasty?

There are two considerations to reinforce the usefulness of post-urethroplasty urethrography. First, it is deemed important to evaluate the condition of the urethral anastomosis and to rule out significant urethral leak as represented by contrast extravasation.

Second, urethrography may aid in assessing early postoperative urethral patency and identify a potential residual narrowness in the area of the anastomosis.

August/September 2021

European Urology Today

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European Urology Today

August/September 2021

Young Urologists/Residents Corner The latest news from the YAU Office YAU representation on the rise in international meetings, research projects, and EAU offices Dr. Juan Gómez Rivas Chair, Young Academic Urologists Madrid (ES)

juangomezr@ gmail.com YAU representation in congresses and meetings Several members of the Young Academic Urologists (YAU) Office have been representing their group in several online congresses and meetings this year.

The first one was the Techno-urology meeting (TUM) held in January 2021. Despite COVID-19 pandemic, the TUM meeting was held in a hybrid format. As the Young Academic Urologists play a key role in the continuous improvement of urological practice, research and education, endorsing meetings such as TUM will contribute to increased visibility of the group and place a bet of the YAU team into the development of innovative technologies.

Despite the virtual setting, the YAU organised a successful session at the Annual EAU Congress (EAU21) which aimed to promote high-quality studies in order to provide strong evidence for the best urological practice. In this session, both scientific and educational contexts were discussed among the members of YAU and the leaders of European Urology.

Also, the winners of the YAU awards for 2021 were announced and acknowledged.

Furthermore, the YAU had online representatives at The Urological Association of Asia Congress and The Mediterranean Minimally Invasive Surgery in Urology meeting.

YAU is going prospective One of the aims of YAU is to improve the academic skills of our members and to provide high-quality evidence. If you are looking forward to submitting your application, please read the recommendations for project proposals: https://uroweb.org/education/ young-urologists-office-yuo/yau/yau-is-goingprospective.

New members and chairs The YAU welcomed 14 full and 18 associate

members who have been accepted in different YAU working parties.

Giovanni Cacciamani becomes the new chair of the Uro-technology working party, Riccardo Campi takes the lead as chair of the Renal Cancer group and Veronique Phé, the winner of the 2021 Crystal Matula Award, has been named chair of the Functional Urology group. We thank Domenico Veneziano, Umberto Capitanio and Tom Marcelissen for their input in YAU through the years.

The workgroups on Prostate Cancer, Reconstructive, Sexual and Reproductive Health, Urolithiasis and Endourology and Functional Urology have new representatives at the Guidelines Office (GO) and together will grant access to the online systematic review training modules produced by the GO Methods Committee (for those YAU members who are not associates) and will search for unmeet areas of evidence in order to work together and improve the quality of studies.

Marco Moschini will be representing the Young academics at the EAU Section of Oncological Urology (ESOU) and Giovanni Cacciamani at the EAU Section of Uro-Technology (ESUT).

Also with European Urology Open Science, the new Open Access journal of the European Urology family, the YAU is expanding its collaboration. The YAU has been asked to nominate motivated members to serve as reviewers.

Growing YAU representation at EAU offices The collaboration between YAU and other EAU Sections and offices is getting stronger and stronger. The YAU workgroups for Reconstructive, Sexual and Reproductive Health have started collaborations with EAU RF to use a new electronic database management system (Castor EDC) that is validated and compliant with GDPR and EU research legislation.

Equality, Inclusion and Diversity (EID) One of the priorities of the EAU for the near future is to promote Equality, Inclusion and Diversity (EID). YAU strongly support this initiative and is committed to broadening participation through diversity in all aspects: gender, race, age, ethnic background, religion, geography, sexual orientation etc. There is a clear need for diversity in society, so YAU invites people around the globe to become part of its ranks.

New YAU working group kidney transplantation Group keen on including young and potential opinion leaders University of Florence (IT). I believe the "world" of KT is truly inspiring for urologists and represents a unique opportunity to grow as a surgeon, being exposed to challenging clinical scenarios and stimulating surgical techniques. It is a huge honour for me to contribute Nowadays, kidney transplantation (KT) is considered to the YAU KT group. We aim to provide highthe best treatment option for patients with end-stage quality research through multi-institutional renal disease, with more than 20,000 KTs being collaborations across Europe and beyond, performed each year in Europe. Given the harnessing the power of young and talented epidemiological relevance and the clinical importance physician-scientists wishing to reinforce the role of of chronic renal failure disease and KT, as well as, the urologists in this amazing field. fundamental role of the urologist in this field, a Romain Boissier (Full dedicated Young Academic Urologists (YAU) Working Group can prove beneficial. Accordingly, in June 2021, member): There is so the YAU Working Group dedicated to KT was created, much urology and daily activity in KT that it is an following the proposal of Angelo Territo and thanks invaluable asset for those to the support of the EAU – YAU board. who wish to become a urologist. As far as my Members of the group research activity is concerned, I studied the Angelo Territo applications of cell (Chairman): Since 2015, I have dedicated myself therapy for the evaluation to KT as well as of the quality of the transplant. This led me to minimally-invasive investigate the modulation of inflammation of the KT surgery and uroduring preservation and urological malignancies in oncology. I had my first candidates for or recipients of KT. The EAU is the fellowship in 2015 at cornerstone of KT in Europe. In 2016, I joined the EAU Fundació Puigvert in Guidelines panel on KT which was chaired by Barcelona (ES) under Dr. Breda, and in 2017, the EAU Section of the supervision of my Transplantation in Urology (ESTU), which was chaired mentor, Dr. Alberto Breda. In 2016, I was selected

by Prof. Dr. Enrique Lledó Garcia. Financial support for the European Urological Scholarship Programme from the EAU enabled me to complete a one-year (EUSP) and partook in an investigative project fellowship at Fundació Puigvert. entitled “Development of a cold ischemia device to improve the temperature control of the graft during Vital Hevia (full KT”. Recently, the step-by-step development (from member): Currently, dry lab to animal model and lastly human testing) I am working at Ramón of this innovative device was reported in the y Cajal Hospital in literature (Territo et al., Eur Urol, May 2021). Finally, Madrid (ES). This is a in 2018, I performed an additional fellowship on very active institution in robotic surgery at the Rijnstate Hospital in Arnhem KT, which, under the (NL) to further improve my robotic skills and direction of my mentor abilities.

Prof. Francisco Javier Burgos Revilla, Riccardo Campi (Ex officio): Since the beginning of maintains extensive my training, I have developed a strong passion for clinical, educational, and research activities in the KT, and I am glad to have the opportunity to work in field. Therefore, I have been able to develop a wide this fascinating field of urology from both clinical range of activities related to KT, including my Ph.D. and research perspectives. I am currently following on oxygen supplementation during hypothermic a Ph.D. programme focused on robotic KT at the machine perfusion, which I expect to conclude this Dr. Angelo Territo Chair of YAU WG Kidney Transplant Uro-oncology and Kidney Transplantation Units Fundació Puigvert Barcelona (ES) territoangelo86@ gmail.com

August/September 2021

year. Additionally, I have the privilege of being part of the EAU Guidelines on KT as an Associate Member under the leadership of Dr. Breda. Lastly, it is my pleasure to be an Associate Member once again of the ESTU Board, which was chaired by Prof. Lledó.

Thomas Prudhomme (Full member): I am currently in my last year of residency at the University Hospital of Toulouse (FR), a renowned centre for KT. My most prominent recent research activities in KT include the assessment of a three-dimensional laparoscopic device for living donor left nephrectomy and evaluation of the safety of new BPH endoscopic surgical procedures in KT recipients. Furthermore, I have completed a Master of Science degree focusing on organ preservation and reconditioning using hypothermic machine perfusion and I plan to develop this into a Ph.D. thesis this year.

Missions of the group and collaborations One of the main missions of the group is to emphasise the role of the urologist in KT, motivating urologists to engage in this broad field, including during pre-transplant urological evaluation, organ retrieval from both living and deceased donors, the performance of vascular suture, and management of intra- and post-operative complications.

However, given the multifaceted nature of the KT field, the creation of multidisciplinary teams will be promoted, involving general and vascular surgeons, nephrologists, and transplant coordinators.

Furthermore, collaboration with other YAU groups, EAU offices, and sections (ESTU, ERUS RAKT group, etc.), and EAU Guidelines panel members will be fundamental in potentiating any initiatives on clinical, basic, and translational research in all fields of KT. Finally, the group will try to establish cooperation between different European countries to extend the kidney exchange programmes “beyond the national borders”.

Research activity and educational projects The research activity will address several issues in the settings of both conventional open KT and emerging robotic surgery. In particular, investigations will be conducted on topics such as urological malignancies in KT recipients, polycystic renal disease and KT, the learning curve in open KT, and the use of innovative devices to ensure better graft preservation during KT. As far as educational projects are concerned, the KT group will promote the development of a structured curriculum for open KT and surgical training in high-volume KT centres through clinical visit or fellowship at the highest volume European centre for KT. In fact, combining research activity with surgical training can be a more exciting way of promoting interest in KT. The YAU Working Group dedicated to KT is a new section, promoting the combination of clinical research and improved surgical skills in the field.

Applications for membership of the group are encouraged and will be evaluated according to the YAU selection criteria and the motivation for wishing to become part of the group.

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

you encountered an even worse case yourself? If so…

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

• What was the case?

• What did you do?

• Was it resolved? If yes, how?

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

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

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

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

European Urology Today

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ERUS-DRUS21: Europe's premier robotic urology event New robot systems at joint meeting with German Society of Robotic Urology The EAU Robotic Urology Section prides itself on hosting Europe’s most important annual meeting on robotic urology, presenting delegates from all over the world with the latest technical developments, opportunities for training and live surgical demonstrations by experts.

For 2021, ERUS hopes to meet in Dusseldorf together with the German Society of Robotic Urology (DRUS), as initially planned for last year. The pandemic forced ERUS20 to go virtual but organisers are optimistic about ERUS-DRUS21 as the meeting is formally titled.

This also marks the first ERUS meeting under the leadership of Prof. Alberto Breda (Barcelona, ES), who took over as ERUS Chairman from Prof. Alex Mottrie (Aalst, BE), who had been its Chairman since ERUS joined the ERUS Chairman EAU in 2011. (see page 27 for Prof. A. Breda more about the new Section Chairs) European Urology Today spoke to Prof. Breda about the upcoming meeting: “The ERUS meetings have always been very well attended and the involvement of all the faculty has always been one of the main strengths of the meeting. I will be sure to keep working this way, to give space to the surgeons, the principal leaders of the ERUS.”

Register now for the late fee!

Deadline: 27 October 2021

ERUS-DRUS21 has a three-day scientific programme from 11-13 November. The meeting has a special programme for nurses (see page 48), for young urologists, and of course several different courses by the European School of Urology. The bulk of the scientific programme (now available online!) consists

Prof. Breda: “Participants will have the opportunity to watch a tremendous amount of live cases. This year we have increased the number of surgeries from 12 to 24 and we have three screens that will show cases simultaneously. Other than this, there will be the possibility to attend different sessions (live and semi-live) on the new robots, including but not limited to Medtronic, CMR and Medicaroid.”

For the complete Scientific Programme visit www.erus21.org

“There will certainly be many roundtables on the main urological topics, including new updates on prostate and kidney cancer as well as functional urology and benign urology. Finally this year we will be cementing our alliance with the German Robotic Society (DRUS) and we will have the opportunity to share expertise among the different groups of speakers and participants.”

ERUS-DRUS21

Robotic Live Surgery

18th Meeting of the EAU Robotic Urology Section in conjunction with ERUS-DRUS21 Robotic the 13th meeting of the German Live 18th Meeting of theUrology EAU Robotic Society of Robotic Surgery Urology Section in conjunction with 11-13 November 2021, Dusseldorf, Germany the 13th meeting of the German www.erus21.org Society of Robotic Urology 11-13 November 2021, Dusseldorf, Germany www.erus21.org

On the prospects of a regular meeting after one and a half years of remote learning, Prof. Breda was carefully optimistic about ERUS-DRUS21 taking place in Dusseldorf.

“I believe people are ready again to come together and discuss robotic urology in a live setting. There is no doubt that remote learning will stay with us in the future, however we, as humans, will always benefit from physical interaction. We are of course dependent on whatever restrictions local authorities will place on events, but as it stands, we are carefully optimistic that we can welcome audiences in Dusseldorf this November.”

An application has been An application has been ® ® made EACCME for CME for CME made toto thethe EACCME accreditation of this accreditation ofevent this event

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

ESGURS21

EUREP21

12th Meeting of the EAU Section of Genito-Urinary Reconstructive

19th European Urology Residents Education Programme

Surgeons

4-9 February 2022 Prague, Czech Republic

7-8 October 2021 www.esgurs21.org

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

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of demonstrations of robotic surgery: live and pre-recorded, case discussions, unusual procedures and the latest robotic systems.

European Urology Today

N ew dates!

Virtual Registration deadline: 1 October 2021

www.eurep21.org August/September 2021

EMUC21 is coming to Athens New crucial updates in GU cancer prevention, diagnosis and management Relive and enjoy the congress experience, meet and connect with peers and key opinion leaders face-to-face, and join the knowledge-exchange first-hand at the much-awaited 13th European Multidisciplinary Congress on Urological Cancers (EMUC21). The congress will welcome delegates from around the world from 25 to 28 November 2021 in picturesque and historic Athens.

Through the collaboration of the EAU, the European Society for Medical Oncology (ESMO), and the European SocieTy for Radiotherapy and Oncology (ESTRO), the four-day congress will constitute of new crucial updates in the prevention, diagnosis and management of genito-urinary (GU) cancers.

be thoroughly discussed, particularly stage imaging and therapy (e.g. PSMA-Radio-LigandTherapy) with PSMA. 2. On bladder and urothelial cancers New developments such as urinary tract topical therapy with a new agent, possible physical enhancement, and more will be presented.

3. On advanced urothelial cancer The status of checkpoint-inhibition and emerging data from recent studies will be examined and deliberated. Furthermore, circulating tumour DNA is a new and promising tool. Researchers from Denmark are at the forefront of this technology and will present exciting perspectives.

In this article, highly-regarded experts and EMUC21 Steering Committee members, Prof. Aristotelis Bamias 4. On renal cell cancer (GR), Prof. Peter Hoskin (GB), and Prof. Arnulf Stenzl The role of local or regional therapy, in addition (AT) shared what participants can expect at the to systemic therapy, will be discussed by a upcoming congress; from current challenges to multidisciplinary panel. Moreover, an update on anticipated breakthroughs in the field. new trials such as FLAME (Focal Lesion Ablative Microboost in prostatE cancer), IMvigor130, CLEAR, and the extent of lymph node dissection For the complete Scientific in prostate cancer, to name a few will be part of Programme visit www.emuc21.org the congress.

New scientific updates in the programme “EMUC21 will cover a plethora of developments with regard to GU cancers, and emphasise the importance of a multidisciplinary approach when providing the best care to our patients. Interactivity will be encouraged,” stated Prof. Bamias. He added, “Some of the major updates at the congress will include the new WHO classification on GU cancers, modern imaging in prostate cancer, integrating systemic therapy in non-muscle-invasive bladder cancer (NMIBC), and molecular developments in the field.”

Prof. Stenzl further elaborated on what new developments the congress will offer: 1. On prostate cancer The diagnostic and therapeutic possibilities of PSMA-PET-CT based on the most recent data will

Prof. Hoskin stated, “A few lectures will focus on the combination of immunotherapy with local treatment in several GU cancers. Then these lectures will be followed by presentations on personalised approaches in GU cancers wherein experts from various disciplines will offer their insights.”

Major challenges in interdisciplinary approach “I think we have entered an era characterised by our belief that metastatic GU cancer can be associated with long-term survival without disease progression, and that cure is possible. This is thanks to the close collaboration and involvement of all disciplines, which are represented in EMUC congresses. The major challenge is the optimal utilisation of our diagnostic tools (including molecular markers) in order to personalise our approach and achieve maximum benefit for our patients,” stated Prof. Bamias.

ESUI21 9th Meeting of the EAU Section of Urological Imaging

"The major challenge is the optimal utilisation of our diagnostic tools (including molecular markers) in order to personalise our approach and achieve maximum benefit for our patients" According to Prof. Stenzl, some of the major challenges in the interdisciplinary approach of patient care include communication, knowledge and understanding. He explained, “Advances in one field may not be communicated well to other disciplines involved in patient treatment. Sometimes, the implications of these advancements may not also be well understood by other disciplines, and can lead to misunderstanding. In practice as an example, we still do not know the role of salvage lymphadenectomy in prostate cancer, treatment of oligometastatic urothelial cancer, the extent of salvage tumour resection/nephrectomy in advanced and/or metastatic renal cell cancer. What is important is the understanding of all disciplines in the sequence of the An impression from EMUC19 in Vienna respective possibilities of treatment.”

Register now for the late fee!

Deadline: 10 November 2021 In the coming decade “In my opinion, further developments in immunotherapy and technology such as diagnosis, circulating tumour DNA for both diagnosing residual disease after priority treatment, and monitoring of systemic therapy. are on the horizon. These will be a great help for all doctors and patients in the field of uro-oncology,” concluded Prof. Stenzl.

How to join EMUC21 Register now to participate in the upcoming congress via www.emuc.org/how-to-register/. Delegates are entitled to access to the scientific sessions, industry sessions and the exhibition.

About ESUI21

9thofMeeting ofofthe EAU Sect The 9th Meeting the EAU Section Urological Imaging (ESUI21) will take place of Urological Imaging on 25 November 2021 in conjunction with EMUC21. Expect extensive assessments of 25applications November 2021, Athens, Greece technological in image-guided approaches. www.esui21.org

ESUI21 will also investigate how imaging enhances urological diagnostics and In conjunction with and the 13th European intraoperative visualisation, helps defineMultidisciplinary Congress on Urological Cancers the standardisation of the reporting of urological cancers. For more information, please visit www.esui.org.

13th European Multidisciplinary Congress on Urological Cancers An application has been made to the EACCME® for CME accreditation of this event

25 November 2021, Athens, Greece www.esui21.org

Working together to improve patient care

In conjunction with the 13th European Multidisciplinary Congress on Urological Cancers

25-28 November 2021 Athens, Greece

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

August/September 2021

www.emuc21.org European Urology Today

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Keen on urological research?

ESUR21 is not to be missed!

By Prof. Kerstin Junker (DE), chair of the EAU Section of Urological Research and Prof. Gabri Van Der Pluijm (NL), president ESUR21 meeting The 27th Meeting of the EAU Section of Urological Research (ESUR21 Virtual) is organised for all scientists and clinicians working in or interested in the field of experimental and translational urological research. Over the course of two days (Friday 8 and Saturday 9 October 2021), outstanding international experts will deliver lectures on the exciting latest results from multiple studies on urological diseases while also considering the translation into clinical practice.

”ESUR21 will give a comprehensive overview on current research activities in urology.“ The meeting is again organised in collaboration with the EAU Section of Uropathology (ESUP). At ESUR21, we will tackle important urological research topics such as mechanisms of tumour progression and therapy resistance, new developments in pathology such as artificial intelligence, novel immunotherapic approaches and treatment combinations, and patient-derived and humanised models for translational cancer research.

Subjects of discussion concerning the lastmentioned topic will be patient-derived 3D cell and explant cultures, ex vivo cultured tumour slices, and murine models with a humanised immune system for cancer immunotherapy studies. Furthermore, we will also discuss the values and pitfalls of metrics used for the evaluation of publications and scientific output, for example the metrics of journal impact factors.

Speed dating ESUR21 will feature new sessions, too, in comparison with our previous meeting in 2019. For

ESUR21

instance, using the opportunities of the online format, we will launch the “Meet the experts” sessions, which are designed for maximum interaction between delegates and faculty, thus maximising the dissemination of knowledge.

27th Meeting of the EAU Section of Urological Research

We will also give project and consortium leaders the opportunity to give a short presentation on their new projects related to urological research in our “Speed dating” session.

8-9 October 2021

Finally, for another new session called “EAU Research Foundation: Awardees”, we have invited awardees of the EAU Research Foundation to present their results and to discuss the opportunities of research support from the EAU.

Virtual

In collaboration with the EAU Section of Uropathology (ESUP)

www.esur21.org

Network interdisciplinarily Overall, ESUR21 will provide an outstanding platform for researchers from urological departments as well as other departments to discuss recent research results and to network interdisciplinarily for urological research. Especially young researchers will get the chance to present their results in poster and oral sessions. ESUR21 will give a comprehensive overview on current research activities in urology and the opportunity to virtually meet experienced senior researchers.

”Using the opportunities of the online format, we will launch the 'Meet the experts' sessions, which are designed for maximum interaction between delegates and faculty.“ For all up-to-date information, including information on registration and the scientific programme, please visit www.esur21.org.

Register for ESUR21!

Early fee deadline: 23 September 2021 Late fee deadline: 9 October 2021

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

ESOU22

CME CPD

19th Meeting of the EAU Section of Oncological Urology 21-23 January 2022, Madrid, Spain www.esou22.org

Expert Insights

Best Practices for Managing Intermediate-Risk and High-Risk NMIBC MODERATOR Ashish M. Kamat, MD, MBBS Professor of Urology and Cancer Research The University of Texas MD Anderson Cancer Center Houston, Texas, United States

PANELISTS Paolo Gontero, MD Professor of Urology Chairman, Department of Urology Molinette Hospital University School of Medicine Torino, Italy Hugh Mostafid, MD, MSc Consultant Urologic Surgeon and Senior Lecturer The Stokes Centre for Urology Royal Surrey County Hospital Guildford, United Kingdom

To review the enduring portion of this live symposium, please visit:

www.medscape.org/summary/intermediate-high-risk-nmibc Supported by an independent educational grant from

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European Urology Today

August/September 2021

EAU Best Papers published in Urological Literature Awards The two EAU Prizes for Best Paper published in Urological Literature are tools through which the EAU encourages young and promising urological scientists to continue their work and to communicate their achievements to the European urological community.

Two awards of € 5,000 each will be made available for the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers have to be published or accepted for publication between 1 October 2020 and 30 September 2021.

The awardee(s) will be honoured during the 37th Annual EAU Congress in Amsterdam, 18-21 March 2022, during the Opening Ceremony.

Rules and Eligibility • Eligible to apply for the EAU Best Paper published in Urological Literature are urologists, urologists-in-training or urology-related scientists. All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author.

• Each author is allowed to submit no more than one paper.

Apply now!

• The paper must be written in English (or translated into English).

• The subject of the paper must be urological or urology related.

• The deadline for submission is 1 November 2021.

How to apply • Please send your paper by e-mail to m.smink@uroweb.org, indicating clearly the category in the subject line: “EAU Best Paper on Clinical Research” or “EAU Best Paper on Fundamental Research”.

• Include a copy of your curriculum vitae.

• Supply a list of all authors who have significantly contributed (if relevant).

• Mention any financial support by companies, government or health organisations.

• A publisher’s letter of acceptance has to be submitted along with your paper.

A review committee consisting of members of the EAU Scientific Congress Office will review all submitted papers and select the winner of the two EAU awards for Best Paper published in Urological Literature.

BALTIC22 EAU Update on Prostate Cancer

Virtual meeting 16 October 2021 www.pca21.org

EAU onco-urology series

7th Baltic Meeting in conjunction with the EAU 27-28 May 2022, Vilnius, Lithuania www.baltic22.org

Call for abstracts: deadline 1 April 2022

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

August/September 2021

European Urology Today

41

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TLX-2021-09-01. Date of Preparation: August 2021.

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European Urology Today

Telixpharma.com info@telixpharma.com August/September 2021

“Long-term and sustained improvements is the goal” Spotlight on the Global Philanthropic Committee organisations, part 1: the AUA The year was 2010 when Dr. Robert Flanigan (US), then secretary of the American Urological Association (AUA), initiated the Global Philanthropic Committee (GPC). The AUA, the European Association of Urology (EAU), and the Société Internationale d'Urologie (SIU) united forces to support education initiatives in “areas where needs are important and resources limited.”

Six years later, the International Continence Society (ICS) joined this collaboration. In this four-part interview series, we are putting the spotlight on each of these four organisations and their respective GPC projects, starting with the AUA represented by its secretary Dr. John Denstedt (CA).

Why did the AUA initiate the GPC? Dr. Denstedt: “The GPC is a way for urology organisations to pool their collective resources to fund larger humanitarian projects in urology. It is a way for the largest urological societies in the world to collaborate and to focus on a common goal of advancing urology in underserved areas.”

“Prof. Olapade-Olaopa noted that since the GPC had begun its support and equipment donations to his institution in Ibadan, Nigeria, he had seen a 30-40% increase in procedures.”

What are the results of the support for these projects?

“In 2013, at the GPC meeting held during the AUA Annual Meeting, Prof. E. Oluwabunmi OlapadeOlaopa (NG) noted that since the GPC had begun its support and equipment donations to his institution in Ibadan, Nigeria, he had seen a 30-40% increase in procedures. He also mentioned that there had been more multidisciplinary interactions between urologists, nurses, and general surgeons, which was an unexpected benefit from the GPC’s support. It’s clear that GPC support has led to long-term improvements in urology care in underserved areas, which is exactly the goal of this collaborative effort.”

Dr. John Denstedt

François de Sale in Port au Prince to manage and oversee urological equipment, and has worked with industry supporters and individual donors to send thousands of dollars worth of equipment and supplies to Haiti. The AUA also works closely with the Global Association for the Support of Haitian Urology (GASHU) and its co-founder, Dr. Angelo Gousse (US), on ongoing projects in Haiti to improve the urological training system and ultimately the urological patient care.”

“As for the GPC support in Haiti, with the nurse in place at the Hôpital Saint François de Sale, a more regular and standard level of training and patient care now occurs. I have visited and performed surgery at this hospital myself as part of a humanitarian mission and found all of the physicians and staff to be very dedicated to improvements in patient care. The AUA has a strong relationship with the Haitian urological leaders and leaders in GASHU and will continue to build upon that strong sense of collaboration. Despite the ongoing unrest in Haiti, we remain in close contact and continue to work together to improve the urological education and care in Haiti.

GASHU will have an on-site meeting at the AUA2021 Annual Meeting in Las Vegas to discuss continued projects in this area.”

What is the AUA’s ultimate goal for the GPC? “In regard to the ongoing humanitarian work in Haiti, the Hôpital Saint François de Sale has served as a good model for other hospitals in Haiti and the hope is to replicate the success there to hospitals in Cap Haitien and other areas of Haiti, which would include having a dedicated nurse at a hospital to maintain the donated equipment. The goal is to elevate the training standards in Haiti and to have strong key opinion leaders in urology here to serve as mentors and leaders for the next generation of urologists in the country. I would think this is a similar goal that other GPC members have with their respective humanitarian projects: long-term and sustained improvements.”

“Learn from and listen to the urologists and patients in other countries.”

What can the average urologist in the western world do to help remove the inequality between the western world and global south?

“Learn from and listen to the urologists and patients in other countries. Furthermore, get involved with groups like the Urology Care Foundation and International Volunteers in Urology.”

What projects has the AUA added to the GPC? “The AUA was closely involved in coordinating the equipment and monetary support for two endourologic centres in Senegal and Nigeria from 2012 to 2013. With our industry partners, we also facilitated a large donation of endoscopic equipment to the University of the West Indies in Jamaica.”

“In addition, we have been very active in Haiti over the last several years. The AUA has held an ultrasound course in Haiti, supported several urological meetings, supports the salary of a nurse at the Hôpital Saint

EAU Hans Marberger Award 2022 For the best European paper published on Minimally Invasive Surgery in Urology The EAU Hans Marberger Award will be handed out for the best European paper published on Minimally Invasive Surgery in Urology. The award, annually given since 2004, is named after Prof. Hans Marberger to honour his pioneering achievements and contributions to endourology and the development of urologic minimally invasive surgical procedures.

The awardee will be honoured during the 37th Annual EAU Congress in Amsterdam, 18-21 March 2022, during the Opening Ceremony.

Rules and Eligibility • All urologists and scientists are invited to send in papers.

• The topic of the paper should deal with Minimally Invasive Surgery in Urology.

• The paper must have been published or accepted for publication in a European Journal between 1 October 2020 and 30 September 2021.

Apply now!

• All papers must be submitted in English.

• All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author.

• Each author is allowed to submit no more than one paper.

• Deadline for submission is 1 November 2021.

A review committee, consisting of members of the EAU Scientific Congress Office, will select the winning paper.

How to apply Please send your paper to the EAU Central Office at m.smink@uroweb.org and mention “EAU Hans Marberger Award 2022” in the subject line of your e-mail.

The EAU Hans Marberger Award is supported by a grant of €5,000 from KARL STORZ SE & CO.KG

August/September 2021

European Urology Today

43

Recipient selection for kidney transplantation Candidate has to meet medical, social, lifestyle and psychosocial criteria for new organ Dr. Javier González Dept. of Urology Renal Transplant Unit General University Hospital Gregorio Marañón Madrid (ES) fjgg1975@yahoo.com

Prof. Enrique Lledó Dept. of Urology Renal Transplant Unit General University Hospital Gregorio Marañón, Madrid (ES) enrique.lledo@ salud.madrid.org Kidney transplantation (KT) is an elective procedure.

Unlike for other solid organ transplants, there are different alternatives such as renal replacement therapy (RRT), representing an option for the treatment of patients with end-stage chronic kidney disease (CKD). Most patients suffering from this condition will benefit from these options. However, providing the patient with sufficient counselling is a prerequisite before including a candidate in the waiting list. Whether or not to include a candidate remains a complex decision that should balance the expected benefits (sometimes detriment) of KT, patient equitability and social responsibilities of the professionals involved in order to allocate the limited supply of donor organs wisely. [1] This article aims to outline and discuss the commonly used selection criteria to help potential recipient screening in an individual fashion.

Selection criteria There are many factors that may render a candidate ineligible for KT. Criteria to put a candidate on the waiting list for KT should take into account the potential risks for surgical complications and issues related to immunosuppression. These criteria, when adequately applied, should limit patient perioperative mortality and screen for conditions that would be exacerbated by immunosuppression.

Overall, practice guidelines always include broad cardiovascular contraindications. However, differences in age cut-offs, estimated life expectancy and glomerular filtration rate do exist among different practice guidelines. In addition, inconsistencies occur in cancer-free intervals, human immunodeficiency virus (HIV) thresholds and adherence to antiretroviral therapy, psychological screening or clinical assessment tools.

Nevertheless, the following four major criteria are quite consistent among the different practices guidelines available: i) ii) iii) iv)

recipient age; life expectancy; medical criteria social, lifestyle, and psychosocial circumstances.

Expected Post-transplant Survival The Scientific Registry of Transplant Recipients Review Committee of the United Network of Organ Sharing (UNOS) has analysed these four factors and their potential role in life expectancy after KT. This analysis led to the Expected Post-transplant Survival (EPTS) score. [2] The score includes the following elements: time on dialysis, current diagnosis of diabetes, prior solid organ transplants, candidate age. The EPTS score is currently used in the UNOS allocation policies and intents to optimise longevity-matching in an effort to maximise the utility of KT.

and psychosocial history and detailed physical examination aimed at detecting such comorbid conditions.

Infection screening Screening for infections is mandatory in the initial evaluation of a potential KT recipient. The presence of hepatitis B and C, syphilis, HIV and tuberculosis viruses should be excluded in advance. Evidence of active infection warrants treatment prior to immunosuppression initiation. Cytomegalovirus (CMV) serostatus guides further post-transplant prophylaxis and should be determined in all candidates.

Immunisation prior to KT should be administered to those candidates who are seronegative for Varicellazoster virus, given that in immunocompromised patients, infection can be devastating. Finally, it is advisable to screen for Epstein-Barr virus serostatus because an increased risk for lymphoproliferative disease is carried by seronegative candidates. In fact, it is also unsafe for these patients to receive betalacept in the post-transplantation period.

Viral hepatitis Active viral hepatitis increases the risk of upregulation of virus replication and favours ongoing liver damage.

In these cases, a transjugular liver biopsy is indicated to assess its underlying severity. The information provided by the liver biopsy may also help in identifying patients at a special risk of liver failure, which facilitates the decision in the case of a dual organ transplantation. Although chronic hepatitis B infection may not be considered an absolute contraindication to KT, candidates affected should undergo a test for virus hepatitis B e-antigen and DNA titers as an additional evaluation to predict the risk of reactivation.

"... in immunocompromised patients, infection can be devastating."

Hepatitis C treatment before KT remains controversial in the light of newer highly effective antiviral agents.

Active hepatitis C patients without advanced liver disease may opt to receive grafts from hepatitis C positive donors. Accepting these grafts may result in earlier transplantation, thus decreasing dialysis time frames and improving transplantation outcomes.

Actually, the treatment of hepatitis C is so successful that the Ethics Committee of UNOS has suggested that it is justifiable to transplant hepatitis C positive kidneys into hepatitis C negative recipients. A wise approach to this issue would be to defer treatment of hepatitis C in patients with stage 0-2 liver fibrosis under proper consent, to treat hepatitis C before KT in patients with liver fibrosis stage 3 to decrease the patient´s risk of cirrhosis, and to refer patients with stage 4 liver fibrosis for combined kidney-liver transplantation.

Cardiovascular screening Cardiovascular comorbid conditions are extremely common in patients with end-stage CKD, particularly asymptomatic coronary artery disease (37-53% for at least one coronary artery stenosis of 50% or greater).

Without a doubt, cardiovascular conditions remain an important source of morbidity and mortality, representing the first cause of death in the immediate postoperative period. In fact, cardiovascular complications account for 30% of deaths with a functioning renal allograft.

The main goal of cardiovascular screening should be to detect the subpopulation of recipients who will probably develop a cardiac event after transplantation and would benefit from a pre-transplant strategy.

However, the appropriate cardiac risk assessment strategy for patients with end-stage CKD is still at contention. The American Society of Transplantation (AST) recommends stress echocardiography or scintigraphy as a part of the screening process.

Depending on these test outcomes, the patient may have to undergo an angiogram (with or without revascularisation) before the KT is attempted.

Conversely, the American Heart Association (AHA) do Although suitability of KT is a topic for debate, most not recommend pre-transplantation cardiac would agree that there are some absolute evaluation since KT can be considered a procedure of contraindications. Active infection or malignancy, substance abuse, reversible renal failure, uncontrolled intermediate risk under adequate functional status. psychiatric disease, documented treatment nonLack of meaningful consensus adherence, and a significantly shortened life expectancy are factors to consider in the suitability of The lack of meaningful consensus leads to difficulty in determining which patients require no testing, KT. Therefore, the initial assessment of a potential recipient should include a thorough medical, surgical non-invasive cardiac testing or invasive interventions.

Screening all patients on the waiting list may turn out to be expensive, time consuming, and impractical. For EAU Section of Transplantation Urology (ESTU) these reasons, many transplant programmes support 44

European Urology Today

the guidelines of the AST. In fact, there is great emphasis on focused screening for patients at a higher risk of coronary artery disease among the group with end-stage CKD. The AST advocates non-invasive cardiac stress imaging for patients with diabetes, prior ischemic heart disease or two of the following criteria: i) men older than 45 years ii) women older than 55 years iii) ischemic disease in a first-degree relative iv) smoking v) hypertension vi) cholesterol level > 200 mg/dL vii) HDL > 35 mg/dL viii) left ventricular hypertrophy [3] The most commonly used non-invasive screening tests for heart disease include exercise electrocardiogram and myocardial perfusion study (Thallium/Sestamibi scintigraphy and echocardiography under exercise/dobutamine). The physical basal condition of the patient under dialysis often does not allow an exercise test due to reduced reserve capacity, making perfusion studies the usual choice. However, the ideal perfusion test remains under debate. Every centre is encouraged to choose the myocardial perfusion test under the consensus of a multidisciplinary team. It seems clear that patients harbouring critical coronary artery lesions should be referred for angioplasty, stent placement or coronary artery bypass graft surgery.

Non-ischemic cardiac conditions There are other non-ischemic cardiac conditions that may impact patient morbidity and mortality after KT including systolic/diastolic cardiac dysfunction, pulmonary hypertension and valvular heart disease.

Structural and functional myocardial impairment is rather frequent among patients with CKD. The term “uremic cardiomyopathy” describes the alterations that explain the diastolic dysfunction that worsens with CKD progression. Abnormalities that arise on echocardiogram in this context, particularly left atrial volume, have emerged as a risk marker of death in patients suffering from end-stage CKD after transplantation. Myocardial dysfunction is directly related to the number of cardiovascular events that occur after transplantation. Conversely, the abnormalities leading to myocardial dysfunction may be counterbalanced (thus returning to normal) in many occasions after KT. If myocardial dysfunction has any point of reversibility, KT should be encouraged.

Otherwise, if the screening of myocardial dysfunction does not show any point of reversibility, the patient should be referred for combined dual heart-kidney transplantation.

treatment are a matter of debate and vary among institutions and cancer types. In situ or superficial cancers may not require any interval until safe transplantation. Conversely, extensive cancer situations may require longer free-intervals. The AST advise in favour of at least a 2-year disease-free interval for most cancers and a 5-year interval for stage II breast cancer, extensive cervical cancer, stage C colorectal cancer, melanoma other than in situ, and locally advanced renal cell carcinoma. A valuable source to be used in ambiguous cases is the American Cancer Society routine cancer screening recommendation for the general population for patients prior to transplantation. [5] An intense screening for renal cell carcinoma is advisable in patients suffering from Balkan nephropathy, analgesic induced nephropathy and Chinese herb-induced nephropathy. Although there is no convincing evidence to support a recommendation, patients with prior exposition to cyclophosphamide may require more intense screening for bladder cancer.

"... cardiovascular complications account for 30% of deaths with a functioning renal allograft."

Psychosocial screening The main purpose of the psychosocial screening is to identify barriers that may impact adherence to a complex medical schedule. These barriers may include behavioural, social and financial issues that most programmes address through a multidisciplinary team including social workers/ mental health professionals with enough experience and expertise in the field.

Patients with end-stage CKD are at substantial risk of psychiatric conditions that may negatively impact adherence to a tight treatment schedule. Depression and anxiety are especially prevalent with incidences reported of 2-16% and up to 39%, respectively.

However, evidence on how these conditions impact morbidity/mortality after transplantation are inconsistent.

Patients suffering from alcohol abuse and other dependencies pose a special challenge. Every effort aimed at treating substances abuse prior to transplantation is advisable. These patients should undergo extensive counselling, and a documented drug-free period may be required.

High cost Financial issues should be evaluated before transplantation. The high cost of medications and the requirements regarding postoperative follow-up may pose a hard-to-afford task for many families, especially if the recipient is the primary source of Pulmonary hypertension Pulmonary hypertension is detected in almost 50% of income. Financial risks may lead to medication discontinuation, miss of follow-up appointments, and patients with end-stage CKD on haemodialysis and has been highlighted as an independent risk factor for thus renal allograft rejection. early graft dysfunction after deceased donor KT. Finally, an intense scrutiny regarding behavioural However, this condition may improve after patterns of adherence to pre-transplantation transplantation. Aggressive diuresis or ultrafiltration medication is advisable since this behaviour predicts on dialysis may favour a substantial decrease in the pattern of adherence to medication in the pulmonary artery pressures. If these measures are postoperative period. Non-adherence to proved unsuccessful, right heart catheterisation may be required to better define the perioperative risk and immunosuppression remains a leading cause of graft failure post-transplantation. This situation can be potential reversibility, making those patients with predicted based on the behaviour the patient shows uncorrected severe pulmonary hypertension poor candidates for transplantation. Valvular heart disease with dietary, medication and treatment compliance in is also rather frequent in patients with end-stage CKD. the dialysis period or the willingness and ability to follow through with transplant screening Although there are no specific guidelines on how to recommendations in a timely manner. proceed with these patients, it seems clear that moderate/severe aortic stenosis should be considered References for valvular replacement in order to increase the 1. Rodríguez-Faba O, Boissier R, Budde K, et al. European chance for better outcomes. [4] Cancer screening The risk of developing cancer in the patient harbouring a kidney allograft has been estimated 2-3 fold higher than that of the general population. Active malignancy remains a major contraindication for two reasons: i) the shortage of organs in the donor pool makes providing an organ to individuals with limited life expectancy unjustifiable ii) the immunosuppression required after KT to ensure optimal graft function may accelerate the progression of an underlying malignancy However, in cancer survivors with end-stage CKD requiring RRT, transplantation may represent an excellent choice. The optimum time free-intervals regarding curation or relapse possibility after cancer

Association of Urology Guidelines on Renal Transplantation: Update 2018. Eur Urol Focus 2018; 4: 208-215. doi: 10.1016/j.euf.2018.07.014.

2. Organ Procurement and Transplantation Network (U.S. Department of Health & Human Services). A Guide to Calculating and Interpreting the Estimated PostTransplant Survival (EPTS) Score Used in the Kidney Allocation System (KAS). https://optn.transplant.hrsa.gov/ media/1511/guide_to_calculating_interpreting_epts.pdf 3. Gill JS. Screening Transplant Waitlist Candidates for Coronary Artery Disease CJASN 2019; 14: 112-114. doi: 10.2215/CJN.10510918 4. Delos Santos RB, Gmurczyk A, Obhrai JS, Watnick SG. Cardiac Evaluation prior to Kidney Transplantation.

Semin Dial. 2010 May-Jun; 23(3): 324–329. doi: 10.1111/j.1525-139X.2010.00725.x 5. http://www.cancer.org/healthy/findcancerearly/ cancerscreeningguidelines/american-cancer-societyguidelines-for-the-early-detection-of-cancer

August/September 2021

Prof. Louis Denis 1933-2021 “Inspiring colleague, freethinker, and academic leader”

Prof. Lodewijk (Louis) Jan Denis, one of urology’s trailblazers and freethinkers, passed away peacefully on 28 July 2021. He was an inspirational urologist, a loyal lieutenant colonel of the Belgium army, and one of the founders of Europa Uomo, the European advocacy movement representing 27 prostate patients’ groups across Europe.

Born in Antwerp, Belgium in January 1933, Prof.

Denis was a son of a Belgian docker. He grew up during the Second World War and spent most of his time with his grandparents. He attended medical school at the University of Ghent, where he joined the university’s basketball team. The team won a bronze medal at the University Olympic Games held in Helsinki, Finland in 1952.

He graduated from medical school in 1957, then began his residency in surgery and urology at the Antwerp City Hospitals.

After his residency, Prof. Denis received an appointment at the Medical College of Virginia in the United States where he received a National Institute of Health (NIH) Grant to join the Prostate Cancer Group. He was often invited by major American institutes such as Brady Urological Institute, Cornell University and MD Anderson to give lectures on this topic.

Prof. Denis’s military career compelled him to return to Belgium in 1964. As Chief of the Urology Antwerp Military Hospital, he was summoned to aid Operation Red Dragon in rescuing over 700 European and American hostages in Stanleyville (formerly Belgian Congo). For his extraordinary accomplishments, he was awarded several Belgian Civil honours such as Knight of the Order of Leopold (1972), Knight of the Order of the Crown (1979), and Commander of the Order of Leopold II (1991).

Prof. Denis left the army in 1973 (he retired as Lt. Colonel in 1991) to become the coordinating chairman of the Urological Department of the Antwerp City Hospitals (AZ Middelheim), and professor at the Flemish Free University of Brussels (VUB) in 1978.

*****

In 1982, he co-founded the European School of Oncology (ESO). He was also a founding member of the Genito-Urinary Group of the European Organisation for Research and Treatment of Cancer (EORTC), where he served as treasurer for many years and as president from 1988 to 1991. He also launched the European Journal of Cancer in London. He took different positions in the Union Internationale Contre le Cancer (UICC) between 1998 and 2006, as treasurer and Secretary General, respectively.

With the foundation of the International Prostate Health Council (IPHC), which he chaired since 1989, Prof. Denis, together with Adolf Steg, Tage Hald, Jens Altwein, Roger Kirby, Peter Boyle, Francesco Pagano and Fritz Schröder, created a think tank to increase worldwide awareness of prostate diseases. This resulted in a pan-European screening initiative that led to the inception of the European Randomized Screening Trial for Prostate Cancer (ERSPC) in 1991.

The ERSPC was a landmark trial which showed that the detection of prostate cancer (PCa) in its early curable stages leads to a highly significant reduction in PCa mortality.

Later in his urological career, Prof. Denis set up the International Consultation in Urological Diseases (ICUD) in 1996 together with Gerry Murphy and Yoshio Asa. Their aim was to establish an international strategy by consensus for the prevention, diagnosis and management of urological diseases. In 1998, he obtained an emeritus status as Professor of Urology at

the VUB and became Director of the Oncology Center Antwerp (OCA).

As a PCa survivor himself, Prof. Denis focused more and more on the organisation of cancer patient coalitions, as well as on the support and education of patients as a whole and PCa patients specifically. He was director of the patients association Wij Ook België (US TOO Belgium), and one of the founding members of the European Patient Coalition for Prostate Cancer and Europa Uomo in 2004. When he planned to step down from the Europa Uomo board, he was asked to extend his governance.

Prof. Denis felt honoured to be one of the first members of the European Association of Urology (EAU). In 2014, he received the EAU Frans Debruyne Lifetime Achievement Award for his enormous contribution to urology. He was instrumental to Europa Uomo and for the recent PIONEER stage 2 application and evaluation process, which is a European network of excellence for big data in PCa. He became an ex officio board member of Europa Uomo. During its General Assembly held on 19 June 2021, he officially resigned.

Just six weeks later he left everything and everybody for good and forever. Prof. Denis’ legacy does not only lie in his exemplary contributions to urology and notable accolades, but also with the people he helped and inspired all throughout his life. He will be dearly missed.

Prof. Chris Chapple (GB): “He was an extremely inspiring colleague, a dear friend, an academic leader, and an Honorary Member of our Association since 2010. It has been a great honour to work with him. He was an eminent urologist who was widely known for his wisdom, courtesy, and tireless dedication to improving urology worldwide. He will be dearly missed by all who knew him and he will be remembered for his commitment to European and global urology.

The urological community has lost a highlyrespected colleague, a great academic, an extremely driven patient advocate, and for many of us, a dear and great friend.” ***** Prof. Hein Van Poppel (BE): “Thank you, Louis, for what you’ve taught me. I will always remember what you once wrote in Cancer World in 2014: “I abhor power, arrogance and elitism”. I recall the time when you were a free-thinker and full Professor at the VUB and I was a Catholic Associate Professor at KU Leuven, pillarization was still very heavy.

People might have expected that we would never get along well but the opposite happened.

Thanks to your trust and friendship, I was able to serve as ICUD treasurer, member of the GU Surgeons (AAGUS), Chair of the Scientific Office of Europa Uomo, contribute to the EORTC GU, and more. In the last few years, your health was getting more fragile. Nonetheless, you were still very instrumental in setting up the newlyestablished EAU Patient Office and Policy Office in 2021. Like many others, I will not forget you.

We will always remember your words: “I want champagne and Scottish bagpipers at my funeral, and I want my friends to remember me as a freethinking man!” *****

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

paul.meria@ sls.aphp.fr

Cystitis unmasked (James Malone-Lee) Cystitis is currently the commonest bacterial disease affecting women. Symptoms associated with acute or recurrent cystitis may be bothersome for women and require medical attention in many cases.

Controversies are frequently arising about various aspects of diagnosis and management of cystitis and J. Malone-Lee, an emeritus professor of Book reviews

August/September 2021

medicine, has assembled in this book a considerable amount of information focusing on the approach of cystitis and other bladder diseases. A critical appraisal of the applicable recommendations is a common theme of this work.

conditions such as pregnancy and others. An overview of the worldwide use of antibiotics and bacterial resistance clarifies the current situation in this field. A special chapter covers the aspects of UTI in children.

The first part of the book covers the historical aspects of urinary tract infections (UTI), over a period of almost 5000 years. This chapter reminds us that the greatest physicians in history were involved in the management of UTI and some of their research is still significant and relevant nowadays. The following chapter considers various aspects of statistics and their clinical application, followed by a critical approach addressing opinion wars, doubts and controversies in various fields related to UTI and other bladder disorders.

This controversial book, written by a non-urologist, provides the reader with a very personal approach and the points of view expressed by the author are far away from current recommendations. Many criticisms are developed against scientific committees and their methods for establishing recommendations, most of them being considered unsuccessful. For example, bladder pain syndromes are attributed to chronic infections and the author offers long-term antibiotic therapy for such diseases.

An important chapter is dedicated to paraclinical explorations, followed by another one dealing with various physio-pathological aspects of UTI.

Consequently, we suggest that the reader should make up his own mind about this provocative book, with a critical approach, just as the author when he wrote his work.

The treatments of UTI and the problems related to antimicrobial resistance are described in the next chapters. The author focuses on many important aspects of patient management, including special

Editors ISBN Publication Edition

: James Malone Lee : 987-1-91007-963-8 : Feb. 2021 : 1st

Publisher Cover Illustrations

Website Price

: TFM Publishing : softback : 3 tables, 43 illustrations, 33 graphs, 9 photos : www.tfmpublishing.com : 30,00€ European Urology Today

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Prostatic Urethral Lift UroLift System abstracts presented at EAU21

Real-world evidence supports value of UroLift System in wide range of LUTS patients Real-world evidence presented at the European Association of Urology congress supports the durable clinical and healthcare resource benefits of the UroLift System in wide range of patients with LUTS from BPH.1-4 The UroLift System (Prostatic Urethral Lift treatment) was designed to meet the needs of patients for safe and effective alternatives to traditional surgical treatment. The UroLift System is designed to relieve symptoms of urinary outflow obstruction without heating, cutting, destruction or removing prostate tissue. The procedure can be done in an outpatient setting, under local anaesthesia.

Patients typically return home the same day without a catheter, and experience rapid symptom relief and recovery with low complication rates.5-13 The UroLift System is the only minimally invasive surgical therapy (MIST) to be recommended with a ‘strong’ strength rating for the treatment of

LUTS in the EAU guidelines.14 The UroLift System is also the only minimally invasive surgical treatment (MIST) mentioned in the EAU’s treatment algorithm for bothersome LUTS,14 where the UroLift System is recommended for all patients with a prostate size of 30-80 ml, regardless of level of risk. It is also the only surgical treatment specifically recommended for patients who are unable to undergo anaesthesia.14

Sub-group analyses presented at the EAU congress examined the durability of treatment with the UroLift System, as well as its use in acute urinary retention2 and in men with obstructive median lobes.4 Analysis of real-world healthcare resource utility was also performed to compare surgical retreatment rates and postoperative complications following different surgical treatments for BPH.3

To date, over 250,000 men have been treated with the UroLift System, and it is now offered in many countries across Europe and the rest of the world. As well as being one of the most studied treatments in Urology, with more than 28 peer-reviewed clinical publications, real-world evidence is also being collected from patients treated with the UroLift System. This Real-World Retrospective (RWR) UroLift System study currently includes 3226 patients across 22 international sites.4

Sub-group analysis of the RWR study presented at the European Association of Urology congress supports the durable clinical and healthcare resource benefits of the UroLift System in a wide range of LUTS patients.1-4 Outcomes from these analyses were also found to be highly comparable with the outcomes from controlled studies with the UroLift System.15,16

UroLift System is effective in treating obstructive median lobe The MedLift controlled study revealed that obstructive median lobe (OML) protrusion can be treated safely and effectively with UroLift System.16 Barber et al analysed data from the 277 patients from the RWR database who had an OML and compared this with data from the 45 patients with OML in the MedLift study.4 Post treatment with UroLift System, both groups improved significantly across all timepoints, and IPSS, QoL and Qmax outcomes were similar throughout follow-up between the two groups (Figure 2).4 There was also no significant difference between post-procedure catheterization rates between the two groups when catheterization was not the standard of care; 9.4% in RWR OML patients and 15.6% in the MedLift OML patients.

Retreatment rates were also similar between the RWR OML patients and the RWR patients without OML. There was no increase in adverse event rates between the groups.

The authors concluded that real world analysis of patients with OML treated with UroLift System confirms results from the MedLift study in patients with OML.4

Large-scale analysis of healthcare resource utility shows UroLift System associated with similar surgical retreatment rates and lower post-operative complications Very few real-world studies have compared the impact on healthcare resource utility following different surgical approaches for the treatment of BPH. The potential reduction in healthcare resource use is particularly important to consider in the context of introducing minimally invasive treatment options such as UroLift System. Kaplan et al analysed longitudinal patient-level data from US Medicare and commercial claims to compare the rates of surgical retreatment and post-operative complications in patients who had undergone traditional surgery (TURP or GreenLight Laser PVP) or minimally invasive treatments (UroLift System or Rezum steam injection) for LUTS from BPH.3 Surgical retreatment was defined as a secondary procedure of TURP, GreenLight, UroLift System, Rezum, or HoLEP following the index procedure. Post-operative complications were defined as other secondary procedures with a CPT or ICD10-PCS code.

Analysis of data for 34,107 patients showed that subsequent surgery for return of symptoms over a 4-year period was recorded in only 6.8% of UroLift System patients. This compared with 9.5% of Rezum patients, 6.3%

of TURP patients, 7.0% of GreenLight patients (logrank p<0.01) (Figure 1).3 At 1 year, the UroLift System was also associated with the lowest incidence of complications defined as a post-operative outpatient procedure during a return visit at (16.3%), compared with Rezum (23.0%), TURP (19.7%) and GreenLight (21.6%)3.

Figure 2. Symptom response to UroLift System in RWR OML and LL flow patients compared with the MedLift OML patients and the LIFT study patients.

Symptom severity may determine durability of the UroLift System, helping to inform discussions with patients about optimal timing of intervention

UroLift System is effective and safe in BPH patients in urinary retention

Durability of the UroLift System has been demonstrated to 5 years in the LIFT study,13 and real-world data has revealed successful outcomes in heterogenous BPH populations.17 Kayes et al analysed patient data from the RWR database to determine how baseline patient characteristics, such as IPSS and Quality of Life scores, correspond to the likelihood of a successful response with the UroLift System.1 Their analysis included the 2714 patients treated with the UroLift System who were not in urinary retention at baseline. It also looked at a sub-group of patients from the RWR database whose baseline characteristics mirrored the inclusion criteria of the LIFT study. Their analysis showed that higher baseline IPSS and QoL scores were significant predictors of reintervention in both study populations1.

Figure 1. Cumulative incidence of surgical retreatment after UroLift System, Rezum, GreenLight, and TURP through 1500 days.

Reproduced with permission from Barber N et al. Prostatic Urethral Lift (PUL) effectiveness in real-world subjects with obstructive median lobes. EAU Abstract, 2021.

If left untreated, urinary retention is a common complication of BPH, giving rise to a significant number of attendances at the Accident and Emergency Department and hospital admissions each year.18 Rochester et al analysed outcomes following treatment with the UroLift System, both in a sub-group of the real-world (RWR) study dataset2 and a controlled study in patients in urinary retention – PULSAR.15 Baseline demographics and outcomes (IPSS, QoL, Qmax, PVR) were compared between the 512 patients from the RWR database who were in active urinary retention at the time of the UroLift System procedure and the 52 retention patients in the PULSAR study. Analysis revealed favourable and stable outcomes at 12 months for patients in retention at the time of UroLift System treatment15. IPSS, Qmax, and PVR outcomes in the RWR patients were equivalent to the PULSAR patients. The authors concluded that these data indicate that UroLift System is effective and safe in retention patients and may be a viable option for this population of men suffering from BPH.2

The authors concluded that a more severe disease state at baseline may increase the likelihood of subsequent BPH surgery and that Urologists may find it helpful to use these findings to inform discussions with patients about intervening earlier in the disease process1.

Reproduced with permission from Kaplan SA et al. Analysis of Real-world Healthcare Claims, EAU Conference Presentation, 2021.

References 1. Kayes O et al. Real-world predictors of durability after Prostatic Urethral Lift (PUL). EAU Abstract, 2021.

2. Rochester M et al. Prostatic Urethral Lift (PUL) in retention patients: 12-month outcomes from RealWorld and PULSAR studies. EAU Abstract, 2021.

3. Kaplan SA et al. Analysis of Real-world Healthcare Claims, EAU Conference Presentation, 2021.

4. Barber N et al. Prostatic Urethral Lift (PUL) effectiveness in real-world subjects with obstructive median lobes. EAU Abstract, 2021.

5. Roehrborn, J Urol 2013.

6. AUA Guidelines 2003.

7. AUA Guidelines 2020.

8. Mirakhur, Can Assoc Rad J 2017.

9. McVary, J Urol 2016.

10. Tutrone, Can J Urol 2020 11. Kadner, World J Urol 2020.

12. Shore, Can J Urol 2014.

13. Roehrborn, Can J Urol 2017.

14. EAU Guidelines 2021.

15. Rochester, EAU Poster 2020.

16. Rukstalis, Prostate Cancer Prostatic Dis 2019.

17. Eure, J Endourol 2019.

18. NHS Digital. (2020). Hospital Admitted Patient Care Activity 2019-20. Diagnosis. * . https://www.urolift.com/physicians/publications?h sCtaTracking=fd638e94-7c4e-4c4d-82493ce9b311028f%7Cfc136105-1949-4fa8-abf290e08795a605

Teleflex, the Teleflex logo and UroLift are trademarks or registered trademarks of Teleflex Incorporated or its affiliates, in the U.S. and/or other countries. Information in this material is not a substitute for the product Instructions for Use. Not all products may be available in all countries. Please contact your local representative. Revised: 08/2021. © 2021 Teleflex Incorporated. All rights reserved. MCI-100414-EN · REV 0 · 09 21 PDF

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August/September 2021

Provision of advanced uro-oncological care Part II: Building a resilient nurse workforce to provide quality care Franziska Geese, PhD cand, MScN, RN Bern University of Applied Sciences Dept. of Health Professions Berne (CH) franziska.geese@ bfh.ch The World Health Organisation and the International Council of Nurses expect that there will be a shortage of 5.7 million nurses internationally until 2030. [1,2] The United States’ cancer care workforce lacks more than 2,300 medical oncologists until 2025. [3] After the current COVID-19 pandemic, it is expected that more (specialised) nurses will leave the profession because they miss physical and psychological safety. [4] Introducing advanced practice nurses To meet patients’ demands and to cope with the shortage of health care professionals, many countries see potential in the introduction of advanced practice nurses (APNs) and their services to national health care systems, as presented in Part I of this EUT series. [5] These specialised nurses with a master degree provide comprehensive care through multi-dimensional interventions, e.g. coordinative activities to manage needs in the interprofessional care team and by counselling to increase patients’ symptom management. [6] The advanced nursing practice services are intended to achieve an improvement in patient quality care. [6] Job satisfaction Nonetheless, a range of organisational and personal factors have an impact on APNs’ job satisfaction and thus on their job performance and patient quality of care. [7] Job satisfaction is understood as a personal feeling that indicates whether an employee is satisfied or dissatisfied with the work, including a number of factors such

as psychological, physiological, and environmental/ organisational. [8] Satisfaction-related factors are divided into intrinsic, which usually increases the feeling of satisfaction, and extrinsic factors, which relates to dissatisfaction. Relevant factors vary regarding the country and organisation-specific environment. Especially APNs working in the primary care setting quite often experience a high case load when providing their services. Even though these APNs enjoy a broad scope of practice, which might relate to a higher level of satisfaction, the remoteness in primary care and the missing educational resources can intensify the feeling of being alone and not supported, which can cause dissatisfaction with the job. [9]

“Supportive interventions for APNs and registered nurses are necessary to help them cope with the demanding work.”

Organisational and personal factors Organisational factors - which are relevant in every care setting, such as the lack of legal regulation of advanced practice competencies and the lack of supervision in clinical training, are negatively related to APN’s job satisfaction. [10] Nonetheless, personal factors, such as a higher number of years of professional experience, a low number of overtime hours, and increased confidence in one's own role are associated with job satisfaction. [11] Variety in work between clinical practice, research, scientific and professional training, and consulting activities leads to a better role satisfaction and favours retention in the role. [12] Nevertheless, if the APNs’ extended scope of practice is not fully exercised, this can cause job dissatisfaction. [13] However, job-satisfaction-related factors that are relevant in the context of patient care (e.g. caring for patients with a uro-oncological condition) was not found in the latest published literature. The author assumed that relevant factors are more associated with organisational and personal factors than with patient characteristics (e.g. diagnosis) or the complexity of care that needs to be provided to patients.

Coping with work stress Providing care to patients in a complex care situation (e.g. patients with a cancer diagnosis) under time pressure leads to work stress and is known as a barrier in providing good nursing care. [14] Literature shows that work stress can result in psychological effects such as burnout, depression, anxiety, and post-traumatic disorders, which are associated with an increased absence from work and the intention to leave the nursing role or profession. [15-17] Supportive interventions for APNs and registered nurses working in specialised care (e.g. uro-oncological care) are therefore necessary to empower them with relevant knowledge and to help them cope with the demanding work. [18] An example of a supportive strategy is the educational resources offered by the European Association of Urology Nurses (EAUN).

If time is lotted for nurses (e.g. in Urology) to attend conferences, meetings, and/or webinars, they may gain knowledge (e.g. learn skills to reduce stress in a demanding working environment). Furthermore, compensation of overtime and the opportunity for personal development might give the needed support. [19] Educational resources To build a resilient nurse workforce in uro-oncological care, the EAUN is working hard to provide different kinds of educational resources. A number of these resources are: • Bimonthly webinars developed by special interest groups (SIG prostate cancer, bladder cancer, continence, endourology); • E-courses available to members; • One to two-day ESUN courses; • The fellowship programme to get an insight into other national nursing care programmes.

Especially in the time of COVID-19, online resources seem to be the most effective way to reach urology nurses internationally. To stay up to date, it is important that national urology nurses organisations and the EAUN collaborate on providing further educational resources about relevant topics. The EAUN is therefore happy to receive further feedback. Please send your ideas or inquiries to eaun@uroweb.org.

References 1. ICN. International Council of Nurses Policy Brief: The Global Nursing shortage and Nurse Retention. 2021 [cited 2021 02.04.]; Available from: https://www.icn.ch/ sites/default/files/inline-files/ICN%20Policy%20Brief_ Nurse%20Shortage%20and%20Retention.pdf.

2. WHO. State of the World`s Nursing Report - 2020. 2020 [cited 2021 02.04.]; Available from: https://www.who.int/ publications/i/item/9789240003279.

3. Mathew, A., Global Survey of Clinical Oncology Workforce. Journal of Global Oncology, 2018(4): p. 1-12.

4. Kim, Y.-J., S.-Y. Lee, and J.-H. Cho, A Study on the Job Retention Intention of Nurses Based on Social Support in the COVID-19 Situation. Sustainability, 2020. 12(18): p.

7276.

5. Geese, F., Provision of advanced uro-oncological care.

Part I - EAUN committed to supporting urology nurses in expertise development. European Urology Today, 2021(January/February): p. 31.

6. Alotaibi, T. and C.A. Al Anizi, The impact of advanced nurse practitioner (ANP) role on adult patients with cancer: A quantitative systematic review. Applied Nursing Research, 2020. 56: p. 151370.

The full list of references of this article is available from the EUT Editorial Office. Please send an e-mail to: EUT@uroweb.org with reference to the article “Provision of advanced uro-oncological care” by Franziska Geese, Aug/Sep issue 2021.

EAUN Board Chair Past chair Board member Board member Board member Board member Board member Board member

Paula Allchorne (UK) Susanne Vahr (DK) Jason Alcorn (UK) Franziska Geese (CH) Ingrid Klinge Iversen (NO) Tiago Santos (PT) Corinne Tillier (NL) Jeannette Verkerk (NL)

www.eaun.uroweb.org

Join the ERUS-EAUN Robotic Urology Nursing Meeting One or three-day update available as part of ERUS-DRUS21 meeting The EAUN is working together with the EAU Robotic Urology Section to offer nurses a three-day meeting in Dusseldorf this November. There will be a full-day nurses’ programme on November 11th, with nurses invited to join the rest of the ERUS meeting on 11-13 November.

The meeting will give participants a complete update on robotic urology and how it differs from conventional surgery, with special attention given to the nurses’ roles in the team. We spoke to Ms. Anna Mohammed, Chair of the EAUN Special Interest Group for Endourology and also Chair of the Nurses’ Programme at ERUS-DRUS21 from London (GB).

The programme “The programme for the 2021 ERUS-EAUN meeting will look at various aspects relating to robotic surgery,” said Ms. Mohammed. “For instance the differences in prostate cancer treatment, nervesparing surgery, the controversial topic of lymph node dissection and whether it makes a difference in cancer surgery. We will also be getting an update on team training and ‘lean methodology’ for efficiency within the theatre team and robotic surgery environment.”

Register now for the late fee!

Deadline: 27 October 2021 “We will also be examining innovative reconstructive surgery, utilising the robot for more than cancer surgery. Finally, we will have an extensive introduction to the idea of developing a curriculum for training and appraisal for all members of the surgical robotic team. It’s quite a packed programme but hopefully everyone will gain as much knowledge and insight into new and upcoming ideas and approaches within the robotic field.”

August/September 2021

This nurses’ programme is part of the larger ERUS-DRUS21 meeting which will be offering (live) surgery to a broader audience of surgeons and other urology specialists. The full programme includes many live and pre-recorded surgery sessions, courses on robotic urology by the European School of Urology and a further nursing and patient sessions (in German). Find out more about ERUS-DRUS21 on p. 38

For the complete Scientific Programme visit www.erus21.org Challenges in the field Ms. Mohammed also weighed in on some of the challenges for nurses who are starting to get involved in robotic urology teams. “I believe the current challenges in the field are continuous and up-to-date evidence-based training for all members of the theatre team. By developing and investing in education for the theatre team, we would be able to retain staff as there is a high rate of attrition in the theatre environment. By making a scientific programme of value to all members of the team, we can share best practice and innovative ideas within the robotic field.”

and understanding MRI, and Prof. Canda’s presentation on nerve sparing, its mechanisms, functional outcomes and grade. Particularly useful for nurses are the presentations on team training and lean methodology and the development of a curriculum for training and appraisal for all members of the surgical robotic team.”

“These updates will enable all members of the robotic team to gain insight and understand the nuances associated with surgery as well as building efficiency within the team. It will also allow individuals to voice their opinions and ideas to improve and allow for further development of our field.”

Find out more about the ERUS-EAUN meeting and register on www.erus21.org

The robotic nurse plays an essential role in a successful robotic surgery

Save the date!

ERUS-EAUN21 ERUS-EAUN Robotic Urology Nursing Meeting 11-13 November 2021, Dusseldorf, Germany In conjunction with the 18th Meeting of the EAU Robotic Urology Section (ERUS-DRUS21)

“...an update on team training and ‘lean methodology’ for efficiency within the theatre team and robotic surgery environment.”

Robotic Urology Nursing

“I would say the entire day is a must-attend event for nurses who are getting involved in robotic urology, but I would say that some highlights for me are the talk on radiology by Prof. Barentsz, about interpreting European Urology Today

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EAUN: Latest developments EAUN board to take on new responsibilities in fast changing environment Mrs. Paula Allchorne, RN, Executive MBA – Health Service Management EAUN Chair London (GB) p.allchorne@ eaun.org I am pleased and honoured to be able to address you as your new chair, since the ratification of my candidacy by the members at the AGM on 4 September last at the EAUN21 Virtual Meeting.

We are living in challenging times, but I will do all that is in my power to step in the shoes of my predecessor and by following her excellent example lead the EAUN to an even stronger organisation to support urology nurses across the world.

“…our social media group will be reaching out more frequently to our members.”

Accreditation The EAUN has been working with the EU-ACME on the development of an accreditation system for online and face to face education. Besides offering online education ourselves, we want to include other organisations that offer useful and accessible education to our urology nurses. So educators and organisers of Education Events for urology nurses worldwide are invited to apply for accreditation.

Accredited education will appear in the event calendar at www.EU-ACME.org.

Social media As our EAUN members live all around the globe, we

are often faced with very different challenges in different continents, but sharing these experiences is vital to all our learning. COVID-19 has reiterated how important it is to ensure we keep everyone updated quickly about changes in the field. By using all communication platforms and channels to promote and share information with our members who follow us on social media, our social media group will be reaching out more frequently to our members.

This conduit of communication includes articles, advertising our education programmes and sharing new developments and guidelines that we hope everyone will find useful.

Guidelines Our guidelines are recognised as best practice, and we are always very proud when we write a new guideline or update one as we know how valuable they are to nursing teams. The guidelines are very time consuming for the experts who kindly offer their knowledge and help write or review them, as it entails doing extensive data extraction and reviewing the published work. Due to the time and demand it takes to write guidelines, we have devised a plan and expanded our resources to gain more expertise to help with each subspeciality area in urology. We have, put a time framework in place to help with the planning and updating of guidelines.

EAUN long-term strategy One of the new board responsibilities is to provide urology nurses and allied professionals further support by sharing good practice and initiating global collaboration and networking. The long-term strategy is currently being reviewed and adapted to fit in with this fast changing environment we are all experiencing. You will find this on our website in the near future and read about it in this newsletter. The start of this decade was not what we hoped for, but I will end by saying a massive thank you to all EAU and EAUN members for your selfless, hard work and resilience during incredibly difficult times. I appreciate the support you gave each other, your families and your patients.

EAUNwebinar

Updates in bladder cancer treatment and care A multidisciplinary team of experts in the field of bladder cancer will give short presentations on key aspects of bladder cancer care, epidemiology, up to date oncological options available, prehabilitation, quality of life and pyscho-social aspects of bladder cancer care.

Learning objectives To enable EAUN members to feel confident in current practices and research available – enabling them to feel updated and confident in managing their bladder cancer patient cohort.

During this webinar participants will be updated on: • Epidemiology and prognosis in bladder cancer • The 2021 status of bladder cancer treatment in medical oncology • The psycho-social aspects in patients undergoing BC treatment • Prehabilitation in patients undergoing radical cystectomy • Quality of life in bladder cancer patients receiving chemo- or immunotherapy

Moderator Dr. B. Thoft Jensen (DK) Presenters Prof. Jorgen Bjerggaard Jensen (DK) Dr. Helen Pappot (DK) Drs. Elke Rammant (BE) Dr. G.A. Taarnhoej (DK) Dr. Susanne Vahr Lauridsen (DK) Date & time Wednesday, 29 September 2021, 19.00 – 20.30 CEST (18.00 – 19:30 GMT)

CNE & Certificate This activity has been accredited with 1 CNE credit.

After attendance a Certificate of Attendance is available in your MyEAU account.

Aim The purpose of this EAUN webinar (provided by the EAUN Bladder Cancer Special Interest Group) is to support and update nurses virtually on current research, practice and bladder cancer treatments available to our patients. Engaging the audience with the hope to offer the opportunity to discuss and share practice from around the globe.

Registration Registration is free.

Support This activity is supported by an educational grant with no involvement in the programme nor speakers.

More information and registration at www.eaun.uroweb.org

HYPERLINKS The International Journal of

Making urology count, 2020 Impact Factor 20.096 EUROPEAN UROLOGY

2020 Impact Factor 5.996 EUROPEAN UROLOGY FOCUS

2020 Impact Factor 7.479 EUROPEAN UROLOGY ONCOLOGY

Open access launched in 2020 EUROPEAN UROLOGY OPEN SCIENCE

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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

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

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

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European Urology Today

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The urological research we publish changes practice and enhances the health and well-being of patients around the globe. Our community of authors, editors, reviewers, and readers are working together to ensure that game-changing research has real impact.

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August/September 2021